We are at an unprecedented time in veterinary medicine.
Never before has the demand for veterinary care been so great, and never before
has the availability of veterinarians to take care of animals been so thin. It
is very important for new grads to understand this. We are also at a place
where the ethics and intentions behind every decision being made within vetmed
has serious long-term consequences. Never before have you had to start making
life changing, and life influencing decisions so soon out of the gate.
No one from the other side is going to tell you this. They
won’t tell you because they need you and they need you to remain new enough to
be green and naive. No good, strong, lasting meaningful relationship starts
with this as the premise.
When I graduated from VT I was looking primarily for two
things; mentorship and long term stability where the fruits of my labors would
reward me with a piece of the pie that I had helped establish. It took me a few
months, and a few practices, to find this place, but once I did, I stayed. What
I didn’t recognize as truly important was the people that I shared my
professional life with. I had been too self-absorbed in trying to become a
great practitioner to understand the importance of a place of belonging. When
all else was turning into a catastrophe soup (and yes, these days are ahead
regardless of where you go), I had a group of people who supported, cared for
and saved me.
I have always been a veterinarian. From my earliest thoughts
and actions, I was meant to be a part of this profession. I suspect most of us
are this way. I was all passion, some training, and dedication in limitless
bundles. What I learned is that patients come and go, your place in their lives,
(albeit incredibly important) is also transient. What is not transient, what
grows and motivates, and moves you into legendary, is the impact you
have on those around you. What has defined legacies of the veterinarians before
you, (and perhaps the veterinarians who helped get you here), is the other
stuff vet med brings to your life.
Your perfect place is out there. It will grow with you,
evolve because of you and be better because you are a part of it. Finding that
place out of the gate will take some self-introspection, some questions you may
not be able to answer fully yet, and courage.
Here are some of the insider employer secrets;
1.If it is all about the money you will leave
vetmed heartbroken/bankrupt. There are sharks among us who are here because of
the money. VC’s are circling and capturing veterinarians in record numbers. You
are a cog in their money-making machine. You can justify a small, transient
existence among them, but you will sacrifice something along the way you will
regret. Money does that. There are limitless lucrative possibilities here, but
know who’s terms you are making them upon.
2.A contract always benefits the house. Don’t sign
anything. You don’t have to, and it doesn’t protect you outside of a short
period of time. Everything in life is negotiable. No one has any business influencing your heart
and soul. Walk away. You need to learn this lesson early. It is ok to say no.
You have a voice and a responsibility to yourself, your patients, and clients (occasionally).
A non-compete, and/or gag-order are hard NO’s IMO for me. Period.
3.Never sell yourself short. We are all growing
and learning and there is beauty and strength in this.
4.Promise yourself you will be honest from minute
one day one. You can admit to anything and be ok. I promise that.
5.Always remind yourself of your WHY. Know
WHY you are here and never stray. You know what it took to get here, and never
abandon that person.
6.Have fun every single day. Nothing is more
valuable than joy. (Purpose is a close second).
7.Remember that mentoring is so much more than
medicine. It is also mentoring for success in every avenue that makes you YOU.
If you truly find an advocate, they care about you without
caring about how it benefits them. Vetmed was founded on this.
If any part of this resonates with you, or if you want to
learn more about how we practice you can find me anytime at my email, or our
social media sites. kmagnifico12@gmail.com
or Jarrettsville Veterinary Center, Jarrettsville Maryland. New grads, interns,
wanderers, curiosity seekers, surgery exposure, or good-deed-doers are always
welcome. We have housing, no contracts, no emergency calls, zero tolerance, and
hard-won cases that heal every bad day in great abundance. We never practice
economic euthanasia and we never break hearts, hope, or good intentions.
Jarrettsville Veterinary Center
more on us here; Jarrettsville Veterinary Center Facebook
The sunshine beaming in my windows delivers just enough warmth to remind me that Spring is right around the corner. I am at home in Southern Pa., close to the Maryland border. It is the last week of February. The tail end of Winter's quiet. The peaceful transition from snowy, sleepy, slumber to the bright burgeoning of the colorful explosion of Spring life. There are a few birds congregating outside my window at the feeder I fill daily. They sing songs of cheerful excitement, catching up on free pickings as if prepping the internal organs for the demand ahead that perpetuating a new generation demands. They skip quickly from the evergreen branches to the feeder weary of a hawk that stands guard above. Even she has an internal clock that ticks and gnaws for the fledglings she must soon create and cultivate. The grass on our lawn sprawls widely on each side with its cropped-tight, still silver-grey veiled surface. Below its feet lies a vibrant spring-greenery hidden safely by the frozen ground soaking up this sunshine while gathering momentum for the weeks that lay just ahead. These are the days between the seasons. The days I run to a warmer place, for just a few days, to avoid the clutches of the Winter doldrums that living in the north forces us to endure.
We arrived home very late last night after a long day of travel from abroad. The five of us; my husband Joe, sister Diedra, and her two boys; Cody and Anthony, went on our second end-of-February trip together to Grand Bahama Island. Grand Bahama Island is a small speck of land, (or atoll as Joe would correct me), that lies just off of the southern tip of Florida. Grand Bahama is replete with sand skirts and coral outcroppings yet oddly quiet all day everyday that the cruise ships aren't berthed to her. Grand Bahama is close, but the travel to and from isn't ever easy, nor, effortlessly quick. The total air time amounted to a scant 3 hours, but our travel time encompassed more than 16. We all got up early to leave our villa by 8 am. Packing took up most of the night before. After a week at the beach our rooms looked like a teenage summer away with clothes, snacks, wrappers, billowing attempts to air dry bathing suits and a cascade of make-shift dive gear strewn between two adjoining rooms. We had booked the rooms with a shared door to allow for the adults to awaken early and the boys to sleep in as per their preferred daybreak sunlight avoidance preferences.
Seven days of expeditions upon sand and we were left with a massive collection of seashells and sea glass to discern/decide, divvy up and divide. Suitcases were repurposed to stow coral encrusted fans and sea-bitten detritus home. The yearly challenge to jettison the unvalued in exchange for the newly found, albeit decades old treasures the sea coughed up for us. We travel here, for this bounty. It is inevitably always the most enjoyable moments of our time there.
The adult section of this entourage wakes up for each sunrise, makes our own percolator coffee, (which we make room for in the packing process to also include our preferred variety of oat milk and miniature grater for fresh cinnamon and nutmeg), always packing enough for the allotted days abroad. Every morning is the same. Up for sunrise, fresh hot cup of coffee in hand, open door to beach to pepper the unmarked sand with our foot prints. We never have to share the beach, or wish another human a "good morning" greeting. We are always alone, and, always plotting the rest of our day ahead. We may have a resident feline with us, and, we welcome their company with great enthusiasm. There are always four or five resident cats here. They appear early in the morning looking for a kind hand of affection, or late in the afternoon seeking a hand-out from the snack hut patrons. They are always young, in early stages of pregnancy, and always bearing the shaved back-ends from over aggressive grooming to keep the fleas at bay. We stop behind the tiki hut bar to make sure the food we scavenged from the previous day, and left before we went to bed, has been taken by the stray dogs that live in the woods behind the abandoned (due to lack of business), HR trailer. Everyday is a copy of the one before; wake, sunrise, grind beans, brew coffee, grate cinnamon and nutmeg, sip, stroll, plan. After the coffee is emptied we dress to go for a run, or to bike to the beach. We always pack a mesh bag to stow whatever treasures we find.
The resort is a gated beach of rambling pastel colored villas scattered across a massive, mostly forgotten, landscape. This place has a long history of chances, intentions, allure, and lost dreams. There are miles and miles of empty beaches. Running along them are paved roads with overgrown, unkempt, planted palm trees, lamp posts (most missing their globes), stop signs, traffic directives, and gutted electric boxes, sewer plates and four buildings. Ten skeletons of homes remain standing. All strewn about the 600 acres of land that stretches from one shore to the other. It is so mind boggling how so much could be built, at such great expense, and have so little to last to show for it. There is an infrastructure of cut canals, golf course, club house and one single home about 80% complete surrounded by nothing. A cemetery of dreams built by a wealth of intentions that fell so tragically hard it is impossible to believe. We wander these roads, these beaches and we reflect on how immense a mistake this was. A billion dollar debacle 4 decades old. These beaches are awash with glass, ceramics and parts of machinery almost unrecognizable. Whole train engines are buried under sand with piston pock marks left as their only identifiable feature. Over 10 years I have collected suitcases of these beaches lore. Many still bear the names of the developers initials, or the resorts names. Some are almost 100 years old. There are so many stories washing up here and I collect them with a curiosity that compels. This is what beaches beckon to me for. A stroll and a collection of trinkets some man made and others sea borne. All with a story unto themselves. They are my treasure, but they began as someone else's dreams.
The point is that I travel far away to rummage through the decades old of castaways of lost, shattered hopes, and massive work efforts gone debunk. Curiously, (and let's be honest concerningly), I am not sure what I am building, or, if any of it will stand the test of time? Maybe all of my efforts will be left to fall into the sea only to be washed up to find some curious fingers in 2074? Perhaps this is all just fodder for reflective pondering of the hopes of one person among the tides of challenges that is inevitably a lifetime of intentions and a hope of longevity? Maybe all of this hard work, exhaustive effort that leads me to run away to far away islands is all futility in the end? Maybe even the biggest dreams, with the loftiest of intentions will end up as trinkets with soft edges, barely recognizable from the original pieces of remains the sea spills over and over onto the shores of harsh, inescapable mortality.
Jack Tarr, or jt
With each return home I am so grateful to be back in my own bed. I am so fortunate to have healthy cats who aren't licking/chewing/scratching to the point of balding on their bellies and backsides. Struggling to have another litter to support whilst scrounging for scraps from the tourists at the tiki bar. In the Bahamas there is an odd twist of fate. The dogs are largely roaming vermin and the cats are more likely to find a kind hand of offerings. Few dogs have a place within the home. A little more so are tied to a pole in the yard, but, the vast majority roam the side streets and stores flea infested, trailing pot-bellied worm gravid bellies and sad bleak faces of indifference based compassion. These souls break me. A constant reminder of how fortunate we are in this country in the vast places I live and frequent. Spaying and neutering is an inconceivable concept there. A way to deny freedom versus protect the high mortality that life on the streets presents.
One of the resident cats staking claim to the sunny spot on the bed
As we arrived on the island a storm erupting above us. We landed in turbulent cross winds that jarred the small plane like dice on a craps table. There were audible outbursts of muffled screams from the passengers caught off guard. We were relieved to have landed safely, but the adventure of reaching our destination was still laying ahead. Our efforts to secure our rental car in the torrential down pour left us soaked through within seconds. The ride from the airport was a constant reminder to "STAY LEFT" while traversing unmarked streets with absent signage. Had it not been for our phone maps we would have never made it outside of the airport parking lot. The downpours left us navigating overflowing unlit streets to find detours from the one road that headed to our end of the island. One 20 foot detour off of the main strip led us to a mixed litter of bobbing puppies and a pack of their parents intent on reminding us that we were not welcome here. Diedra and I decided we would rather risk drowning in the street puddle than traversing this motley angry gang. There was a heated argument on whether we could even safely turn around without running over a straggling starving puppy.
Life is like that in this part of the world. While blessed with beaches they are poor with interventional actions for the other inhabitants of the paradise isle.
As the off-mainland veterinary colleges sprout up in record numbers in adjacent islands the standard of living for the cats and dogs in their neighborhood improves markedly as they begin to receive out reach support for the vet students training purposes. Ask any vet school student from these institutions how many are brought home each year and the numbers will speak for themselves. Why are so many colleges being built? Two reasons; there is a desperate shortage of veterinarians, and, they are highly, (much easier to get accredited and more lucrative than the human doctor factories), profitable. Kids will go into astounding, unrecoverable debt to go to vet school. We are hounds to a bone with blind oblivion to the consequences.
My vacation time was spent unplugged. I intentionally kept my cellular roaming capability off. If I don't begin to take time off I will pay for it in blood pressure statins and botox. The reality of my professional life is that I am not feeling my cup as full anymore. Too many tiny holes in the mainframe to allow a full tank. I repeatedly ask myself if this is more than exhaustion? Perhaps a bit of lacking in the enthusiasm department when the gauge reads within the eligibility for retirement age.
There are benchmarks that mark your life. The calendar being our primary measuring tool. Mine is in the place where most of my peers have paid for the kids colleges and weddings and now find themselves free from allowances to dependents. I am at the place we never believed we would actually find; debt-free. My last loan to the 20 year purchase agreement for the clinic is due in under 60 days. How did that happen? How did the sun actually circumscribe the heavens enough times to reach the maturity date on that loan? Two decades ago, as a brand new graduate veterinarian that number was so mammoth in its zero's that I just assumed I would expire before it did. Who works this long in one place?
What I didn't realize was that as that sun was doing its donuts around my best of intentions a village was being built. Passionate efforts day after day, week after week, for years on end got me to this place. Intentions manifested into a lifetime of stories that involved wet noses and wags. There is a proud assertion of power that comes from standing on the top of the mountain you created. A sense of accomplishment to assuage your aches. A quiet sense of reflection for the lives you made stronger, happier, more inclined to nap than have to fret about the litter you cannot support. The choices you had the luxury of deciding. The knowledge that yours are free from the streets, the unmet pleas for empathy, and the heart songs of the moments of the life you got to share. For every dream a veterinarian ponders there is this life I paid for in hopes and got reimbursed for in reflections I don't want to escape from. I am so lucky,, maybe even as lucky as these pets I call my kids.
I remember that first day of vet school so vividly. My starched white jacket, my green nametag, that symbol of the snake and the cross, so ancient Roman impressive in its unpronounceable title, and me,,, wondering how I had gotten here after so much determination and grit, and an interminable 4 years ahead to try to keep that determination burning despite the challenges I knew I would face. Twenty years after graduation I have done vet school 5 times over. Who stays this long at anything, and why? To put those numbers into perspective I joined vet school after a ten year stint at sea. My second career is twice as long as my first, granted I adore this one and found great challenge in even attempting to like the first (no dogs or cats, or anything even remotely feminine at sea).
I can travel to get away from myself, but I always find out that I am happier with what I have built than what I want to get away from. That's the only kind of reflection that I should make time for at this point. Isn't it?
Maybe all of this effort will only amount to a cascade of colors with softened edges and hazy opacities. Maybe everything with even the best of intentions ends of rolling itself up on the shores of another lifetime as either detirtus or treasure? Maybe its only a matter of being the eye of the beholder and not wanting anything more than gratitude for the adventure given to us all?
For any of you interested in the history of this resort here goes. Enjoy,, I loved running down this rabbit hole. Finding the back story behind these fragments found in the tidal vomitus.
It has been a week since I last flossed. It seems like a confessional to the internal self to seek a
pardon, and once again, promise to do better. It seems I seek a peaceful acceptance of all of my
inadequacies within my inabilities too often.
This week was exactly like this… a series of internal
confessions with a humble begging for forgiveness to a self that doesn’t take
disappointment, or failure, easily.
This day, this Wednesday evening, within this moment, was about Mollie, Genie, Maxi, Taylor, and Sophie. They were all in some degree of desperate dying. Each patient was supported by at least two technicians, all wondering the same thing as I; how could so many
catastrophes happen at once?, and, which one would start to crash/die on us
first?
“We are not an E.R.” I hear myself produce these words almost
daily these days. I am not sure why I even try to explain, or, perhaps more realistically,
excuse myself. For every 100 times I recommend to a client that they transfer to the ER, 1 actually
consents and goes. People just don’t/can’t/won't/refuse to go. For some of these cases they
have already tried to get in. They have called, been directed to sign in via the
online portal, and been notified that there is a 10 to 24 hour waiting period. People who
are desperately worried for their pet’s life are not going to wait 10 hours.
So, they drive to us. Many just show up. Arrive unannounced. Crash a party and
hope that the door is open and the staff is welcoming. Depending on the degree
of the emergency they may have called us. May have spoken to our Charge
Tech to plea their case, which gets parlayed to a vet, and almost always given
permission to “come up, be patient, and we will do our best.” I try
with each case to set the stage for the reality that we are “not an ER” and may
have to transfer them to one should it be in the best interest of the patient
to do so. I know that even with this preface, this CYA blanket statement, that
I invite the chaos, and hence, I internally beg for forgiveness yet again when
I get myself too deep in the shit pile.
At 7 pm I was standing, circling and losing my
mind amid the evenings vetmed emergency offerings I had unintentionally invited
to my own misery party. I looked into the surgery room. On the table to the
left was an 8-month-old puppy. I’ll call her Sophie. She was intubated, on
oxygen, and poorly to absently responsive. Under her head sat a bucket of vomit
with specks of white pills. To the right of her was Taylor. A five-month-old
tabby with fluid in his chest. He was sleeping in a clear plastic box full of life saving, life giving super saturated 100% oxygen. He was happy
and loving his time with us, thanks to the oxygen. Just outside the doors to
the surgery in a little stainless-steel cage sat Mollie. She was barely visible behind her cluttered cage door with its two fluid pumps, iv fluid bags, (also two),
and a clipboard holding checklist of her too numerous medications. You couldn't see her adorable face with its white fluff mane that surrounded her blunted nose and omni present wide mouthed grin framed within the haloed plastic e-collar. She
was sitting up on her front feet but straining and posturing her back legs. She
had spent the last week like this. Trying in vain to push out a stone that was
lodged so deep down her urethra it was only permitting a drop of urine at a
time to pass. In the cage beneath Mollie was Genie. A sweet, slow, aged Dobie who
had been vomiting for four days. She came in as a mystery ailment and she
remained the same until the next day when the 4-year-old in her family confessed
to feeding her a whole box of chewy milk-bones. She was in critical condition
and not able to move, except for the vomiting that just spilled out of her
mouth as she lacked the strength to pick up her head. Skip a few feet to the
left and there was Tigger. I.v. catheter running saline into his veins in the hopes
we could flush out the grit in his bladder and dodge the need to place a urinary
catheter. He had arrived 3 days earlier just about to block. We mounted the
most aggressive defensive plan we could to spare him a urinary catheter and his
mom the price tag it came with.
Gastric lavage
Within these moments time stands still. I have to suspend it. It is the only way I
can muster all of the senses to attention to compute the vulnerabilities and re-assign staff
to guard the weak points. I know, I know deep in the seat of my gut, that at
least 2, maybe even four of these guys are going to die in front of me. Probably
in the next few minutes to hours. “I am not an E.R.” I remind only myself this
time.
This is one of the best examples I can give of where vetmed
is now. We have burnt so many people they don’t trust, or don’t want to be sent
to an ER. For all of the many reasons the ER’s have gotten themselves in the
predicament our clients see them as, it doesn’t change the reality that
accidents, illnesses and yes, even death comes to find us.
I see my husband for about 15 minutes daily. 15 minutes when
I get home, typically around 9 pm, starving and exhausted. He has a meal
waiting, typically two hours old, as I never get my ETA correct. I do not
recollect any of the meals from the last week. Only that I inhaled them, and
that the portions were too large. We go to bed with me feeling like a bloated corpse,
and him angry that I cannot ever say “no.” He reminds me of my limitations and
the power of “NO.” I remind him that there are few options in these scenarios that I can live with.
I remind him that I am reminded that if I don’t help, I don’t know if anyone else will. If martyrdom was a pageant, I
could have a crown to sit upon. Think I am being foolish? Well, lets talk about
each of these cases in a little more detail. Wonder why I don’t floss? Well, I don’t
do anything in this state. I fall asleep as soon as I hit my bed. Surrendering to the exhaustion like the coma that claims me. I repeat this
Monday-Tuesday-Wednesday and Thursday. I fall off to sleep worried for the
patients I saw. Fearful for those I failed, and afraid for those I will see. I
cannot say “No” to these either. They find me in my dreams. Even here, as I try to rest I see them. I worry and react for them. I send them treatments, and apologies. A figment of a life preserver even here, when they aren’t near me.
The routine day
On the night before a dog arrived with much the same scenario; "ER has a 10 hour wait. Patient is bleeding everywhere from a dog fight." We explain to the caller that we will do our best to help, but, if sedation or anesthesia is needed they will have to head to the ER. When they arrived it was after 6 pm. I was told that he was "bleeding everywhere" so I rushed in to see him. There was blood splatter on every wall in the exam room. He had been there for less than 5 minutes. The wounds to his left ear were so significant that I was not able to fully assess whether ear needed reconstructive surgery. The ear was not being held up at a normal (or symmetrical) angle on head. There were about a dozen (maybe more) wounds to the top of his head that included both puncture wounds and lacerations. Some appeared to have pocketing and underlying muscle damage. Again too bloody and painful to assess. Wounds appeared to go over to right ear, base of ear and included the neck. As with all wounds of this severity he was too painful to assess fully without pain meds and sedation, and most probably required general anesthesia. I advised them to go to ER. When I mentioned the ER the owner became volatile. She shouted and became angered. She would not to go to ER! she yelled, so I offered analgesics and antibiotics as initial treatment option but again warned that wounds may need clean up to check for degree of soft damage, and tissue damage. I told the owner I was also concerned about pain, bleeding, and high infection rates with dog bite wounds. Owner declined again to go to the ER, and take any medications. The owner went on to say that "this dog had cancer and she would not wait 10 hours at ER to be told he doesn't need anything." I attempted to diffuse her and offered pain management and antibiotics again. She stated that I was being rude. The owner got up, took her dog by the neck and began to leave exam room. She kept yelling, repeating that I was rude, and she was not going to ER. As she was leaving I told her to not return to us, nor treat staff this way. When I said this she turned around and charged at me with a hand in my face and the words "I'm going to beat your face."
That's what advising someone to go to the ER can get you. She was served with banning papers from the Sherriff the next day. Yet another gem to add to my Wednesday fiasco.
My Storm,, his happy place.
Sophie is 8 months old. She is a wire-haired terrier just
fostered and adopted by an older couple who adore her. For all of the mischievousness
of a terrier, (vets tongue-in-cheek refer to them as “terrorists”). They find
her antics, her strong opinions, and fierce compulsions, adorable. (I can relate,
my parents felt the same about theirs. I grew up with 5 generations of Jack Russell
Terrorists. They killed our cats. They killed any small thing that scurried). Sophie has a boxy face, tan highlights to a brown face and inquisitive soft intelligent
eyes. Her ears stand with a little bow at the tips and she is formidable in a
compact package of taught muscles and youthful velvet softness. Sophie was
carried into the clinic in her mom’s arms as she burst in the front doors like
a hurricane. I was alerted to their arrival by my receptionist who quickly came
rushing into the treatment area yelling, “EMERGENCY! WE HAVE AN EMERGENCY!” arms
flailing above as if waving down a passing car. I walked to the front and her
sobbing mom attempted to pass over her lifeless puppy to me and asked myself, “why does this place feel like a firehouse on some days?”
It is exactly in this moment that I have to decide. I do not
extend my arms. I do not rush to offer some act of heroism in a crucible of mercy. I have to make that
split second decision as to who I am and who I want to be remembered as. It is
in this second that your marrow matters. It is here that your consequences, your
good deeds, your ethos, and every second of every tid-bit of training finds you.
Your actions here will haunt you. I know this. This is the place where some
vets will offer “humane euthanasia” while others will offer extremis estimates for a
chance, and many will take a bad situation and make it hopeless. (To be honest I
never quite know if I ever pick the right offering of an answer. More on this
with Genie’s story to follow). What I wanted to do was ask her to remain there.
Put her on a pause, holding her rag-like puppy and make a quick physical exam
assessment and,,, punt. HARD. I did not want to be responsible for her. I did
not want to be responsible for a hysterical mom feeling guilty about an
accident I have seen so many times before. I did not want this dying puppy. I didn’t
want any of the hers in front of me asking for help. Now I know this sounds cold
and cruel, but the reality was that I had just finished a long morning of over
booked surgeries. I had come in early, after getting home very late, to try to
cram in all of the things that I had scheduled. There was not enough room for
them, never mind the falling deaths from the skies. I know this. I know I am supposed to say "NO!" I looked at her puppy, I looked
at her, the words slipped out softly, “I am not an ER.” I knew we didn’t have
the manpower, the time, nor the facility to help a puppy in this state to the
degree she needed. Sophie was purple, barely responsive and I was pretty sure she
was dying in her moms arms, if not already dead, and would die on her way to
the ER. I clumsily said as much. Mom begged me to “try” and I am a sucker for
that word. It is my verbal kryptonite. No other word compels me. Mom was hysterical.
Mom was not safe to drive. Mom was not going to make it to the ER with Sophie alive.
Sophie was in such a terrible state that I knew she had a
very narrow window. I took her in my arms and we headed into the treatment area. Over the next few minutes the story
of Sophie’s predicament unfolded. Her parents had left her at home for a few
hours. When they came back she ran to greet them, same as always. Within a few
minutes she had vomited and then they found the chewed up pill bottle. Scattered
around the bottle were large white aspirin-powdered pills. Baclofen. The label
was so chewed up that we had to use the pills and pharmacy information to
identify them. The bottle was filled for a 30 count. 13 remained. As the
technician called Pet Poison I debated her degree of consciousness and whether she
was awake enough to induce vomiting. She was not. Sophie had dried bloody,
thick, taffy-like saliva and vomit in her mouth. I tried to clear it. It was a sticky-spiderweb
goo that left your hands incapable. Sophie was placed on the x-ray table. She
had a huge distended stomach full of,,,, well, seemingly dog food and pills. We
whisked her to the surgery table, quickly intubated her and provided oxygen to
her purple lips and tongue. She was slipping into a coma. Four people, two of
them veterinarians, swarmed around her tiny new body. We placed a stomach tube.
We lavaged the stomach contents in a desperate effort to remove as much pill-peppered-ingesta
from her stomach as we could. The clear plastic tube sucked out tan kibble speckled
with white powdery-pieces of pills. She gagged once, whimpered once, and lay
lifeless for the rest of it. I gave her intermittent breaths of oxygen and told
her that I was sorry. I told her she was loved and I watched the staff so
desperate to help and so foreign in this act of emergency procedures. Sophie gathered a crowd and I barked orders to try to turn a tide I knew we were all
likely to drown within. I called the hospital manager down. I told her to call
all of the rest of my evening appointments and tell them we were swamped with
emergencies. “Offer to reschedule, (knowing this never works), and ask them to
be patient if they don’t want to. Go in all of the exam rooms, (I knew all 7
were filled with people waiting for us), and tell them the same.” I put her on
the reception desk and pulled the last two techs to the back treatment area.
For three doctors we had 8 technicians scurrying. We also had 17 patients in
our building, 7 wanted to crash and expire if you blinked.
I got on the phone with a veterinarian from the Pet Poison Helpline. He
was slow spoken, jovial, and the calmness on his side of the line was re-assuring
and yet vexingly annoying. “Baclofen is a common toxicity. Have you had one
before?” There it came again, “No, I am not an ER.” ‘Don’t kill the messenger’
and ‘be nice.’ I said to myself. He is here to help me. (Does he know that I have
7 other animals trying to die around me?).
“Baclofen is a muscle relaxant,” (yeah, I can see that). “It
has a very narrow index of safety in dogs” (Like 1 pill? How about 17?). “Unfortunately,
(never want to hear a sentence start with this), most dogs, if they survive,
(never want to hear this either), need supportive care for 72 hours to up to 6
days. Many need to go on a ventilator.” (Crap, who has a ventilator? Only the veterinary
teaching hospitals, I thought). I kept
going. We kept lavaging, hoping, and telling her that I loved her with a gentle
pat to her head. I stroked her ears in between her oxygen bag compressions. If
she was going to slip away it would not be without my whole heart and soul going
with her.
Over the next hour we tried fluids and desperate attempts to
stabilize. She was the last patient to leave the hospital that night. I called the local
ER to refer. “No,” they had not had this toxicity either. “No,” they didn’t have
a ventilator, but, “Yes” UPenn vet hospital does. They had sent a patient last
week. Estimate given for this was $18,000 to $30,000. OMG Crap.
I look back on Sophie and I want to cry. I want to be upset
about how many times pets get into things we think that they are smart enough
to avoid. I want to put up billboards to say, “NO! crate training is not
punishment. It is the safest place for your pets to be.” My pups are 4 years
old. They are my children. My most beloved. They are also raccoons in
autographed collars. They will get into everything if I turn my head for a
second. They are trouble. I know that. They are crated when I am at work. They
are in a cage at the clinic. They are in a crate in the bedroom when we go out
the door. I don’t care if it is 5 minutes or 5 hours. They have been raised
this way. Every pill bottle in this house is double locked. A bottle in a
closed drawer. Never, ever is it out. Have you ever shaken a pill bottle next
to a pet toy? It’s all the same inviting tune.
In a sea of crashing waves, tumultuous and treacherous, I
will never forget Sophie’s face. I will never forget that yellow pill bottle
with its perfectly intact child-resistant white top, labeled as such. Tattooed with
its cursory; “push-down and turn” orange letters. Shrapnel-ed bottle, completely
missing any recognizable bottom, or rounded edges. The label chewed, swallowed
and obliterated in casual terrorist fashion.
Sophie was sent to the ER at 830 pm. She was transferred
without her breathing tube. She coded overnight. She never regained
consciousness.
I hope that she heard me. I hope that she knew she was
always adored. I hope that she forgives as much as I hope I can forgive myself.
Maybe I could have/should have used warmer water in her lavage? Maybe I should
have done it just one more time?
My Raffles,, on our daily "dog" walk
Maybe forgiveness holds as much power as intentions? Maybe
peaceful acceptance maintains the balance?
Maybe the other 6 will survive. Maybe I am an ER, if only in
sheep’s clothing?
That’s what I remember most vividly. There was still a big
cardboard tag, the kind that keeps you from being able to fit the merchandise in your pocket
as a theft deterrent device, still attached to the obviously brand new toy she held so proudly in her mouth. It was the kind of tag that allows it to be hung on
a rack for easy display whilst also providing the descriptor that announces the
features of the toy that your pup might find most exciting and enjoyable. The
colorful cardboard backing to allow plastic ties to prop up mouthpiece rope
from the stuffed animal body and prohibit easy pilfering. That tag was hanging
out of one side of her mouth as she clung to the beloved toy that dangled from the other. Toy and tag in tandem swinging from one end of her while the other wagged tail so hard it
made her bony hips hula.
Her name was so endearing it made me stop to smile. Her
name, a blossom in springtime, a flower in the glimmer of an eye, the baby of a
movie star who wanted to be cool and still maintain cute. I’ll call her Honey.
She was bright-eyed, exuberant, bubbly, bounding and exploding with joy to be
around people. She is the lab pup every Labrador-lover dreamt of. She is pure
love and kisses in your face the minute she gets close enough to steal your cheek
unguarded. She is the reason I became a veterinarian. She is the reason every
pet loving person grieves for decades when they lose their beloved pet. She is
perfect. BUT, she is also old. 11 years old to be exact. She has not been to the vet in
many years and her very dapperly dressed dad is sitting quietly in his designer
loafers without laces, cross-legged in pressed, creased herringbone tweed
pants. Where Honey is outgoing and energetic, he is stoic and reserved.
There is a foot of snow on the ground outside and every inch
of landscape is slush and snow. I look at his buff-tan-kidskin leather loafers
and wonder how he got from his car to our exam room on this yacht shoes missing
soles. I look for an assistant who must have carried him in, knowing Honey
wouldn’t have permitted an easy passage and yet he shows no sign of snow or
wet.
I sit on the floor next to Honey and she cuddles up in my lap immediately.
I am here in this room with them both, on the floor embracing Honey and delivering the hardest conversation I ever have to be present for.
This is Biscuit.. she reminds me of Honey. I adore this girl,, and she knows it
I look at Honeys overdressed dad and say, “I’m sorry but the
veterinarian doesn’t feel right about this.” He is quiet, his eyes narrowing
and his composure tightening. He is waiting for me to dig in, and I see him returning
the favor.
You see Honey is here, brand new toy in tow, wagging, happy and excited to be with us, to be euthanized. Her dad is here, holding her tight on a short leash, stoic, reserved and yet determined to make this a one way trip for her.
I go on to say; “We have a terrible problem with burnout,
suicide and mental health. I do not force anyone to do anything they don’t feel
right about.” I let the words fall around him hoping they landed softly enough
to allow a crack in the façade to let the light in just a little bit?
I waited. I stroked Honey’s head and whispered a mental “I
love you,” knowing I would likely never see her again.
These are the moments of the days of my veterinary life I
despise. The moments that remind me to be brave and stay true to my heart,,
even if I am alone in this.
I was the fourth person to enter this room with Honey today.
The first had been our vet tech who had placed both in the Comfort Room as his
appointment with Honey had been scheduled as a “QOL” exam, short for quality
of life. We do not book euthanasia appointments with out a veterinarians
prior consent. This is not a slaughterhouse. You do not drop off to pick up
remains later. We are a family who loves pets as our own family. We take this request
as a discussion and a decision not lightly agreed upon. If pets are truly property
there is no conscious of grief to surrender yourself to. But we all know pets
are so much more than this to all of us. We know that they are our truest
friend. Our most adoring confidant, our reason for early wake-ups and long
walks. When everything else in life seems questionable and unreliable your pets
will remind you they are your constant. We don’t need much more than the belonging
they inherently give us.
The technician came back to the treatment area to report
that Honey was walking well, seemed happy as a lark, was carrying a toy to show
us how delighted she was to have it, and that she was deeply concerned that Honey looked
A-OK. She couldn’t imagine what kind of quality her dad was in search
of. Honey had bounced up to her, thrust her toy in her face, dropped it to the ground
and planted a big wet kiss on her face. The technician was smitten with Honey.
The second person to enter the Comfort Room was the
veterinarian. In less than a minute Honey had given her the same welcome, and
after a brief exam it seemed that Honey had aging back legs and might benefit
from an analgesic and NSAID. The veterinarian also offered to run some routine
diagnostics and see if we could provide some options to help improve her quality
and spare her life. A discussion ensued about cost, benefit, possible side
effects, and after a few moments Honeys dad said, “the family has decided. We
are ready to put her down.” It hit like a blow. The veterinarian countered. “Would
you consider surrendering her?” He nodded, she left and the office manager
entered.
In the bowels of the hospital the staff gathered to hear
what the veterinarian recalled. “He’s going to sign Honey over to us. Call
Heidi, see if she will come down and meet Honey.” We started to make plans to find
Honey a new home, and we started to draft a list of diagnostics to run to make
sure we knew what Honey had going on inside. The techs were excited, bustling
and congratulating each other on their interventional good deed. There was a
levity that spread, it was hope packaged in healing hands and warm hearts. It
is the lifeblood that feeds the marrow of a place like this. It is the small miracles
that fill our long days with purpose and stories and the passing of intentions
into matters that build our souls and fill our sails. For a place like our
veterinary clinic it is the small wins to help make the inevitable tragedies
more palatable.
A few minutes later the office manager came into the treatment
area. We all knew by her quiet entrance that the news was bad. “He won’t surrender
her.” The girls begged for a “why!?” She replied; “He doesn’t want her to be with anyone
else.”
None of us could accept it. They all argued with how the
hopes had been dashed so quickly. Had she asked the wrong question? Had it been
lost on him in translation between a vet and a manager? Should we send the vet
back in?
The girls suggested alternatives to save her life, spare her from being disposed of so coldly and unconscionably, ..
“Can’t we just say we euthanized her? He doesn’t want to be
with her anyway?” The first option they threw out.
“What if we only give a little bit of the solution?” Like adding a splash of water to the euthanasia solution might dilute it to the place where it wasn't effective.
Desperate pleas for a desperate place.
There were no answers left to offer. We only had one choice
left.
Honey's dad wasn't going to let her have any other option than the one he walked into our door deciding she deserved. These places, these cases, these are the ones that kill you. For some of us, literally and completely. They destroy lives that care and our ability to care again.
I looked at the other veterinarian. She looked back at me.
We both didn’t want to be the other persons answer. The mirror of responsibility
to the staff who always had their hearts on their sleeves and worked so hard to
just be a kind heart to a pet in need. We didn’t want to put the other in a
place of heart-wrenching decision making.
“I can’t do it,” she said. “I just can’t.”
I looked at the office manager. “He is not going to
surrender her.”
That left me. Alone, and with a Honey of a problem to reconcile alone.
I walked into the room with Honey. The fourth person she
brought her new toy to. The fourth person she was as excited as the first. I
sat on the floor, she flopped, toy in tow bouncing with its cardboard tag alongside
her tongue into my lap.
I whispered silently to her longing eyes of love, “I love
you.”
Honey is not alone. She has me rooting for her. Alone in a
quest to remind her father, her family, whoever, that there has to be compassion,
even in times of mercy, and we have to remember how precious each day is and
fight for our chance at seeing tomorrow with love, hope, and kindness in our
hearts.
Honeys dad tried to argue our stance. He made phone calls,
he stood fast in his decision. When I cam back into the room some minutes later
I handed him two bottles of analgesic hope and a paper that said Honeys
treatments had been on the house. I added that I hoped it help her feel better
and that we were here if we could help her again.
I extended an olive branch of defiance. I stood by my staff
who would have been balling and questioning my cruelty had I chosen Honeys family’s side. I stood by being kind when it wasn’t
the right thing for me to do for her family. I stand here now not knowing if it
was the right thing for Honey, and why I should be asking about it being
anything other than that.
Here's more on Honey's case;
..and so the question remains? What would you do?
I posted this story within a few days of it occurring. I had to find a place to put the heavy heart I was carrying. This job, this heart on your sleeve, and this degree of emotional investment has a cost.
Three months later (to the day) we got a phone call. Honey was still alive and her family wanted to surrender her to us. We were blown away, excited, and relieved. We just didn't know what condition she would be in. We knew that her dad had been back once to buy more analgesics for her. He also wanted to surrender the other dog she was with. (WHAT!? Another dog)? We said yes!
Honey with her new friend Emma, on her first day in rescue
After I posted this blog, and the follow up news, the local social media pages blew up with stories about these two dogs. Here are some of the excerpts;
Here is the place Honey spent most of her life. I have heard from multiple people that she was either locked up in the cage outside or in a crate in the garage.
I want to reiterate that it kindness to bring her to us. To surrender her took effort and compassion. I am going to hold onto this.
Cats with a urinary blockage always need to be addressed as an emergency. Unless you have experience with this condition before almost all of these patients arrive at the clinic as an emergency. Most commonly they have been blocked for some period of time and this leads to a higher likelihood of either bladder rupture or toxic changes to the heart.
Beau. Blocked three times. $8,000 for two ER trips, then he found us. Third block and a PU surgery; $1500 on a payment plan.
I have to recommend that you go immediately to a vet if you suspect that your cat has a urinary blockage. I also have to caution that most clinics either refer to the local ER, or, charge a hefty price to treat this.
Please go back to the first blog in this series now (go here) if you haven't read it already. The first chapter will define what a urinary obstructed cat looks like.
The singular goal of this is to get your cat out alive. If you are like most of us you live in financial constraints and your cat is a vital, beloved member of your family. The profession knows this, and the profession has profited greatly because of it. We know you love your cat, and we know your cat is going to die from this, soon, if you don't cough up the admission fee for us to treat it. It's the culture of the American way. Make as much money as you can from wherever you can. Ask yourself how you are a part of the problem and then ask yourself what you are doing about it. Sure, I am disappointed in my profession for killing so many treatable pets, but, this is the world we all decided to emulate. Every rich person has profited from the misfortune of another. Medicine should be the neutral, sacred territory. It isn't.
Here is my professional advice, as a veterinarian of 20 years, on getting your cat out alive when they have a urinary obstruction (aka a blocked cat).
Tips;
be nice
be honest
be insistent
be ready to challenge every interaction
never lose hope
never walk away without knowing that the only advocate in your pets life is you
be willing to surrender your cat if it means it might save their life.
ask for help from everyone. Build an Army around your cause and then help pay it forward. If you find a way to get out alive pay that forward to someone else. The current practice of blocked cats in almost every ER setting is so expensive it is forcing most of these cats to either suffer or be euthanized. There are only these two options. Why is it that we allow these cats to go home and die a horrific death of suffering? or shame you into paying for something that has such an incredible mark up we lose the ability to heal?
If your cat is demonstrating any of the clinical signs listed in the first blog on this (see here) then you must bring them to a veterinarian.
Start with the exam. Blocked Y/N if YES, then ask for a written copy of the exam findings. Immediately. If the staff or vet declines, ask them to give a verbal description using the form provided below. Do not leave your cat without this. You should always have a copy, or have documented a detailed list of what has been done for your cat and what you have consented to. This is very important to help manage your cAts care and the expense associated with it. A blocked cat should be diagnosed by physical examination alone. The cat will often have a painful bladder that is hard, large and unable to be expressed (able to produce urine). If you sign anything ask for a copy of it immediately.
From the initial examination an estimate is given for the expected, or recommended, treatment plan. Here is the first place that negotiations should begin. Here is the first place where I recommend that clients challenge the options being presented.
Next;
Is the estimate is affordable? IF YES, (your cat is blocked) and the estimate/deposit required is affordable walk away. Sign paperwork, get a copy, and walk away. Your cat is in good hands, and the safest place they can be. The veterinary clinics are set up to provide top tier medicine and provide appropriate treatments for the worst case scenario. The problem is that most people cannot afford this, and, in almost all cases you are charged for worst case scenario treatment even though most cases do not require them to be successful. The veterinary clinic benefits greatly by being prepared to treat your cat as the worst case scenario outlier even though most are not. No client should have to pay for Gold Standard care if the case does not need it. Further, if you cannot afford the first estimate you should be permitted to be given the treatment plan tailored to your cats needs at a price you can afford to get the best possible outcome. THIS IS NOT BASED ON THE AMOUNT OF TIME YOU CAN AFFORD, BUT THE CARE YOUR CAT NEEDS. I recommend that your cat stay on iv fluids and with a urinary catheter in place for a minimum of 3 days. Your cat should stay in their care until urine runs clear. Your cat decides the length of stay,, not the hospital. They should do the following; full blood work. ECG, abdominal radiographs, do ultrasound, do urine culture and sensitivity. Provide analgesics, appropriate urinary diet, appetite stimulant, stress free housing. The cost of this at a specialty hospital with ER has been reported as $6,000 up. Reminder; your cat has a chance of re-blocking. I.e. you and your cat may be back here again, soon. Budget accordingly.
IF NO;
If the estimate is not affordable; No? Everything from here is based on budget and time. The house decides your cats prognosis based on your budget. The smaller the budget the less ideal the care. Why do they get to decide that?
If blocked and you cannot afford the estimate; ask for all of the diagnostics to be declined before cutting the in hospital time. If the hospital will not do this ask to see the manager. Ask for the reason in writing. Do not leave with out this. There is this incorrect notion that vetcare is a one way street. We tell you what to do, and how much it is going to cost and you either pay or you hit the road. It is not the case. Veterinarians can decline to treat, but they are expected to give you a place to go for care. You can decline line items. You can ask for written prescriptions to fill elsewhere, and NO they cannot charge you for this. You can decline all diagnostics and ask for your cat to be unblocked. You can even decline pain medications, although I strongly disagree with this. Unblocking your cat, providing fluids (even in the case of a fluids kit you bring home to provide SQ fluids at home) is an option. Taking your cat home after they have placed an iv catheter and a urinary catheter is your right. In cases where the cost of care is so high I recommend that you tell the vet that you are transferring your cat to another clinic and they they be transferred with BOTH the urinary and i.v. catheter in place. I know of many (in fact I know of only 1 case where this was provided). In all other cases the specialty practice pulled BOTH catheters and then sent the cat to me. I had to replace both and this was detrimental to both the patient and the client. IF you paid for these you own them. Remind the practice this after you pay. (See form below).
If you cannot afford anything ask for a cystocentesis to remove as much urine as possible, go home find a general practitioner who will help. Call every rescue, shelter, veterinarian, put out a social media plea. Start a fund raising campaign. Offer to surrender your cat. Any person who refuses to surrender their cat appears more interested in ownership then compassion and the life of their pet.
<$500; exam, comatose cats can be catheterized without sedation or analgesia. Take a video of how your cat presents to the ER. Ask if sedation is needed? If not it should be removed from your invoice. place urinary catheter ask if you can go home with sq fluids kit and urinary catheter in place. The act of placing a catheter is traumatic to the urethra that is already not functional. Placing and then removing before the tissue has healed is problematic, if not further worsening the cats prognosis.
Decision Tree;
blocked -> Yes, AND I can afford the suggested treatment plan., sign forms, get copy, go home. See you in a few days. (Warning patients can re-block in days to weeks).
Blocked-> Yes, BUT I cannot afford first treatment option provided; I would like to decline all diagnostics to have a urinary catheter and iv catheter placed, and at least 3 days of both with in hospital care.
Blocked-> Yes, not enough money for multiple days iv fluids and urinary catheter treatment, then place both and take home. Find a vet who will help at an affordable price. Give this directive in writing. If your vet pulls the catheters after providing written or verbal directive see your State Veterinary Board and file a complaint.
Blocked-> Yes, cannot afford urinary catheter or iv catheter, decompress bladder (place a needle in the bladder and remove as much urine as possible. This will buy you a few hours to find a vet who can help. (Find me in Jarrettsville Maryland, or Denton County Animal ER in Denton Texas).
I, ________________________________________, authorize care for my cat __________________ to relieve his urinary obstruction in the most affordable means necessary to provide him immediate relief. I authorize pain management be given to him in any and all options possible including a written prescription that I can fill elsewhere. I understand that this may include declining best care practices and recommendations in an effort to help manage funds to allow him the best chance at cure/survival based on unknown future factors that might influence his healing and prognosis.
I request all medical findings be provided as they are done and before other treatments are provided.
I request that if a catheter is placed (intravenous or urinary) that I be notified and offered the option to decline either, or any, be removed so that I might be able to transfer my cats care elsewhere.
I understand that my cat has a very serious, potentially life threatening condition and that by declining treatments, and treatment options I may be worsening their prognosis.
I understand that my cat has options for care. I request that decisions be made with my consent and with all options for care, and subsequent treatments in an open, up front, transparent manner. I request that more than one option be provided at each discussion.
I understand that euthanasia is my option at anytime. I understand that declining this as a case of economic euthanasia as a treatment option is also at my discretion.
I understand that denying care based on this document might be considered judgement, prejudice and impact my cats life. I understand that I am responsible for paying for his care and consenting with honesty and integrity is both parties right and responsibility.
I request the name of the veterinarian caring for my cat at all times to include transferring care should they no longer be on duty. I request this in writing at each transference of my cats care while he is here.
I request the name of the entity, or responsible party employing this veterinarian. I request this in writing at the time that I sign to consent of care for my pet.
I understand that my behavior is my responsibility. I will remain courteous and available for questions and discussions about my cats care.
I understand that the most important part of my cats treatment plan is to relieve the obstruction and provide fluids. I request that fluids be offered in anyway possible to allow me to care for my cat. I request the ability to take home an fluid bag to include the appropriate iv tubing and needles. If you cannot provide this I request a written script to purchase it elsewhere to include my veterinarians office, or an online provider (including Chewy.com).
If I cannot afford to hospitalize my cat based on the written provided estimate given to me, and signed by me then I request he have a cystocentesis to remove as much urine as possible so that he can be transferred to another provider. I understand that this is not without potential adverse consequences and I have consented to these with an understanding that my cat might die from any and all procedures and any and all treatments.
I am asking for assistance in providing the best chance possible to my cat surviving this disease with the limited funds I have.
If possible I will relinquish ownership of my cat to get him the care he needs to survive.
I am grateful for your time, your medical skills, and your compassion as we try to save our cats life.
Sincerely, __________________________________________ (write and sign your name)
Raffles and Birdie
Please note this is a guide. I am not a lawyer, and I do not provide legal advice.
For all of the documents veterinarians give to pet parents requesting signatures to authorize care it is time that pet parents start to advocate for their pets and find a way to get them out alive. All of those of us practicing medicine with our patients at the epicenter of care already practice this way. We already offer any and every option to keep these family members with their families.
.jpg)
.jpg)
.HEIC)
.jpg)
