COVID's prisoners. Dying in the age of a pandemic. My moms story.

Vacuuming ants off the table. It’s what I do now. Daily, let me add. They are there not because of the flowers I cut for her yesterday, (as she chooses to believe), but, because there is always food on the table, or, around the table, or, under the table, (found a half an orange there yesterday, desiccated and chewed clear of its pulp). Food lies in small unbitten nibbles everywhere around her make shift hospital bed. All have been placed there sporadically, sprinkled throughout the day. There for encouragement. Should the fancy strike her. Which these days it rarely does. The ants keep her honest at least.

The hyporexic is my mom. She has stage 4 metastatic breast cancer. She needs a lot of help these days. The whole COVID crap has made dying a much lonelier event than anticipated. I have become the nurse and the house cleaner. My dad and my husband are the only others on her visitation list. It’s a small tight group. We all know too much about each other. It leads to fighting most of the time.

Hence, I vacuum. Or bide my oversight time cleaning, often.

Like all things in these days nothing is easy. To get to the vacuum I had to beat back the dust around and within the broom closet. To get it to turn on it had to unbury it from the cobwebs that quarantined it. To get to that I had to uncover the post Katrina WHO deposit of stacked bottled water that could serve Flint for the remainder of the year. This is the broom closet of a husband who never had to do housework before his wife fell ill, and, the paranoid couple who refuse to drink tap water after moving from a farm with well water. Trying to convince them that there is at least some oversight on the town water supply versus the farm well that I once saw a dead ground hog floating in is like yelling at the tornado to stop at your doorstep’s threshold. There is a mole hills mountain of poetic justice and politically driven pardons sitting here at my feet these days. I too often have to find the comic relief in the utter aging madness I have fallen into.

Quarantined with a dying person inside their house is a never-ending loop of t.v., feedings, medications, questions about if its ‘time again?” for medications, and self-checking her vital signs. The t.v. is tuned to CNN non-stop. It is her way she will tell you, of “still being a part of the world.” To which I remind her that that’s going to shit too. Maybe don’t turn there for joining society and being a part of the whole we left soo many weeks ago.

At her house I clean, like a mad person. It's my ADD that I cannot apply to CNN and the myriad of measured pills in their clock driven doses. Providing some degree of order, civility and modicum of acceptance that the world will go on around me is placed in sanitizing swipes at cobwebs too distant for her to see never the less attempt to reach.

Food is a battle. Like all aspects of her life now. She’s is wasting away. She is so thin and weak she can no longer stand without metallic wrap around support and hand grips. Shuffling from across the room to the small bathroom she exists between. My mom wants endless hours of all-day small talk. The escape she yearns for outside of the destruction her body is catabolizing. I am not a chatterer. I never have been, and asking me to figure that out for the last inning of the last game is too hard to go back to parochial school for. There is no room for normalcy here. I cannot seem to embed it in the cleaning to provide relief to the endless news cycles. And yet I continue to clean. Keep moving. Try to be productive and helpful as I uncover artifacts from a once functional home. Small items cause major melt downs. A half-eaten pie sitting useless in the fridge is a day long discussion on appropriate resolution. Obsessing on triviality and the time consumption it fills the day with is the reality of four people in too close proximity for too long already and no end in sight.

My mom's painting of Lilly.

“I cannot always be just as you want me to be.” I know it is not what she wants to hear. She wants me to be like the rest of her cheering squad. Professing love, sending her peace and Gods warm embrace. Telling her ‘this too shall pass’ and reminding her of all the beauty that surrounds her. The blissful passivity to all things holy and predetermined. The baking squad sitting on the bench proud to be sitting this one out. Gleeful to let the uniformed players who actually showed up for practice and have a discipline to put the blood sweat and tears in. I am not one of them. I don’t even know if I could become one? A spectator in her last hurrah.

This is the horrible place I am right now. Standing at the intersection of letting go and surrendering the hope I felt I would never unclench. She has stopped trying. I am not sure if it is all exhaustion that caused her to surrender her hope, or, the pain that her fear gave up. But all are gone.

Today was the day I decided I had to come to terms with goodbye being only a few moments away. For as much as we are so similar, my mother and I, I am most assuredly the human of voicing and reasoning while she is the soul of submission and omission. She won’t ever tell you what is right at the tip of her tongue. She will never confess. She will never say she is dying. She won’t give that up. She will only remind you with her every single action that she checked out a long while ago. I can look back now and know exactly when that happened. We were all sitting around her hospital bed when the doctor came in to visit, one week into her hospitalization to manage pain trip, to break the bone scan findings to her. “It is bad…. (long,,,, long pause…..)…. Really bad. She has cancer everywhere.” Yes, these were his exact words. She swallowed the words slowly and lowered her pale worn face and gave up. She had her pass to never doing anything again that she didn’t want to and she has ridden that pony into where we are today.

Cait

That discussion and discovery was over two months ago. At that time it had been over two months since her biopsy came back as cancerous. We now knew she had advanced metastic cancer in all of her bones which no longer allowed her to be candidate for chemo or radiation. They gave up on her as being too late, and she gave up on them as offering too little. She left to go home to try to come to terms with the cards dealt.

Today we are at her monthly oncology check-up. She was wheeled in, after being carried from her home to my car. COVID screening threw a new twist onto today's visit. We were met at a distance by greeting staff to check our temperature with a forehead thermal scan and provided and required to don a mask and gloves and asked a series of questions to try to insure we were not infected, or around anyone who was. Even the hospital is afraid.

4/14/2020, UPMC oncology

Two floors up we were met by the oncology nurses. Check in includes the cursory checklist on the clip board. They took her blood pressure and temp again. We collectively lifted her on to the scale and waited. As a veterinarian the scale is one of the most important diagnostic tools I rely upon. It doesn’t lie and it reveals a wealth of clues if you have been diligent in recording it. When the digital screen came to its stand still even the nurse wouldn’t say the value aloud. It was another long pause in a diagnosis of too many already. She recorded it and moved on. The scale read 76. As in 76 pounds. She is 74 years old. We started this collision course in December of 2019. Five months ago at 106 pounds.

I saw the blue numbers flash, swallowed my silence and gave up. Today I have lost hope for her. That hope for her chance to ever function again in the capacity that I have known her has passed.

It has been months of days that were up for as many times as they were down. She is painful, almost uncontrollably painful. She is on higher doses of opioids than I ever thought were humanly possible, especially for the fact that she barely ever hit a hundred pounds in her whole lifetime. She is not, as her oncologist put it today, “opioid naïve.” I was almost proud of her. It might be the first time she has ever surprised me with a title she didn’t earn from years of perfecting a skill. She is an amazing artist. She has always been an incredibly talented artist. She can sketch, paint, imagine any beauty into a canvas. Her work is all around us. At the vet clinic. Every room of my house, but a hard-core opioid aficionado I never saw destined for her resume. Today she was classified as becoming immune to their affects. Her body was acclimating to them. Starting to blow them off as inferior, paltry, innocuous. Today we carried her out of the house. Wheel chaired her into the hospital. Pushed her in a wheel chair into every room, every exam, and every treatment. She is a skeleton you can push without effort and pick up without exertion. She is bones and an oxygen pump spewing little hiccup-coughs into her nose. Her lifeline to failing lungs. She will need more drugs, at higher doses to get the pain at bay this time. Higher doses, shorter time frequencies and more side effects because of them. They will take away her pain as the collaterally steal her gut function, cognition, and conscious time.

4/3/20

There is nothing left for her to give up. There is only one last designation left to be made. No one wants to call it, although everyone mentions it. Hospice is all that is left for her. We can discuss a 24/7 assisted living home. A place that can help her with the things she can no longer do by herself. Bathe, prepare food, get water, manage stairs to get to her kitchen, her shower, or her bathroom. She is here. She won’t face it. She needs more than her family can give her. Once she lies down and cannot get up, which is likely at 75 pounds, that is the only option next to hospice. We got here so fast I cannot masticate the bitterness and the toughness of it. But the care facilities are all COVID magnets now. Sending her there surely leaves her a defenseless victim to this? Which is worse? I don’t even know?

my moms Easter canvas circa 2015

My dad is seemingly un-phased by the whole thing. The unraveling and the diminished ambulatory, unhappy being she is now. He is short tempered, over-burdened, and oblivious. I don’t know if this is a self-protective measure of avoidance? He goes through the motions and yet he doesn’t see the changes within her. “Hey, have you seen that bump on her back?” he announced yesterday.

“It’s her shoulder blade.” She is misshapen, misaligned due to a lifetime of scoliosis and the aging of osteoporosis. Her spine is “S” shaped and her shoulder has always been left elevated and prominent. She now lacks the 30 pounds to hide it.

The vacuuming leads to laundry. The monotony of never-ending laundry. Put in the dirty, smelly old people funk, and, POOF! Out it comes anew. Refreshed.

“Mom, we have to figure this out?” I implore her. I don’t think she cares to entertain my burdened inquisitive agenda. I think I am just speaking out loud. I think I am being my own therapist. She already has her plan laid out. The analytical doctor used to non-speaking patients hiding their illnesses and masking their diseases is who I am at my best. She is another patient puzzle to solve. I can solve this. It’s a cancer patient like so many I have had before.

D.C.

And yet, we haven’t figured her shit out. Not her treatments, not her desires, not her abilities, Nothing. That’s the truth. She won’t even talk about end of life stuff and I can’t let go of that. Doesn’t everyone plan? The finality exists only for me. I cannot ask her to apply any sense of wishes to an end that looms in front of us both. Her agenda is maximizing time into flowery closing scene experiences.

Ambrose

I’m venting now. I would do it aloud to try to mitigate my cortisol level, but I have to do it silently and furtively. The walker lurks too nearby to allow a release in the open forum of the room we are both imprisoned within.

No, I didn’t dissolution myself to believe this would be easy. But dying under house arrest in a pandemic that seems extra cruel. There is no way out. I could try my dads’ approach, be so caustic the best recourse is silence, and then do whatever I wanted to anyway, but then she would be completely alone. And she’s still dying without any chance of a better tomorrow so I type in hard puncture wound passes.

Easter box painting 4/3/20

There are days that are bad. Days so painfully long and full of so much demanding angst that I want this to end. Days that are full of meaningless errands. Answering a barrage of demands for things I cannot find sense in. Like removing Christmas decorations in April. Always with the same preamble “can you just do me one more favor…?” The red bow on the mantle. It should have gone weeks ago. It drives her crazy, which then in turn, of course, drives me crazy too. I have a home I haven’t vacuumed, cleaned, done laundry in in weeks, and I’m at her house cleaning it.

There is a disconnect between her preferences and her immediate, vital needs. The clock is ticking.

Yesterday was a bad day. The second in as many. It was a day full of moaning, crying, and pleading for the only relief I can give her, short of drug advice, companionship. She is alone too much. The loneliness causes anxiety which manifests into sleepless nights and further exacerbates her fear of pain and loneliness.

She is afraid to fall asleep for fear of not waking up. We should all be so lucky to die so peacefully. Me, I don’t want to wake up in the morning. Find some quiet place to bury my head under the bedclothes, a mummy wrapped for the long voyage to the underworld. She cannot find peace while awake. Her pain refuses to relent, and yet she cannot find salvation in sleep. It is a never ending roller coaster of unfair and unyielding.

It took her 30 minutes to muster the courage to sit up. Shaking, eyes closed, willing herself into moving the tiny rigid structure that used to house her options of freedom and choosing. She is now a prisoner to a broken body breaking down without any reconstructive abilities.

She is melting into nothingness. Evaporating, decaying, just crumbling. She cannot stand up straight. Cannot sit in a chair and face her dinner plate without being bent over and buckled into her own lap.

Oxygen is a commodity she obsesses over. She is hooked into a clear tubing pushing her lungs to accept what they can no longer obtain independently. She has multiple redundant units and miles of spare tubing. She checks her own oxygen levels hourly, half-hourly, obsessively. It is a race she wants to beat herself at. I have decided asking, inquiring about her obsessions merely feeds the monster that dictates them. The questions are met with anxiety ridden hostility. She has no patience for reason any longer. I try to talk about what she does with the information she collects. The nurses regimen of monitoring her own stats? This is another battle with no end point suitable to perpetuate the understanding of her data.

“Is 99 degrees too high?” She wants to be ready to alert the front line should she fall victim to COVID. It's part of her vitals monitoring ritual.

“Do you know what a normal body temperature is?” I ask.

“No,”

“Then you’re fine. Don’t worry.

We spent months trying to identify the source of her pain while we also tried to get it under control. We are back at square one. She has returned to that place where everything is impossible. Moving is too painful to do. We are here this time with 5 medications, three of them opioids, and drugs to chase the side effects of the drugs. “It wasn’t any fun there the first time around. Was it?” She nodded with a dejection of reluctant silent admission. We can’t go back there. Back to that place without answers, suffering met but a struggle to plea for anyone listen, hoping without precedence that one person will stop their busy over burdened life and actually hold her hand and invest their talents, dare even themselves, into her cause. There is an impressive amount of competence and excellence in her doctors, but,, there isn’t much in the way of genuine heart break for her plight. Maybe they have seen too many before her? Made themselves into little fortresses of medical indifference? A short dismissive hello, here’s what we can offer, a keep in touch, and a farewell to another time. The only thing left is to increase the doses of everything. Add an anti-depressant to help her sleep. Make the fear of not waking up a thing forgotten. Sedate her. Medicate and sedate is all that is left. What will that cost her I wonder? It will cost her everything she has left. And she will willingly surrender it. Pain is unacceptable. Pain and fear is her deaths last demand. We gave in to it as I surrendered hope today for anything else.

I can tell you a few things about this journey. I didn’t expect it to be easy. I knew it would be grueling, but I had no idea how alone we would both feel within it. Helpless, well, I haven’t accepted that one yet. We both have some coming to terms with the cards life has dealt us.

For more on my moms journey see the previous blogs here;

Silver Linings Of COVID-19.

The Journey. Missed Pit Stops and The Pile Of Regret Souvenirs.

For more information on me, my vet clinic Jarrettsville Veterinary Center in Jarrettsville MD, or for our Facebook page, or, free pet care help please go to Pawbly.com.

Me and my girl Seraphina, COVID 19 PPE prepared.

Thank you to all of my dear friends and family for helping me through this. I sincerely appreciate everyone's support.

krista

Linear Foreign String Body In A Cat. What happens when your cat swallows a piece of string and it gets stuck in their intestines.

This is Bella. She is a 3 year old indoor only long haired spayed cat. She was brought to the local ER about 1 week before I saw her. At that time she had not been eating for about 1 week and had been vomiting.

At the ER she was given an examination. They found a string stuck under her tongue. In vet med, especially with cats, checking under the tongue is a super important place to look for the culprit of a sick cat of unknown origin. All ER vets know this, and, I hope every other vet, and cat parent also knows this now. If your cat isn't eating get a really (really!!, and not always easy to do) good look under their tongue. About once in every 500 cats (my guess) we find the problem hiding here. The biggest fear we have with cats and linear foreign bodies, (like a piece of string or ribbon), is that the start playing with it and the little barbs on their tongues that allow them to be such successful groomers,  causes them to start swallowing the string. It is not uncommon for the linear foreign body to get stuck under their tongue as the esophagus keeps trying to swallow.

The ER vets advice was to run some blood work, take an x-ray and possibly even do an exploratory surgery to see if the string was able to be removed and how much damage it had done to her internally. It was a good and thorough plan, but it was also an expensive plan. Bellas parents could not afford any of this. The emergency exploratory surgery that was recommended included an estimate of $1500 to $4000 plus. Without any funds to do any of the recommended services the only thing anyone could do was cut the string under the tongue, which would at least relieve it from further cutting into and strangulating the tongue, and, hope (really, really hoping here) that if it was freed it would pass through the gi tract on its own.

Can you tell that she is in pain? Cats hide it very well.

So, that's what was done. Bella went home.

A week after the ER visit she came to see me.

She was laying on her side, very reluctant to move, and very painful. I took an x-ray and saw the classic "string of pearls" plication pattern. Plication is the gathering  of the intestines when something inside of it is pulling it together which is an indication that there is intestinal bunching.

After I saw Bellas x-ray, how painful she was when I touched her abdomen, and how sweet she was even though I knew she was beyond miserable, I just felt compelled to help her. Her mom told me that she had recently been homeless and that Bella had been the reason she got through all of the rough spots her life had recently given her. "Bella was everything, and, she just didn't know what she would do without her?" I understood exactly what she meant. I had been in just her shoes many years ago, before I went to vet school. It wasn't just Bella who spoke to me, who moved me to take pause and want to help, it was her mom too. They both needed me, and, I was pretty sure I could help. I could at least help to see what was going on inside. Whether I was too late to save Bella had yet to be determined, but, I knew that if I didn't help Bella she would die.

I told Bellas mom I thought that it would be best if she left Bella with us at the clinic. It was a Sunday,, and although we weren't going to be at the clinic late that day Bella needed fluids, antibiotics and pain medications. I also wanted her to be with us first thing in the morning on Monday so I could get her started on all the things she would need the day of her surgery.

I can't explain it to those who don't understand. I have almost given up trying. I knew that I could help Bella and I wanted to try. When I talk about finding and living your purpose I am talking about cases like Bellas. She is the reason I went to vet school. She is also the reason I still love being a vet. I can help her, it won't cost me a fortune to do so, and if I don't no one else is likely to intervene. Some people would think me unlucky to have cases like this. I think just the opposite. I think I learn my value here.

I told Bella's mom that I would keep her in the clinic overnight to do surgery the next day. She needed fluids, antibiotics and pain medication immediately.

The is what "bunched up" plication of the intestines looks like.

This is the string that I could see tearing its way through the intestines. It popped and poked out of about a hundred places along the whole intestines.

I spent about an hour gently removing the string from her very unhappy intestines. It was a slow, tedious process. Although we never want to see anything tearing through any organ, especially the intestines, it was actually fairly easy to remove the string. It had been in there long enough that where it was lodged it was cutting through. The holes it was making as it lanced its way through were pinpoint sized. Too small to suture. And there were far too many to even try to close. The point of the needle was going to do just as much damage as the thread had, and make her even more susceptible to leaking fluid that was supposed to stay inside her muscular tube of intestines into her open abdomen which will lead to sepsis, and probable death. 

The string ran the  entire length of her intestines. At the top of the intestines is the stomach. The stomach is a big pouch. Stuff only gets stuck here if it cannot be dissolved or digested in the acidic juices it produces, or if it wedges at the outlet, called the pylorus. In the top section of the intestines I grabbed the first place the string was tearing through. Very gently I pulled it out of the  stomach. Having one end is helpful. But, having it running through the whole rest of the gut was not. I could see and feel it running all the way down to the colon. It literally ran the whole gut. Not good!

I carefully pulled it out all the way down to (almost) the colon. We never, ever want to open the colon. So, I did what we all (vets) have done about a ba-zillion times. We glove up and go rectal fishing. I actually employed my smallest fingered person to help. As I tried to push the tiny amount of poop I could feel in the colon to her awaiting inside the rectum finger I hoped she could find the other end and then I could cut my end as she pulled it out. 

After a few minutes and a few fecal balls we had no luck. I cut the string as close to the large intestine as I could. I expected that there was only a few inches outside of the colon that had to advance and she would easily pass the rest. It was a little leap of faith, but, based on everything we had going against us I was hopeful.

I said a little prayer to her red, angry, yet peristalsis moving intestines. Peristalsis means the muscular tube is moving, and therefore still functional and the best indication it can recover that there is.

I carefully replaced all of her intestines back in her abdominal cavity and started to close her up.

As a veterinarian this is the place we all stop, breathe and hope. There is nothing more I can do.

There were still things to worry about. Because she is such a small cat and she has been unable to eat for so long and it had been so long with the string in her, she wasn't the best candidate for surgery. I had also spent a long period of time trying to remove the string with her whole belly open. This causes severe hypothermia pretty fast.. I know had to worry if she was going to wake up.

She came off the table at 95 degrees. Normal is about 101F. She had to warm up. We cuddled her in a big wrapped burrito blanket and heating pads. The techs stayed with her for about an hour. Pain meds were given and she actually looked happier from the moment she opened her eyes, despite the incision on her belly that ran sternum to pubis. She was awake and she was relieved of the excruciating pain I cannot even imagine how horrible it was. Veterinarians take an oath for this. How many of us forget pain is part of suffering? Relieving pain requires relieving the cause.

Here is her culprit. The string measured about 16 inches long.

Here she is the next day. Can you see the difference in her from day one? She is laying on her side. Stretched out and looking for attention. A different pose than curled up in the back of her cage and not wanting to engage, or say hello. She is inherently a social calm girl, but guarded, hiding, retreating and reluctant to move are all key signs that there is a problem.. Her parents saw not eating, I saw misery. It's why we ask all pet parents to call us the moment your pet isn't acting normally.

Here is her abdominal incision a few days later.

If anyone ever has the chance to give back, for just the simple pleasure of seeing a smiling face of gratitude back, take it. Paychecks come and go,, gratitude and all the joy it brigs last far longer.

I am sure people will think I am crazy for this, but, I donated my time for her. I felt really good about doing it.

This is Bella about 10 days post op. She is up, walking, comfortable and eating!!

I still love this cat. I am so glad she did so well.

Here is the cost breakdown of Bellas procedure;

walk in non-client Sunday exam $75

NSAID for pain $18

Day of surgery;

propoflo induction $60

exploratory surgery $350

surgical package (i.v. catheter, i.v. fluids, i.v. fluid pump, instrument pack) $250

anesthesia $125

additional suture packs $30

e-collar $15

overnight boarding 2 nights $40

Total for procedure; $950

I donated my time and $500 towards her surgery. I do so because I have the help of our internal Good Samaritan Fund. I have found that as much as I take from it our friends and supporters refill it.. I never let cost be a reason to deny care. I give more than I have to and in return I get more than I expect. It keeps me feeling whole and purposeful. It keeps me feeling grateful to be able to work, to help, and to be a part of someone else's story. Isn't that we all want?

Related Blogs;

What Gets Swallowed Must Go Through.... or else. Foreign Body Obstruction Surgery. Levi's blog.

For those of you interested in learning more about pet care please visit my YouTube channel. 

If you have any questions about your pets health you can ask me for free at Pawbly.com.

For more information on our clinic, Jarrettsville Veterinary Center please find us on our website JarrettsvilleVet.com, or our Facebook page, Jarrettsville Vet.

Please be safe everyone.

The Silver Linings Of COVID-19. The Life Choices We Surrender To A Virus.

There must be silver linings in the storms that life inevitably delivers. Lately I’m struggling to find them, identify them, and, keep a rosy eyed perspective as I attempt in earnest to magnify them.
It is the middle of March 2020 and the entire globe is focused on the pandemic looming around us called COVID-19. It is the fodder for previously produced thrillers too numerous to mention and the story is actively unfolding a little deeper and gloomier with each passing day. Everything that provides us our day to day normalcy is either under closure for safety reasons, or, threatened to become the next place shut down to ensure self- isolation to attempt to stop the spread of a tiny bug our immune systems won’t recognize and thereby might not respond to appropriately to save its host.

Fear based hysteria is influencing our very scientifically based safety precautions. The world has been our guinea pigs and we should remain thankful that we aren’t Italy, S. Korea, or China. There is some small saving grace in not being first country to start red dots that balloon into whole country-wide zones. You can learn a lot from the first guys mistakes, or misgivings. It isn’t a hoax, and this is our dress rehearsal. Fear is a great motivator and based on the grocery store brawls over toilet paper and sanitizers it can be the seasoning to remind us we have yet to evolve.

The COVID-19 mania is causing whole nations into forced quarantines. Communities are losing swaths of citizens and the novelty of a new big possibly highly virulent disease has scientists reeling over understanding it as fast as is humanly possible. We will have a vaccine for this faster than ever seen before in history. This will happen because we are so motivated to find it, and so practiced in the methods employed to do so. With each great advance comes an ever-increasing expectation. For me this virus is pure novel once in a lifetime science. Biology meets marvelous fragility. You cannot admire the incredible brilliance of microorganisms without conceding to their immense power. Take yourself out of the equation and the scales of survival are all pushed to equality. There is hope in mortality. Where one dies another survives. Without balance there is no beauty and humility. I know it sounds crazy to admire a virus, but we cannot convince ourselves we are so superior we forget to preserve the lives around us, can we? It is the silver lining to the once in a lifetime disease du jour.

Personally, for as much as I want to gawk and pine as the self-proclaimed science geek addicted to COVID-19 melodramas over the real-time emerging information and science of this new disease with the way it so effectively fertilizes its mark on the world, I have to take myself out of 30,000 foot view  and refocus on the other fish I have to fry. I have a hospital to oversee and a real fear that one disease for one species will strangle the ability for us to care for any other species. Every veterinarian I know went into vet medicine because we chose the other species over our own. The silver lining of unconditional love compelled us to serve one and allow the other to pay us for that. You learn fairly quickly that your heart may always lie with your furry patients, but your solidarity lies in the details of disease and its clear killing allegiance to its victims. There are times you must choose to protect the human at your adorable furred patients’ expense. I also have to brace myself for the lunacy of paranoia that people will abandon, or kill, their pets if the fake news starts concocting stories about that one 17 year old Pomeranian, who may, or may not, have or not had, we think it was two or three times tested? from a yet to be deemed credible internist in an otherwise yet to be relied upon country (China) who would rather control the news, their people, and their own reputation as being “powerful” than being honest and transparent. For now, your pets are safe. They won’t give it to you, get it from you, and they are still the best chance any of us will ever have at unconditional love as we are potentially put on house arrest.

My mom has been one of the billions of collateral victims held hostage by COVID-19. She was diagnosed with her stage 4 metastatic breast cancer at about the same time corona made its first victim. Her story of the duel between her body and its terminator started as COVID-19 patient zero found theirs. Her disease story started in December 2019. It has been a many months long process of finding her answers, providing her care, understanding her options with each choice and predicament, and uncovering resources and services to optimize an acceptable end of life plan. Its been a lot of shit to dig through while accepting the losses she never saw coming. For most of January and February she was in a hospital. She was released from that to her rehab facility early March. There was a choice here, but in retrospect it may have been the wrong one. At that time COVID didn’t exist on the radar. The choice was hers and the options were to go home, or, go to physician, nurse and therapist assisted 24/7 care? She wanted to go home. But she knew she couldn’t manage there in her current state. If she went home she had stairs to ascend and descend on her toothpick bones with lungs that wouldn’t propel her and an aluminum walker in her protective arsenal. She was now expected to be an 80-pound pack mule who couldn’t breathe. It wasn’t going to work. We, her family, the hospital staff, the social workers, everyone in her life, convinced her that a “short stay in rehab was her best chance at recovering some lost ground to be able to go home.” I put it plainly, “we are setting you up to fail, again, (this would be the third strike), at home. Your next stop, slip, bad card, etc. is hospice.” (Why I feel so compelled to tell her what no one else wants to say out loud to her has me facing the only regrets about this whole debacle that I expect. Personal notes; What the heck am I supposed to do? Lie? Purse my lips? Just live blissfully with the crowd in denial? I honestly don’t know. I do know that she prefers I shut up and act stupid. Just talk about the happy stuff” she pleads. I’m honestly trying).

My mom was transferred from the last 2-week hospital stay that proved fruitful in both diagnosing her and getting her indexed vocabulary of opioids in order to the rehab facility in Bel Air, MD. She was moved from an hour plus away hospital to a rehab facility within 30 minutes. We were hopeful that with her willing commitment to get a team approach to her muscle weakness, walker and oxygen dependency that she could go home stronger than the hospital bed, massive opioid slumber that pain eradication costs you.  She has nurses who provide a never-ending list of medication options on a daily rotation. She is now an expert on requesting and medicating the pain away. In vet med we caution every patient to find their “lowest effective dose.” That combination and frequency that permits the smallest amount of medications to produce the most tolerable degree of comfort without the sedation, if at all possible. My mom just wants pills delivered and pain eradicated no matter the consequence. There are lots of consequences. Desire to ambulate, breathing, and constipation rank amongst the greatest victors in the exchange. She also has lost the ability to manage these on her own and going home as such is going to be a real challenge.

It is hard for a fighter within me with no white flag in my wardrobe to concede. I cannot find a silver lining with all of her decisions. And yet she is holed away in confinement and I cannot meddle. Maybe that is both of our silver linings?

I call her daily. Dig for little tidbits of information. The interrogator in the room with civil rights and a fifth amendment defense strategy. She knows I dig. She attempts to pull the parent card, I usually remind myself to bow, she has the reaper to bargain with, why waste energy on me? There is her silver lining in having a common enemy and an hour glass with sand slipping away.

When we first went to visit her in the rehab facility I was taken back by the residents all lined up in their wheel chairs in the hallway outside their rooms. Some looked up at you, few smiled, almost none interacted if you said “hello.” They were the institutionalized form of ‘stoopers,’ the term we use in Baltimore City for the people who sit on their front steps and watch the city pass them by. When I was at the Academy we had “fall out.” We would all rush out of our rooms and line up like little soldiers, head bowed, cap covering our eyes (you are only a real person if you have eyes, I think was the point?). Shoulders pressed back, hands plastered to our sides, pushing the wall back into our rooms awaiting the next shouted directive to remind us that we had no place in the world and no one to save us. It was shit. I don’t know why I had no rational cognition of the person I was shaping myself to be under anyone’s command. Yet all these came flooding back to me as I walked those halls the first time all the while thinking, these people must be lifers?

I called her yesterday.
“Hey mom, what are you doing?”

“I’m in the hallway. I couldn’t stay in my room any longer, and I am not going to become one of those bed ridden people.” For her it is a simple step away from her worst-case scenario and not towards mine.

She is there. Locked away. Safe. And I am on the outside trying to not get swept away in the hysteria. Trying to understand all of the implications for all of my actions and decisions and knowing that little ferocious bug has me within my straw house in his favor.

At the finale of every long hard health battle beside the ones you love most there is a feeling of shedding the weight from your shoulders so heavy you couldn’t move out from under it until they passed. After yearlong battles with Jekyll, and before him Savannah, my beloved beagles I spent a year each fighting for and doting over, despite each day just being an accumulation of massive causalities that they gained along the way when they finally lost their battles there was this overwhelming feeling of relief. The burden, both emotional and physical, was now behind me. There was also immense guilt in that, but it was still true none the less. I can’t go see my mom and she can’t make me feel guilty, or neglectful, or even argumentative in my interventions as the over bearing guardian we swapped crowns for. Corona has taken these responsibilities off my plate. I cannot micromanage her, and, she has given up on that influencing her recovery. There is time passing between us that we don’t have. I can’t watch her with my calculating ever scrutinizing analytical medical eye. (As Diedra, my sister would me and say, I always have an agenda.” And she knows she is right). I am supposed to see what others don’t. I am supposed to be one step ahead of her next pitfall and help her side step it. And now remotely, my critiqued questions are blunted, and, or, more aptly ignored.

Her silver lining has been in the prisoners feeling of isolation and the oddly placed security that provides. She has people around her. She finds great comfort in that. Her self-imposed home isolation wouldn’t afford her that luxury. If she was at home she would not be able to have visitors. NOT ONE! She is the worst at risk patient there can be. She has precious limited time and she would be banished to spend those last days in solitude. At her rehab facility she has food delivered at her command, anything she requests, made to order and delivered without a tip required. She has people she can share her story with. For the first time in her 7-decade life she has learned what living with others is like. She never had a dorm, roommates in an apartment, or, anything where she had to share. She has never seen death, suffering, and disease cripple and control. It has been a lesson on humility, humanity, and empathy. She is enjoying exploring new experiences. Ones she would never had exposure too, and, honestly spent a whole lifetime avoiding.

I call her every day, at least twice a day. She is still her firing, pistol self. “So, mom have you met the people around you? Do you know the names of the people in the rooms adjacent to you?” I pick small sentences and direct questions. She is on elephant doses of opioids she can get lost in the sentence if it has too many curves. “Krista! Some of them can’t talk. I don’t have time for that.” And, the empathy recedes as the parent reprimands. I guess I am expecting too much. The vet in me wants to understand these people, and their conditions much more than the talking patients. Maybe that apple rolled too far from that tree?

The house is falling. The pain won’t win, but the body has lost its hope in walking independently. Stairs of any measure greater than one, and a tube in each nostril pushing atmospheric ether into her lungs that can’t muster the strength to tug on the diaphragm anymore. There are weak protests of pleas to let her “conserve her energy” which always sounds like handing the draw to the house. It is not a bluff but a fold.

I want her to know I am still sitting in the bleachers. Still rooting her on, and yet there is only the half-answered phone calls and the locked building that takes care packages at the front door. She is in there. Confined within her fear, and, passing precautions to me in the big scary germ filled freedom.
I know that if things get worse she will only have two options. Forced confinement if she is feared to be exposed or infected, and, home isolation if the bed she resides in gets too precious to permit her to stay in her already terminal state. How could it be worse? Die alone or die alone?

The veterinary clinic is being allowed to remain open, for now. The MD governor has us in his “essential personal” graces. We are rationing provisions, adapting protocols to minimize congregating of people, washing everything as obsessively as possible and trying to allow people, the staff most importantly, to do what they feel is best for them. They are able to take time off, stay home with their kids as all of the kids are out of school, and we will provide as much support as we can. There is no end date for a virus. Just curves charts and accumulated data compared against the previous days and weeks of data.

Life is a roulette game. Chance and luck, fate and frailty, and yet we are tiny specks in a timeline without boundaries. But she is my mom and her silver linings are fleeting locked up for her own good. I really only care how she chooses to spend her time. She has a team rooting for her while I cannot be seen or heard outside of her cell phone tucked away in her wheelchair. Her lifeline to the life she has on hold in the world of germs and equality irrespective of mass or intelligence scales.

Thank you for reading. If you would like to read more about my moms journey you can find it here.
Human vs Veterinary Medicine. My personal experience in dealing with both.

The Journey and The Pile of Regret Souvenirs.

For more blogs on subjects mentioned above see;

Terminal Mom. Losing my pups.

The Phantom Effect. Grieving the loss of your pet.

My Beloved Jekyll-pup. May you run through the fields forever.

Survivors Remorse.

The Distracted Hearts Recovering. Getting up and moving on after the loss of your pet.

I also host a free pet health network. If you have a pet related question you can find me there Pawbly.com.

I am also on YouTube, Facebook, and our clinic website JarrettsvilleVet.com

Be safe everyone, there is a virus out there.

The Journey, The Missed Pit Stops and The Pile Of Regret Souvenirs

There were a litany of advantages to calling this blog a diary. It gives a considerable degree of artistic latitude and an avalanche of protection to the scrutiny of the squawkers so willing to judge and cast doubt.

Life lately is at a tipping point. That place where life changes indelibly and irrevocably. It is death lurking. The ominous threat has found my mom. She is 74, (everyone always asks me that, so, I will answer it from the git go).

She has breast cancer, no big thrill of the exotic here. Thing is it wasn't the most usual of presentations. It is a real example of how medicine and our options, lessons learned and advancements have influenced us.

Maize Quest Corn Maze October 19, 2019

My mom had a unilateral (one sided) mastectomy 23 years ago. At that time I was away sailing on big ships at sea. Pretty much out of reach for anything other than a fax, or satellite call which no one ever (ever!) made of short of, and singularly for one thing, and one alone; death. If you got called to take a satellite call you knew it was bad. You knew it was going to be really, really bad. Knowing this most family members spare you the notification until the ship hits the shore. No sense fretting alone for the rest for the months long voyage. I wasn't in the picture for her day to day life 23 years ago. She found a lump, went to her doctor and they had a small chat. She elected, (as she did this time too), to be as aggressive as possible. It was removed with very large margins that included the entire organ. The lump went with the breast. It is exactly what we do in vet med. (Except of course women like to have their boobs back after they are taken, so in human medicine there is this branch called "reconstructive." No such stuff in vet med). My mom is tiny, like really tiny. No one would ever know anything happened. She wore the same clothes and never missed a beat. Nothing was done for follow up, or clean up. Things have changed for oncology two decades later..

23 years went by,, and in mid 2019 she found another lump. It generated a quick call to her general practitioner, who sent her to dermatology under the suspicion of being an ingrown "something". The dermatologist sent her to a plastic surgeon who sent her to oncology. Took four months for this table tennis match to play out. Four wasted months with her prior history being dished out at each appointment and loads of passing the buck..

A fine needle aspirate at the oncologists led to a "high degree of suspicion" that her cancer was back. She elected for a matching mastectomy. It was done within a few weeks.

She stayed one night in the hospital post op. Went home with drains, but feeling pretty good.

Four days later she started with back pain. Over the next few weeks it got to the point she couldn't walk. Four doctors over four weeks and finally it was so bad she was admitted to the hospital for "pain management." Now I am not a human physician, and no one likes a back seat driver, and yes, hindsight is always 2020, blah, blah, but the fact that she, or anyone would have to go through so many weeks of being given driveled aliquots of escalating pain medications is something that NEVER happens at my practice. EVER. If a pet is brought to us in pain we provide lots of pain options. We don't start at skimpy and let pets suffer. If the client declines them I provide them for free. Pain under my care is not acceptable.

Over eight weeks of trickled paltry doses of every medication imaginable and available, some of which were included in her week plus hospital stay and the medications were still not enough to manage her pain. She, to this day, is still unable to leave her bedroom. Its heartbreaking to think you might end up spending your last days bed ridden from incurable, unmanageable intractable pain.

September 16, 2019, my house cook-out.

Early on, like right as the biopsy was delivered I sat her down to talk about what I know her doctors won't, we talked about ALL of the options.

"Mom, once you decide you are sort of committed to the journey that they have planned out for you. That is about six months of chemo and radiation. It should be something that you want to do so that you can have the best chance at the best outcome. It will be a long, hard, tiresome and toilsome  journey, but you have to have the long game in mind when you start that race. Or, you can sell everything you own, lock up shop, and just not get on that bus. Move to Paris, drink wine, enjoy whatever it is, wherever you want. It's your choice."

Things changed before the wait began at the bus stop.

After 5 days in the pain management hospital stay, and her tenth diagnostic proved still yet unfruitful, and me being there daily, we called another all hands meeting.

"My mom has been here for 5 days. She is on, or has been on, every possible pain medication including opioids. She has morphine given intravenously every 4 hours, and she is still in pain. This isn't soft tissue. This is something more insidious. We all know that,,, right?"

Quiet faces replied.

"What modality is left to find the answer? What haven't we done, or, need to do again?"

"A bone scan." Her doctor replied.

"Ok, can we get one?"

It was ordered and done a few hours later. That night all of her doctors met in private in the basement, which is apparently where the diagnostic machinery is housed. That night they broke the news to her. I wasn't present but it was reported back to me as, "it's really bad."

Didn't we all already know that? I asked myself. I had given up pushing her to do anything other than find an answer and not over exert herself which only brought on more pain than she could bear at week two.

All of this has been a cascade of events without enough time to really put our feet on the ground to make any sort of plans or decisions. It is a tornado of shit and no umbrella will shield you.

The prognosis is, they say, (they being her tiny oncologist who is unwavering, exceedingly smiley and abundantly optimistic, after all how else do you be, get,, stay this way, in this field? Or, she's really new to this?), one to three years.

This sentence, her stay of her own bodies execution, is also a really big terminal exclamation point. No subtly, no chance of a get out of jail card. It's like a done deal.

September 24, 2019, at JVC.

Now it is natural to presume that you know your parents fairly, if not exceeding, well. I would be so bold as to say that I know my mom better than anyone, her husband included. This whole new twist in our lives has me having to rethink those words. I am perplexed, perhaps even shocked and peeved, about her reaction to all of this. All of the doctors, all of the tests, all of the pokes, prods, probing inquisitive conversations, the constant turnstile of nurses, social workers, therapists, scars, bruises, drains and pill bottles, never mind the hidden emotional and mental anguish without a destination to dump them at. This is a journey of destructive accumulation not liberty, peace, or freedom. She will lose all of that if it hasn't already been willingly surrendered to this disease taking them, one by one. As they slip from her fingers she retreats deeper into her home. Her world shrinks to a place without public view. There is no plan for ticking off the Bucket List of life. No anger, no list of experiences to dive full-on cannonball dive into. No making the biggest splash to fully immerse and drown yourself in, damn the torpedoes! I'm having the greatest difficulty here. Feeling like fighting, arguing, and challenging every one, their expertise, their opinions. Why isn't she doing what I would do? Just living on my terms, my way, to the last breath,, And yet, maybe that's what she is doing, just not in the way I would wish for her?

August 25, 2019. My last photo of Jekyll. He died the next day.

It has been months but she has her medical answers. She has their recommended treatment plan. It's just not the plan I want for her. It's not the fireworks fanfare that a finale should have. She wants to stay home. Exist within her three rooms she has handicapped access to and be visited as often as possible.

Don't we all want to exit with the fat lady singing some crescendo to a lifetime worth reminiscing over?

And so for all the things she can't do, didn't do, and has't yet experienced, I find myself filling buckets of lists of experiences I can't live this life AND NOT DO! I can't accept having lived without having also nicked more notches into my belt. There are so many places yet to go. Things to see. Blogs to write. Videos to make. Things to eat on sun setting shores that span the globe. Hands to hold, pups to belly rub upside down, and cats to purr on my shoulder as we bid another long day of hard work I am immensely proud to be asked to participate in. I only have this lifetime to try to fit all of these into. I just don't know when to start. I don't know how to be my moms caregiver companion as I remind my own wanderlust to sit quietly, as it has for the decade of sea, the decade of clinic ownership, the decade of giving to the patients I so adore and the cement it barnacles in between my toes as she whispers her beckoned calls to stay with her, just a little longer.

Easter egg hunt 2019

Thank you to all who ask, who offer help, words of encouragement, concern and love. I am genuinely grateful.

To the girl I feel obliged to fill and conquer a Bucket List, I hear you too. We will go, soon enough, try to be patient a little longer.

Related story;

Human Vs Veterinary Medicine: Real-Life Case Meets the Dueling Ring. Who's Better and Why?

For the me inside still serving the greater good of the companions in our community I am here in the following spaces;

YouTube channel

Facebook Page for Jarrettsville Veterinary Center

Jarrettsville Veterinary Center website (with our price list)

Pawbly.com is the place for those who don't visit me at the clinic to help with their pets care, And it's
FREE!

Blame The Other Guy. Where Fault In Vet Med Costs Us All

We all want to point the finger.. It is natural when we are smacked in the face with something so devastating we can't find the place to put our feet back on the ground. We point, blame, and spew angry hateful things when life sends us reeling for safer waters. It is so insanely common we do it in almost every aspect of our lives.

My cat Wren,, basking on the warmest spot in the house.

We are living in a time and place where people are struggling. Struggling to stay afloat as they yearn to get ahead, and, dare perhaps to even get ahead. We are also struggling to find a place where we are loved for some semblance of a peaceful respite in the all too chaotic world we wander within.

I live it. I live it every single day. I see the most needful in this world, and, I see it in the most compassionate of us all. Also, and this is vitally important to remember, I see it in the voiceless, meekest, and most vulnerable. I see it in the eyes that no one else looks into.

Have you ever tried to extinguish the life of a tiny creature still fighting to live? Do you know how soul crushing that can be? Do you know what the price for this act is?

Do you have to look into the eyes of the small, meek, suffering, struggling, and fighting to live anyway and ask yourself the really hard questions? How do you reason with your own internal understanding of ability without advocacy? Or, how about the person, your client, who is so devoted to their beloved pet that they can't see reason in anything? What if you don't have the resources or knowledge base to help manage this medical and emotional debacle? It's a mess at all sides and all levels. How to avoid all of this messy stuff? Just disengage? Turn yourself off and walk away. There is a lot of this going on in our society.

We live in a place and time where medicine can provide miraculous cures. We also live in a place where fewer and fewer people help their fellow man at a sacrifice to themselves. This is a time where costs of care are skyrocketing and indifference about who is responsible for this is thriving.

The tiniest creatures cross my threshold every single day. And with each face (and they all have a face, and a voice, and a personality and a huge list of needs), I have to ask myself what I am going to do about it? What am I going to do about meeting their needs as I try to remain within my own? How do I find the place where both can be met? How do I place a value, a price, a conciliatory explanation on finding the answer, within the confines of need, for a life that costs me, emotionally and financially when neither are secure, nor, established within mine? Who do I place first in line for a feast of rations?

I could concoct a million excuses. Find a bazillion reasons,, wouldn't you? Wouldn't you rather make her little needy desperate face someone else's problem? Let them figure it out. Just turn a blind eye, make an excuse, who cares? Right? Isn't that the point? Does anyone really care if no one else knows her plight? If no one else hears her heart stop in this wood, did it ever beat to begin with?

This is a blog about blame. The safest place to retreat to when you lack the conviction to do anything more.

So, lets talk about blame.

Veterinary care is too expensive. I mean isn't it? Five thousand for knee surgery. Ten thousand for hips to be replaced. Hit by car with multiple fractures, a few days, maybe a  week in the specialty clinic and you are looking at maybe twelve grand? Maybe more?

A blocked cat starts at fifteen hundred. A puppy with a sock stuck in his gut will set you back three grand,,, to start, complications, which can happen, will cause that to increase. And, remember these are all treatable. Maybe not accessible, maybe not affordable to the masses, but treatable doesn't change the fact we can help them.

So decide.. Take a chance, everything in health care is a chance, cough up a few thousand dollars.

Who pays if no one cares? What about if someone cares but no one can produce viable accessible options? Well I hope we all know the answer. The most obvious victim is the patient. They all too commonly pay for the blame with their lives. Why let them suffer any longer? There is after all no guarantee that they will recover? Why not just save your pennies from the risk of losing them, and your pet, and just blame the vet?

Your vet thinks that the blame is all yours, and, yours alone. Here's why;

• You waited too long. 
• You never got the preventative care to avoid this mess. 
• You weren't prepared for the bumps that are inevitable in every living things life.
• You should have had an emergency fund available.
• You shouldn't have spent two grand on this dog when it was a puppy and not be willing to invest 500 bucks in them at age 10 of never having spent a nickel the last decade short of dry crappy kibble.
• You should have saved your pennies for the pet you claim to so deeply love instead of getting your nails done, your tattoos done, your new car, your new phone, your boob-job. 

Your poor choices are not mine to bail out.

The venom knows no bounds.

Always observant. My pups Storm and Fripp.

We live in a country where we can't care enough to provide humans health care, or, hungry kids school meals. Or decent housing that is affordable at minimum wage.

You want to place blame? Go ahead it won't get us anywhere. But you can feel better about yourself can't you?

So here we are,,, living in a place where people want monthly wellness plans. They think they are getting a good deal. I mean aren't they? Well, maybe in the short run you are, but, ask yourself, better yet ask your vet at that corporate practice how much it is going to be for these;

If you have a male cat.. How much will it cost to unblock them? What if it happens at 2 pm on a Wednesday? Or 2 am on a Saturday? Are you prepared for these? Will they even help you if it does happen? Many, dare I say, most, will send you to the ER. Starts at about $1500. I know someone who spent $9,000. Can you afford that Wellness Plan now?

If you have a 3 year old Lab who ate 5 tampons and is now lethargic, vomiting and can't keep anything down?

What if you have a cat who likes to play with thread/string?

What about the German Shepherd with the basketball distended abdomen?

Or the dog fight dog who has multiple bleeding lacerations?

I know people who have spent $400 on a broken toenail. Want to place blame on exorbitant care costs? This seems like an easy target to start with.

If you are cold enough to look at these faces and not see a life worth fighting for then you will never understand why the blame is cousin to the hateful accusations you are going to get.

People love their pets. We veterinarians love our pets. If we don't love them anymore there is a blame based excuse at the crux of our armored indifference?

We are all choosing to live a life of blame based justification. It's safer here. No vulnerability, no guilt, no shame. No one cares after all, do they? Do you?

At this time and place the last local ER is closing its doors. For good. It was the last place I could send people at 2 am to have that sock, tampon, urinary stone, twisted gut, broken nail, etc.. to go. Now the only choices are two corporately owned clinics. They are bright, shiny, well-staffed and making some group of middle aged venture capitalists driving very nice cars, with very nice clothes and very cushy vacation homes in places we have never been. Want to live their life? Own a forty-thousand dollar bag that the K's tote their laundry in? Well, it's easy. It will only cost  you every other pet with a face you cannot see beyond the doe-eyes for. Just turn them away, kill them as a resolution to their ailment. You don't care do you? You love your stuff more. Its not your fault is it?

You have bills to pay. Vet school bills, a mortgage, kids to put through college, a car loan, and you need your car so you can get  to work. And those poor vet techs. If we don't pay them a decent wage we can't possible help the pets who need us. And if I don't buy the most expensive x-ray machine out there, and have loads of licensed techs I can't attract a decent vet to help me stay open all of the hours that my clients need me to.

Always adorable,, really innocent. Fripp.

So who's fault is it?

Maybe we all need to care more? Care about the choices you make? The businesses you support? The long term acute and emergent choices you make? Maybe the blame is so evenly distributed that one small change can start an avalanche of infectious cures? Maybe you are not prepared? Maybe you love your pets like children? And, maybe on some dark Saturday night at 2 am you will be living this nightmare that is called economic euthanasia so some corporate shark can drive a convertible in a snappy zip code? He doesn't care about you, or your pet? And, really, let's be honest, you don't care about him either.

Charleston. My senior, a local Humane Society find.

If you would like to learn more about veterinary medicine you can follow me here, at my blog KMDVM.blogspot.com, or my clinics website JarrettsvilleVet.com, or, our Facebook page Jarrettsville Vet Center.

I also have a YouTube channel, and the best place for free pet centered advice at Pawbly.com.