Doc, Linear Foreign Body Surgery

In veterinary school we are taught to think based on provided data. I was taught the following numbers about cats; the average lifespan of an indoor cat is 12. The average lifespan of an outdoor cat is 3. In private practice I routinely see indoor cats living up to late teens. I have some patients who have lived to 20 or more years old. Medicine and science love numbers. Data. Tangible, emotionless, critically scrutiniz-able graphs. The problem with reducing a life to a number, or a population of lives to a grouping of statistics, is that we are each our own beings. None of us want to go the doctor to be told we have to meet the criteria of a bell curve and therefore be given a treatment option based on what a computer tells us to do based on the masses.

I use this analogy for other things; like the lottery, and contracting rabies. Both very unlikely, and yet we still participate against the odds that are astronomically not in our favor. (I know there are some anti-vaxxers out there, but goodness-me watching an animal die of rabies is about the most horrific thing you have ever seen!). My point here is that in veterinary school we are given statistics about how much longer indoor cats live than outdoor cats. Upon reflection I think these numbers are based on black and white. Totally indoor couch potatoes, and totally outdoor colony cats. Life, as we all know, isn't just black and white. Some of these cats are merles, shades of grey, don't-put-kitty-in-a-corner felines. Some of these cats need more than a couch and a bowl of dry cat food that sits out 24/7 and never gets a second thought about its contents or underlying sediment layer. Cats are compact, stealthy ninjas. I wish every cat parent saw them as little hidden predators. They need more stimuli than they often get inside, and on the flip side, outdoor only cats need way less stress. Outdoor cats have to spend their whole lives on the defense. Every moment (awake or asleep) is spent afraid. Afraid your safe harbor will be invaded, removed, lost, taken, destroyed, repossessed, or your food will follow the same dismal vanishing at any moment suit. You have to fight, or deliver babies, (then try to feed them when you have no food security yourself), and then hope you aren't eaten, run over, or attacked and left injured. This, is an unfair and unkind life. Human beings brought domestic cats into existence we are therefore responsible for them. They might fancy themselves as assassin, but they still want to be manicured and look pretty whilst furtively stalking the demise of another.

Indoor cats need a life of their own. They need to feel that there is a meal to hunt, grass to chew, eat, roll in, and a food source that brings joy and interest. (Sounds like me I know). Indoor cats are at greater risk for foreign bodies because they are searching for something to either play with or eat and have inorganic options to choose from. In the wild it is far less likely that they will chew, play, or eat an inorganic substance. They have no time, or energy for that outside of kittendom. In our homes we provide toys, they find toys of their choosing and they nibble, chew, and make poor decisions. Of the most problematic ingested foreign bodies are linear foreign bodies. The things like thread, ribbon, carpet (think long strings of synthetic fiber found in Berber carpet). For some pets they put something in their mouth and the reflex to swallow takes over. This is especially disastrous if you keep swallowing and ingest a long thin item. Cats are also poorly designed to avoid this because the tongue has backward facing barbs on it. They help with grooming, but also act like a Velcro-conveyer belt to move items into the back of the mouth and into the esophagus/stomach. Once they get the end of a linear foreign body in the mouth it is very likely to end up in the gi tract.

For some cats (and dogs) they seem to have an affinity for eating things they shouldn't. 

Cats swallow the following; Hair ties, string/thread, non-plant imposters, stuffing, rubber, plastic.

Dogs swallow; tampons (bleck!), socks, corncobs, rocks, balls (they tend to catch or retrieve and then swallow by accident), bones, and for the dogs who are constant chewers; pieces of plastic because they chew off tiny pieces of the items they gnaw on.

Doc is one of these cats. He has a history of swallowing things he shouldn't. As with every patient I see there is a story there. They have things to tell us, problems for us to help solve, and BOTH an immediate need and long term desire. Doc is one of these poignant cases. 

Doc came to us because his mom knew that he had a predilection for eating things. He had been to the ER previously for eating plastic off of a sippy cup. Emergency surgeries at the ER are always expensive. There is no way around the increase in charges with the access to 24 hour staffing and the inconsistency of volume. In almost all cases that I see an ER visit for a foreign body surgery is going to be over $4,000. Most people cannot afford this. When Doc had his second suspected foreign body his mom came to us. 

Doc presented to us as many of these cats do. Quiet, not eating and presumed guilty based on previous infractions. 

Doc had been to the ER. The ER had taken an xray and also suspected that there was a foreign body. They gave an injection for nausea, a pain medication and some fluids. He was discharged from the ER to see us for his surgery.

My biggest gripe with veterinary medicine remains in the increasingly larger gap between affordability and access to care. Almost no one can afford to go to the ER anymore. It has gotten increasingly futile to send our clients to them. If we cannot send clients and patients to the place they need to be because afforable options are not provided then I do what anyone who cries "wolf!" often enough does,,, I stop referring. It is now common practice to call the referral center before sending. We used to call to see if they had availability for transfers, now we just ask about affordability. 75% (or more) of the time clients cannot go due to cost. 

Doc was dropped off in the morning. I rechecked his xray to make sure it was consistent with the previous one. We never want to start a surgery without knowing how the patient is doing. Blood work had not been done so we took a sample and ran it through our in house machine. On physical exam Doc looked good. One of the very important pearls you learn is that the patient will tell you what you need to know. Doctors want to know data. We want numbers. The more nuggets of information we have on our patients the better we feel about our decisions and actions. This is also how we have become so profitable. There is gold in them there diagnostics. BUT, diagnostics do not treat your pets or patients. Diagnostics give you excuses to not treat them. Actions, not incomes, matter. Doc's xrays looked much like the last. Doc needed an exploratory surgery asap. 

Here is his xray;

Doc had a few things in his favor. He is a very sweet boy. (Fractious cats are really hard to manage without sedation. It is hard to give sedation orally when they are trying to bite). He also has a mom who recognized he needed help and then was willing to work with us to get it. She offered to surrender him if it meant treating him. As silly, (or whatever adjective you choose to add here), as it sounds, if you cannot afford life-saving care at least let the pet get care elsewhere. The people who watch their pets die so they can retain ownership are putting themselves above their pets. If a pets life at risk let them go and live. If more people offered to help in the caregiving process more animals would be saved. Never once has someone offered to help at the clinic to offset the price of care. I have three people who volunteer weekly so that their pets are considered employee pets and get care at little (or no cost). That is a parent invested in their family. 

Here is Doc's YouTube video:

The cost of Doc's care was trimmed as much as we could to allow for his treatment. We are so fortunate to be in a community where when we ask for help we get it. 

As a veterinarian who is trying to stay committed to her patients and insure that they get the care that they need, we made a promise to ourselves that we would help every patient who came to us. There would always be hope, kindness, and care offered. In some cases we will give away free diagnostics so we can help understand the disease process,  this gives incite into the patients prognosis and helps with the decisions based on them. In others we provide free euthanasia to provide peaceful passage. In others as long as we believe that the condition is treatable, and the outcome favorable for a return to a normal, healthy life we will use our non-profit; Pet Good Samaritan Fund to help bridge the gap between provider costs and client resources. 

Here is more on Docs case, and how we manage emergency care with a client who has financial constraints;

The goal of the PGSF is to provide a safety net for all whose focus is helping pets in need. 

Here is the link to the homepage; Pet Good Samaritan Fund Guidelines, application, and contact information can be found there.

Doc is like all of us; a complicated, unique individual with specific needs, desires, thoughts, feelings and compulsions. Doc has had two exploratory surgeries. Its time to listen, offer an environment with stimuli, safe things to eat, and enrichment. I have 5 cats. Each one of them likes different things. Two love to be outside. Crouching by the bird feeder. Climbing trees, digging in the dirt, or going for walks with the dogs and us. I have never had a cat with a foreign body, but, I do have a cat that eats cat grass everyday. I grow it for her. If I don't she will eat things that are not for her. 

My views on ideal cat care have evolved since the bar chart in vet school. We are who we are and finding what works for my pets is what works for me.

Here is the breakdown of Doc's care at my clinic Jarrettsville Veterinary Center, Jarrettsville Maryland.

• surgical pack; $250 (iv catheter, iv fluids, fluids, fluids pump, anesthesia 30 mins, surgical instrument pack
• exploratory surgery feline; $400
• additional surgical time; $70
• hospital boarding; $45
• surgical materials; (sponges, suture) $200
• medications; (surgical, peri-op, and post-op) $150
• x-ray; $175
• e-collar; $23

            total; $1400

You can find more about me on YouTube, Instagram, and Facebook

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

What would you do?

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

How does this profession address these cases? 

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

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

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

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

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

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

What do you think?

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

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

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

Here is the site for Maryland reporting of animal cruelty. 

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

I AM NOT AN E.R. The Story Of Sophie. Baclofen Toxicity

It has been a week since I last flossed. It seems like a confessional to the internal self to seek a pardon, and once again, promise to do better. It seems I seek a peaceful acceptance of all of my inadequacies within my inabilities too often.

This week was exactly like this… a series of internal confessions with a humble begging for forgiveness to a self that doesn’t take disappointment, or failure, easily.

This day, this Wednesday evening, within this moment, was about Mollie, Genie, Maxi, Taylor, and Sophie. They were all in some degree of desperate dying. Each patient was supported by at least two technicians, all wondering the same thing as I; how could so many catastrophes happen at once?, and, which one would start to crash/die on us first?

“We are not an E.R.” I hear myself produce these words almost daily these days. I am not sure why I even try to explain, or, perhaps more realistically, excuse myself. For every 100 times I recommend to a client that they transfer to the ER, 1 actually consents and goes. People just don’t/can’t/won't/refuse to go. For some of these cases they have already tried to get in. They have called, been directed to sign in via the online portal, and been notified that there is a 10 to 24 hour waiting period. People who are desperately worried for their pet’s life are not going to wait 10 hours. So, they drive to us. Many just show up. Arrive unannounced. Crash a party and hope that the door is open and the staff is welcoming. Depending on the degree of the emergency they may have called us. May have spoken to our Charge Tech to plea their case, which gets parlayed to a vet, and almost always given permission to “come up, be patient, and we will do our best.” I try with each case to set the stage for the reality that we are “not an ER” and may have to transfer them to one should it be in the best interest of the patient to do so. I know that even with this preface, this CYA blanket statement, that I invite the chaos, and hence, I internally beg for forgiveness yet again when I get myself too deep in the shit pile.

At 7 pm I was standing, circling and losing my mind amid the evenings vetmed emergency offerings I had unintentionally invited to my own misery party. I looked into the surgery room. On the table to the left was an 8-month-old puppy. I’ll call her Sophie. She was intubated, on oxygen, and poorly to absently responsive. Under her head sat a bucket of vomit with specks of white pills. To the right of her was Taylor. A five-month-old tabby with fluid in his chest. He was sleeping in a clear plastic box full of life saving, life giving super saturated 100% oxygen. He was happy and loving his time with us, thanks to the oxygen. Just outside the doors to the surgery in a little stainless-steel cage sat Mollie. She was barely visible behind her cluttered cage door with its two fluid pumps, iv fluid bags, (also two), and a clipboard holding checklist of her too numerous medications. You couldn't see her adorable face with its white fluff mane that surrounded her blunted nose and omni present wide mouthed grin framed within the haloed plastic e-collar. She was sitting up on her front feet but straining and posturing her back legs. She had spent the last week like this. Trying in vain to push out a stone that was lodged so deep down her urethra it was only permitting a drop of urine at a time to pass. In the cage beneath Mollie was Genie. A sweet, slow, aged Dobie who had been vomiting for four days. She came in as a mystery ailment and she remained the same until the next day when the 4-year-old in her family confessed to feeding her a whole box of chewy milk-bones. She was in critical condition and not able to move, except for the vomiting that just spilled out of her mouth as she lacked the strength to pick up her head. Skip a few feet to the left and there was Tigger. I.v. catheter running saline into his veins in the hopes we could flush out the grit in his bladder and dodge the need to place a urinary catheter. He had arrived 3 days earlier just about to block. We mounted the most aggressive defensive plan we could to spare him a urinary catheter and his mom the price tag it came with.

Gastric lavage

Within these moments time stands still. I have to suspend it. It is the only way I can muster all of the senses to attention to compute the vulnerabilities and re-assign staff to guard the weak points. I know, I know deep in the seat of my gut, that at least 2, maybe even four of these guys are going to die in front of me. Probably in the next few minutes to hours. “I am not an E.R.” I remind only myself this time.

This is one of the best examples I can give of where vetmed is now. We have burnt so many people they don’t trust, or don’t want to be sent to an ER. For all of the many reasons the ER’s have gotten themselves in the predicament our clients see them as, it doesn’t change the reality that accidents, illnesses and yes, even death comes to find us.

I see my husband for about 15 minutes daily. 15 minutes when I get home, typically around 9 pm, starving and exhausted. He has a meal waiting, typically two hours old, as I never get my ETA correct. I do not recollect any of the meals from the last week. Only that I inhaled them, and that the portions were too large. We go to bed with me feeling like a bloated corpse, and him angry that I cannot ever say “no.” He reminds me of my limitations and the power of “NO.” I remind him that there are few options in these scenarios that I can live with. I remind him that I am reminded that if I don’t help, I don’t know if anyone else will. If martyrdom was a pageant, I could have a crown to sit upon. Think I am being foolish? Well, lets talk about each of these cases in a little more detail. Wonder why I don’t floss? Well, I don’t do anything in this state. I fall asleep as soon as I hit my bed. Surrendering to the exhaustion like the coma that claims me. I repeat this Monday-Tuesday-Wednesday and Thursday. I fall off to sleep worried for the patients I saw. Fearful for those I failed, and afraid for those I will see. I cannot say “No” to these either. They find me in my dreams.  Even here, as I try to rest I see them. I worry and react for them. I send them treatments, and apologies. A figment of a life preserver even here, when they aren’t near me. 

The routine day

On the night before a dog arrived with much the same scenario; "ER has a 10 hour wait. Patient is bleeding everywhere from a dog fight." We explain to the caller that we will do our best to help, but, if sedation or anesthesia is needed they will have to head to the ER. When they arrived it was after 6 pm. I was told that he was "bleeding everywhere" so I rushed in to see him. There was blood splatter on every wall in the exam room. He had been there for less than 5 minutes. The wounds to his left ear were so significant that I was not able to fully assess whether ear needed reconstructive surgery. The ear was not being held up at a normal (or symmetrical) angle on head. There were about a dozen (maybe more) wounds to the top of his head that included both puncture wounds and lacerations. Some appeared to have pocketing and underlying muscle damage. Again too bloody and painful to assess. Wounds appeared to go over to right ear, base of ear and included the neck. As with all wounds of this severity he was too painful to assess fully without pain meds and sedation, and most probably required general anesthesia. I advised them to go to ER. When I mentioned the ER the owner became volatile. She shouted and became angered. She would not to go to ER! she yelled, so I offered analgesics and antibiotics as initial treatment option but again warned that wounds may need clean up to check for degree of soft damage, and tissue damage. I told the owner I was also concerned about pain, bleeding, and high infection rates with dog bite wounds. Owner declined again to go to the ER, and take any medications. The owner went on to say that "this dog had cancer and she would not wait 10 hours at ER to be told he doesn't need anything." I attempted to diffuse her and offered pain management and antibiotics again. She stated that I was being rude. The owner got up, took her dog by the neck and began to leave exam room. She kept yelling, repeating that I was rude, and she was not going to ER. As she was leaving I told her to not return to us, nor treat staff this way. When I said this she turned around and charged at me with a hand in my face and the words "I'm going to beat your face." 

That's what advising someone to go to the ER can get you. She was served with banning papers from the Sherriff the next day. Yet another gem to add to my Wednesday fiasco.

My Storm,, his happy place.

Sophie is 8 months old. She is a wire-haired terrier just fostered and adopted by an older couple who adore her. For all of the mischievousness of a terrier, (vets tongue-in-cheek refer to them as “terrorists”). They find her antics, her strong opinions, and fierce compulsions, adorable. (I can relate, my parents felt the same about theirs. I grew up with 5 generations of Jack Russell Terrorists. They killed our cats. They killed any small thing that scurried). Sophie has a boxy face, tan highlights to a brown face and inquisitive soft intelligent eyes. Her ears stand with a little bow at the tips and she is formidable in a compact package of taught muscles and youthful velvet softness. Sophie was carried into the clinic in her mom’s arms as she burst in the front doors like a hurricane. I was alerted to their arrival by my receptionist who quickly came rushing into the treatment area yelling, “EMERGENCY! WE HAVE AN EMERGENCY!” arms flailing above as if waving down a passing car. I walked to the front and her sobbing mom attempted to pass over her lifeless puppy to me and asked myself, “why does this place feel like a firehouse on some days?” 

It is exactly in this moment that I have to decide. I do not extend my arms. I do not rush to offer some act of heroism in a crucible of mercy. I have to make that split second decision as to who I am and who I want to be remembered as. It is in this second that your marrow matters. It is here that your consequences, your good deeds, your ethos, and every second of every tid-bit of training finds you. Your actions here will haunt you. I know this. This is the place where some vets will offer “humane euthanasia” while others will offer extremis estimates for a chance, and many will take a bad situation and make it hopeless. (To be honest I never quite know if I ever pick the right offering of an answer. More on this with Genie’s story to follow). What I wanted to do was ask her to remain there. Put her on a pause, holding her rag-like puppy and make a quick physical exam assessment and,,, punt. HARD. I did not want to be responsible for her. I did not want to be responsible for a hysterical mom feeling guilty about an accident I have seen so many times before. I did not want this dying puppy. I didn’t want any of the hers in front of me asking for help. Now I know this sounds cold and cruel, but the reality was that I had just finished a long morning of over booked surgeries. I had come in early, after getting home very late, to try to cram in all of the things that I had scheduled. There was not enough room for them, never mind the falling deaths from the skies. I know this. I know I am supposed to say "NO!" I looked at her puppy, I looked at her, the words slipped out softly, “I am not an ER.” I knew we didn’t have the manpower, the time, nor the facility to help a puppy in this state to the degree she needed. Sophie was purple, barely responsive and I was pretty sure she was dying in her moms arms, if not already dead, and would die on her way to the ER. I clumsily said as much. Mom begged me to “try” and I am a sucker for that word. It is my verbal kryptonite. No other word compels me. Mom was hysterical. Mom was not safe to drive. Mom was not going to make it to the ER with Sophie alive.

 

Sophie was in such a terrible state that I knew she had a very narrow window. I took her in my arms and we headed into the treatment area. Over the next few minutes the story of Sophie’s predicament unfolded. Her parents had left her at home for a few hours. When they came back she ran to greet them, same as always. Within a few minutes she had vomited and then they found the chewed up pill bottle. Scattered around the bottle were large white aspirin-powdered pills. Baclofen. The label was so chewed up that we had to use the pills and pharmacy information to identify them. The bottle was filled for a 30 count. 13 remained. As the technician called Pet Poison I debated her degree of consciousness and whether she was awake enough to induce vomiting. She was not. Sophie had dried bloody, thick, taffy-like saliva and vomit in her mouth. I tried to clear it. It was a sticky-spiderweb goo that left your hands incapable. Sophie was placed on the x-ray table. She had a huge distended stomach full of,,,, well, seemingly dog food and pills. We whisked her to the surgery table, quickly intubated her and provided oxygen to her purple lips and tongue. She was slipping into a coma. Four people, two of them veterinarians, swarmed around her tiny new body. We placed a stomach tube. We lavaged the stomach contents in a desperate effort to remove as much pill-peppered-ingesta from her stomach as we could. The clear plastic tube sucked out tan kibble speckled with white powdery-pieces of pills. She gagged once, whimpered once, and lay lifeless for the rest of it. I gave her intermittent breaths of oxygen and told her that I was sorry. I told her she was loved and I watched the staff so desperate to help and so foreign in this act of emergency procedures. Sophie gathered a crowd and I barked orders to try to turn a tide I knew we were all likely to drown within. I called the hospital manager down. I told her to call all of the rest of my evening appointments and tell them we were swamped with emergencies. “Offer to reschedule, (knowing this never works), and ask them to be patient if they don’t want to. Go in all of the exam rooms, (I knew all 7 were filled with people waiting for us), and tell them the same.” I put her on the reception desk and pulled the last two techs to the back treatment area. For three doctors we had 8 technicians scurrying. We also had 17 patients in our building, 7 wanted to crash and expire if you blinked.

I got on the phone with a veterinarian from the Pet Poison Helpline. He was slow spoken, jovial, and the calmness on his side of the line was re-assuring and yet vexingly annoying. “Baclofen is a common toxicity. Have you had one before?” There it came again, “No, I am not an ER.” ‘Don’t kill the messenger’ and ‘be nice.’ I said to myself. He is here to help me. (Does he know that I have 7 other animals trying to die around me?).

“Baclofen is a muscle relaxant,” (yeah, I can see that). “It has a very narrow index of safety in dogs” (Like 1 pill? How about 17?). “Unfortunately, (never want to hear a sentence start with this), most dogs, if they survive, (never want to hear this either), need supportive care for 72 hours to up to 6 days. Many need to go on a ventilator.” (Crap, who has a ventilator? Only the veterinary teaching hospitals, I thought). I kept going. We kept lavaging, hoping, and telling her that I loved her with a gentle pat to her head. I stroked her ears in between her oxygen bag compressions. If she was going to slip away it would not be without my whole heart and soul going with her.

Over the next hour we tried fluids and desperate attempts to stabilize. She was the last patient to leave the hospital that night. I called the local ER to refer. “No,” they had not had this toxicity either. “No,” they didn’t have a ventilator, but, “Yes” UPenn vet hospital does. They had sent a patient last week. Estimate given for this was $18,000 to $30,000. OMG Crap.

I look back on Sophie and I want to cry. I want to be upset about how many times pets get into things we think that they are smart enough to avoid. I want to put up billboards to say, “NO! crate training is not punishment. It is the safest place for your pets to be.” My pups are 4 years old. They are my children. My most beloved. They are also raccoons in autographed collars. They will get into everything if I turn my head for a second. They are trouble. I know that. They are crated when I am at work. They are in a cage at the clinic. They are in a crate in the bedroom when we go out the door. I don’t care if it is 5 minutes or 5 hours. They have been raised this way. Every pill bottle in this house is double locked. A bottle in a closed drawer. Never, ever is it out. Have you ever shaken a pill bottle next to a pet toy? It’s all the same inviting tune.

In a sea of crashing waves, tumultuous and treacherous, I will never forget Sophie’s face. I will never forget that yellow pill bottle with its perfectly intact child-resistant white top, labeled as such. Tattooed with its cursory; “push-down and turn” orange letters. Shrapnel-ed bottle, completely missing any recognizable bottom, or rounded edges. The label chewed, swallowed and obliterated in casual terrorist fashion.

Sophie was sent to the ER at 830 pm. She was transferred without her breathing tube. She coded overnight. She never regained consciousness.

I hope that she heard me. I hope that she knew she was always adored. I hope that she forgives as much as I hope I can forgive myself. Maybe I could have/should have used warmer water in her lavage? Maybe I should have done it just one more time?

My Raffles,, on our daily "dog" walk

Maybe forgiveness holds as much power as intentions? Maybe peaceful acceptance maintains the balance?

Maybe the other 6 will survive. Maybe I am an ER, if only in sheep’s clothing?

My Frippie and Storm

Blocked Cats; My Cause and My Advice

A "blocked cat" in vetmed terms is a cat who cannot pass urine normally, or, at all. "Blocked" refers to urinary bladder blockage. A blocked cat is a medical emergency and should be treated as such.

Here is how I treat a blocked cat, and, why/how these cases often come to find me.

Stripes. Presented blocked and unhappy about it.

The typical scenario for a blocked cat presentation is this;

• Cat is in and out of the litter box, 
• Often crying, meowing, and/or, in distress 
• Little to no urine is being produced

Client and blocked cat show up at vet office or ER. Cat is examined and owner is asked to produce a $2,000 deposit for care. Most struggle to afford this. Many cannot. Therefore, they call me for help.

Here is a look at how I manage blocked cat cases with financial constraints at my veterinary practice.

Almost all cats can be diagnosed without diagnostics (outside of the above mentioned physical exam and history).  I DO NOT RUN DIAGNOSTICS IF IT WILL AFFECT A PATIENTS ABILITY TO RECEIVE TREATMENT. This is a practice that has become all too common place and the systemic practice of economic euthanasia to allow for diagnostics is unethical and warrants state board and AVMA scrutiny and policy changes.

KEY POINT; This should be provided in documentation after the examination is done. At each client documentation/signature request the client MUST get a copy, and, there MUST be current patient status listed. A client has the right to deny diagnostics and still receive life saving care. The egregious practice of turning away clients if they will not meet a practices proposed standard of care, and the corresponding costs associated with them, is also in need of AVMA and state board examination. We allow the euthanasia of patients because we reduce them to property status when it suits our prejudice and financial gain discretion. A blocked cat is typically young, otherwise healthy and free from any other medical conditions. They may present looking, and feeling, bad, but, they are treatable in almost 100% of these cases IF UNBLOCKED.

Urine, rally bloody, from a recently unblocked cat

I am going to describe the typical blocked cat cases that I see, and, how I manage them. Almost all of these are owned by people who have financial limitations. I am also providing challenges to the typical way an ER manages these cases to help highlight areas we can help allocate resources to as I call it, “get out alive.”

                First challenge; diagnostics are not needed to diagnose. Short of a very obese cat a competent physical exam AND thorough history will diagnose the majority of these cases. Why does everyone run diagnostics? Why, again, are we not talking about the client’s budget at the beginning of spending their money?

                Second challenge; diagnostics, regardless of their findings do not influence the care needed. ALL of these cats need to be unblocked immediately. In some very rare cases there are some patients who should not be treated, or, have a poor prognosis regardless of treatment. (i.e. geriatric cats with comorbidities, fractious, feral, unknown rabies history, cats we will not be able to safely manage fluids/urinary catheter on, loss neural function, etc). These patients/clients deserve to be notified before treatment, or estimates, are provided. Futility* medicine should be as ethically bound as economic euthanasia defaults, and over padded invoices that prohibit care ability because finances have been drained in the diagnostic phase.

I would like to provide users with a step by step approach to their cats care. Challenge the suggested treatment protocols to save clients from economic euthanasia

Next challenge; vets do not talk to clients about managing financial resources to allow for the expected stumbles in this disease process.

Challenge; talk about whole pet care, not point of care emergency. Who else talks to clients like I do? I say, once we start treating we are all committed to a positive outcome. This is NOT based on financial ability. It is based on needed patient care. Vet med withholds this until it is perceived that clients are dry and then we offer euthanasia as the only affordable option.

Challenge; these cats are typically young (under 3-4 years old) and otherwise very healthy. We are over-euthanizing young, previously perfectly healthy cats simply because we have priced them out of care. These cases have been around for decades. Decades where we treated them at minimal cost and saved the majority of these cats. Why are more cats dying now? We priced people out of care while better educating the public on this disease. That is unethical. This needs to be challenged.

Challenge; why do we run blood work on ALL of these cats? And then tell owners that ALL of these cats blood work looks bad, because, well simply they are sick, they are critical and they do look bad. What were we expecting the blood work to look like? We do it to make money, and, we do it to CYA, and we do it because someone made us believe it was a liability otherwise? It’s time to challenge pricing pets out of care while we CYA.

Challenge ALL of these cats in my experience go back to perfectly normal blood work indices after their obstruction is removed and they are given time to recover. They do not start out in kidney failure although all of them have blood work that looks like kidney failure while they are blocked and present for care. Vets use this to their advantage when discussing euthanasia, or repeating blood work. It is deceitful.

In cases of financial limitations (this is decided up front at the first visit/interaction) we have an ethical obligation to discuss what we expect, what we have seen to be true, and that this is not a one and done fix. We need to start with a whole cat case approach, not a singular point in time under emergency induced emotional duress and take clients for a one and done as much as we can get them for and to-hell-if the cat is euthanized along the way approach. We know better, even if our clients don’t.

Challenge; This ridiculous, archaic practice of not having vets discuss money (see equally ridiculous reasons here)

Challenge; most ER vets are unblocking without general anesthesia between cases. We can do it so quickly that the charge given to the owner is exorbitant. In many cases we can unblock a cat in the same time it can take to pass an i.v. catheter.

Challenge a line item list of how a cat is unblocked is not provided to the client.

Documentation on the procedure and the time necessary to unblock is not provided. This should be provided before treatments are given AND confirmed before invoice is given. 

Challenge; Removing a urinary catheter before 72 hours, or before the urine is running diluted and clear is setting the patient up to reblock. I would argue that we use time based estimates which are always egregiously too short thereby setting the patient up to reblock. Veterinarians should expect, and do, the cat to reblock within a very short period of time. We make more money with the cats failure. The ethics of this should be challenged. If clients cannot afford to keep a patient in the hospital they should be allowed to be transferred to a primary care facility, i.e. their normal veterinarian (even if they do not have 24 hour care), and/or allowed to go home with the intravenous catheter AND urinary catheter in place to be monitored at home. Challenge; I have never seen this happen. In all cases these are removed by the ER facility. These critical goods are paid for and owned by the client. Removing them without consent is a breach of consensual care and a done to the detriment of the patient.

We should all expect that a cat that has blocked once, will soon block again. How many times can the client pay for this? We should be addressing this at the first visit. We should be using the clients ability for the expected treatment course, and not the typical one time financial hit. We require a deposit for care, and that deposit is typically exhausted within the first 12-24 hours leaving cats to be discharged before they are ready, and setting the client up for a repeat obstruction within days to weeks. Where a small percentage of cats are treated on the first obstruction many are not on the second. Further the trauma of the blockage compounded by the passing of a urinary catheter causes excessive damage to the patient urethra. I would argue that the removal of a urinary catheter prematurely causes an increased chance of reblocking and therefore makes the veterinary team responsible for re-current obstructions that frequently occur within days. 

The inflammation from BOTH the blockage AND the urinary catheter always needs more than 12-24 hours to resolve.

Challenge; a client pays for the goods and services provided to the patient. Why then do vets insist on removing these? At least we should unblock and transfer elsewhere to provide these patients a longer fluid therapy plan. We need to be documenting and insisting these cats continue care elsewhere. Even if this at the owners home, if it cannot happen at a veterinary facility.

Although not ideal we keep cats in our vet hospital for 3-5 days even though there is no overnight care.

These cats need fluid therapy AND urinary catheterization for 3-5 days.

Unblocking a cat at my clinic; Client call to front desk with any of the above clinical signs is sent immediately to the Charge Tech. They immediately notify a veterinarian of the cat being blocked. If the cat is an existing patient we direct them to go to the ER immediately, or come to us. Upon arrival we immediately  examine to confirm bladder is large, painful and no urine will pass. Do not squeeze too hard. Bladder can rupture. This is always a surgical emergency, financially constrained clients will not be able to afford this.

Treatment tree looks like this; 

•  cold laser therapy of prepuce. Will reduce inflammation and allow some sediment to pass.  
• massage penis to remove calculi. May allow urine to pass, 
• attempt to place/pass a urinary catheter. Catheter selection matters, avoid tomcats and red rubbers, try Tom Tiddle, 3.5 french. Lots of lube! 
• Start i.v. fluids as fast as able. These cats die from dehydration causing cardiac fatality.
•  If unable to pass Ucath, try to relieve urethral obstruction with olive tipped syringe and 20 ml saline to retropulse obstruction back into the bladder. Lots of lube 
• If unable to olive tipped syringe decompress bladder with 22 gauge needle. Remove as much urine as able. I leave needle in bladder and switch out 20 ml syringes until bladder is soft. Warning, bladder rupture is possible.  
• Continue laser, massage and retropulsion with olive tipped. In almost all cases you can feel obstruction move as these are done. 
• Attempt to place Tom Tiddle and suture stopper to prepuce. If able;
• Flush bladder with sterile saline to remove as much debris, and blood as able. 
• Place collection back onto Ucath 
•  Start iv fluids. We use NaCl for ivf therapy 
• If a higher degree of difficulty in passing ucath take lateral caudal ab xray to look for bladder stones. This may indicate a cystotomy is needed.

Challenge; it is easier to unblock a cat then spay a large, fat dog. Why then is this done at 4 plus times the cost to the owner?

Why is it ethical to be charging so much just because this is an emergency? I would also challenge that these cats are easier to treat than a big aged dog spay, Which we do routinely and charge for at a fraction of the cost, because people can find this surgery at almost every veterinary facility. Where there is competition there is a lower price point. Further a spay is (typically) elective.

At home care after urine is clear; the following are my patients; 

• Teach owner how to palpate for the urinary bladder. 
• Place patient on a steroid to encourage drinking water and reduce inflammation. 
• Feed a wet food only urinary diet. Add water to each meal. The diet should be a urinary prescription formula and it should be used for the rest of the cats life. 
• Encourage water intake with a fountain,. 
• Encourage play. 
• Reduce stress in any and every way possible. 
• Monitor litter boxes lifelong. New litter options are being produced to help guide clients in detecting and monitoring for possible issues. 
• Use anti anxiety medications like gabapentin. 
• Or, long term medications like fluoxetine. 
• Use analgesics like transmucosal/dermal buprinex. Pain medications will help these patients quality of life. Reduce stress and reduce likelihood of recurrent stress induced cystitis, further reducing chances of reblocking. 
• Give sq fluids at home for days to weeks post op. Fluid kits are available on Chewy.com

We need to develop ways to allow in home care and supervision. Pawbly.com can help.  Start a savings account for the next urinary issue. If necessary discuss a PU surgery as the next treatment option. See VetBilling.com for pet savings plan options. 

PU surgery.

Here is a video from my YouTube channel on unblocking a patient of mine. More videos can be found there. Link here

How do I get these patients treated for about $1,000 (and, yes, even I admit this is too costly for many people), I invest in my clients AND patients care. We start with a goal. We talk about options. Every single option. They are all weighted equally to reinforce that we are in this together. From start to finish. If none of these seem acceptable to the client I ask, "what will it take for me to help your cat?"

We start there.

If you have a cat, particularly an adult (greater than 1 year of age), indoor, neutered, male on a dry food diet (particularly a grocery store brand) you need to ask your vet what would happen if your cat blocked? Would they refer you to an ER? If so. how much might this cost? Be prepared before this happens to you. Please follow my blog, my Jarrettsville Veterinary Center Facebook page, my YouTube channel for more on this, and other pet care issues. Please also stay tuned for a step by step guide to managing your cats emergencies, especially if you do not have an emergency pet care fund with at least $2,000 in it, as we are working on it now.

For more help you can ask our pet care professionals for free at Pawbly.com

References;

CareCredit. Hate Talking About Money? You Are Not Alone.

*Futility Medicine; 

UW Dept Of Bioethics discussion.

Medical Futility Is Commonly Encountered In Small Animal Medicine.

 

Lock Down At The Veterinary Clinic.

Twice. This has happened twice in about 4 years. The vet clinic has gone into lock down over a client showing up enraged and threatening us..

There are safety and terrorist drills that every place of business, social meeting area, community gathering place and institution needs to practice. Sadly, this also includes the veterinary hospital.

Both cases of lock-down were eerily similar; an enraged client came in seeking immediate action after their phone calls to the clinic were not answered quickly enough. The phone calls were belligerent, accusatory, demanding, threatening and intimidating to the girls at the front desk. The front staff are not naive to difficult phone calls. They tried to explain that the messages had been delivered and that someone would get back to them. This wasn't an acceptable answer.

The phone calls start as short and frequent. They quickly (within hours) escalate to demanding and threatening. The avalanche has started and you should expect the rest of the catastrophic destruction to follow.

The next action was to show up at the clinic enraged. Their anger has turned into threats and demands in person and with immediate expectation of engagement.

There is nothing you can say or do at this point other than to call the police. You don't know what these people are capable of and you cannot diffuse this situation and concurrently take care of your business. From my perspective I am also responsible for the health and safety of the other clients, staff and patients in our care. I don't dare risk their emotional or physical safety, and my ego doesn't believe I am a superhero who can swoop in to save the day. I have learned to NOT ENGAGE.

There is a back story to the culmination of these lock downs, (of course), they all went a little like this;

New pet parents arrive with Amish puppy mill, OR, Craig's List, puppy a few weeks earlier. It is very apparent to everyone that they are unprepared and uninformed about the cost, care, and responsibility of owning a pet. All routine pet services are explained in detail, associated costs provided and many are dismissed as being "not needed" or "too expensive". It is not uncommon, nor unreasonable to space out vaccines, visits, services and instructions for new pet parents rather than try to overwhelm and scare them away. We take our time and break the whole process into little easily digestible pieces. These visits take a huge amount of time and energy. They are also vitally important for the safety, well fare and well-being of these clients and patients. As is customary for us we offered brochures on products (preventatives are often confusing and difficult to understand the value of with new parents), and vaccine schedules. Written personalized instructions go home with the owner along with pre-booked next appointments. In this particular case I also strongly encouraged enrolling in a puppy/new pet classes. Phone numbers and recommendations are also given for these. We go to great lengths to provide a safety net and support network to new parents.

There are vet visits where you feel like a pre-puppy/pet-selection process should be law. There should be a screening process, an application, a review of the home and a waiting period. This requires time and patience. You can buy an Amish/Craig's List puppy/pet cheap and get them quick.

The clients admit to their pet purchase because they had been turned down by all of the rescues. People may castigate the potential adoption process but it has its purpose and reason and is often correct in their assessment of adopters.

Not everyone should have a pet. They are not little neatly packaged ready to go inanimate creatures. They are the worst example of Ikea's "lots of assembly required" challenges. They have needs. Their needs have zero respect for yours. There is no ideal time for a broken bone, infection or acute diarrhea episode. When they happen (and they always do) the unprepared new parents with angst and disdain always behave the same.. Anger, yelling and excuses about a "defective pet." (I cannot even tell you how many times I have had this discussion).

What I have to politically say nicely is "All pets come with and will have medical and/or behavioral challenges." They are intelligent, intuitive, needful beings. They need help with the challenges of life like all of us do."

BUT,

What I want to say is; "What the hell were you expecting? A pre-programmed self sufficient robot? Of course they cry for attention. Of course they will poop and pee in your house if you haven't trained them. Of course they need love and exercise!"

The worst cases of new pet parent failures end in death. I have come to know this, fear this, and see this. If you don't put time and attention into your children they fail to adapt to society and are ill-equipped to live happily in it. The behavior issues turn from disappointment to cast away outside to surrendering at the shelter to euthanasia appointment. It is the awful reality of property that fails to serve its owners purpose. Or, it turns into an anxious pet who bites or lashes out, which turns into death by euthanasia, or, abandonment which in too many cases causes death by predation or designation of "unadoptable" which subsequently leads to euthanasia.

At some point in this timeline a frustrated owner starts providing clues that the relationship is not mutually reciprocating of adoration. The parent cannot understand and assist the pet and the pet is still desperate for love and attention but unable to articulate their needs and wants, IF the vet, or pet professional doesn't intercede at this point it will cause a shortened cheated life for the pet.

Here is where our lock down happened. The new pet parents told us on multiple occasions to multiple people that he didn't want this pet. It is not uncommon for vets, and vet staff, to hear clients disparage and complain about their pets care and cost of care in front of us. Perhaps they do it to try to complain indirectly about the bill? Perhaps it is poor coping skills? Regardless, I am not able to ignore it. I have been heartbroken too many times to not intervene.

After an odd peeing incident and a heated visit with the dreaded "defective" label being thrown out as a reason to not pay, and not wanting the pet. I called to offer help and try to explain that these things happen. I attempted to explain that "perhaps she needs more time, more training and help? We are here to help her, and them. We can't do one without the other." What I feared was that her "odd behaviors" were a direct result of the anger and angst they felt toward her?

The next day the client shows up unannounced to leave her. "She is too much work and too expensive." The client is in such a rush he doesn't want to wait to sign papers. (You cannot just drop off a dog at a vets office). To be honest we only take them to get them into a rescue to try to save their lives. At almost every shelter in the country a surrendered pet is a most often designated a "euthanizable" pet. These pets pay for their humans inadequacies and instabilities.

Three days later the phone is ringing, the messages are stacking up, and a few hours later a very angry guy is at the front desk making demands.

It was lunchtime and my sister (our hospital manager) and I were out to get a few minutes of much awaited spring time sunshine. What the client didn't know was that I, the practice owner, had just returned from hospice vigil and hadn't been at the clinic for a few days. It is not something I felt I needed to share, but, it is not outrageous for a phone call to take a day, or even two, to be answered when they do not include patient health care requests.

The client was so belligerent that my mom (cleaning the clinic that day) hid in an exam room and called my dad to come rescue her.

Texts to my sister and I quickly escalated to phone calls for help.

"Call the police NOW! And, lock all of the doors" imagining them fearing for their safety as they were unable to diffuse the demanding lunatic in the front office.

That's my advice for every out of control situation. You just call the police. Let them try to manage the person who is not willing to talk like a mature adult. Never escalate, never engage, and never allow anyone to make you feel threatened.

The police arrived as the client departed. There is now a record outside of yours to corroborate your concerns. If you are worried enough inquire about a restraining order. It is a the best way to protect your business, your self, and your staff while at work. You also will benefit from having a police officer present at the time of request.

"If they show up again call us. We are one mile away. We will send extra patrol cars to visit today and tomorrow. We can even post one to stay if you need us." It was the most consoling offer of protection and peace we could have gotten. It was the only thing that allowed us to stay open the rest of the day.

Where am I in all of this? I am back to being afraid of people who will harm you if they feel embarrassed and/or not in control and the collateral turmoil of not trying to save the pet in the middle. It is the world we live in. Where guns are prolific and temper tantrums happen in traffic, workplaces and even school yards.

A phone call from their lawyer followed. "They want their dog back. They have had a change of heart." Lawyers ALWAYS get involved. If you are lucky, they get involved early. Lawyers at least have boundaries and repercussions if the client is a psychopath. Any, and every, mediator should be welcomed. It is yet another barrier to becoming engaged with an unknown unpredictable person. It is a way to provide leverage and pressure. Every vet needs to have a lawyer on retainer, or at least PLIT insurance. Call your lawyer as quickly as the hairs on the back of your neck take notice. The point about "not engaging" also includes passing the buck when appropriate.

My reply; "My job is to take care of my patients. I am still here to take care of them. The pet is in a home with people who love her and they don't want to give her up. It was stated to us on multiple occasions to multiple staff members that your client did not want this pet. I also need to notify you that the police were called when your client threatened the staff would not leave after being asked to. The police were called to the clinic to remove him and are on alert to return if he does. The clinic went into lock down because the staff was so afraid."

Why am I posting this? Well, because we have been threatened before. Threatened with lawsuits, physical harm, and intense harassment. I have had to go so far as to get a restraining order, (it takes four visits to the police and courtroom to get), and I know what the consequences to my patients are if I don't offer to help. I also feel compelled to share this story with other vets and vet staff to try to encourage them to say something when a client states they don't want their pet, threatens abandonment, physical harm or personal injury. Do not ignore a threat, ever! Document and get backup corroboration to support the claim immediately. This case has multiple entries in the medical record to support the statements made in both our presence and in phone calls/email exchanges. I was granted a restraining order because I had emails and witnesses to support the threats made.

Do I think this is the end of this? NO, I don't. I think this man doesn't take "No" lightly. I think that in some cases standing up for your staff and protecting the people you care about makes you a target. I also think this blog allows me a place to post fears, concerns, and educate all of us about how behaviors influence outcomes.

How hard it is to stick your neck out with people who threaten and intimidate? How easy it is to turn a blind eye on your patients to spare your butt? Vets have to ask themselves this question every single day. It can break you. I have had to become comfortable with repercussions in order to stay true to my ethical code of my obligation to caring for my patients. It is not a code my profession shares publicly. I also think that veterinarians deal with the a ridiculously ambiguous fundamentally unfit status of pets being deemed "property". It denies us ability to intervene, advocate and make meaningful life saving pleas. At will on demand euthanasia is a viable option to every pet owner. If I push to hard every patient can be euthanized, and some clients will do so just to spite and hurt others. That is absurd and reality.

Here are my tips for preparing your staff for potential Lock Down scenarios;

1. Never engage. Ever. The minute you feel threatened or that the situation is out of control just pick up the phone and dial 911. You don't have to warn the client, you don't need to explain, and you should never apologize. Just pick up and dial. Every front desk employee has a phone at their fingertips.

2. Start recording the event. Any other staff member should discreetly pull their phone out and hit record. Evidence will save you time and money.

3. Have a protocol in place. Get people outside. Lock doors so others don't walk into the heated situation as it boils over. And, never call in more civilians. The police are your only call.

4. Get photos. I had to get a restraining order on a client under daily psychiatric care who was threatening to kill someone. Of course he didn't exist in any social media platforms and has never had a photo of himself taken (that I could find).. It is harder to alert the staff to call the cops if he shows up if only a few staff members know him by face. We were given make and model of the cars the owned to post for staff's attention.

5. Stay on the phone with the police dispatcher. They can help you to keep calm and be safe.

End note; I really never imagined that being a vet who cares so much about pets would leave me to having to decide whether to stand by protecting their lives would leave me sitting in the cross hairs of my own. We live in a dangerous and unpredictable world. It shouldn't be governed by so much pervasive fear and hate, that's not what our pets bring us, that's simply humans.

Where is JVC going to go to help deal with the ever increasingly hotheads who are making the job of an underpaid vet assistant question why they stay? We will be adding video surveillance to the hospital. They will be in every public space, including examination rooms, and parking areas. We are also recording telephone calls. Too often I have a receptionist find me frantically befuddled to notify me that a "very difficult, angry client" is on the phone. Many of these phone calls include threats, harassment, profanities and requests they cannot acquiesce to. I ALWAYS take these calls. Overwhelmingly the client is nice as pie to me. There is some unwritten excuse to being able to be rude to the staff and nice to the doctors. For every client who does so I ALWAYS ask the client if they were rude to the staff? I know that most clients are put off that I ask, but, I explain that we are never rude to clients and it is expected this is reciprocated in return. Every single client had provided a firm and disgusted "NO!" For the repeat offenders they are given a written letter of warning and at the third infraction; fired. Every practice owner needs to both protect their staff AND hold clients to a standard with consequences. No vet staff member is ever paid enough to allow or tolerate abuse.

Clues to Lock Down worthy clients; (Note; I am not a psychologist AND I am way out of my vet hat boundaries.,, But, these have been my experiences. I add them as personal reflections).

1. They are usually new clients. Never people you have seen and known for years.

2. They have seen multiple practices over multiple years.

3. They provide red flags at every single interaction. Pay attention to the little voice that tells you to be careful.

4. They do not provide small talk unless it is somewhat uncomfortable and moderately inappropriate. Like asking for your private information, or, disparaging others to find a common enemy.

5. They seem to exist on the ends of the spectrum. Either too nice, or, too angry. You never know which you are going to get?

6. The pet goes from happy and jubilant one visit, to afraid and shy the next. ALWAYS pay attention to the pets and the kids. They tell you what you need to know.

Here is a reference from Psychology Today on Dangerous Personality traits. The men of this blog possess many (or all of them). Please read this article if you are a woman, vet, vet staff, person, employee, anyone and everyone.

Footnote; None of the photos in this blog are of the pets involved in these cases. The situations and scenarios are collected experiences based on previous situations within the clinic. Names have been omitted and references to actual clients have been altered to protect the staff from further harassment and client instability and instigation.

About me;
I am a small animal veterinarian and the owner of Jarrettsville Veterinary Center in northern Harford County, Maryland. We are here to help you and your pet at every step of their lives. Please check out our amazing Facebook page JarrettsvilleVet. Or find our 2017 Jarrettsville Vet Price List here.

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And of course we hope that you will Please always Be Kind to every living creature.