Death Of A Lobster

 

It's said that the lobster sitting in the pot as the water gets hotter around him doesn’t recognize his own imminent impending demise. The gradual boiling of the lifeblood giving rise to a peaceful slumber, pain free. Whilst the brown pincher-ed self screams as it meets the inferno being drowned in the cauldron boiling to his final crimson curtain. I, like most veterinarians, spend a disturbing amount of time obsessing, questioning, and seeking peaceful death. We are the worlds pre-eminent experts of dying peacefully. We have more experience than any other earth bound shepherds. You, me, all of us in the companion animal side of vet med get no dress rehearsals, no free pass, no second chances at the delivering death if we cannot make it pretty. It's really a twisted request when you think about it. A conversation I have had to have too many times. How to make this passing peaceful and welcomed. Truth is the body, any and all, do not want to surrender. We have to use inordinate amounts of seriously concentrated narcotics to trick the heart, lungs and mastermind of it all; brain, into letting their primitive and archaic, hard-wired and determined to preserve at all other costs self to take pause and trip up just long enough that it cannot restart or resume. Our organs are prehistorically programmed to keep on beating, breathing, and firing even under the most intense of insults. Death isn’t supposed to be quick, easy, or pretty, no matter how much you desire it to be. Accept that. It is what has kept you alive through all of the accidents, injuries, diseases and disasters a lifetime endures.

But let's get back to my lobster.

Does anyone plan for their blushing oblivion? What about the life we live in between the here and the thereafter? Surely lots of us veterinarians do. Right? I mean how else can we euthanize one, two, or even three or four patients a day and not get smacked in the face so repeatedly that we don’t start asking ourselves if we are living the life we chose, or just living the life outside of the cauldron.

This morning I stood in the shower long enough to turn my own fleshy peach Crayola exoskeleton into a blushing burnt umber. Winter is here and I remained frozen between the day I had to face and the numbness of turning the hot water a little at a time toward scalding. There is the ocean and the fire and chasm of indecision between the two. 

If you don’t know vet med in its own current state of matter it's a hellish inferno. A secret kept so dark that it is reduced to a statistic instead of a biography. That shower for me each morning is my threshold between the two worlds. The world I sit quietly and creatively trying to exist within and the black hole vortex of the clinic which I am both immensely proud of, inherently petrified for. Because of these I am unable to break free from it. It’s a glue trap of purpose wrapped in good intentions. It is as consuming as the soaking sauna that lobster marinates within. Unless you live it it is hard to fathom. We all love what we do and hate what it does to us. We all came here with such fierce conviction to become a veterinarian that it captured us within its hopeful dreaming. And yet we all wish for the day we are independently wealthy enough to walk away, bags packed, scalpels silent, and yet knowing as we look back from our recliners that the notches in our belts had meaning and value.

Today I leave my sanctuary home to drive into work to check in on Harper, the Dalmatian who arrived so down trodden I feared for her ability to survive another few days. The dog who was so charming she smiles. Her dad was a tough nut to crack. The lobster debating his own destiny. He was intent on managing this mysterious ailment, the one who had her not eating for 5 days, on a scrawny budget. I begged to run diagnostics. They came back over 24 hours, not the 1 hour his timeframe based on budgetary constraints was based upon. I had an ultrasound and xray telling me that her gut was at an all stop. She was 2 years old. She may need an emergency surgery if my guess was obstruction. That starts at about $800. I asked him to go to the ER for overnight care. He couldn’t afford that. I asked him if she could come back to us first thing the next day. He said he wasn’t going to be able to do that. I took a long pregnant dare-I-step-here pause,, and,,, these words came out of my mouth. “What do I have to do to try to save her life?” I had already offered a payment plan. When that was refused I offered to take care of her pro bono. That was refused too.

Why did I do all of this? It was that smile. That Harper grin that I had only known for a few hours, and this gut feeling that there was a mystery to solve and a patient I could save. That nagging, gnawing knowing that this patient was not to be let go back into the ocean.

We agreed to leave her overnight. She settled into her cage as I walked out the door at 9 pm. I was fairly certain she would look much the same 11 hours later  when I could start her on i.v. fluids and wait for her blood work to return from the lab.

The next morning the fluids ran. She perked up just a little bit. Her blood work arrived from the lab mid morning. And there it was,, my answer,, Addison's disease! Of course!

TREATABLE!! Wishes of little girls dreaming to be their own James Herriott take up the bugles!

I called to report that I was fairly certain I had her diagnosis. I gave him the budget for managing this under best case scenario. We agreed to try the injection for the treatment. I told him that if we were correct on our diagnosis she would look like her old self in the next few hours. He ok’d the $200 injection of DOCP.

He came to pick her up at the end of the day. When he came in to see her she smiled, wagged and bolted toward him. We all cried. We were all so grateful for two lobsters who wouldn’t let the tide carry us into the cauldron.

 This is a profession of emotional turmoil so intoxicating it can kill you. It is a minefield of emotional decay that breeds indifference for your own survival. There are lives in the balance at every 30 minute appointment slot. It is not for the meek, or the dreamers, or the lobsters with the rubber banded pinchers outstretched.

Its been 5 days. She is back to being her happy, energetic, adorably endearing self. I, well, I am out of the shower and headed back to the frying pan clinic. Another notch in my belt.

Harper

P.S. Harper is about 40 days into her Addison's disease and doing very well. Her story has a happy ending because there is courage, determination, and an emotional investment in everyone involved with her care. We are going to save her on a tight budget. Although it is never ideal, it is exactly what her case requires. We all come to the vet with a heartful of pain, burden and extenuating circumstances. Harpers family needs Harper and I am here to help. 

Leave Funds Available For Euthanasia. The things vets say to each other that would appall the pet parents they serve.

On a Facebook page for vets to assist other vets I saw this comment. It stopped me in my tracks. It also made me question where this profession is at, and, whether we want to change our collective persona. It was also another reminder that the veterinary world that I live and work in is a far cry from what others do. 

Storm in his holiday cheer

There are numerous Facebook groups dedicated to vets helping other vets with difficult cases, and, of course the clients that come along with them. It is our international social media network for vetmed advice. This particular post, like many of them, was about a perplexing case with a client who had limited resources, or as we like to coin it, "financial constraints" aka no money. Most of these cases have the typical presenting facts; dog, age, breed, spayed/neutered, pertinent history, along with presenting owner concerns, and, veterinarians physical exam findings. This particular case involved a cat who was having trouble breathing. Scant details about patients history, (and/or details the vet thought the client was withholding to look better; think marijuana, drugs, illegal ingestion or access to stuff), and therefore vet really only had that and their physical exam findings to go on. This is an all too common scenario. People show up with a very sick animal and little-to-no details about how, when, why, or even last time the pet saw a vet. Think; umm? don't know how long the pet has been like this? Don't know when, or if ever, it saw a vet? Don't know if they could have gotten into something (like weed or toxins)? Don't know when they last ate, or, went to the bathroom? Or any tiny tidbit of relevant helpful information to assist in this case. Turns out the vet thought the chest sounded too quiet, (indicating there might be fluid in the chest making breathing harder, and hence, breath sounds absent). When a client without any money for things like x-rays, or a chest tap (to try to remove the suffocating chest fluid) the patient has little help of getting help because the clients didn't have enough money to allow for the most basic of diagnostics. It happens with almost every case. We make do with little diagnostic dough on a daily basis. It is almost impossible for me to try to explain how hard practicing medicine is when you don't have the liberty to run tests.. like any tests. Even the most basic/cheap diagnostic tests. Try to analyze a sick, almost lifeless non-verbal being with just your eyes, ears, hands, and nose. We do it all day every day. We also get convinced to guess so much that it too often makes us believe that we are truly very good guessers. I dare say we are too often cocky with our presumptive diagnoses as there is no one to prove us wrong. The clairvoyant diagnostician with no data to ever prove us a charlatan.  

What was most shocking to me about this particular post wasn't that people weren't giving the advice I give my vets (which is listed below), but, worst of all that one vets advice was to; 

"not spend all of the clients money so that they could no longer afford euthanasia." 

I suppose I am deeply and ethically perplexed that this is valid advice. I also wonder how many of us veterinarians live here in this place where mercy only comes with a price tag? And, why would we want to? Aren't we being both neglectful and hypocritical if so? Aren't we both absent in our compassion towards our patients (and no, I did not say client,, because we all know that we love to punish them), but also hypocritical in our own advice of "it's neglect if people get a pet that they cannot afford?" Can we really be so cold and cruel to allow suffering if it doesn't make us money? Don't we dish that judgmental sputum daily? Blame the pet parents when their pet gets sick because they couldn't prevent the preventable? And then deny them a compassionate end when they run out if resources to permit it? Aren't we complicit in promoting negligence that perpetuates suffering because we do not offer affordable euthanasia's? I know of some places that charge $400-600 for euthanasia. (It is $125 here at my clinic). If you cannot afford it, AND, (big and here!) if we truly believe that it is in the pets best interest to be euthanized, should we then be doing it for free? Are we really reminding each other that we should spare the $600 to help save the pet so that we can euthanize them profitably? 

Holy Crap where has this profession gone?

I don't (and won't ever) add the cost of a euthanasia into the cost of a patients care. I also don't list it as a treatment option. It's an option, as it should be for every living being that suffers in dying, but lets not elevate it to a "treatment". It is not the last line item in the long list of charges for both goods and services that I feel the patient will need to get better. After all isn't that our primary goal? Getting patients better? Aren't we all collectively responsible for helping pets get and feel better? No veterinarian should withhold euthanasia due to cost. And yet it seems we do? I have never even considered adding/budgeting/listing this on an invoice when a patient is at the clinic asking for care. As if the tally of the 'total cost of care' needs to include this? Is euthanasia part of our "care" package? I am not arguing that it isn't, but, I am asking why we make room for this at the expense of doing what we all came here to do? Am I asking for too much room? Too much compassion? (Yes, probably). I am asking for a sliding scale of care. You know the kind that gives you a "freebie" euthanasia when financially warranted after a client has exhausted the meaningful list of possible curative treatment options. A rewards program of sorts so that we can care for pets by making them better versus incentivizing euthanasia. How many times do we send animals home to suffer while they die because we used up all of the funds beforehand? Doesn't that sound cruel? How can we preach being ethical and responsible and then send pets home suffering for our economic gain. Let one vet get charged with intentionally cruelty when they deny affordable euthanasia. Then maybe our collective conscious would outweigh our judgmental pragmatism. How sad that it might come to this?

Frippie, sock thief.

When veterinarians wonder why the state if the profession has come to this place where we can boast of our astronomical suicide rates, or, having made the worst return on investment possible by profession decision, or, the fallen trust status we used to boastfully proclaim, it is no wonder that we struggle and suffer to the degree we do. We created it. We are responsible for it, and now we wonder how to repair it? 

To my fellow veterinarians out there.. (whom I suspect will be pissed at me for my publicly stating this viewpoint) argue with me all you want.. and, then ask yourself whose side you are on? Who do you serve? If you said yourself, then ask yourself how she thinks that is compassionate care giving to be proud of.. ?

Zeba and Honeybrook waking up from surgery. Kept in kind oversight by Michele.

The following is the list, (long, short, detailed, and just silly I suppose) that I wish my mentor had given me before I started practicing vetmed. This profession is too reliant on learning hard lessons. Trial by fire, and thrown in to see if you can swim. For a profession too settled upon self doubt in the face of loads of guessing prognoses, not to mention our imposter syndrome frailties alongside the suicide factor it isn’t appropriate any longer. We can, and need, to do better.

Home at the end of a long adventure in the park.

The vet practice I bought has had a 17 year history of this sort of practice owner advice. My advice to the vets who follow. I keep the list growing. Accumulating pearls of practice to pay forward. A playbook for the other doctors and our staff. It consists of permission slips, warnings, and some basic ground rules as we all try to live within this landmine filled landscape full of wet noses, heartbeats and heartbreak trying to keep healthy the most important lives in other humans lives. We are just like them. Us, the veterinarians and staff, and them, our clients. We love our pets as the lifeblood to our souls in need of companionship, purpose and joy. It is imperative to always remember this.

My Frippie sleeping guard over our tree.

To the veterinarians and staff of Jarrettsville Vet, I ask you to ponder these;

I would like to start by saying one thing that I hope you hold true and tight to your heart. You have to be brave enough to be vulnerable and courageous enough to fail. Too many of us let our fear apprehend us. Too many lives slip away because of this. Jump in! Challenge yourself and be both proud and hungry for the next. Invest yourself into every patient every single time. Sometimes you will walk away with only that. And that is always enough. The rest is short loved transient and holds little value.

Likability matters. In medicine it is the single first influence to motivate your success. Smile. Engage. Offer more than you have to, and, more than the rest do. You can risk vulnerability but the reward more than makes up for the soft spot exposure.

The secret to the report card (the summary of the pets visit that we send home from every examination); it is the measure of your time with your patient. Let it reflect it accurately and definitively. People need a tangible piece of the experience. It is also the ticket to the next stop in many cases. Let it be the road map for where you came from, where you are and where to go next.

I summarize the report card as having the following key pieces in each;

• Summarize the exam findings. 
• Provide your presumptive diagnosis, or worst case scenario. State them both. It is our responsibility to hope for the best and prepare for the worst. This is life, both happen.
• List the diagnostics or measures to confirm this. i.e. “our next step is blood work, xray, u/s. Etc”
• Provide guidance as to what to do next, i.e. “if this, then that.” I tell every client what I expect and when I expect it by. I also leave a timeline. i.e. “if the coughing isn’t better in 48 hours call me. If the coughing leads to open mouth breathing, or is intractable, go immediately to the ER.”
• Give estimates for the suggestions you make. Use the support tools provided to generate this estimate. 
• Talk about payment options. We all too often just assume people have excessive disposal income. 
• Help people understand the journey. Be the guide and the sherpa.
• Lay out the plan but keep the focus on the needed steps to getting their pets quality of life back. I.e. do not exhaust resources so that treatment is out of reach. It sounds scary I know, but, if you think a pet is dying and needs surgical intervention, or, medication to survive and resources are tight, skip whatever diagnostics you have to to allow curative treatment to occur. 
• Never paint a picture you can't back up if the case ends up being the worst possible scenario. Being caught off guard, or, letting a pet suffer because you didn't educate the client in what to look for is negligence and makes us complicit in that patients suffering. 
• CYA every day and every interaction. We are dealing with disease. Potentially deadly diseases where many can be passed onto humans. We also have this sticky situation of having to protect the people around our patients. Dangerous dogs, feral cats, zoonotic vectors, and human limitations to the "ideal at home treatment" plans. 
• Always be honest. It's ok to apologize. It is always right to make it right. In some cases I just say that, “what do you think I need to do to make it right?” There is a drought of admission of responsibility in vet med. This too must change. We aren't fallible humans when we cannot be honest and culpable. 
• Pro bono is allowed. Anytime or place that you want to help a patient (or even client) for the sake of helping we will support you. Take a free radiograph to look for pulmonary edema vs a met lesion if it means you can sleep better at night. There is a serious mental health issue in vet med... don't let the few scant dollars it takes to help you feel better about what you are doing here preclude you from resting just a little easier at night. These cases follow us.. the dark shadow. The grim reaper at 2 am, is there a price for these? Yes, but don't let a few give-away diagnostics be the culprit. I promise that what you give away comes back 10 times over. You can tell the appreciative and needy from the rest. And to be honest there aren't many who will take advantage of you when they know that you are here because you care about their pet with them.

Here’s where we fail people. We don’t explain enough. Talk.. talk,, talk… but try to be clear and concise.

Two of the 52 cats we helped to save in our most recent pro bono endeavor.

• Take good care of the staff, they will return it in spades. You may be in that white coat at the head of the line but there is an Army behind you.
• Clean up after yourself. You look like a jerk if you are too good to get dirty, or, think that you are above it. 
• Ask for help. It is available everywhere. Us (the other vets), our broad network of specialists and referrals. (Hey, psst,, did you know that there is a whole enormous group of specialists out there that can give your vet free advice? So, if they tell you they don't know what's going on, or, need help figuring it out ask them if they asked for help from the vet team that supports them. i.e. referral lab, online specialists, Facebook groups. The vets who invest and care will utilize these for the benefit of their patients. If your vet isn't one of these move).
• Don’t send out a referral without a head up as to what they should expect once they get there. Most often this is the price tag, but, it might also include diagnostics which they might be unaware of. Explain as much as possible. Call for estimates, then tell them they are welcome to come back to us if the options from the specialists don't meet their needs. 

Clarke. One of the many faces that I find purpose in this cause.

• Everything is offered a referral. Everything. If they don’t trust us, if they are worried to "don't know what to do paralysis", or, if the molehill looks like it might have a mountain of ugly behind it, CYA and refer. I have a "three times I try and then I punt" rule. If I can't figure it out within three visits I punt to a specialist. Or, I at least strongly encourage/offer. Everyone's time is precious. Further (brace yourself) we are not always such impressive/perfect guessors.

I hope this list grows. I hope that others add to it. Maybe we can all learn from each other and we don’t need to trip so often to remind ourselves who we are or what we are capable of.

Most of all I hope that we remember how powerful the love of a pet in our lives is. That we hold it sacred and feel honored to be caring for each other and giving as much, if not more, than we receive with the spirit of our pets unconditional love to guide us and serve as the inspiration for us to follow.

Jennifer, the Office Manager and our beloved clinic cat Seraphina.
For more on Seraphina read her story here.

If you are a pet parent struggling I am here to help. You can find me at my veterinary clinic Jarrettsville Veterinary Center in Northern Maryland, or, for free pet advice meet me at Pawbly.com.

References;

What is the ROI of your college degree?

Professions With Highest Suicide Rates

How Much Does It Cost To Euthanize A Pet.

Being me... Who do I blame for my grief?

This is a blog written in response to a meeting I had with a group (I'll call them Joey's Group) getting lots of attention in both the private arena of veterinary medicine and the many veterinary groups where vets seek shelter from the too often cruel world we live in. Pet parents who feel their pets suffered at the hands of their veterinarians  are growing angry to the point of building support groups centered around their pets injustice. I contacted them to try to understand their feelings and thoughts as well as try to understand their advice on how to resolve the injustices they feel are occurring. I also feel that I align with their pain more often than the vet forums my profession has created. I love my pets like they are children. My life is devoted to them. Losing them is an unbearably painful experience. Trying to imagine how that grief would change when I believed my pets loss was due to malpractice would probably make that pain morph into anger fueled by seeking retribution just so they could hurt a little bit as much as I was. This group wants more accountability, more legal means to seek compensation, and license consequences much harder and easier to obtain than presently found in the veterinary leadership. These members are hurt, angry, and now organized and seeking vengeance. Here is my attempt to introduce the difficulty that being a practicing veterinarian in this climate presents. This blog is not to chose sides, it is to attempt to inform based on my life's experiences.  

Our annual vet clinic Pets With Santa photo

I love my pets more than anyone could imagine. I also know that when it comes to that time of losing them it can cripple you. I have felt as so many of us do; that no one can understand my grief, my loss, and that only I can feel my palpably paralyzing pain and suffering. What do we do when the grief is so consuming? We either fall into ourselves as the introvert and hole up with the hopelessness so it drowns us in despair that feels too suffocating to begin to contemplate addressing, or, we lash out. We use our anger to fuel the pain of the grief that we know we must do something about, but, don’t want to lay up all emotional over. Putting that grief to something that makes a difference, fuels a purpose that gives that life you miss so tragically meaning, well, that’s the harder, longer more arduous path.

I wish that I could tell you I consistently chose the last. Unfortunately, I am a mom who has tragically and utterly bereft with grief in losing my two beagles, and my dear diabetic cat who (almost) broke me. To make their death even more bitterly corrosive I feel that I can only blame myself for their passing. I am after all a veterinarian, shouldn’t I above all others be able to make miracles happen? Isn’t that the reason I went into vet school to begin with? I dedicated my life to them, my career, every tiny tidbit of my professional knowledge base just so that when the time came that I needed all of those tools, resources, pearls of knowledge, I could bestow all of it into some cumulative tsunami of healing re-genesis. My kids, my dear beagles, cats, (and yes, two potbellied pigs), were, and, should have lived forever because I have spent every moment of my life to make that so.

My Storm. Who saved who?
Rescued before minutes before euthanasia. He had just been surrendered to a NC shelter who was about to kill him as they all evacuated an impending hurricane.

Of course, life is that elusive magical thing that only insures one other thing; death. We are all going to die. That inescapable ending looms for all of us, even those of us who deny it. 

What do we all have in common? How do we start to understand why I react, or not, so differently than you? We all love our companions as our own family. We allow ourselves to be vulnerable. It destroys us when that leads to heart break. My dearest friend lost his mom and his dog within 4 months of each other. What hit him harder? His dog, he confessed. I just last week lost my mom after a swift devastating 6-month battle with breast cancer. I have also lost numerous dogs, cats, pigs, and although each one reduced me to a puddle of emotional waterfalls, but my moms’ passing lingers in a different way. I can’t even quantify one versus the other, but, where grieving fatigue burdened by responsibility pain struck me with the pets, I am angry-furious about her loss. It is a different kind of anger that I didn’t have with my pets. Why is that? Well, because in my mom’s case I wasn’t in charge of medical care. Her medical team (all 20 or so of them) smiled, held her hand and then went on their merry way to their next patient. They gave paltry advice in dribbles of meaningless drops, and in the end, they failed her a million times over. She died in pain because it was the only way to treat her relentless and excruciating pain effectively. Palliative care was an afterthought. I say that because for 5 months her biggest single request was help with paralyzing pain. Always too little too late. I blame them not for her cancer, but for her suffering. I have lived a life as a practitioner never exchanging one for the other. Palliative care is as much apart of every treatment package as antibiotics and vaccines. They are interwoven, interdependent and unwaveringly provided upon each other. Diagnostic tests, referrals, care in all forms and fashions ALWAYS comes with the patient’s comfort placed first and foremost. Her doctors wanted tests with answers before focusing on her pain. When asked what she desired most she would reply every single time with the same singular answer; "help with the pain." They got all of their tests, (which took forever as she suffered), and she was only pain free for the two weeks before her death. Furious, unethical, malpractice. She, and all patients, deserve better. So, you see I understand loss and grief, and yes, blame too. Where do I go with this? I make my decisions as a veterinarian with an open honest heart. I remember with each patient that my job is to serve them, my furried calling, (the puppies, kittens are the ones that break you). You see as veterinarians we have to serve multiple parties. Too often I have to make an immediate on the spot and under great duress choice about loyalties. In some cases these cannot always be to serve my clients, the people holding the leash as their motives are not as transparent. Human motives are complicated, sticky, and it makes me incredibly vulnerable to try to unravel theirs as I try to focus on unraveling my patient’s needs. Add to the burden of paying clients seeking care that is not always putting patient needs first, I also have to answer to public health threats and law mandated requirements. I truly have to decide who outranks whom. Do I put the patient first (my heart always does), the government public health requirements (ever worried about whether your life is in danger because you might have been bitten by a rabid animal? What about the four year old kid that was?), or, the client who is abusive and threatens you if you don't give them what they want? (Ever gone to court to get a restraining order on them because you really fear they will show up and unload an automatic weapon on the whole lot of us?).

I want to end my moms story with a few thoughts. I went with her to every appointment. I brought every concern to their attention. I asked my mom at every interaction “what her goals were?” I never, ever let them lose sight of her in their process. I have a very clear conscious about what my intervening on her behalf brought us. She is not me. I fight. She wanted to be comfortable. Do I wish I had mettled with her medication plan? Yes, I would have adjusted it every 3 days when it failed to deliver. I would have put my license in jeopardy as they were unwilling to do with theirs, (I suppose?). But she would have passed away sooner, which would have been my choice, it wasn’t hers. I have to forgive for the things I cannot change. I am working on it.

My pups. My life.

There is a bond we have with our pets that elevates them to children, best friends, companions we fear we cannot exist without. That’s what all we have in common, you, the pet parent, and me, the veterinarian. That love, devotion and companionship drives us to madness, feeling broken, shattered unable to go on without them. It is loss at its most intense and we try to replace that loss with suffering elsewhere. We try to blame. I live it, I know it, and I also know why I do it. But, I also know what it is like to live a life as a veterinarian who feels vulnerable because I am a human. I make mistakes, assumptions, and I am asked to be someone I am not too often. I am not everyone to every case. Human medicine is built upon referrals. Clear defined lines in the sand with boundaries. My mom was shuffled to the point of being a patient under numerous specialties; oncology, surgery, nephrology, general medicine, and even mental health. She was not my mom for those few minutes in their office that she waited weeks for, no, she a time slot and a quick visit, then shuffled to the next hat in the next specialty. All of that fractured care meant not one of her medical team was personally invested. That’s what veterinarians never hope to be, and yet, pressures dictate we must too often. 

My Fripp. The girl who reminded me I could forgive, move on, and love again.

Perhaps this all sounds foreign to you? Let me try to explain how different it is to be a veterinarian in a humans world. This is how your vet sees you and your companion in a time of medical need;

• Established client-doctor relationships. Does your vet, or this vet caring for your pet, know you? How can I if time hasn’t provided the luxury or history? I am incredibly blessed now to have been at my practice for 15 years. The first five were painfully rough. I wasn’t the vet they were used to. I wasn’t the old charismatic-charming-congenially and perpetually smiling guy they had know for over 3 decades. I was the newbie. Which pretty much equates to "worthless". Having the advantage of knowing your clients allows the assumptions (the deadliest part of this profession) to be a little more palatable. For example on an almost constant basis I know based on previous experience how each particular client values their pet(s). I adjust my internal and external patient plan based on this. 

• Value is influential. I suspect that based on knowing and being a part of Joey’s audience, it was the most influential factor. If your veterinarian had known what the value your companion brings to your life it would have, (might have?), changed everything? If your pet is your life tell your vet. Ask for "gold standard" of care. Make it public knowledge that your pets life is of paramount importance to you. You may assume that everyone feels this way about their pets. That everyone thinks the sun rises and sets on their whiskered wet nose, but, believe me they don’t. Here’s what you don’t know. Loads of people do not love their pet as much as you and I do, or, even a tiny fraction as much as you do. Or, they have struggles in their lives you cannot imagine, nor perhaps even relate to. If I know I cannot be the Jack-of-all-trades to every patient don’t I also know that I cannot be the vet to all people? Should my absolute requirement to keep my business alive, which is also the lifeline to my staff, influence who I am for them? Do I take on cases I know I want no part of? Can I afford to do that? Decades ago it was expected that every vet take on every case and you that you adapt to the clients needs and demands, and, you do it without judgement or personal reflection. The vet I bought my practice from was beloved. I had shoes impossible to fill. I was lucky enough to not need the same degree of financial stability most other new practice owners, and, new graduates, need. I got rid of (yes, harsh term but true), about 30% of his clients because trying to be who they needed me to be was going to kill me, or, at least bankrupt me emotionally to the point I would have to kill myself (in some degree) or walk away from the part of me I had worked forever to manifest. He was the vet to everyone regardless of what that meant to the patient. He had clients who wanted to euthanize because it was cheaper to "just buy a new one." And so he did that. I am not second guessing his decisions, I am merely saying I couldn't do what he did for the reasons he did them. He never lost a client, I never euthanize a treatable patient. There is the right vet for you out there. I wasn’t the right one for part of the population he called his own. Maybe it would be helpful for every client to know their vet as much as they love their pet before disaster strikes? Understanding a pet’s emergency warrants a referral to an emergency facility. Understanding that they don’t know you, or your companion warrants a willing ready and able compromise that you are going to pay twice as much at the ER as you will almost any other general veterinary practice. Being honest implies a degree of humility that all sides are arguing for more of. 

• Money decides almost every case. There is almost no pet insurance in this country. Humans can walk into any ER at any time with any condition and they must be treated. Not so in vet med. You walk in and you are expected to pay. I can tell you that most clients decide patient care (even for their most beloved companions) based on price point. If you have a price point you are obligated to state it up front. If you don’t have budgetary limits go to a referral hospital at every occasion that your pet is not acting perfectly normal. It may not seem intuitive but let’s use human medicine as the example. Asking your GP to see you when you are vomiting/diarrhea blood, or poorly responsive, or purple, labored breathing, weak, unstable, etc., is ludicrous. You know, at least I hope you know, that every single human medicine receptionist and answering service in the country starts with “if you are having a life-threatening emergency please hang up and go to the ER” statement. For all of the veterinary audience expecting human grade care go to the ER, not your vet, at the onset of an emergency. You will absolutely need immediate access to funds. These days you should expect an upfront deposit of, up to, and perhaps significantly more than, $5,000 available on credit cards or in cash. Do you have that if it is 2 am on a Sunday morning? The expectation that your companion is your life and we veterinarians are all about the money leaves us no place to move forward cohesively or productively. This is the dilemma vets face every single minute. Invested and devoted pet parents want the highest standard of care, but, they cannot, or too often, will not, pay for it. Try being everyone at every price point to strangers. It’s a landmine field of fear-based existence. It is one of the many reasons we have the suicide rate we do. 

• Blame the other guy. The best way to understand who is to blame is to accept that we are all party to the case at hand. The rest of the hurtful banter is fuel for litigation. Where most victims feel that they had no party in the disastrous consequences that unfolded I can say from experience that losing a pet is not always unavoidable, but, if all parties were respectful, kind, patient and willing to listen the outcomes don’t need to scar everyone indefinitely. Medicine costs money to access and provide. I often have clients come to me with an open admission of having “$50 only" for care. The exam at my clinic is $45. Can anyone really expect a treatment plan for $5? Yes, they indeed do. Where others would say it is impossible, I would add it is my ethical obligation to try. In all cases of a client with a pet in need every patient is seen. After that an open honest conversation is had. The truly compassionate people will listen. The others get angry. Here is how these real-life cases unfold. For $45 dollars I perform a thorough physical examination. I am obligated to give my honest assessment. I rarely know the diagnosis by an exam alone. I then offer my diagnostic plan and proposed treatment options. A list of all of these are made with the appropriate cost estimates for each. If everything needs to be declined we focus on the treatment options. If all else fails, i.e. we cannot find a friend to help financially, we construct the best plan possible based on the options at hand. I will write a script to be filled at a big box store, or, donate to the cause myself, or, use funds from our Good Samaritan Fund, or start a social media campaign (with permission of course), or even offer to have the pet surrendered if the cost of care and, or, follow up care is believed to be too great. What often happens? A client gets irate. I hear things like, “I am all about the money.” Which I clearly am not if I let them come in the door with only $50. Or, worst of all, “I would rather have him dead than with anyone else.” Well, doesn’t that let me know how invested you are in your companions life? Those are the people I know I cannot help. The anger will kill us all. It makes it hard for me to like what I do, hard for me to remember where my allegiances lie, and hard for me to find that common ground. Anger will be the death of medicine. Not malpractice, not mistakes, liability or standard of care. Anger. You cannot love and let anger rule. Think this isn't really true? Meet Mufasa. He is at my clinic now. More on him here.

• Mistakes happen. People aren’t prepared for the emergencies that present. (That is the clients fault, right?). They aren’t prepared to make on the spot hard decisions which have to be made because pets aren’t people and the ER cannot provide care without consent. (Which we should add would also influence your ability to euthanize when you feel "it's time"). My mom, well, I wish she had this option. Suffering is something that should only be saved for the human who elects it for themselves. We've already discussed how people are expected to know things they cannot know; like whether you love your pet above all things. Whether you can care for a sick, debilitated animal, and whether you will walk away from telling the vet “to do anything and everything possible” and not feel like your vet profited from your pets ending in suffering. Who makes these mistakes? Are they all based on assumptions with unrealistic expectations influencing a vet to offer any and all possible treatments, even if they think your pet is going to die anyway? There is a consequence to every action and decision. Isn’t it more honest to say that both parties are responsible for a pets care and eventual outcome. Vets love to use the line “if you cannot afford a pet you shouldn’t have one.” Or, “having a pet is a responsibility, not a right.” Both are so offensive they drive a wedge of hatred into our clients we ask to trust us. Both are so counterproductive to both sides we must abandon them.

• Resilience. Why are the vets so cold and callous? Well, because life, our ability to survive, and I use the tag line all the time, “we all have to get out of this alive,” depends on our own resilience. Try euthanizing a treatable puppy because its owner knows its cheaper to euthanize than treat, and that puppy has about a $50 value to them. What would you do? Let’s add the fact that if that owner tells you to euthanize you have two choices, euthanize and harden your heart so you don’t have nightmares for the rest of your life, or, say no, and imagine it being drowned in the bathtub at their home. Which by the way is legal, and/or at least almost impossible to prosecute. Most vets know the death at their hands is far more humane, so we do it. How do you feel about our life choices now? Oh, and for all of you delusional Polly-Annas out there, I always, (ALWAYS!) offer to take the pet myself. Want to know how many people take me up on that offer? Less than 20%. They are offended. That makes them feel like they are a shitty person. They would rather have a dead pet than feel responsible.

• Abilities. Do you know how hard, like impossible it is to be the Jack of all trades? How can you be the master of any while you are trying to wear all of them? This expectation is unrealistic. A good vet will try to dabble only to be able to recognize when it is time to refer to a specialist. Think there isn’t a can of worms with that? You would be wrong. Many clients will become irate at the mention of a referral. Why would I dare assume that they can afford that!? If I can’t fix it, then, it isn’t going to be fixed (thanks for the pressure). Or, (and this is the excuse I most commonly get) “Doc, I trust you. I don’t know them. I don’t want to bring Fluffy anywhere else.” To which I always reply, “thanks, but we are here to do what’s best for Fluffy. She will be better served by someone who only focuses on this particular ailment.” What I really want to say is, “you are setting us all up for disappointment, despair, and an unhappy ending.” I would guess that 75% of the time people won’t go to a referral. At least on the first visit and recommendation. I can get a client to go about 50% after the third request for a cardiology consult.. that’s usually three years later. Not the optimal time to intervene on a heart condition. And yet, still I am so grateful they finally are willing to go I would never elucidate that disappointment. Think a human GP would do a heart assessment on you because, well, ya know, you know her and it is so much more convenient to not have to make another appointment or waste a trip elsewhere. NOPE!

People are hard. Pets, the whole driving force that veterinarians chose to work harder, make less money and deal with grief that drives a suicide rate every single pet loving person should be compelled to act on behalf of, are easy. Pets will not give you a false sense of security. They won’t take their grief and use it against you. They won’t blame you for loving them, although they aren’t always understanding of i.v. catheter placements, nail trims, and restraint. They are pure live in the moment unconditional love. They are why clients, heck even ourselves go a little crazy on the grief scale bereavement.

After all that spilling my guts to you, ranting about how incredibly hard my job is, how I am routinely set up to fail, asked to do impossible things and then expected to be a whole, fulfilled person on top of that, where do I go now? I am brutally honest. I fess up. I make hard calls. I clearly know that I am in the profession I have always wanted to be in. I treat people fairly. I love unconditionally (patients absolutely, people I am trying). I do not judge. I assume everyone loves their pets as much as I love mine. If they don’t they need to find a vet that suits them. I say no, a lot, and I stand by it. I don’t do convenience euthanasia’s. I don’t turn away clients who need me. I am transparent, honest and accessible. (Want to see for yourself? Go to my YouTube channel, my blog KMDVM.blogspot.com, or Pawbly.com to see real-life cases with costs of care included.) I stand by my patients every  time they need me. I call the authorities on neglect cases, and I stick my neck out for pets every single time. It has cost me huge. I will walk away still liking how I am, even if others don’t.

What is my job now? 

• Forgive. I have to know that I always did the best I could. It was never able to be perfect, but perhaps the flaws remind me that it was real. I got to live it. The textures added the uniqueness and that was what made it recognizable to me as my own.

• Let go so I can love again. Jumping back into another companion has always been fraught with too much scrutiny to make it easy. The one truly amazing part of my profession is that the more I put myself out there to help the more disastrous cases I place myself in the path of, (the moth to the flame), the more lives I learn I could make a meaningful change to. Hiding as the introvert so my grief, fear, anxiety and depression wallow over me leaves me just there. I may not be able to see out of this place when I am in it, but, damn I hate only knowing that landscape. Go to a rescue, hug another pet just for the sake of feeling their warmth. Jump back in. you will never be ready so don’t wait for that stop on the road of life. Try. You may fail, but the real magic only happens in the risk taking of trying.

• Not forget the whole reason I came to this place. The joy my kids bring to my life and the perspective I have to chose are those that tell me my life still has purpose. If I allow myself to stray from who I came here to be, allow the pain and loss to define me how is that a memory worth preserving. Action is an admirable quality. Putting someone before you is unconditional love, and remembering that forgiveness is the peace gained from a life well lived if only how it brightened others is the real magic to a perfect love story that never lasted long enough no matter how you tried to preserve it.

To the vets out there still assuming, still wondering about the expectations of our clients we don’t know well enough to dare to guess, and to those of us struggling with not being perfect at every avenue of medicine, I want to remind us all that we know who we are. Why we came here. You have to get out of this alive. For me, that is doing more than I have to. Being braver than I think I can be. Jumping back in when the lunacies of life pop-up in front of you, and yes, helping every furried creature that crosses my path. I cannot save them all but I am damned sure never going to stop trying. I have to take only myself to my grave, I darn sure don’t want to spend eternity with her still being angry that I didn’t try, and still like and respect myself along that long road to my coffin.

Here’s my advice for Joeys members;

1. Interview your vet beforehand. Tell them who you are, how you feel about your pet and what you are willing to do for them. Put that in your pets (all of them) medical records.

2. Expect a bigger bill when an emergency strikes. Also expect to be sent to an ER. Be prepared for both of these and be grateful for both.

3. Go interview the ER. If you are unhappy with them interview others. Here’s a pearl; go to a veterinary teaching hospital at any and all times possible. They are exceptional in all areas of companion care. You will never get better service or a more reasonable fee. 

4. Avoid corporate veterinary care if you are financially restrained. They are, in general, less willing to work with clients who need help with cost of care. 

5. Have available credit for emergencies. They will happen so you should be prepared. 

6. Ask to record every moment of every conversation with the vet (write down their name(s) and vet staff (names). If they are recording you, which most are, then you should be granted the same. If they decline write every word of every conversation down. Leave a copy with them as you leave. Paper trails matter more than any other piece of legal fodder. Sign the copy of the account and make a copy for them in their presence. If they deny a copy make a note. 

7. Ask for a copy of the medical record upon your departure from the clinic. If they do not have it ready ask them how long it will take? Tell them you are making a note of their response and return on the day and time they say it will be ready. If they decline make a note ask them if they would like a copy of your notes? Sign and date with time. (note longer than two days is unacceptable by most board standards, unless the patient is still present for care).

8. Never leave your pet behind if you don’t feel confident about it. Stay at the hospital. Tell them you are staying. Be a pest. Not rude, but your pet, like my mom was, is your responsibility. 

9. If you aren’t comfortable there move to another place. I am not the vet for everyone, I don’t even want to try to be. Its ok to admit that.

10. Have a follow up plan for each visit. If they aren’t telling you what to watch out for, and what to do about it, then you don’t have a follow up plan. Ask for it is writing. Every vet, like every descent doctor, has you leaving with a written plan. Accountability only follows reputability. 

11. For the crowd holding torches remember the anger and threats breed more of the same. Transparency is two-way, honesty is the same. I know that vet med lacks transparency. It is our greatest fatal flaw. It sets us up for unrealistic expectations. Lacking honesty is a grave sucker. No one goes through life happily if they aren’t honest. You cannot demand others have ethics or honesty. So, we are left only to be the example.

Want to know how is the center of every decision, action, and motive I have? Here it is.

Who are you here to be? And whose hand of loyalty do you hold? For veterinarians these are too often a difficult questions to answer.

If you would like to know more about my side of the exam table please find me at the following;

Pawbly.com. It is a place for all pet people to exchange information to benefit pets worldwide. It is free to use. We are always looking for credible, reputable pet care experts to offer advice, and we welcome people posting their pets stories so that others may benefit from them.

My blog can be found at KMDVM.blogspot.com. It is called “Real-Life of a Veterinarian” and that’s exactly what it is.

YouTube is Krista Magnifico, DVM. Meet my real cases and my real-life responses.

For everyone struggling you are not alone, your pets are never forgotten. Be well and I wish you peace. 

I’m wishing the same for myself. 

The Problem In Veterinary Medicine Exists In ONE Place, While The Answer Resides Everywhere.

The problem is the divide.

The divide can exist in education and intellect, a matter of resources, privileges and perspective. Or, it can exist in accessibility and willingness to assist.

Vet medicine is drifting to many of these divisions as the infrastructure for our services becomes more coldly organized, corporatized, and managed. Somewhere not too long ago we veterinarians needed help to become increasingly solvent in our business, (or lack there of), decisions. We were a profession of talented 'make-do' surgeons and 'Jack-of-all trades' practitioners and never the pencil pusher accountants everyone told us we should/needed to be. We lacked the business-infused intellect to help us grow out of our fledgling single owner practices into the shiny-gleaming white marbled fish tanked towers of our vision of what "successful" looked like. We were valuable, but, we just weren't bragging rights "profitable." Things changed. We surrendered the management of our practices to the suits to make easier money with less hard feelings and started to sacrifice those who we knew couldn't afford us to pay off our loans and increase our standards of care. The divide began.

Veterinary medicine is a profession built on trust. We are too poorly regulated and overseen to be anything else. The trust is never going to be present in any sort of guiding magnitude if it is built consistently and singularly on financial gain. They are inherently polar opposites. As the desire/need/cost increases and the inability to meet them rises, the trust decreases. It is the nature of humanities basis being neglected intentionally for profit.

There are endless days I spend stuck in the dilemma of "unmet need" meets "unwilling ability." It is what the experts would call 'ethical dilemmas' and trying to carry the weight of the increasingly indifferent world on your shoulders. I get asked, advised, and notified on a daily basis about the dangers of this predicament and my unwillingness to not walk away from them. Desperation breeds innovation and/or despair. I am stuck here trying to solve this great divide and looking into the desperate AND treatable eyes of the forgotten/unprofitable as I do so.

Me and Dimples.
Rescued by me from the local shelter, heartworm positive and a pit bull.
Needs love, care, and someone to vouch for her deserving a second chance.
She is one of the many faces we dispose of too easily.
She is one of the many reasons we lose our souls when we make excuses to forget these lives matter.

Every single day I am asked to provide some veterinary need or service to a client who has been turned away elsewhere. It is the second opinion for affordable options that someone else can provide but won't, usually because of inability to meet a standard of care that makes the cost inaccessible (or so they say?). Every day I am asked to help. Everyday I am faced with unwillingness and unmet need. Too often at life threatening crisis status state. The degree of unmet need is overwhelming. The depth of emotional ties that people have to their pets is also undeniable.

People LOVE their pets. Why are we ALL not starting here? Why are we starting at "ability to pay" as the measure of acceptable pet parent worth?

Henry. The face of cerebellar hypoplasia.
His devoted mom is fighting to bring awareness and compassion to these kittens.

When did the veterinary medicine goal become anything else other than providing assistance to save lives? Can't we all agree on this being the seat of the veterinarians soul?

I often feel stuck, tortured, and tormented by need versus ability and this great divide. I know I am not alone. There are others out there who love and care for pets, animals, and feel burdened and compelled to help them. We are being pulled emotionally, physically and ethically as the rest push them away.

Jasmine, our second PB heartworm positive rescue.
Both looking for a home and a sponsor.

The divide is also polarizing the ends of the spectrum. Caught in the middle are those of us, (overwhelmingly women, does anyone ask why this is?), who feel alone, abandoned and asking themselves where to go? We have to chose a side. Too often this act of inner reflection feels as if it will cost us our livelihood, or, our community. Too often we instead chose to give up on ourselves as we cannot chose.

Innovation is the child of conflict and this divide is ripe, ready, and in desperate need for disruption.

What if we fractured the system so significantly it forced the current managed systems to meet the pleas of the divide instead of growing it? What if the part of the equation that limits public social assistance is the key to the answer of the problem? What if we leveraged the worst part of the animal care equation to be the tipping point for revolutionary change?

Luna

What if obsession to solve a problem allows innovation that pushes boundaries, redefines public access, and empowers the person as a being and not a "thing"? They are all related. They are all the keys to the problem and the keys to the solution.

Luna, shelter rescue, learning to trust again even after humans have failed her.

Radical change is coming. The forces, the polarity, and the divide will collide and the demand, the integrity and the ultimate survival will become mandatory as it becomes transparent. The meek will inherit the destiny that compassion and trust inhabit. It is where this profession came from, and it is the place we will go back to. Less death lives there.

Related blogs;

Find What Breaks Your Heart and Change It.

Gratitude; The Grace That Hardship Brings. 

Mobbing and Lobbying, The Backlash to the Video Rant.

Ethical Fatigue and the Crossroad of Vet Med and the Public Conscious Awakening

Affordable Options Are Everyone's Right.

More information on me, my YouTube channel, my company Pawbly.com, and my vet clinic Jarrettsville Veterinary Center, and my clinics Facebook page, are all available to you and your pets needs anytime. Almost all of this is FREE! We are an Army of activists set on saving lives, our own included. Join us. You are all welcome and all pets are loved here.