Sunday, November 19, 2017

Fate vs Indifference.

Perhaps I have had it all wrong this whole time?

Perhaps it is not that I am supposed to be forced into indifference, but rather the acceptance of fate? Fate beyond my stubborn dogged determination to thwart, remold, and re-imagine. Fate as the force that is dictated by something far beyond my perception.

I had to euthanize another kitten I had grown too fond of today.. One I had invested my heart and soul into, and another I refused to be "sensible, rational, or honest" about.

Last week it was Moana, the kitten with four broken legs who was too cute to refuse, and too pitiful to turn away. It was a massive exhaustive team effort to try to save her, her four broken legs and their open flesh of jagged bone. In the end the cost of trying amounted to many thousands of dollars and immeasurable stress as we all worry who might become a casualty in the disease no one unarmed wins; rabies.

Today it was Wallace. The kitten with the prolapsed rectum I spent countless hours trying to coerce into functional compliance. In the end his colon did stay inside his abdomen, but the rest of him decayed secondary to FIV (which we had tested in his intake). I lost two souls I battled over, cried over, sweated over, and refused to concede to. Even after all of this I lost. Worst of all, they had to die at my hand. I hate, absolutely hate, having to be this person. The hand of death, the last warrior in the duel I know I yield more weapons in.

I hate the grief process and the juxtaposition of knowing I did try everything, and am left to play the part of both the slayer and the fool, again.
How can I try so hard, (to bend and alter fate just a little?) and be disappointed,, again?
How many times do I keep trying even if heartbreak and losing is the cost?
Has every other veterinarian learned this lesson already?
I thought I had to avoid the "professional indifference" to preserve my "compassionate heart"?
But was this really just "unavoidable fate" the whole time?
Does acceptance lead to indifference?

I will never learn. I know no other way, and I accept the fate terms on the conditions I applied for.

So today I cried Wallace away with all the love he always had from all of us. I buried him in our pet cemetery to keep the others company. And, I moved onto another. Meet Scotty. Last week he was trapped, neutered, ear tipped and almost (should have) died on the operating table as he tried to bleed out for three hours in front of us. He didn't. He's turned into a love bug. And I'm thinking that this one might really be the one?

Scotty
 Wallace and Moana...
Celebrating on the day Wallace was adopted.
Moana
Post Script;
I secretly fear the repercussions of this post. The reminder I will get from some awful cold hearted venomous vet who has told me that I am #atrainwreck and an #idiot for every reason imaginable. Because I remain an eternal blind Polly-Anna. I try too hard. I think I can and it will be. Whatever reason they choose to hurl at me in hurtful fists and contempt. That they can take comfort in my failing is the side I grapple with confessing. It is the voice of the afraid, who still sits here heart-on-my-sleeve trying. Maybe losing here and there, maybe feeling like I haven't quite learned whatever lesson is supposed to bring me clarity. But still here. As if the self worth, doubt, and hardship isn't enough.

If you have any questions or comments please find me on Twitter at @FreePetAdvice, or ask me any pet question for free at Pawbly.com I am also at the clinic Jarrettsville Veterinary Center in Jarrettsville Maryland. 

Saturday, November 18, 2017

get out alive..

at some point you get to the place where a choice is needed...

at some point you get to a place where your life is being surrendered, taken or foregone as not being your own any longer...

At some point you are just trying to get out alive.

There is hardship in life, no one gets out of it. It is as universal as it is inescapable.

I'm trying to remember why,,,,

why i am still here,

why i am still trying,,,

and why the world, the world that too often makes no sense, has no fairness, and holds the cards too close to the chest, still let me in.

There are little pieces of me everywhere. In each case I invested a little piece of myself. In some cases I invested more than the return might yield, and in the cases you cannot foresee you can go bust. It is the nature of the game. You can occasionally, outwit, and outsmart, but life cannot be outlived.

I hit the wall, I fell to the floor, I hid it, (I tried to at least), and I found myself at the place I know others have been... I found myself asking whether it was time?

you walk away knowing you have to,

or,

you walk away a different person,

simply to get out alive.

There is still a voice here. There is also still a soul, broken, beaten, afraid, and yet still determined.

Maybe only determined to get out alive, and maybe that's enough to resurrect the rest of me.

If this little place is mine, and there is a place for me to be simply me here, then I need to stay small, think large, and hope that courage is enough to sustain me,,

and I have to have hope,,, hope I can get out alive with some small voice I am not too afraid to abandon.

Friday, November 10, 2017

Is Suffering Really So Bad?

Preface: This is a blog about my experiences as a veterinarian and the professional dilemmas present, hence, it is titled as a "diary". This is not a one-off account and it is not intended to be proclamation of the state of the profession. If you are a pet parent and you pined over the passing of your pet to alleviate their suffering and you did so with love in your heart be at peace with that. For those within the profession who believe this doesn't apply to our day to day lives I hope it opens a productive conversation about who we are, what services we provide, and why there is such a divide between those with resources and hope and those without either. 

It wasn't too long ago that I was one of those many voices in the veterinary chorus.

"We treat our pets better than our own fellow man. We at least can deny them the long struggle and suffering to their death." It our professional credo that our pink syringe of stillness delivers mercy we deny our fellow man. The power, the glory and the compassion that a quick easy death brings was once my 'salvation lies in my arms' song.

It is a well known joke that the most sincere accolades given to our profession often reside with the provision of euthanasia.

Veterinarians, take pride in our merciful ability to provide an end to suffering. It is the one place where we are not bullied nor liable. The clients regale in our easy efficient willingness to provide it and it is the one safe place for a practitioner to practice.

Pride. Mercy. Suffering. They shouldn't be strung together in a cohesive sentence when compassion and healing are the thread that binds us to our professional oath.

I used to be that bold. That cocky. That drunk in my own delusional deliverance. I used to drink the proverbial, (not lost on my sarcasm), pink Kool-Aid with beaming pride.

Murray lived 1 year after his family brought him in to euthanize him
as he required a "diaper" for his bladder tumor incontinence.
I am a veterinarian, (with a few more decades under my belt), who has begun to question that the pervasive denial of struggling (or 'suffering' as we too willy-nilly coin it) has instead brought us to the place where life is cheap and death is easy. The pride in yielding either instantly is costing us our desire to face the struggles of life along with the acceptance that the marrow of living a full life with all of its deep, difficult, confounding troubles builds us to be who we weren't before.

Kittens dumped on the road,,
there are after all too many of them, and they can "fend for themselves."
The drive to and from work every day is exactly 22 minutes. I know this because my smart phone stalked me in my previous travels and knows what I am about do before I pull out of my 'park' position. It prompts me with push notifications to simplify my unconscious dependence upon it. Along the way I pass the local police station. Everyday the numeric tally of "overdoses" and "deaths"  creeps incrementally higher. It is the communities annual count up reminder in ticker tape tally form of local lives lost to the losing war on drugs. Overdoses have become our generations escape gone wrong to avoid the perils of daily life and the struggles it takes to get through. The lives behind those statistics often seek relief from suffering, escape from pain, boredom or anxiety. Drugs today are expansive and omnipresent in the big pharma saturated advertising society.* We can't settle to living in the middle of mediocre, and yet we deal the deadly wish for death when a struggle might be looming.

A treasured Murray moment.
In vet med we euthanize too much and too often. So much so that we can justify just about every conceivable scenario as a way to accept it. So much so that we HAVE TO OFFER IT AS A TREATMENT OPTION, a mandated, OPTION, to clients. If you are a practicing veterinarian you HAVE to tell people they can euthanize to TREAT their pets dilemma. It is so pervasive that I often find people who won't go to the vet for help because they FEAR WE WILL FORCE THEM TO EUTHANIZE. How did we get to the place where anyone feels they will be forced to kill their pet? Isn't that admission of fear enough to cause us to take pause as to the power we yield and the divide that exists?

I fear that we give up too often and now we have colleagues who build their whole career on providing that home catered "peaceful passage". The pervasive push for making everything easier has cost us our ability to feel the ends of the spectrum. Our kids are spared the edges where questions lie, the earth shifts beneath you, and the answers may not have a consolation prize, or a merit badge "just for trying." We give up so often that our profession has an alarming, suicide rate to prove it.

Now I am very well aware how much pride veterinarians take in being so compassionate to end the suffering of our beloved pets. (After all it is the place where you all love us the most). We are without question a big part of the "avoid the responsibility" problem. We, far too often, place the option to end 'suffering', (even when it is not 'suffering' by any stretch of any medically based imagination), to every single ailment imaginable. Parasites, infection, half-baked guesses of cancer, the homeless, the elderly, the sick and too young, the overwhelmed and too many to account for... the list includes every conceivable reason making a problem go away. Death, euthanasia, makes it all go away quick, cheap, and easy. We can call it suffering, but it has been too often my experience that we don't try. We don't want to be inconvenienced, and we don't want to invest in a potentially losing proposition. It is after all, cheaper, easier, quicker, and legal to do so. If our clients can't/won't/don't want to we can offer a "peaceful passage" and in some odd twist of humanity, be hero's for it. (No wonder we are confused about who we are and where we stand anymore?).

Life, death, and every trudging crippling, staggering step along the way can be brutal. Heartbreaking, mind numbing, fall to your knees in hopes the rain will cease to drive you into a shallow grave, hard. It can be unfair, unkind, and unyielding. Isn't that what we are supposed to teach our kids? Remind them to not feign from? And yet, why, WHY?, do we so malevolently permit it so eagerly when we acquiesce to providing death to so many?

Bottle baby from a feral colony.
We cannot have it both ways. The victim to a heartless hard society where drugs luring escape is so intoxicating we need a public billboard to be updated daily as the head count rises AND the compassionate society that bears peace via pink syringe to remove your responsibility to the life you don't want to face any longer. We give up too often because it is easier, cheaper, and we want people to like us. Worse yet, we do it to make our (the vets who need payment upon services rendered) don't/can't/won't try to make a life matter more. We all matter more. The beauty lies just as richly and deeply in the struggling/suffering and the despair as it does in the joy of sunny days and puppy breathe. If we deny the end of the difficult spectrum we cheat ourselves and others from understanding that they can get through it. To deny anyone any chance at hope that there is more to life than the quick and easy and chose to surrender to deny the edges is the true worst side of this society.


References;
1. Nine Reasons People Use Drugs. The Jennifer Act.


Sunday, October 29, 2017

Wallace's Story; Prolapsed Rectum, Feline, Colopexy, How To Save These Cats, How Much Time It Takes, Costs, Prognosis

The cases that pull you into pieces,, return. Just to poke you at the tender marrow and remind you that you are a simply a whisper among the tsunami of burdens that another more powerful force decides. As with every hard lesson in the journey of life you will face the same challenges over and over until you learn said lesson, or, you expire. I have lost the battle of prolapses before. It is an adversary I hold personal contempt for.

Veterinarians influence, too often we don't decide. Sure, we can decide death, but that power is for the defeated and the exhausted. It isn't what happens at Jarrettsville Vet.

This is Wallace's story.



Wallace is a barn kitten. One of thousands in our community. Wallace had gone for a routine poop one day and out of his anus slipped his colon. We call it rectal prolapse. He came to us in desperate need of immediate veterinary intervention having never had even the most basic kitten stuff. He came to us too skinny, full of fleas, old cloudy injuries to both eyes, and his delicate colon swollen and protruding from his anus. It had been there long enough to become dry, distended from the tourniquet of circular sphincter anal muscle that opens when your brain tells you it is appropriate to unload, and turning tan from its normal bright happy moist pink.

Intestines are exceedingly intolerant of the outside world and respond almost immediately by drying, swelling and cascading to death. Dead intestines cost you your ability to decide when you poop, and what that poop looks like. For a barn kitten fecal incontinence is a show-stopper.


Moist tissue lives. Clean moist tissue has a chance. We immediately submerged him in a very dilute warm surgical scrub. Clean first, shrink second. As a nod to those vets before us who were still able to save little lives with little overhead nor extensive specialty training, we also had him sit in a copious handful of sugar. The sugar will "pull out" the fluid from the swollen tissue as it works like a hyperosmotic agent. It takes about 15-30 minutes to work. Although the tissue appears to be a fluid filled sac it is instead an edematous protrusion of tissue.

IT IS NOT POSSIBLE TO REPLACE THE COLON WITHOUT REDUCING THE SWELLING AND GENERAL ANESTHESIA. (It is too difficult and painful to do).

Practice pearl; This condition is an emergency and requires veterinary intervention immediately for the most successful prognosis.


After the tissue shrank we then applied huge amounts of lubricant. Here is where anesthesia is vital.. All of that tissue needs to go back where it belongs. This requires three people, holding the patient nose to the ground, butt to the sky, gentle traction and external palpation of the colon (located along and under the spine) to "milk" it back into it's original position, and at least four hands with fingers at 12, 3, 6, and 9 o'clock to gently push it back inside the anus. It takes time, patience, and anesthesia.


In some cases I also use a thermometer, or long cotton tipped applicator to help maintain the center of the tissue as we try to coax it back inside. It will go back inside, but you have to be gentle and patient. Once it is there it is required to place a purse string suture around the opening of the anus to hold it in place. There is an art to this. The right size of the anal opening, the correct amount of time to leave it in? It's an art I have yet to master.


Once the colon gets back into its intended place it is time to do the hard detective work. I have only had a few of these cases and they are difficult at every step and they stay that way for weeks. In theory the usual suspects are;
  1. Parasites. Intestinal parasites cause diarrhea. In kittens the diarrhea can lead to tenesmus which is the persistent urgent need to defecate. You can strain for so long that the stop check mechanism that is the anal sphincters surrender and the contents they have kept at bay fall out.
  2. Chronic diarrhea, or severe acute diarrhea. In kittens if it isn't parasites it can be a poor diet. Milk, kitten formula past nursing age, or sudden diet changes are all common historical findings.
  3. Congenital spinal deformities. The spine protects the core conductor network to talk to the muscles that allow us to function. If there is a break or disruption along the pathway things don't function normally.
  4. Trauma. Kittens in barns get hurt, intentionally or accidentally. 

What I have learned in these cases is that they are all one of two things; parasites and parasites. I do serial intestinal parasite (fecals) exams, and I treat anyway. I treat for every common intestinal parasite and keep on treating.


Wallace is like every other intelligent feline. He will forgive you once. He will tolerate you twice, and by attempt number three he will curse, bite, fight and defend his assertive ways by any means he feels necessary. He won't apologize to you afterward. (Even if you try to explain that all of it was "for his own good.") You have to be assertive, aggressive, hyper-vigilant and prepared to invest copious amounts of time into these cases. It is very unlikely it will be "fixed" at attempt number one.

Purse string Suture Technique and Plan;

I keep it in place for as long as I can each time. The literature varies on this advice. Some say 3-5 days. This is never long enough from my experience. I placed and replaced the suture. Each time I tried to leave the anal lumen opening a little larger.  The opening went from 0.5 cm to 1 cm diameter, using a thermometer, 22 gauge syringe cap, to 22 gauge syringe cover as my guide. Each time Wallace formed a fecal ball that needed to be manually broken down to pass, regardless of the food we fed, the laxatives, softeners and motility agents we tried.


Butt bath time, again, before the anesthesia and replacement of his purse string.

Once a purse string suture is in place it is time to;

  1. Submit a fecal sample to the lab for analysis (I do not recommend doing this in the clinic alone).
  2. Deworm prophylactically (for everything)
  3. Start a liquid diet to maintain a soft, easy to pass stool. The purse string requires soft stool to permit passage.
  4. Find a high quality high calorie diet and feed small amounts frequently. Dry food can be pulverized and liquefied if no other options exist. Remember adding water dilutes out calories. Feed every 2-3 hours, or whenever hungry.
  5. Get them active if they are underweight and undermuscled. 
  6. THESE CASES STAY INSIDE, UNDER HYPER-FOCUSED OBSERVATION FOR WEEKS! Wallace moved in with us. He cannot be left alone for more than a few hours. (These are not easy cases).
Wallace began straining to defecate again in about 3 days. We removed and replaced his purse string at all hours of the day and night, three times. These cases are so hard. Emotionally. Mentally. And yet that meow. Ugh, Wallace kills me with that meow.

Guide for anus opening, 22 gauge  needle cap. 


Another pursestring in place,, another waking up Wallace.


It is very important to not lose the patient in the treatment plan. Our immediate short term goal is to get him healthy and functional, but he needs to find a home, he needs to be happy, and he is a kitten who loves other cats. We kept him with others as often as we could. They helped him play and learn his social skills. Wallace also had underdeveloped rear leg muscle mass. Playing with others is the best way to build strength and stamina.

Wallace and Dory.
Sure enough, three weeks of purse string attempts failed. The last trick in the bag was a colopexy. A colopexy involves opening the abdomen to anchor the colon to the side of the internal abdominal wall. In essence you suture the straight section of the colon to the inside of the belly. It is not a difficult procedure BUT the following need to be discussed pre-op:

  • These cats are typically already too thin. Thin cats with large abdominal surgeries get cold fast. Be ready for this. Be quick with your surgery, and keep them warm before, during and after.
  • The tissue of the abdominal wall is like tissue paper. Scarify BOTH the abdominal serosa AND large intestine serosa to and including the layer of the muscularis to get adequate adhesions, take a long swath of suture (texts say 1-2 cm), I say at least a third of the descending colon. I also place a "tack" suture at the most cranial aspect of the colon. 
  • Run two parallel lines of suture (deep and superficial about 2 mm to 4 mm apart).
  • Go bigger on suture size than you think you might need. These fail. Failure and repair are less likely to be opted by a client already significantly emotionally disheartened and financially stressed. 
  • If it can hold 4 weeks you are probably out of the woods. If it fails in this time frame it was a surgical failure. Go back, try again. 








Wallace's problem hinges on his flaccid external anal sphincter.
It took me about 3 weeks to determine this.
It is hard to diagnose when it has been repeatedly stretched.

An abdominal surgery in a tiny kitten always results in  hypothermia even though we tried to do everything to avoid it. Wallace warmed up quickly with cuddles and blankets.

The last attempt at a large opening pursestring.
I also neutered him knowing that my window of restraint ability was quickly closing.

Not so fun. a colopexy in a 2 pound, underweight, undermuscled kitten. The thickness of the abdominal wall is almost transparent. These are the cases I sweat. They are also the cases with nothing left to lose and a broken heart on the line. They are the reasons I still love vet med. Don't tread lightly behind a shield of excuses as to "why you can't/shouldn't." Jump in!



It has been 8 weeks of colonic coersion. The colopexy had its own set of setbacks. The colon was anchored to the internal abdominal wall. It meant that his internal muscular squeezing tube couldn't push the feces out. It was painful to push, difficult to do, and he became constipated with diarrhea as a result. He was not happy for the first week post-op. He felt like he had to go, was punished with pain when he tried, and then started to pucker around the large pursestring as a result.

After a week of adding promotility agents, adjusting and readjusting the laxatives we had to remove the pursestring again. 

"My last hope lies on this colopexy working on it's own." My last attempt in the same situation with a different patient had failed. After two months with the previous cat I had to euthanize as he was so fractious and his colon so compromised neither of us could continue. His name was Willy. I will forever bear the pain of that case. It marks me as a cautious reminder of investing too much and treading in poorly chartered diseases.


I always talk about cost of care with my cases. This one is really hard to quantitate. 

Each purse string surgery cost about;
  • anesthesia, about $100
  • placing pursestring takes about 10 minutes $50
  • ecollar $10-25 (ask to make your own).
Monitoring is 24/7. Being prepared for it to reprolapse means keeping your cat under close supervision. These cats must be inside only. Must be checked frequently, and, must be brought to the vet as quickly as possible if they do re-prolapse. At least keep the tissue clean, moist, and away from self-traumatization until you can get to the vet. If I could grant you all one power it would be some way to be able to replace these without vet expense. I don't think there is a way to do it... (I'll keep thinking). 

The cost of the colopexy was;
  • Anesthesia $100
  • Surgery, abdominal colopexy $200 (probably should be more, find a vet who wants to try).
  • pain medication needed. Cost about $25.

Wallace's meow.. one meow and you understand why we were so determined to win this case.




Update; Wallace was humanely euthanized after he developed severe respiratory difficulties and was found to be FIV positive (he had been tested twice before and was previously negative both times). He was a kitten who was loved beyond all measure. He will be missed. 

Related blogs;


So what happens if you find yourself with a pet who has this condition? You can come ask me on Pawbly.com for help. Pawbly is about sharing stories, swapping advice, providing encouragement and offering assistance to better help pet people in their pets care. It is free to use, open to everyone, and dedicated to improving pets lives globally.

What if you have a pet who has had a similar condition we would like to share your story. Please send it me us at wags@pawbly.com. We are collecting stories, pet care experiences and your pet care costs to help provide others assistance in understanding the world of veterinary medicine.

Pawbly.com is about saving lives, and providing options with data. Let the data set the standard of care and integrity via transparency be the guide.

If you care about pets, believe in making happy endings happen, and want to help others please join me on our Jarrettsville Vet Facebook page, our Pawbly Facebook page,and also on Twitter and YouTube.

Please note; I am not a veterinary surgeon. This case, as with all of the blogs I publish is based on my personal experience when no other options were available to the patients I treat. Please discuss your pet case with your vet. All care should be provided under the close supervision of your pets primary care veterinarian and referred to all specialists they deem appropriate.

Saturday, October 21, 2017

Remembering the Vet Who Inspired Me Most. My Grateful Farewell to Dr Stephen Barsanti.

We never walk alone.

The building and shaping of a veterinarian is a collage. A little bit of pieces you borrow, collect, and compose from the others around you. While I know that compassion is the force that pulls you toward the journey of amassing the degree to publicly share your trade, the essence of who you are once you get there is made of little pieces of the peregrination you walk to that place where paper represents your destination.

There are mentors who come in all sizes and shapes, often in obscure and unintentional places or events. I was always that little girl..

The little girl who sought solace and comfort inside the calling of being alone with the animals. There was not ever another calling. When you are little and compelled it can feel lonely. I didn't have much guidance and veterinary medicine wasn't one of the options that met parental consent for "career" criteria. It was someone else's opinion and it drove too many decisions that my vote never counted for.

Then I started to try to spread my wings. As every resourceful child knows, false pretense can provide parental neglect and opportune access.

My childhood vet was Alton Veterinary Clinic, in a very small town by the bucolic Lake Winnipesaukee of New Hampshire. My parents had left the suburbs of Long Island to live the picturesque New England life. Again, it was not the postcard life I had ever contemplated. The singular exception to benefit my new quiet boring existence was the addition of having pets. In short order of buying land, old salt box home and a barn they acquired a horse, a dog, a cat, and a sheep. It was also the same time that I found Dr James Herriotts books for companionship. If divine intervention existed this was my beacon of hope to survive the winters even bird brained geese knew to flee from.

When the small town vet, of the newly minted Alton Veterinary Center, had their first child the opportunity to increase the veterinary staff from 3; Dr Stephen Barsanti, veterinarian, hospital receptionist, his wife Sherri, (who in short order became my second mom), and vet tech assistant, grew to 4, which now included a babysitter. I knew that this was my chance to get inside the building for longer than a nosy clients kids visit.

If you could time your transit to school by the Alton Veterinary Center (which was conveniently and tiny NH small town apropos two blocks down from the intersection of school and main streets) accordingly you could get front row unobstructed seats to the big picture window that faced the street for the weekday lunchtime cinema. Surgery!

That big flat glass window shielded me from where I knew the heart of the practice lay. That big multi-paned window, obscured from the neck down with a gossamer veil to keep the patients innards clandestine, was the peep hole to all the secrets of the magic that I longed to be elbow deep in. With the coveted title of "vet assistant" newly donned I was now allowed the back stage pass to see the innards in person, finally! Day by day I was lucky enough to be tolerated as the shy, intrigued, girl who got to spend lunchtimes, babysitting breaks, and eventually anytime I could sneak away from the banal obligatory school days. My earliest happy memories were those covered in smelly dogs, porcupine tatted pups, and Primo the parrot who barked when the afraid cat was the the adjacent exam room, or the pathetic meow when the hound was. That little home on corner was my utopia incarnate. I lived Dr Herriott's life for only that short time with Dr Barsanti. It was the magic of my adolescence and the compass to my lifelong path.

Dr Stephen Barsanti was the epitome of every professional veterinary battle we have forgotten to cherish. He was kind to everyone. He was sincerely compassionate. He was also inherently humble and generous to everyone and everything. He answered every 2 am call with a plan absent of an estimate. He was who I will spend my whole life trying to be more like. There are vets who leave two page obits in the veterinary professional rags, and there are vets like Steve who quietly walk out of a world they made a real tangible meaningful difference in. Not just in alleviating the suffering of their four legged patients, but in the hearts and souls of the communities they humbly served. The small town heroes who shaped lives, provided a foundation for dreamers, and passed on a legacy far beyond buildings, bank accounts, and honorary accolades.



Thank you to the whole Barsanti for sharing Steve with me during every Monday through Friday matinee surgery. On every 2 am cold downed horse call-out, and to a little girl lost in her own place in a world few others understood.  I will miss that smile of his, that charm destined to be much bigger than a baby blue off buttoned attendee shirt, and that laugh where any reality was not an impossibility.

Related blogs; Alton Veterinary Clinic


me, steve, diedra
Post script; I spent the day at home today after a long troubled interrupted sleep. Diedra's 15 year old rescue needed an emergency cholecystectomy (gall bladder removal) surgery yesterday. It was not a surgery I had ever done before, but her condition was grave and it was either jump in and try or surrender your patient to a possibly treatable disease. I always think of Steve in these cases. How he would have encouraged me to never be afraid. To always be the veterinarian I had dreamt of becoming. If I could diagnose it, and there was a possibility, you jump in. You never learn or grow otherwise. I know he would have been proud of me yesterday. I know he would have been singing praises regardless of the patient outcome. I know above all that there is grace in compassion and that it can be passed on beyond our days on earth.


Monday, October 16, 2017

Canine Pyometra. The Dog Edition. What You Need To Know To Get Your Dog Out Alive. Cost, Options, Advice. (warning surgery photos included)

Shyyann,, this is her pyo story
This is Shyyann. She came to see me on a Sunday afternoon. She had left the ER about an hour before where it was determined by an ultrasound that she had an infection in her uterus. She is 10 plus years old, the light of her dads life, and about the sweetest, kindest, gentlest girl you have ever met.

As with every single appointment, I get a brief synopsis from the technician who takes the vitals, documents the history and provides me a brief description of all of this along with the presenting concern. This day, it was Laura reporting Shyyann's story to me.

"They saw your video. She has a pyo. Everyone in the room is crying. She's a pittie. A really nice pittie. They are afraid you are going to tell them to put her to sleep. I don't know if they are here for a second opinion or to euthanize?"

She knows me as well as I know her. Laura dropped every hint she knew was important. She was smitten by this dog, and had great hope for Shyyann. She is my calm to the storms I too often find myself lost in. She is a big part of the reason I still hope and always try. I walk in the room.. as I always do.. ready to fight a war and looking for troops to enlist.

Thick hemorrhagic purulent (blood and puss) discharge.

Shyyann's estimate for her pyometra surgery was $2500. (Based on this estimate I know where she came from. Lately I am seeing pyo referral estimates ranging from $2,000 to $5,500). Through tears from her mom, (who just had a baby a few weeks ago), she said "we just don't have that kind of money. We don't have half of that."

What they did have, that one special thing that they all have, is a story. A story of a family who loved their dog. If you have that, if you can start there, you can make miracles happen. It is not about how much money, it is about how deep the love lies. It is where Laura and I, and the rest of the staff at JVC, reside.

Shyyann was sick. There was no doubt. She was depressed, weak, and tired. She hadn't eaten in two days, had been sick for weeks, and had been given a diagnosis devoid of one stitch of any kind of treatment to help her. I find that one simple act of omission an all too common theme. Don't use resources on anything before a mutually acceptable AND affordable treatment plan is in place! Especially when the diagnosis is acutely obvious. In the new age of "standard of care" we are forgetting to be resourceful. We are forgetting that our patients are OURS to be collectively responsible for. I hope we get ourselves back to the foundations of care. I also hope people can get drive-thru fluid therapy clinics if the primary care vets don't give them at least that. That one little act of $80 bucks (subcutaneous fluids and antibiotics) at my clinic can buy precious time and countless lives.

We cannot forget to treat while we collect scant resources and diagnose.

Shyyann, her family, and I had a long hard talk. Here's how I see it; she needs help immediately. The soonest I can get her this help is tomorrow morning. It will cost about $1,000. She is not the best surgical candidate. But that is the best I can do. I can give her fluids and antibiotics to try to help get her through the night. We talked payment plans, options, and faith.

Everyone left with a plan, and Shyyann's family left with hope. You can never steal that from someone. It will break them. It will ripple forward in ways you cannot imagine.

Here is Shyyann's surgery.

Distended angry uterus.

Think it didn't look big in the photo above?
50 pound Shyyann minus her 4.5 pound uterus



The surgery is done.


Waking up

Resting after recovery

The video of a prior pyometra surgery.. the message is always the same. Spay now, avoid the pyo later. 







So why don't people spay?

  • They cannot afford it. Please ask your vet, shelter, rescues for assistance in finding low cost options. Or, start saving. At Jarrettsville Vet we have Pre-Payment Plans to help.
  • They are afraid of anesthesia. Pre-existing conditions like heart murmurs, small pets, prior anesthetic adverse events, the list of reasons to be afraid shouldn't put your pets health in jeopardy.
  • You didn't realize that a pyometra could happen. (I hear this every single day!)

Here is what Shyyann's bill looked like at JVC

Pawbly.com is about saving lives, and providing options with data. Let the data set the standard of care and integrity via transparency be the guide.

If you care about pets, believe in making happy endings happen, and want to help others please join me on our Jarrettsville Vet Facebook page, our Pawbly Facebook page,and also on Twitter and YouTube.

Sunday, October 15, 2017

1:15 pyometras left this ER alive..

I asked people to share their pet care stories with me,, and oh my goodness, did I ever get them! The stories that have been forwarded about pet parents experiences in veterinary clinics, ER's and the treatment they and their pets have been given has crossed every single scenario about everything imaginable in between. Most are sad and very disheartening. This is a part of the current state of my profession.

I work as a vet assistant at an emergency vet clinic in XXXX. I find it very heartbreaking every time I have to tell someone who can't afford our services how much it would cost to test their pet! At our clinic our exam fee is $69.00 (just the physical), radiographs are $190, complete bloodwork is $160 and a parvo test is $70; that is just a start. Where I work all payments are due in full at the time of service no exceptions! If the pet needs surgery or hospitalization it is around $1000!! In the over 1 1/2 years I have worked here (using pyometra) I have only seen one survive (1 out of 15) and all the others have been euthanized.  What my employers have told me is the the reason why the policy is in place is because our clinic has been "used and abused" and people will walk out without paying their bill! I simply find this hard to believe. I wish that there was something I could do. One of the problems is that the clinic I work at is owned by ALL the veterinarians in the county (so they can get the weekends, evenings and holidays off).  At some points I wish I could quit my job because I am tired of the heart break from watching pets go without care or very little care because the owners can't afford anything better!

These are the statistics the veterinary profession is striving so hard to disregard, excuse and shift the light from. We try so hard to maintain our public persona of being "the trusted healthcare provider for your four legged family," yet we cannot hear, acknowledge, or accept the pleas, cries, and heartbreak from those we have abandoned? We don't want these testimonies made public. These are opportunities lost. These are part of the greater divide leading to skepticism and divisiveness. These are our patients lives, our clients grief, and significant part of the swell of tragedies on both sides of the exam room table. This is how we got here. Stop blaming, stop shaming, start talking.. even if it is uncomfortable in the exam room for that 5 minutes before the fate on the wall is written and sealed.

I am going to do A LOT of talking about pyometras. I have to. I have to because stories like the one above are happening at a proportional skyrocketing rate and no one is telling people they have options. That, that my friends is.. (well, I stated it clearly in my video),,, that, as a private practitioner to a community we have served for over 60 years is called killing our patients. Every night I fall asleep I wonder how many I won't wake to in the morning?

More than 1 in 15 pyometras is NOT what I see in private practice. In fact in 12 years, with (approximately) three times as many cases, I have lost 1. One in 45. That dog was euthanized because she was comatose at arrival and needed overnight care her family could not afford. She deserved better. She waited over a week before she came from two states away to find me. One in 15 happens because people are scared and vets don't offer it another way. Try! For GODS SAKE try! Try fluids, antibiotics, TRY EVERYTHING BEFORE EUTHANASIA. Let's see what the statistics look like after that motto of "compassion before euthanasia" is the cornerstone of our practice in practice.

There ARE ALWAYS (ALWAYS!!) options. Until these options are given to every single case I am going to keep talking. Here is where I will start.

Say the following instead;
YES! To fluids!
YES! To antibiotics!
And, yes, to finding a vet you can afford, who won't use words that revolve around anything else but giving you and your dog the help they need to try to recover from this infection. Help in understanding there are options, and that you have choices, and your  deserves a chance.


We, the veterinary profession, have compiled every single marketing brochure with a cute puppy or kitten being coddled by a smiling white coated stethoscope draped professional all beaming glee front and center. This is the persona we pitch. The stories that have been sent to me are far from what we lobby ourselves as. We pitch ourselves as the hands of healing and compassion and yet the public has become weary of our lured commercials. To many the profession has become an over priced commodity only sought when disaster meets impending death. The educational obligation we have to our clients cannot be over emphasized.


Where to go from here? Just say NO TO EUTHANASIA and YES TO EVERYTHING ELSE!


Recently I have been flooded with requests for pyometra consults. At every single one of these meetings I ask if the client was "ever told this might happen if they didn't spay their dog?". Every single one of them have all said "No, I didn't know this could happen, and I certainly had no idea it would be this expensive." Most thought the vet profession was recommending spaying and neutering as a part of  our revenue generating income stream. A compulsory line item equivalent to the vaccines, preventatives, and dental cleanings we propose as being 'needed' while they heard "optional". We are not informing clients as to why these items are vital to our patients health and longevity. And, if we are in some small ancillary footnote, we are not providing these with data, written take home explanations that we know to be true as our own real-life previous horror stories that a previous client learned the hard way. We know these cases, we have lived through them. Why not use these experiences as a pay-it -forward exchange? Why to are we not also giving estimates for procedures now and later? A real-life tangible cost risk analyses. "It will cost you $250 to spay now, or, $2,000 to spay a pyometra later. Either way, there will be a spay involved." We say this to ourselves, don't we? We have no hesitation asking clients to sign a medical release that places blame back on them when they go "against our medical advice" and leave the clinic without medications, hospitalizations, and follow up specialist consults, but, why not with the more routine day to day omissions? Do I lose clients over my hard sells and case based experience? Absolutely! I absolutely am much more concerned about my patients health than my clients liking me. They may question whether I am trying to up-sell them, but I put my experience into my practice and they can't turn around later and not say that "I didn't tell them this wasn't a possibility." Further, I put my money where my mouth is. Every client has the ability to pay forward for care, use third party billing, and in some cases I will give the client a break, or the product on the house. This marketing scheme is written into every manufacturer contract I sign, it is also provided with an in-clinic resource guide for clients with financial constraints.

I know the reply from veterinarians ready to jump and attack this blog. I know their defensive tone deaf ears and accusatory vitriol to these stories is all the same. Blame, shame, and excuse the heartbreak. We tell them and each other that "it is their fault. Theirs alone." It is not. Let the stories prove this to be wrong. We have yet to stand up to our accusers and provide culpability.

Clients are not given options based on numbers. All made available at the initial consult. Every single option given and then let the client decide. Veterinary medicine does not provide enough transparency. And the numbers don't lie. Give them prices, choices, and prognoses ALL UP FRONT.

Where are those numbers? Want to argue with your credibility intact? "SHOW THEM THE NUMBERS! Not just your own, show them mine too. Tell them that my clinic provides 90 (plus) % survival rate at $1100, and then give them yours. Let them decide what to do with their family members life.

Pawbly.com is about saving lives, and providing options with data. Let the data set the standard of care and integrity via transparency be the guide.


If you care about pets, believe in making happy endings happen, and want to help others please join me on our Jarrettsville Vet Facebook page, our Pawbly Facebook page,and also on Twitter and YouTube.

Sunday, October 1, 2017

K.I. S.S.

K.I.S.S = Keep It Simple Stupid. Something every vet learns in vet school.

So here it goes;

You either represent the establishment or the individual, 
if you are a caregiver the answer should be obvious.

Tori Star, surrendered at the shelter by a former client.
The shleter called us we brought her back to live at the clinic.
If you are a part of our family once you are a part of it always.

Saturday, September 30, 2017

Cyberbullying and the Dragonslayer

,,, and sometimes you walk away to slay the dragon another day.

I'm off to hug my dog.. I'll be back in armor tomorrow...

(PS #trainwreck has an ethical code to her patients and family,, and fathers should be very careful what they put out there in the world.)


stay tuned,, this is a work in progress,,

The Second Round of Denial, Self-Pity.

Take a little stroll through LinkedIn, the Facebook pages of the veterinary management professionals, or, if you have access, take another little peak inside the "secret" pages of Facebook veterinary organizations. The backlash of complaining, sniveling, and nastiness is unsurpassed. The themes all center on a key point. They refer to "a video" or a "divisive rant" but the professionals of these are all circling their wagons, mounting their ammunition, and feeding the frenzy of fear based anger with more palatable axioms like "fatigue", "ethics" and "self righteousness." The war is real.

The anger runs deep and cuts hard. It runs on all sides now. At least for whatever consequences we all face the anger is universal. People are hurt, deeply. They are legitimately scarred. There is, however, NOT a universal responsibility to all sides to acknowledge this. Sure, the vet community at large can shoot the messenger, punish the singular face that brought this into light, but the mob behind the viral video is awake and now they feel acknowledged. The first weeks of the videos backlash included personal attacks to all of my social media, the clinic staff, and a real fear for my personal safety. This last week has become an onslaught of blogs by veterinary professionals feeling sorry for themselves. They are "tired". Well, for the record, are all tired. Let's just give each other that. Except that the other side has been tired for decades. (Who is the other side anymore?) At least you aren't also heartbroken that you were made to feel like an irresponsible, uncaring parent. Or lied to. Or guilt-tripped into paying for something without full disclosure that the same service might be available for a fraction of the cost down the road? Because that might be unethical? We are all tired. Tired of feeling inadequate, uncompensated, and unacknowledged. People put their pets down. We (the whole vet professional community) knew this, we tolerated it, we at worst excused and accepted this, and now we are too tired to say "I'm sorry" and move forward together. It's just another divide we place.

The wave of millions of people who feel that we failed them, (read the comments,, they use stronger words like "lied", "cheated", "killed", "extorted", etc) is real. These are real people. Real clients. People who loved, lost and can't get over it. Stop blaming them, they don't need judgement. They need help and we are responsible for too much of the vitriol to be ganging up, feeding more anger, and fess up.

You aren't tired, your burden is the anger that swells. For some it is self doubt, self reflection, inability to admit you are not perfect and that blind spot is the face of indifference you show the public countered by the mob mentality you show the vet community. You're burdened. The burden makes you feel "tired". The only way to unload the burden is to face it. Acknowledging your role in it by listening to those who feel wronged, accepting your part in it, and offering open ended solutions to resolving it.

Somewhere between both sides lies responsibility to uncover the truth.. maybe the only sincere way to set the burdened consciousness free for both sides. I'm exhausted too. Exhausted from apologizing when no one else can. When no one else will stand up for the people we serve when we disappoint them. Because the hurt goes both ways. And in the middle is the pet. That's the middle. Where the truth lies.


P.S. This blog was posted and pulled last week when a few torch bearing vets missed its point. I have attempted to edit it so as they might better understand it's intent. This, again, is not about you OR me, it is about the pet parents.. stop being such a bunch of egotistical haters, grow up, say you are sorry if you hurt someone. It's what you are teaching your kids to do in times of conflict,, isn't it?

P.S.S If you are such a coward as to leave an anonymous comment I reserve the right to delete it, post it, and/or cut and paste it with your IP address link.

If you have a pet who is the love of your life we want to hear about it. We are here for pet people across the globe. Building a place where information is free, compassion is universal and the pet ALWAYS COMES FIRST. Please join us on Pawbly.com. Open to everyone who loves pets. Dedicated to education, inspiration and empowerment. Because no one is ever alone,,, even if they are "exhausted".

Related articles; No More Blaming and Shaming: What Vets & Pet Parents Need To Understand About Each Other. Vet Billing, Suzanne Cannon.

I am also at Jarrettsville Vet, in Jarrettsville Maryland, where "economic euthanasia" is never a treatment option, and compassion is always free AND readily available.

Also on Twitter, YouTube, and Facebook (where the troll guards are still (sadly) on duty.. ;-) ).

Video here.

Want to know about the costs at Jarrettsville Vet? Look here on our website Jarrettsvillevet.com

Saturday, September 23, 2017

The Storm Behind The Rage. When The Truth Threatens. Backlash of Rant Video

It has taken me days to begin to try to understand the reasons for the intense backlash I am facing.
You see I posted this video. It went viral. It was an emotional plea for the veterinary community to do better than we have. To help people find meaningful AND affordable answers when they come to us in need. It focused on how expensive care has gotten, and how, for too many, veterinary care has gotten out of reach.

The example, (which in retrospect I would have changed and made less about the individual case and more about the systemic problem as a whole), was met by intense anger, threats, harassment and about the worst week of my life. I was attacked, ostracized, banned, bullied and castigated by, what appears to be (almost) the entire veterinary community. I am being called "the most hated person in veterinary medicine," "the reason the suicide rate is so high," and told that "you are under attack so be careful."

It is a burden of despair I would never wish on anyone. I find myself alone, afraid, and questioning everything I thought I stood for and belonged to. While I would never publicly attack anyone (maybe just politicians, if I am being open and honest), I would not ever name a business, or "throw anyone under the bus." You may choose to not believe that, but to most people outside of the veterinary community they seem to understand my point and my message without placing blame on any single person, business, or facet of our profession.

There is a problem. It is a very big, very deep, very emotionally charged problem. I am not the first person to bring it up, although I might be the strongest voice heard across the greatest distance. To deny the problem is futile. The number of people who have added their stories, relived and recounted their tragedies and their grief to the video feed proves this. The inane reaction to justify this 'out of reach for too many high cost' explanation from the vets that "our cost of education is $XXX (too high), our expertise and training, our overhead, our long hours, overnight/holiday/weekend schedules, etc. etc." are not falling on ears who understand, identify with, or even for the most part care. The general public can be told repeatedly about all of the reasons the costs are so high, but when their family members life is on the line, they don't care. They don't care why it is soo expensive, they overwhelming, over-archingly and quite verbally feel this is simply the case. Further, it doesn't motivate them to find resources they don't have.

Now I understand the arguments from the vet side that are being placed on the pet parents. All of the blame we place on them. This is also a waste of time, and a further divide we place on an already tenuous situation. They are where they are. Telling them they should have known better is salt in a wound simmering in shame and disdain. They are your customers. We wouldn't have a job if they knew how to avoid us.

Stop blaming. Stop shaming, and start listening.

Where does my personal discontent lie? I don't care how much anything costs when someone can afford it. The number of zeros, the placement of that comma sign are not relevant when a pet parent can pay. It ONLY matters when they come to us (yes, I know many of my colleagues now take offense at my use of "us" as I am, in their eyes no longer a part of "them") with a pet in need and we forget, or omit, or disregard their journey and their plight. We HAVE to listen. We have to offer assistance AND, most importantly, WE have to help. Realistically, when rubber meets the pavement, we have to speak a common language with a common patient centered goal and make it work. Start to finish. Everyone walks out feeling the patient was put first.

A significant part of the veterinary profession is focused on the top 20%. Those people (I, in truth doubt it is even 20%) who have lots of disposable income and are willing and able to pay regardless of the cost. These clients spend tens of thousands of dollars on their pets care. There is an inordinate amount of options for this population. They are well served and under representative of the pet owning population. The problem is that the able love their pets as much as the struggling.

I live with my pets, who are the only beings who will ever have my name to carry as their legacy (not silly to me) and I will fight for their well being for as long and as much as I am able to pay. I am a pet parent and they are my first and truest love and obligation. I am like all of those millions of passionate viewers. We, all of us, know this, we need to make this relationship paramount in every single decision making process and every single word we utter. It is the center of our duty regardless of which side of the exam table, or operating table you stand on. It has no price and yet it too often has narrowly defined options based only on available cash resources.

When a person comes to a vet they should not ever feel that their decision to love their pet depends on a dollar figure. It is possible in almost all cases to allow a pet parent to leave our facility feeling "ok" with their decisions. They may not have won the battle between life and death, but walking away accepting the consequences does not hinge on ability to pay large sums of money. We owe, I owe, each other that. We have forgotten, or overlooked in our defensive, protective posturing, to remind ourselves that compassion is still free.

So, I am at day 6 of this pit of pity. I cry everyday. Sometimes over the stories people have shared and the terrible heart ache they still carry. The overwhelming burden to help them move on if they can only forgive themselves. The fear that I cannot wear a name tag to a veterinary conference, of which I have to go to ( I am seriously considering going abroad for this next year), and the anguish I think I am putting my family and clinic through. I wish I were even more isolated so I could spare them this journey. It is that bad for me right now.

Medicine is all about dealing with worst case scenarios. Looking at a case and asking yourself what you need to do, what approach you need to take for the patient, how you can protect them from whatever this case might be if it is indeed the 'worst case scenario'. It is also about cajoling that client to understand your perspective on their pet, and encourage them to take the next steps needed to alleviate the condition. I am trying to strategize my own worst case scenario. Let the lynch mob of angry vets, who can't take responsibility, cannot for reasons I find inexcusable say that they have failed to meet our clients expectations and say that they are sorry (I sincerely feel like I am the only person able to utter these important over due words) and move forward. There seems to be only 2 or 3 people inside this profession who get this. Why is that? That is my question? Why do I see the world so differently than so many of my colleagues, and for heavens sake why can't anyone step up, hear the million people screaming for their pets, and say something! Why are we still throwing more division into an already over divisive topic?

The fact remains, vet care is too expensive for too many. It has to be mitigated somewhere.  We (vets) don't want low price options being offered out in our own neighborhood, yet, we don't want to lower our own prices. We aren't shy about asking for clients to pay thousands for our services, but we don't talk about the W2's we file. Why is that? Don't tout the same old "no one gets into veterinary medicine to become rich" when there are a number of vets, who would very closely approximate the definition of "wealthy" to the mass majority of the public we serve if their salary was revealed. Don't try to bull- your way into telling people they aren't worth your time because you aren't trying to get rich. Most people, (which is open to each persons interpretation), are trying to get rich. Most do it on the backs of others less fortunate. Be honest here. The vet profession can show a little integrity in this department. We all look for less expensive options. It is the nature of our being. Getting something for less because you have access to the price is called an open free market society. Getting rich by charging more, or spending less, is the formula to wealth. Wealth is still perceived as a sign of success. The cost of Vet med these days are squeezing this ability out of peoples reach. The divide between finding affordable accessible care and 'Ivory Tower' or "ideal standard of care" case management is harder to find and less appealing to offer. Where there is a market there is an opportunity. Maybe that is what is so threatening?

The profession may think I am attacking, undermining, or belittling them. Their efforts, their intentions, their heart and soul, but I am not. This is not about an individual, although we are of course a collection of the sum of our parts, this is an outcry for change in the system. It will happen, it has to happen.

Care costs, but that cost has options, real life-saving, life-changing options.. Decline a full blood work and do a PCV/TP and do the damned pyo surgery for $200 less. Why not? What do you have to lose? A dog, or a paycheck?



As always I wish you all love, peace, and kindness.

Find me, anytime, at Jarrettsville Vet, on Pawbly.com and after the shit-storm passes back on social media.

If you have a story to tell you can email me.. If you have a voice to help others in their quest for help for their pets care and well-being join me on Pawbly.com. It is free for all and dedicated to providing real help for real people.. I cannot always tell people what they want to hear, but, we will always be compassionate to your pets.

Krista..