The Hardest Days.

The hardest days are lived in snapshots.

Frozen moments of the day that solidify, remain indelible, and scar. 

I have collected mountains of them. Held them in my arms like a clutch of kittens too fragile to walk away from and too demanding to dismiss. I know they are the villains to my story that makes the read worthwhile, but when away and alone I sit and wonder if I need to be so burdened by them. How can I extract the color without bleaching the meaning they must hold for me to carry them for so long?

The past few weeks have been vibrant and jarring. The color that propels heartrates into arrythmias.

I live within the proverb; intentions matter. I also suffocate screaming for merciful reprieve because these two words are so impactful. Within these intentions you are left to question motives at every movement. Veterinary medicine is a quagmire of bipolar extremes. Emotionally charged, diabolically opposing, with violently swinging requests of the pet care spectrum you often cannot foresee. What gives a family the gift of a graceful, peaceful passage, also leaves the other owner with a disposable/replaceable burden they simply want eradicated. The purveyor of these passings is too often  given a heavy burden. Or, what one family wants and will fight for another will dispose of without whim or wait. I have been bullied, berated and threatened for caring too much, and too little. Never have I euthanized a treatable pet without fighting to give them every chance, at no cost, which somehow vilified me even more. I have been dumped for an easier practitioner who works on an upfront-pay-and-I'll-remain-mute basis because I dared to open my mouth to attempt to defend a pets life. I have been threatened when I refused to be a part of a pets undoing unjustly. And with each I remind myself "that no good deed" often comes with punishment, however unintended, and unwarranted. I have also come to realize that a dignified end of life death is often a merciful act. But, dare I try to be the inspector of this intention, question the reason, and the tables will swiftly turn from humble request to angry accusations. How is it my place, my duty, and my obligation to question who dies and when? 

I am often asked if euthanasia's are the toughest part of my job, (I have written about this before), and no, when I am being asked this it is always at the hand of someone who loves so deeply they see beyond themselves. A euthanasia request for a pet that hasn't seen a vet in years and is suffering from a treatable condition they still don't want to try to treat, yeah, that's soul-sucking. A euthanasia request because it's cheaper to buy a new one than deal with the old one, yeah, that's a cancer you never recover from. This is my life. The one I chose. The one I fought so hard for.

For the pet owner (emphasis on owner for this is the only title that provides such privilege), the mere perception that I would ever question their intentions or motives can/has unleashed raw anger and threats of questioning your own compassionate humanity. On the flip side there are so many euthanasia's I have declined for fearing my thinly skinned heart could not bear witness, nor survivors remorse, from the act. I believe that for almost all of us veterinarians our internal parting words for excusing these acts, even when we cannot understand, nor agree with the motive(s), are; "if not us, who?" For within these requests there is always a pet, this piece of property, that will be/can be abandoned, tortured, hurt, or dropped to be surrendered at the shelter for the same request. If an owner wants it to be done, it will be done. Just as all property can be disposed of. No law, shame, or unjust reason will change this. So it happens, almost always, that these pets can leave by my hand with me telling them softly that they mattered and they are seen. I, in every goodbye, steal a moment for myself to say that they are everything that holds value and they are loved. I can at least always give them that. And then pardon myself in silent solidarity later. 

Euthanasia, in vetmed is the Medusa of intentions. I am the Master of my own acceptance that I am confident in my own intentions, I will never be everything to everyone. I have grown into an adult who rarely cares anymore if I am liked. I am not mute and I insist on this being married to my intentions.

This week brought us two families who tragically had to say goodbye to two pets within the same day, two days apart. When I admit that this has never happened before in my 18 years of practice I cannot believe it happened two days in a row. How is it that luck never translates to lottery tickets? I had been asked if I would do both dogs at the same visit? A way to condense the pain into a more efficient way to let one dog say goodbye to the other before we said goodbye to him? Thankfully we both agreed this would be too difficult on our hearts.

I have done double euthanasia's on two other occasions. Both were excruciating. After each I promised myself I wouldn't/couldn't do this again. The grief around these always leaves me reeling. I feel twisted in my intentions, and guilty in considering to deny it. How can I be a veterinarian who knows there needs to an end to a suffering we cannot avoid, and not feel a stab of feeling selfish within considering how to address and face this request. Euthanasia's however hard, can't ever be about me I reminded my inner gooey-yolk of a heart.

The first double euthanasia was two old black labs. They were 13 years old brothers, struggling to remain ambulatory. They had great difficulty getting up and walking more than a few steps without collapsing in pain. They lived on a sprawling, verdant bucolic farm and their quality of life was significantly impacted. The owner was not able to get one of them in the car, never mind two, so I agreed to come to the house. When I arrived they saw me approaching, and as if by some divine interventional miracle managed enough energy to get up from the front porch and run a half a mile in different directions. I followed the slower one to the west, sunset in my eyes, dragging my medical bag to the edge of the property to find him solo. I knew then that I had made a significant rookie mistake; coming alone, agreeing to do this in the first place and a massive miscalculation on time, ability to drag a deceased 80 pound dog back to the house and then repeat the process on the other. I too had not planned for how I was going to get them into my car. (Have we ever talked about the physics of dead weight being much heavier than alive? Someone has to have done a research paper on this?). The logistics, inability to walk so far, bring dogs back from so far and the emotional turmoil about how to make this horrible day less horrible for a pet parent who couldn't/wouldn't help me with this was traumatizing to all of us. Pets, all animals, all living beings, seem to sense goodbyes, and regardless of how warranted they are, they react. The reserve of adrenaline to preserve their life defies all diagnostics and prognostic indicators. The primitive call to get up and run even when you know you are no longer viable to evade allows bodies to defy biology and physiology. I can tell myself every moment of my professional, and personal life that I am here to relieve suffering, but yes, the desperate plea of those pitifully sad eyes looking at you as you send them away can hurt so bad you cannot find solace in the present, nor your intentions.

The second double pet euthanasia was a long time client who battled a many-years long breast cancer battle. When she went into remission after a year of treatment she bought herself a Corgi puppy. She had set that as her accomplishment prize and she wanted to be well enough to take on another Corgi. Her original Corgi was about 3 years old by now. Young enough for a sibling and sweet enough to allow one without bitterness or jealousy. She wanted to be sure she would be well enough to care for both of them. Almost 8 years passed and her battle reappeared and raged again. In a matter of a few short months she lost all of her body weight, her hair and her spicy wit. When she elected hospice her last wish was for her dogs to be with her in her casket. She made an appointment with me to ask me if I would be there for her in this request as I had been there with her in all of the rest of her pets lives. I struggled with this request so deeply and profoundly that it almost broke me. Truly, it was the single most wrenching thing to be asked. I was this woman's trusted veterinarian for almost 12 years. She valued my compassionate care for her dogs, and knew that I cared for her as I cared for them.  We had been a team for all that was our lives with her most beloved companions and she had one more request for me to assist her with. She wanted the four of us to be together to say goodbye to her dogs that she could no longer take care of. I spent hours almost begging her to see if we could find them a place to go together. She was convinced that they would be neglected, mistreated, or unable to build a new life without her. She wanted to be present at their departure and she wanted them to be with her as she was laid to rest. It was one of the most emotionally gutting moments. How do I put all of my love, attention and energy into one euthanasia and then within moments try to muster it all genuinely for the other? I had flashbacks of being at the county shelter where the pets would be lined up as if in a genocide to clear the cages. One, after another, after another, Void of the dignity that ending a life turned into out right killing should be made of. It was the longest, most brutal, most conflicting experience. A few months later their mom passed away at home from metastatic breast cancer, I hope they are all together on a couch feeling like their family of love has enough belly rubs and wiggle-butt endearments to make the after life as magnificent as we all hope it to be.

These last weeks I have averaged about 3 euthanasia's a day. We joke that euthanasia requests always uptick in the days before major holidays, (Thanksgiving for the win), with all of the family arriving and the incontinent pet being the main incentive. Or the days before Summer vacation departure when you cannot come to terms with the emotional trauma of leaving a sick pet in someone else's care, or the inner turmoil of cancelling the trip because you expected they wouldn't have lived this long when you booked it 6-8 months ago. Or the back to school chaos and the days that you have to go back to work, the kids will be away all day and the luxury of constant care via Summers timetable. 

Last week a very old, very poorly looking lab came calling for help. She could barely walk or lift her head. She was labored, exhausted and sporting a severely distended belly of fluid. Within a few minutes I had confirmed what my fears told me. She was bleeding internally and there were only two options and a stopwatch timer to decide them within. She was dying in front of us and we either needed to get her on the surgery table immediately or euthanasize her now before she died imminently.

The response is universally the same. A tidal wave of tears, and a few moments to talk amongst the family to decide. They decided to let her go but only after they called the kids to come say goodbye. What ensued was two girls under age 6 bawling and screaming in agonal grief. The girls insisted on being present, a decision I feel very strongly is not theirs to decide, and subsequent hatred toward the veterinarian who was "killing" their dog. I was yelled at, thrown fists at, and made to feel like the most horrible human on the planet, which to this day, and likely every day of their lives I will be referred to as. How else can they process their heart break? How would I have been any different at their age? Why do we have to let our little kids see things that aren't going to be anything other than devastatingly painful?

And why do my shoulders have to be so broad as my heart grows so hypertrophied, thin, big and bulging with the responsibility I cannot always accept as kind?

Why if I am so convinced about the inherent holiness of my intentions do my convictions question my motives?

Ok, I know this one was a tough one,, so for all of us who need a reminder.,,, Here are some photos of my week and why I still love being who I am and doing what I do,, and how often one bleeds its color into the other,,, my ombre life.

Seraphina,, my beloved cat waiting for me to get back in my desk chair.

Winnie takes a quick nap while waiting for more treats during her puppy visit.

One of my favorite faces,, this is Goose. He always makes me feel like being a veterinarian is the highest honor possible.

Josie getting ready to go home after her spay.

These two are my giggles in my day., This is Lydia and Grace holding our beloved Hamilton.
If a clinic has a soul it is the reflection of the people who make all we do possible

Penny,, and her worried face. Beagles are my favorite breed but the lack the badge of courage,, which they make up for in adorable-ness. She was here for a 2 second visit and a hug from her mom.

The most challenging internal medicine case of my career is crowned by this little one. This is Snickers.. the most loved pup you will ever find. 

I write about the life I live. Complicated, conflicted and full of purpose. For more please search a topic and see what 10 years of blogging and 18 years of practice yields.

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.