Thursday, June 8, 2017

"It's Not My Cat Either"

Seems that many people believe that every stray, hurt, or unwanted animal is the vets responsibility. It's as if everyone in the community believes that we have signed some imaginary contract, or make some voluntary pledge upon graduation, to the neighborhood we hang our shingle in that we are the local receptacle for all things four legged in need.

Mystique and Cy.
Both are at the clinic now and in need of a home.
I suppose many would say that I did it to myself. That when we at Jarrettsville Vet began taking on these forlorn creatures who had no other compassionate options elsewhere that we were opening Pandora's box and inviting the perception that we are also a shelter. What else was I supposed to do? If I can help I feel obligated and compelled to do so. And so we do. We try very hard to do as much as we can. But when you crack the gates you should be prepared for the flood to follow.

We are now getting calls from loads and loads of people. It was intended to be a safety net for our patients and clients but has become pleas from friends of "friends", shelters referring anyone and everyone, and even other vets referring their financially strapped clients to us. It becomes unmanageable. We simply do not have room for them all. Worst of all too few people who find pets and say they are "trying to help" really want to make, take, or provide any meaningful help. They want to think and feel like they are "helping", but it can't "cost them anything," and they "can't really do anything." If you don't shoulder the burden of this needy pet and thereby remove the guilt from their eyes they too often become angry/unkind with pointed fingers and blame insinuating that somehow we retracted our obligation to be the safety net for societies furry citizens.

Angus.
Also in need of a home.
"I found this cat near my house. If I didn't take her inside the foxes would have eaten her. (Client then takes out ipad to show me pictures of said fox). She's not my cat. She's a stray. I can't pay for stuff that isn't for my cat. What if the owner comes forward after I spend all this money?"

It's a sales pitch. A way to clean the palate of impending doom. She came prepared with slides and a business plan. I am the skeptical Philanthropist. Between us sits a tabby cat contentedly sleeping.

"OK, let me get this straight?" My first words to the prosecution begin as;
  • "She is, or, is not, a stray? You seemed sure that she was 5 minutes ago when you gave me that long winded description of living far away from everyone (hence the circling foxes), and the only place she might have come from was one of the many farms with barn cats? But you don't want to ask the farmers if she is their cat because they won't know?"
  • "And you don't think you should have to pay for anything because she is not your cat, although you are willing to give her a home once someone else pays for her vaccines, spay, FeLV/FIV test, fecal exam etc.." 
  • "She's too nice to be put back outside as you fear she might become "fox bait" which would be on my conscious because you are the Good Sam kind hearted person and I am the person screwing you out of the money you shouldn't have to pay to fix someone else's cat."
Debate begins about presumed ownership of said nice cat...

"It's not my cat," her.
"It's not my cat," me.
"Well, it's not my cat either."

"She was at your house. She is in your carrier. You want to keep her if I perform everything for free, (or some significant capped fraction of what it might cost), and then you want her to be your cat?"

She volleys back; "It's not my cat."

Eye roll,,, (I don't think she saw it).

I pack up. The verbal arm wrestling will end with a retreat.

Monica.
Looking for a home now.

The dilemma revolves primarily around the fact that this self proclaimed Good Samaritan adopted a cat from us two years ago for $100. At the time of her adoption she was spayed, vaccinated, microchipped, tested and dewormed. She expects the same deal with this cat.

"I'm sorry it doesn't work like that. You can surrender her and we will have one of our rescues find her a home. You can bring her to the Humane Society. We can give you a payment plan to help space out any charges her care might require. Or, we can give you information on low cost spay and vaccine clinics." These are the options I provide her.

"No, I'm leaving,,, (pointed finger in my face, yelling and the "you're screwing me!" statement follow),,, "I'm going to dump her at someone else's house." She grabs the tabby from her slumber and puts her in the carrier. Opens the exam room door and starts walking out the front door. 

"That's horrible and illegal!" I blurt out in shock and incredulity.

She leaves the clinic angrily after making a scene to anyone present in the front office.

Twenty minutes later her very elderly mother calls me to berate me for "making her daughter feel bad. Not giving her any options, and punishing her for being a Good Samaritan." Grandma reminds me that she has "been a long time client who spent thousands of dollars here over the many decades she's been with us. She will not be back."

"Music to my ears." ( I think she hung up on me before she heard me).

.... and now I lose sleep at night with worry that two cats are in peril because I preferred to not feel taken advantage of than help them. 

Joey.
Monica's brother, also in need of a home at JVC
I want to write her a letter that somehow shifts the guilt and blame back on to their shoulders. I want to throw a temper tantrum like a disgruntled two year old in the off chance I feel better afterwards... But, I don't. I let the days go by. I try to see it from their side? But, all that happens is I feel worse and I fear more that the cat is being torn apart by foxes,,, screaming for her life.  I try to hold a tiny bit of faith that the sweet unwanted cat can win over her angry, manipulative, sorry heart. Lord knows I couldn't.

There are some games that you play with some people you cannot win. In these games you try to walk away at a draw. In vet med the pet always pays when you do. The vet always knows this. There is a time when you have to choose who to abandon. Your ability to be profitable, your setting precedence that puts you right back here in the same predicament next week, the pet, the person, or the grief you sleep with every single night. The grief that makes you want to vomit from stress on the drive into work the next day. You have to choose who to walk away from. I promise you that in every single scenario like this every vet wants to chose to walk away from the person. It is never, ever, the patient, and too often instead we chose to walk away from ourselves as the easiest, least publicly visible painful option. 

Another JVC kitten up for adoption
Many Thanks to the people who make JVC such an amazing place. We are surrounded by so many generous people. The people who help adopt, foster, and share the posts of the pets seeking second chances, recovering from disease, illness, accidents, and misfortune. Without you we wouldn't be possible, and these miracles wouldn't happen.

...and please be kind, to your pets and the people who work so hard to keep them safe and healthy.

Related blogs;

Compassion Fatigue

The Holes In The Safety Net

Pieces Of Me

Ethical Fatigue

For anyone with a pet, anyone who loves, or has loved a pet, and anyone in search of helping others with pets I hope that you will join me at Pawbly.com. We are a community driven platform designed to help pet people by empowering and educating them. It is free to use and join.

Please also visit me on the other social media places I frequent; YouTube, Facebook, Twitter @FreePetAdvice our clinic site JarrettsvilleVet.com and the clinic Jarrettsville Vet in Harford County Maryland.

Thursday, June 1, 2017

What Gets Swallowed Must Go Through,, Or Else... Foreign Body Obstructions.

This is a blog about foreign bodies.. This is a blog about saving lives at the precipice of death.

This is also a blog about Levi.. He has been a source of my writings before. He is one of those patients who teaches you, tortures you, and reinforces where medicine diverges from sentience.

Levi has not had the best of luck. He was given up by his first owner because "it was cheaper to get a new dog without a problem than to treat his epilepsy." We parted ways permanently and with sincere words of disappointment and I kept Levi.

Levi found his real parents a few weeks later. They have been inseparable and in love since... but,,, the seizures have required medications which produced polyphagic mania. Levi has become a voracious counter surfer, toy eater, and frequent flyer for pancreatitis and induction of emesis. He has been to the ER or us for eating two loaves of banana bread, 6 loaves of sandwich bread (in plastic bags), two sleeves of gauze, a ceramic butter dish, and numerous other less disastrous close calls.

He is an excellent example of the meat of this blog.

Levi
In my experience the foreign body dogs fall into one of three categories;

1. The "OCD needy" type. The dogs who are inside, with their people fully integrated into their family unit. Often a single female who bonds so closely to the dog that the dog can no longer deal with anything without her, see also separation disorder, OR, the embedded family dog with the busy active lives, the dog thinks of themselves as a human child (because that is the only reality they know) and can't deal with them being out of the house for any reason including school, work, social life. These pets eat their way out of the stress of being alone. Labs, Border Collies and German Shepherds are over represented in this category.

2. The "keep my mouth busy because my body isn't" pets. There is no exchanging exercise and tiredness with indoor activities. All dogs need the outside, their nose in the dirt/grass/leaves/sidewalk, brain chugging away on primal sight/smell/touch/sensory experiences. This is a core part of their being. If your current daily regimen isn't getting you the desired results change it. If your dog is chewing, biting, stressing, needing, whatever and they are inside the majority of them time get outside (with them (this is imperative)) and let them share their life with you.

3. The "demons inside of me make me do it" pets. Drugs, stress, fear, paranoia, imbalance, pain, gi discomfort, etc., are all reasons that dogs eat things other than their food. Do not ignore this group. We know that pain can be inside, hidden from view, and that many of these pets live with chronic pain and/or disease that manifests as chewing/eating/ foreign body ingestion (this can also include hair, wounds to the body, and pica).

Some of my gang in the sunshine
I have a long list of questions to ask owners when I get a pet in the clinic with a affinity for eating/ingesting items that are not provided to them in their food bowls.

There should be a long discussion with your veterinarian the first time (and even longer discussions with any subsequent infractions)  your dog eats something that is non-sensical.

Levi arrives for surgery
In past blogs and videos I have mentioned the previous pica items that I have seen pets eat (see my blog about tampons, underwear, rocks, toys, balls, nuts, and even endless yards of Berber carpet which is a beast to surgically remove from intestines (it sort of melts and snakes through yards of gut making it almost impossible to extract). I find this behavior most commonly in larger breed dogs who are primarily inside and often younger versus older. I think there is a very strong correlation to obsessive-compulsive disorder, boredom, and behavioral problems. I am not saying that every dog who eats a sock, or other random non-food item needs a psych evaluation but I do think that every person involved in the pets life should at least be thinking about what their pet is trying to tell them, and why they are eating things that are not food. (P.S. an older dog who starts eating random non-food items is trying to tell you something. listen. dig. figure it out.)

The other group of indiscriminate PAC-MANesque pets are those on anti-seizure meds and steroids. These guys are driven by the drug that makes them voracious eaters who will eat a blanket if it even smells like it had a crumb hiding within it. Ask Levi the epileptic who ate a whole ceramic butter dish, lid included. (When we induced vomiting in him he spit out a collection of ceramic rubble akin to an archaeological dig... had I known what it would have looked like on the floor I would have thought twice about all the jagged ceramic edges transiting his esophagus AGAIN on the way up).

Doesn't anyone but me ever wonder what possesses them to eat these things?
Levi's catheter conundrums.
When you have had i.v. catheters placed as many times as Levi has
you surrender to the process and your veins are impossible to access.
When you bring up the discussion with your vet please make sure to be discussing the following items;

1. Diet. I always want to know what specifically you are feeding. This includes the dry food, the wet food, and the snacks. I want to know every item that you are putting in your pets mouth. Treats count! If you have a pet with an oral fixation on food they may become compulsive about always eating. You have essentially trained them to be constantly rewarded with food. Breakfast and dinner and play, love and exercise in between is the ideal way to spend the day. If you are feeding a deficient, substandard diet your pet will seek food/nutrients elsewhere.

2. How much exercise your pet gets? How much of it is structured? By this I mean is it a regularly scheduled daily event? Does the breed of your dog have an activity level that meets their needs? I often find that many house dogs are being asked to live a lifestyle that is too sedate and placid for their mental stability and health. Having a fenced in yard does not guarantee that your pet is actually out AND exercising in it. Please try to take daily walks of a measured distance. It is a wonderful activity to bond with your pet, provide enrichment and help both of your cardiovascular systems.

3. Stress. When I say stress for a pet I am talking about anything that your pet might find disconcerting. Not what you and I think about as stressful, but rather what your pet might see as stressful. Is there a change in activity in the house? Are their new or different noises? Or anything that their highly sensitive noses might be detecting? What about their super perceptive bionic ears? Or is anyone in the household upset? New neighbors? New family members? I know it is hard to try to think like your pet, but often they are picking up on something that is very disturbing for them and we are completely oblivious to it.

4. I often have my clients keep a daily journal of every aspect of their pets day so we can go over it together and try to identify any sources of any possible reason that their pet is now chewing on the furniture , or swallowing the items they find in the trash bin.

5. The "pacifier" dogs . These are the pups who we provide treat-stuffed-toys, bully bones, antlers, chewies, (etc., etc.) to in the hope we can keep them 'busy, 'quiet' 'entertained' for a few hours. Dogs with a high chew drive, or, those who have been repeatedly "pacified" by being given a treat when they are demanding attention are taught to be acquiesced only by chewing.. When the chewing leads to ingesting these items they can become deadly.

Levi post-op, I know he feels better already.
Levi  was actually seen swallowing his toy. His parents knew it went down. They couldn't believe how huge the toy was, and that it could have even been swallowed. I can't tell you how many times I hear this! I have seen whole towels, beds, toys, golf balls, tennis balls, walnuts, and cutlery swallowed in one fell and fast GULP!. Since then he had a decrease in eating for a few days, persistent vomiting, lethargy, and general malaise. His belly seemed painful and his x-rays showed something in the stomach,, even though we were all fairly certain it wasn't food.


The size, material and amount of time since ingestion all matter.

If you know your pet has ingested something other than their food it is best to do the following;

1. Call your vet immediately. Ask for guidance on what to do. They may advise that you;

2. Call the Pet Poison Helpline. Although there is a cost associated with this in some cases of toxin ingestion the information they provide you and your vet is well worth it.

3. Induce vomiting. Only do this after confirming with one of the above.

4. Watch and wait. If the material is able to be broken down by the stomach or small enough and benign enough to pass through the gut you may never see it until it is defecated out.



Any sign of the following indicates an immediate trip to the vet or ER;

1. Vomiting that is persistent, intractable, or producing material that is stuck in the mouth. Vomiting of more than 4 times, or, lasts longer than 3-4 hours, or consistent over more than 12 hours. (These are my guidelines). OR, if your pet is acting quiet, lethargic, depressed, seems distended in the abdomen, or is trying to vomit but not producing anything.

2. Straining to defecate and not producing feces, producing scant amount of feces, or there is material protruding from the rectum.
Levi's stomach is full of...
well, that's the fun of exploratory surgeries in pets.
You never know what you are going to find in them.

DO NOT PULL ANYTHING OUT OF ANY END OF YOUR PET! If you pull and tear something it could kill your pet.

This came out of the back end of Levi on the same day that  we removed his toy from his stomach.

This is the toy we took out of Levi's stomach.


When I examine a pet for a suspected foreign body I start with the following;

1. History: Many of these pets are repeat offenders. Serial swallowers. The first time it happens I go over all of the above information so that it never happens again. You can either decide to stop wearing socks, underwear and using sanitary products, OR, cage your dog when you aren't supervising, OR, don't train your dog to be a chewer. Every client with a chew-swallow dog knows they have one.. don't create, perpetuate, or hope the problem away. Or, buy pet insurance.

2. Exam; I know no one wants to go to the vet every time you fear your dog swallowed something they shouldn't have,, but, your vet can tell a lot about your dog based on an exam. I was called out of bed at 1030 pm to check on a dog who vomited up a sock and undies. Based on the exam I felt pretty comfortable he wouldn't need surgery that night. Which saved her about $2500 at the ER. "Has your dog ever eaten socks before?" I asked. "Yes, all the time," IS NOT what I want to hear at 1030 pm. He threw some of them up at 1 pm, has been lethargic and vomiting all day and I get called panic stricken at 1030 pm? "It's time to stop wearing socks and panties, cage your dog when you aren't there to supervise or get pet insurance. I'm going back to bed." About $50-$100

Exam for a blocked dog usually has the following; history of ingestion, painful abdomen, distended intestines, elevated heart rate, elevated respiratory rate.

3. Radiographs are the cornerstone for confirming a suspected foreign body obstruction. Start with a radiograph. Based on history, exam and radiograph you can try to manage conservatively with fluid therapy. Start i.v. fluids as quickly as possible. In some cases the fluids will help relax and restore pliability to the intestines and allow the obstruction to move through. Additional radiographs should be taken to confirm this. This is the conservative, avoid surgery (and cost associated with it) plan. Expect to pay about $200 for radiographs per series. Usually a few series are needed a few hours/day apart.

4. Ultrasound can be used to help confirm a suspected foreign body. If you can afford ultrasound make sure you can also afford surgery. About $200-$500.

My preference is to understand and discuss the best and worst case scenarios and keep the end game in mind as you manage the financial resources. If my client can only afford surgery we start there. Worst case scenario is that the patient needs surgery to survive this. Spending thousands of dollars to confirm this and then running out of money when you realize this is.... unethical, unimaginable, and happens far too often.


After about the third or fourth time going into the abdomen to cut out an obstruction it becomes nearly impossible due to the scar tissue and fibrosis inside and around the intestines. Please do everything to have the first obstructive surgery be the last.

Here's to Levi.. The epileptic with the phenobarb telling him to eat it.. We are pulling a toy out of his stomach today. He is also the butter dish eater.

Levi heads home
And to Buster, the sock and panty guy. Who dodged the scalpel thanks to i.v. fluids and time.

And to the countless other labs who can't seem to either stop chewing or aren't caught fast enough before swallowing.

When it comes to the surgery to remove a foreign body I offer the following advice;

1. Never euthanize based on price alone. Call for help if you cannot afford the first estimate given. Drive to wherever you can afford it. BUT, keep the pet on fluids, antibiotics and analgesics until you get there. I have had numerous pets wait overnight at the ER to have surgery the next day with us. Often at a savings of about $2000. It is not ideal, but it can save a pets life.

2. An obstruction is an emergency. The faster it is removed the more favorable the prognosis.

For those of you concerned about the prices of Levi's care his care was provided over three days and amounted to about $1400 for everything. If you are unable to afford surgery ask us how you may be able to pare down the price by visiting Pawbly.com for help.

If you have any questions or comments please find me at @FreePetAdvice, or Pawbly.com. I am also at the clinic Jarrettsville Veterinary Center in Jarrettsville Maryland. I am also sharing these videos on YouTube.

On average an exploratory surgery at my clinic costs about $800 to $1200. Our clinic price list is available on our website.

I look forward to hearing from you...




Related stories;
Corncob obstruction. Video included on corncob surgery removal,, (it's a goodie!)

Toy removal in a dog video here;


Friday, May 26, 2017

Believe in Me.

Being a veterinarian and most especially the practice owner, is essentially nothing more than asking people to believe in you.

True, I need to have studied, practiced, and display the fundamental skills associated with being a veterinary medical doctor, but, there is very little oversight and even less direction provided for us while we are out in the trenches. Leadership skills are not provided as one of the important tools to carry in your medical bag. Some of us are born with them, others fight gallantly to escape having to earn them, and still others flee with great fear at the idea of having to take charge of anything.

I have had the audacity to try to build something far outside of the normal parameters of a vet hospital. I have learned the hard way there is a price to pay for that.

I believed I could do more. I also believe I can do it honestly, transparently and with integrity. It presents its own set of challenges.

If I invest the majority of my heart and soul into my practice I run the risk, like in every other relationship, of being taken advantage of, dumped, and/or feeling heartbroken. I can confess that this happens. I don't know how else to trudge through? How do I possibly remain a "heart on my sleeve bleeding heart kind of person" and not maintain some degree of caring when I get rejected?

I don't know how to be any different? I don't even know if I even want to? Which leaves me sitting here staring at the stars wondering where my place in the world is? How do I remain the eternal optimist in humanity, reason, fate, and the tiny steps of this ethical minefield, full of precious pets and messed up humans that I have to navigate through? (OK, I am trying to remain optimistic,, in fact I am jaded and jilted, and maybe even a little paranoid about the next perpetrator of my vulnerability).

Believe in me? Do I still believe in me? There are days.. when,, I... just... don't... know?

The problem is that you have to keep convincing yourself that you still believe in you when it seems that no one else does.

At the intermission of this one lifetime I know I made some hard decisions, taken some leaps of faith and tried every single time to be kind instead of right. I leave my head and neck on the chopping block because I don't see a pet, an animal, any living thing as a piece of property. I vehemently disagree with my colleagues policy of euthanasia as an acceptable answer to every-damned thing. I also give a great deal and expect to be treated respectfully and honestly.

This week I said "no" to two requests. I dug my heels in, left myself vulnerable to whatever legal repercussions to follow and I stood up to protect a pet knowing that the client might just walk out the door, drive 0.2 miles up the road to the next nearest vet clinic, walk-in, pay the $50 bucks for euthanasia on request and walk out 10 minutes later free of the burden their pet became. (PS to my vet neighbor up the road who may, or may not, hate or love me? I know I am probably the biggest PIA neighbor-vet who ever lived).

I have also made business relationships that transitioned into personal friendships. I provided an expectation for special treatments to these 'friends' and then disappointed them. The example list is long with friends who have "unfriended" me because I drew a line. I cannot ever leave well enough alone...Why? Why do I over extend myself and then feel hurt when I get dumped? Why do I always muddy the waters between business and friendship? (OK, I do know the answer to this.. because I feel obligated and compelled to be there for my patients, like, always).

Let's review my jilted list and see if it is an exercise in cathartism, or, just a gross display of dirty laundry? (Please refrain from casting a vote).
  • The many decade long client with too many dogs who worries I will rat them out for not having a kennel license because they have too many dogs. (Did I ever mention I once had 12 cats?). They want special boarding prices because they cannot afford to board them all. They left the clinic when we didn't provide special pricing. (PS we are the cheapest place in town.. we know,, we checked). 
  • The client who calls screaming that her dog "isn't breathing! She is coming in right NOW!" We direct her to the ER. We are closing within minutes. She is a nurse and she is livid. I try to call her the next day to explain that if anyone of her patients called her general practitioners office with this condition the first thing that would be said is "If this is a life threatening emergency please hang up and dial 911." Apparently added fuel to the fire. Relationship extinguished. (PS an emergency should always be treated like an emergency).
  • The client who routinely calls demanding immediate appointments for whatever disaster-du-jour has occurred. If not provided an immediate appointment I get a personal cell phone call requesting such. All are always granted, and always seen within hours of the phone call. I am fairly certain the other vets at the clinic hate me for always insisting they see emergencies even when we are booked. Who do I try to make happy? (PS I still don't have the answer).
  • Financially capable client requests an extension on paying the latest emergency bill. This request turns into constantly carrying a multi hundred dollar account for months. We ask nicely for payment, we are met with hostility, until finally the account is paid and they move to a "better" clinic. Who knew there are "better clinics" that are free? (I will pass along the info when I get their name).
  • The client who has over 40 cats spayed/neutered/vaccinated and treated pro bono who accuses a popular widely used topical flea & tick preventative of killing their cats. Hysteria ensues at the clinic, adverse event report case is opened and then they refuse to answer any phone calls or provide any information because there is a "vet and vet manufacturer conspiracy" theory going on. They ended up getting away with over $3,000 worth of vet care and services and think I am the "corrupt" one.
  • The number of vets who have left for greener pastures and the promised land. This one breaks me.. (note to self,, stop getting attached.).
  • The client who is always reprehensibly nasty to the receptionists.. Why? Why would anyone be mean to them? I bid them adieu.. and I always call to tell them why. No one deserves to be spoken to with derogatory comments, profanities, and anger. (OK, I have no remorse here. But I find it sad that these clients are always nice to me. Like that's ok? If you have a boss who lets you get walked on, while they get treated like royalty call me,, anonymously., I will call your boss. What the hell do I have to lose? Doesn't everyone deserve a friend with a big mouth who has your back?).

I need healthy boundaries. I am not good at this..

Maybe I only need to believe in me? Maybe, if I am super lucky there will be others who stick with my vet clinic-pet crusade quest and we can change the world? Maybe one single pet at a time, and maybe only with my soul still inside my own heart.

No one ever said this life was easy.. at least I can bank on that.

(PS to those who think this is a personal note of defeat and submission I will leave a post script here to spare the phone tag inquiries.. I am OK. Promise. A diary, public as it may be, is still a one way vessel. You don't need to intervene. I m, learning, growing, and trying to spare my compassionate obsessive self along the way.. Maybe tomorrow? Maybe I can do it all better tomorrow?)

For those of you in vet med I know you understand this.. for those of you not in vet med please understand that all of us are human beings with big hearts (too often on our sleeves). To not care is to grow indifferent which is the death of the soul that fuels the heart of a caregiver.

Juice.. saved by JVC twice.

If you want to help pets please reach out to me. Leave a comment here, join me on Pawbly.com, or find me at the clinic Jarrettsville Veterinary CenterFacebook at Jarrettsville Vet, Twitter @FreePetAdvice, or YouTube.

Stop and Smell the Reflection.

"Please submit 5 stories for review and consideration."

A personal letter from a dear old veterinary friend came in the mail a few weeks ago. It was short, simple and inquiring about using my veterinary blog posts for submission to a compilation book about the stories that make the fabric of a veterinarians life.

"Sure! I would be happy to submit a few of my stories!" I replied eagerly and instantly... I mean, come on,, I write a blog! I have tons of stories. It will be easy to find five.

And thus began the stroll through the 900 stories I have written. Easy? Right? Well, not so much. Seems about three years ago I started writing cases, all cases. Cases to learn from. Cases to help others. Cases to provide transparency for pet parents to learn from,, and in the process I lost my fun. I became the rote routine pet care professional who was all business and no cute fluffy stories. I lost my ability to share what I love most about being a vet in an effort to help other pets..

I took a little break from writing. I had to. I had to remind myself about what my voice was and who I wanted to read about if I was the audience. There had to be balance. Truth be told the world is a mess and I felt lost and disheartened to be in it.

It seemed that I had to shed my joy to shoulder the ever burgeoning burden of need. I feel that Jarrettsville Vet needs to be the answer to all of the pet problems in my community. Jarrettsville Vet also has become the place I spend the biggest part of my life. I am not alone. I know many other practice owners of every other kind of business share this ideology and compulsion. It can take you over. There are many vets before me who have given up everything else to the point that they don't remember, recognize or even reflect on what life used to look like.

We call it our "work-life balance". The terminology the new grads throw around in interviews when they chart the 'pros' v 'cons' list. They have to feel like you aren't over loading them because they need to preserve their "work-life balance". To which I reply, "you just got out of vet school, you never had it and you shouldn't be protecting it now." But I am not that predecessor and these are millennials. They feign from intimidation and crumble under pressure. They don't want any advice that I have short of mentorship on a healthy, less than 40 hours a week.

For me the balance has not been re-calibrated and the work became the life. Hard as I tried to be savvy and see it coming.

The request asked for 5 stories and I had three Herriott-esque ones from my first year out,, none since then. The reflection in the blog mirror proved I had become what I saw coming, drove into, and plead no contest to. Sure, I could dismiss it, pardon it, or even refuse to believe it, but, it happened.

I lost the puppy in the exam of the search for congenital deformities. The purr in the auscultation of abnormal lung sounds. The wag in the assessment of neurological function. The joy in the patient that is more than the sum if its parts. The emotional had succumbed to the analytical.

I needed, I wanted, and I had better take a second to stop and smell the roses. I at least needed to take pause to check my own health status.  There has to be a funny, cute, happy ending story in my day?

Maybe I will try to find the comfort in the challenge of the situation?

Maybe I will just try to recognize my own reflection and ask her if she knows where I went? Or if I just temporarily misplaced her?

Maybe too many of us work harder to find the balance and can't stop the pendulum from swinging higher as we jump from side to side?

Maybe all of this is what makes the greatness within the greater good? Or, maybe I let the grindstone take my nose to spite my intentions otherwise?

Blackjack
A happy ending lives here
About me;
I am available to answer  pet questions for free if you visit Pawbly.com. Pawbly is an open online pet community dedicated to educating, empowering and inspiring pet parents around the globe. 

I can also be found at Jarrettsville Vet in Jarrettsville, Maryland for appointments, or visit us on Facebook

I am also on Twitter @FreePetAdvice. Or check out my YouTube channel.

Thursday, May 25, 2017

Lost In The Sea Of Need. When the Vet Needs the Advice.

Hello Everyone,

While my usual blog posts are about my veterinary life's stories and experiences in an effort to educate and inform the public about the pet needs I see as imperative to overall pet health and welfare this post is different.

In this post I am asking for YOUR advice. Hard as I have tried I don't seem to have figured out how to come to peace with how to not feel compelled to help those pets and their parents in need.

Weasely's Story

Here's the typical scenario...

The phone rings and someone on the other end of the line is desperately pleading for help for their pets condition that they cannot afford to treat elsewhere. We have gotten calls from across the country, the Big Apple (where everything is astronomically expensive), to around the globe (these are especially puzzling. How do I help you in South Africa?), to our own backyard.

Whenever possible we offer the following;

1. Come in for an exam and assessment. We will give you an honest opinion and reasonable prices. We are also full-service which implies we can do the work-up and surgery on premises. It is the whole reason we publish prices and cases.

2. We offer options. Options come in all sizes, shapes and scenarios. They can be life-saving and/or life changing.

3. A chance. Often we just offer a chance.

Some of these cases involve an ambiguous undefined disease process that after a quick exam are deemed "lost cause-leading to pro bono euthanasia". It may sound cold and cruel BUT life can be exactly that. We see cases that are so progressed and difficult the prognosis is grave and eminent. This is suffering without tangible hope to improve. These are the cases where mercy was overlooked at the last rest stop. These are the cases I feel compelled to intervene as the last option for empathy to provide peace. Even with these too-little-too-late cases; a client without resources, a pet dying in front of us, and no real way to provide even the most bare-boned plan for any chance at remission or cure, even then, SOME of these cases are not provided a consensual to euthanasia. If you think suffering is bad, dying without hope, or, hospice care, is worse. Despair is unavoidable, but, the crippling inability to relieve suffering is cruel and criminal. It is as unsettling as the suffering you know is occurring. It is where my words need to be concise, direct, and well-intentioned. For these cases clients have to step outside of their grief, their blame and their denial. These cases call for real-life intervention. They are not frequent but they do happen. I don't need advice for resolving these cases. I need advice for how to notify clients to avoid them in the first place.

One of the pets who needed us.

We, the whole lot of us in veterinary medicine, need help in providing guidance so that too late isn't when we are sought to begin. 

What is the most basic tidbit of advice I can give them?

Don't assume that you don't have any options, OR, wait so long that you don't have any left. 


I need help in spreading this message!

Tammy

Here is a real-life example.,,

We received an email asking to help a dog with a suspected pyometra who was living in the DC area. The dog belonged to an older woman who didn't realize how sick her dog was. Her daughter was visiting and on inquiry was told that the dog hadn't eaten or gotten up in days. She rushed the dog to the local vet to be told it was likely a pyo and the cost would be upwards of $2,000. They, like many of us, couldn't afford this. They went online looking for affordable help. They found me, via this blog, and called the clinic looking for help. This was on a Friday. We offered to see them but explained that we don't do surgeries on Saturday or Sunday and urged that they call every shelter, rescue, and vet they could asking for a quicker surgery and a way to afford it.

The next time we heard from them was Monday morning. We saw them on Monday night. By this time the dog was almost in a coma. She couldn't stand, walk, or lift her head. Her color was purple-blue knocking on deaths door. She was labored to just try to breathe. They had $300.

I made myself a promise many years ago to never walk away from a pyo or a parvo. Two savable conditions that never survive with a death syringe, but often surprise you with skill and time.

The conversation with the owners went like this...

"I'm sorry." Anything and everything that could be said after was irrelevant and shaded with unneeded character references.

The conversation with the staff and associate vet seeing them was that they couldn't afford even the most pared down treatment plan. Three hundred dollars wouldn't get us past anesthesia and antibiotics. They needed a $500 surgery on top of these to remove the rotting uterus festering inside of her. Even if we offered to use the Good Sam Fund (overlooking that fact that they aren't a client) this dog needed to go to the ER after and that was going to cost at least $500. The ER isn't going to admit a dog without a deposit. If I had to guess I gave her a less than 10% chance of making it through surgery even if they had enough money for the intensive care she needed to provide any real chance at survival. It is not about the money, it is about what is fair for everyone involved. I didn't even think she would survive surgery  and I felt that it wasn't right or fair to them to take the little money they did have for a patient who wouldn't survive.

When I explained this to the client she said she wanted to take her dog home.

While I had elected to withhold my previous chatter to spare the client from feeling any more sadness than they already did, it was time to be the advocate for the patient.

"What can you do for her at home? She needs medical and surgical help that you haven't been able to find elsewhere. I am afraid she will die on the way home, and even if she does make it home she will probably not make it through the night. How are you going to feel if that happens? What do you think you would want if you were in her position? She is dying and she is suffering."

After 30 minutes of deliberating they put her down. Everyone felt better after. It is something we don't often admit, but, peace can come after death.

Sweet Baby Rae.. mom needed in patient help Baby Rae needs a home.

I need help in figuring out how to not get cases at this point. 

The next scenario is the more common one...

The phone call goes like this...

"The shelter/the vet I go to/my friend told me to call you and that you could help my  pet...."

Nothing (yes, NOTHING!!) burns my butt like my neighboring vets referring cases to us that they can do, but don't want to do because the client lacks the money up front. These are YOUR clients and YOUR patients...  Shouldn't they be YOUR responsibility? Or, do you just help those who can pay upfront? Take a note from our play book. Use CareCredit! Offer third party billing! OR, ask for help from your compassionate clients who WILL HELP IF YOU ASK! Heck, you might even get more Facebook likes and more clients because you CARE.

Yes, these clients often have little to no available money, BUT, they all have desperate and dying pets. They all also have DEAD pets if someone who can help doesn't step in. 

When one of our patients is surrendered at a shelter we go and get them.
Beignette,, she needs a home too.
What might happen if you surrender your pet at a shelter.

So my friends,, 

WHAT SHOULD WE DO? How do we make an impactful, meaningful difference for these pets? 

For those of you who aren't familair with how we extend our help to our clients in need, here is a review of our policy;

1. We do not deny care to our patients when they are in need. Emergencies may need to be referred on a case by case basis, but, we will assist the pet if it is safe to do so. 

2. We do not offer "economic euthanasia" (euthanasia as a means of treating due to financial constraints).

3. We provide multiple ways to pay for needed care. 

4. We provide the option of signing over a pet to one of our affiliated rescues if the burden is more than the client can or will provide for.

5. The vet has the option of providing pro bono care IF they want to, IF the case has a reasonable chance of survival, and IF we believe the client can follow through with the after care needed to insure successful resolution.

6. We don't treat a good paying client's pet any differently than a struggling financially client. Their pets have exactly the same diseases, conditions, and needs. Financial profiling should be so distaseful and shameful that the profession should take a stand AND do something about it! WHAT ARE WE WAITING FOR? A MUTINY? A competitor to figure this out (P.S. It is my dream to have PAWBLY be that meaningful change for these animals).

Extension outreach foster family

Here's where I need help! 
  • What should we do so that we can provide meaningful timely help?
  • How do we extend that reach to people who aren't local?
  • Can we convince other animal care facilities to be both the business and the provider when the situation is complicated and resources are tight? If we haven't been able to do it on the human side can we do it on the veterinary side?
  • The rescues think the vets are the problem (we have priced ourselves out of accessibility AND we don't care), and the vets think it is the public's problem (after all if you cannot afford a pet you shouldn't have one). Meanwhile pet is sick and dying.. don't argue when the need is in front of your face.
  • What does your vet do? Have you ever asked "what would happen if your pet needed something that you couldn't afford?" Are you prepared for the answer?
Thanks everyone for reading and contemplating. I am all ears.. let the ideas fly!

One of our TNR friends.

Related Blogs;

Jarrettsville Veterinary Center For Clients With Financial Constraints blog.

Affordable Options Are Everyone's Right.

Rescue Economics. When The Expense Costs You Your Ability To Care.


If you want to help pets please reach out to me. Leave a comment here, join me on Pawbly.com, or find me at the clinic Jarrettsville Veterinary Center, Facebook at Jarrettsville Vet, Twitter @FreePetAdvice, or YouTube.


Together we can save lives! It is who we are and at the heart of every pet parent and animal lover.

Friday, April 21, 2017

Lock Down At The Veterinary Clinic.

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


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

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

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

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

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

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

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


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

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


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

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

BUT,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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



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

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

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

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

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

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



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

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



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

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

2. They have seen multiple practices over multiple years.

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

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

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

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

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


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

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

If you would like to learn more about pet care or ask a free pet related question please visit Pawbly.com. It is free to use and open to all of those who love pets.

If you want to help others and you have experience with pet care please join us on Pawbly.com. Pet care is about helping others and we are built on this alone. I also have educational videos on YouTube, or @FreePetAdvice.

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