VMDiva

This past November I was presented with an all-too-familiar case of economic euthanasia. For those who don’t know, economic euthanasias are performed when pet owners cannot afford or choose not to pursue veterinary care for their pets due to monetary concerns. A 2.5 year female spayed tortoise shell prsesented to my practice with a solitary bladder stone. Her owners were going to euthanize her instead of electing a curative cystotomy.  These situations have arisen even more in the last few years of economic down-turn and are a very frustrating part of my job. My ethical compass couldn’t let me euthanize this wonderful kitty so I had her signed over to me.

Miss Pigglesworth is two months post-cystotomy and is thriving in our home. She was obese, weighing in at a robust 15.7lbs. Two months of strict caloric restriction and increased activity and she is down to 13.2lbs! Go Piggles! She’s our only female (and I am thrilled to have more estrogen in the house!) and gets along well with her brothers. We love her already and look forward to many healthy years ahead.

Dietary indiscretion can make for some good blog fodder. This year’s more memorable consumptions weren’t too hard to remember. I’ve left out the non-descript fetid balls of fabric, the shredded toys, bones, and rawhides due to their predictability and opted to let you in on some of the more ludicrous, dangerous, and enormous meals my client’s dogs have enjoyed.

Note: Labradors are overrepresented in this top ten.

10. One M&M

A panicked chocolate toxicity call always spices up an evening at work. But no, a solitary M&M is not anywhere close to a toxic-dose for Fido. For toxic doses of chocolate, check out this old Chocolate Toxicity Post.

9. Silica Gel Packets

The Animal Poison Control Center reports a large number of calls about dogs consuming these tiny desiccating packets. These little delicacies that come with your new shoes must taste great. Relax, this little nosh is non-toxic but can cause GI upset.

8. 50+ Pieces of Orbit Xylitol-Containing gum

This little Yorkie had a hankering for spearmint. What she didn’t count on was the dangerous hypoglycemia and potential liver damage from this outrageously high toxic dose of Xylitol. She lived to tell the tale and her owner has vowed to never have gum in the house again.

7. Feces

One of the most common complaints I get revolve around a dog’s proclivity to eat its own feces, other dog’s feces, any feces. Does it indicate a nutritional deficiency like some speculate? Maybe. Consumption an innate way to camouflage the dog’s presence in the environment? Could be. Does it taste good? Definitely. Another reason not to let Jake lick your face!

6. A Full Bottle of MultiVitamins

This proud pooch didn’t have a vitamin deficiency, just an apomorphine deficiency. We happily obliged, induced emesis, and Fluffy went home without complication.

5. Transmission Fluid

Perhaps the foulest smelling diarrhea I have ever smelled (yes, worse than parvo) came from a Labrador who consumed the remnants of a bottle of transmission fluid while exploring the garage. The mixture of feces and lubricant smelled like the tar used on telephone poles. Despite the cathartic effect, this guy didn’t miss a meal.

4. A bag of Cat Nip, Reese’s Peanut Butter Trees, and Styrofoam

If I told you this dog had no diarrhea, would you believe me? I suggest not putting your Christmas presents under the tree until it’s time to open them. While large amounts of styrofoam can cause an obstruction, this lucky dog simply enjoyed opening everyone’s gifts a few days early.

3. Tampons (Twice In One Year)

You’d think the first foreign body surgery to remove a tampon from your dog’s intestines would be enough of an incentive to buy a garbage can with a lid or close the door. I guess not.

2. Two boxes of Andes mints, 2 bags of Lindor Peanut Butter Truffles, 2 boxes of Pop-Tarts, and the box for a creme brulee baking kit.

This one goes to my parents’ three labradors, who diligently found their way through a closed door and consumed all of the above without consequence. A chronicle of all of their indiscretions is the subject of it’s own blog.

1. One bulk box of Cheese Its, one bulk box of Pepperidge Farm Goldfish, 16oz of Almond Slivers, 16oz  of Raisins

Both of these labradors can’t seem to stop eating their owners out of house and home. These repeat offenders raided the pantry after their owners came home with purchases from a wholesale club. They pranced into our office thrilled to have their dietary indiscretions rewarded with a trip to the vet. They were more than eager to eat up wet food laced with hydrogen peroxide and savored their spoils – for about 5 minutes. Waves of nausea hit the ladies but neither would…errr…cough up the goods. Good old Labrador iron gilded skulls and stomachs. Activated charcoal treatments, IV fluids, lab work, and two days of hospitalization later I decided to crown these two with Top Digestive Honors for 2010!

Months ago the previously prescription-only flea preventatives Advantage and Frontline became available over-the-counter at pet stores and large chains. Veterinarians were, for obvious reasons, not happy to have to compete with discount giants like Walmart. A recent trip to Petsmart reminded me we veterinary practices are still in a competitive market when I saw our prices were comparable. Other practices that have created a cash cow out of their prescription flea preventatives are not so lucky. Finances aside, I see a prominent silver lining in the change from prescription to OTC.

I see failure after failure with home flea remedies and OTC products from Hartz and Sergeants flea products. Garlic and these products are not effective. I’m sure I’ll get a backlash from the garlic crowd, but find me scientific evidence garlic does anything for your pet other than cause anemia. I digress. With a population of folks who rarely bring pets to the veterinarian, these people can never procure quality flea and tick products. From a zoonosis and quality of life view, it is critical to have pets on flea and tick prevention no matter their veterinary-patient-client relationship. The availability of Frontline and Advantage now allows all dog and cat owners to provide their pets the best prevention.

Advice to my peers: Don’t lament the loss of your cash cow and celebrate the progress in animal and human health.

I received one of the best compliments of my professional career this week when a client said he “wished his doctor was as good” as me. Wow.  His comment got me thinking: What makes me so different from his MD? Did his MD fail to engage him, encourage him to speak, make eye contact? I certainly am not that fabulous. I wondered where his MD fell short. I thanked him and told him my motto to veterinary medicine is to “Laugh so you don’t cry.” It’s important to keep it light when you can or you’ll end up crushed by the burden of the profession.

My quantum leap in thought took me back to college when I began as a biology major and a pre-medical student. That’s right. I coveted an emergency room physician position.  I had done work in an emergency room as a senior in high school and knew medicine was my destiny. Medicine was my destiny, just not human medicine. As a person who has seen both sides of the coin, I can draw some informed comparisons and contrasts.

I think the greatest agreement between the two fields comes in our education. Both veterinarians and doctors are taught how to diagnose and treat diseases all over the spectrum. From simple skin diseases to complex endocrine diseases, we learn them all. Veterinarians are problem-solvers most like ER Physicians. We must be prepared for anything that walks in the door and see a variety of cases throughout the day. Both vets and doctors (at least the good ones) must possess terrific “people skills” as medicine serves the public.

The biggest contrast between the two professions is probably directed by litigation and finances. A veterinarian’s pursuit of diagnostics and treatment is frequently limited due to cost.  I often find myself saying, “If we only can do one test, then I pick this one because….” I fantasize what my job could be like if I had unlimited access to blood tests and imaging. Bliss! Fear of litigation and the financial ability to perform diagnostics drives physicians to order a battery of tests. This is no indictment of MDs, on the contrary, I would find myself in the same situation had my career aspirations not done an about face in college!

Additionally, the high specialization in human medicine greatly contrasts with the average small animal general practitioner’s position. A specialist has a depth of knowledge in their niche that cannot be rivaled. In the span of a day, an endocrinologist may see five diabetics, two patients with thyroid disease, and several patients with obesity. My day consists of surgery, dental extractions, diagnosing heart disease, kidney disease, thyroid disease, and dermatologic disease all while managing a dog hit by a car and a rabies suspect. My breadth of knowledge adds spice to my career and keeps me fresh. The surge in veterinary specialists is slowly changing the profession’s focus but the vast majority of veterinarians still engage in the many facets of veterinary medicine.

Despite the differences one thing rings true: Good veterinarians and physicians care deeply about their patients’ health.

Coming off of a summer hiatus from VMDiva, I have many updates for you. This summer proved hectic: vacation, home projects (how about a leaking roof!), graduations, parties. It’s a wonder I’m still standing. Check out all the updates from some of my previous posts and of things to come!

Snotty Cat Remedy (original post)

My chronically ill cat, Winston, was the recipient of an experimental vaccine protocol in an attempt to curb his chronic upper respiratory congestion. If you missed that post, check it out. I approached this protocol with skepticism. C’mon, a vaccine will fix a problem he’s had for six years? I was amazed that, 24 hours post-vaccine, Winston could breathe unimpeded through his nose! I’ve followed the booster schedule and am pleased to report we are 70-80% improved. The occasional snork and sneeze arises but my walls are free of snot! I’ve instituted this program at my practice and have about six cats I am currently monitoring. All have seen some improvement.

Goldie Hawn (original post)

I am sad to report I lost one of my very favorite patients a few weeks ago. Goldie Hawn succumbed to her osteosarcoma. She survived for seven months following her left hind limb amputation. I waited a harrowing three weeks for a pathology report that indicated she had “very early osteosarcoma”. I was joyful we amputated the limb correctly and devastated a young, wonderful dog was plagued with this darkness. She received chemotherapy at my Alma mater, MJR Veterinary Hospital at the University of Pennsylvania (VHUP). She did excellent under chemotherapy and, following the full course, staged clean of osteosarcoma. I hoped we had beat it. Things took a turn for the worse when she presented to our hospital severely limping on her right hindlimb. One of my associates diagnosed her with a cruciate ligament tear, a devastating diagnosis given her tripawd status. After discussing all the options, she received TPLO surgery at VHUP and recovered well.  Flash forward several weeks and she presented again, this time not looking well. She had an inoperable basketball-sized lymph node in her abdomen.

Horizons

I am now a member in training for the Pennsylvania State Animal Response Team. I will help provide veterinary care and expertise in the event of a disaster. I look forward to sharing m experiences with you!

Recent news out of Australia slammed physicians for instituting late fees for patients who show up more than 10 minutes late to their appointments. Many argue these physicians are implementing a double standard given how far doctors log behind during their appointments. Perhaps this is a double standard but I guarantee one argument you’ll hear from these physicians is the patient’s tardiness contributes to the physician’s tardiness.

I have toyed with the idea of implementing late fees for chronically tardy clients (and we all have them, usually know them by name, and plan accordingly). My practice runs on a busy 15-minute appointment schedule. A client’s 10-minute tardiness can throw off the entire block of appointments. I know a late fee would go over like a lead balloon and so it remains an idea droning in my temples every time a client shows up late on a busy night. It’s my fantasy revenge.

The facts against a late fee remain: Most clients are on-time or early for their appointments. Legitimate excuses happen. You can’t teach common courtesy.

I have found some of the best ways of dealing with tardiness are as follows:

• If owner’s are more than 10 minutes late, have front desk staff politely inform them they will need to wait because the veterinarian is seeing her next appointment. It’s unfair to clients who show up on time to have to wait even longer for their appointment.
• Squash clients who decide to “sneak” that extra pet into their 15-minute appointment. If you simply cannot fit her in without making clients with appointments wait longer, do not do it. If you do have time to look at Little Lucy’s skin condition, use the line “Fortunately I have time to see her tonight without an appointment, but just make sure to have one down the road for when we are booked solid so we make sure to address your needs.” Spin the situation toward looking out for the owner’s best interest and you’ll avoid an awkward moment. You know the saying “If you give a mouse a cookie….” Set the tone for future appointments.
• Veterinarians must practice excellent time management given the frequently unpredictable and sometimes emergency laden appointment schedule. If a two-minute recheck and a sick exam arrive at the same time, see the recheck while the technicians triage the sick patient.
• Apologize and offer a reschedule. Veterinarians run behind, mostly, due to surprise illnesses mentioned at annual examinations, emergencies, and sick patients who require admission. Once we are behind it’s very difficult to catch up and we find ourselves rushing through appointments. Sometimes it’s better to reschedule than make a client sit an hour in the waiting room with a labrador who has chewed through the leash, peed on the wall, and jumped on the counter during the wait.

I’m a follower of the adage ‘do unto clients as…‘ and believe the best business practices start with that idea in mind. However, sometimes in business, the “Golden Rule” mentality doesn’t quite cut it. My wants and needs as a pet owner don’t match the wants and needs of all pet owners. When I read this article by Gladys Edmunds of USA Today, it begged for reposting! It highlights the importance of open communication and proper training with staff.

The diversity of my appointment schedule never ceases to amaze me. From the blissfully smooth to the guilt-inducing no-money client, I fluctuate between joy and stress throughout my day. One hair-pulling situation involves the disabled pet owner of two small fluffy dogs who routinely appoints her caregiver the task of bringing the aging beasts to me for exams. Following the visit, I then call the owner to discuss my findings, diagnosis, and plan. I’m struck with minor annoyance by having to repeat the entire appointment over the phone but can understand the owner’s absence.

The real trouble arose when I realized the owner and caregiver have a palpable distrust of each other. The caregiver revealed the owner doesn’t want her present at the exams. The owner called before an appointment to ask that I not tell the caregiver too much. The caregiver tells me the owner fails to give medications as prescribed and refuses to follow recommendations. The owner assured me she gave the medication and the dog is still no better. I’ve found myself in the middle of a owner/caregiver/dog triangle and needed to find the fastest way to the best outcome for my patients.

I’m tasked with placing the dogs’ health at the forefront while still adhering to the wishes of their owner. Now, I’m no fool and realize owners lie to me about giving medications, diets, and who knows what else on a regular basis. I rarely have foreknowledge of the impending lie. I tend to believe the caregiver’s story  because there is no rational reason for her to lie about the owner lying. The owner, with her impaired faculties, probably believes admitting to her lack of compliance will result in relinquishment of her pets. Despite this, I refused to cut some back-exam-room-deal with the caregiver to reach the treatment plan these dogs need. The owner has exclusive right to chose as long as she adheres to anti-cruelty statutes. So instead, I’ve employed my straight talker tactic.

I asked the owner pointed questions about completing courses of antibiotics and reasons she wished to pursue XYZ courses of action. We spoke candidly about quality of life and her ability to provide adequate medical care to her pets. I built trust and after we had a rapport, I reiterated the importance of all the things we discussed and planned. I cannot control whether she does them or not which is a lesson in patience and understanding only time teaches.

And I haven’t forgotten to document, document, document!

Anyone else out there find themselves in a similar situation? How did you handle it?

It’s internship season which always makes me wonder: Is life after an internship so radically different from spending your first year in private practice? I decided to forgo an internship, mostly for financial and marital reasons. Kudos to my husband who tolerated my indebtedness for four years of vet school. This year’s new veterinary graduates are faced with a decision that has educational, financial, and personal implications: Pursue an internship or full-time employment? About 40% of new veterinarians are entering internships upon graduation, leaving the remainder to *fingers-crossed* find strong mentorship at a private practice. New graduates have the base knowledge needed to develop a list of differential diagnosis but have yet to learn the the art of recognizing nuances of disease in practice, delivering bad news, and having confidence in their abilities.

In an academic setting, influences from specialists and the constant inundation of “ivory tower” medicine can easily persuade students to pursue additional training after graduation. Many of my classmates pursued an internship with knowledge they would never pursue a residency. But why? I argue many new graduates lack confidence in their knowledge and instead find themselves leaning on an internship as a crutch, that stepping stone between student and independent veterinarian. It’s not wrong to feel insecure but it warrants recognition for what it is. I’ve heard many reasons for pursuing an internship from: inexperienced, not ready, want more emergency training, not sure about specialization. Most of these reasons boil down to fear.

I felt fear and, admittedly nausea, on my first day of work as a veterinarian in private practice. I don’t regret my decision to forgo an internship. Within months I felt at home, climbed the steep learning curve, and blossomed into the veterinarian I am today. Interns earn a pittance, work double the hours of a private practitioner, and defer loan payments for one more year all the while accruing interest. I challenge new graduates to honestly explore the reason for pursuit of an internship because that path is wrought with challenges.  If the pursuit is for more education and career advancement – go for it! If it is fear of primary case responsibility and decision making – take the brave step, find a mentor in private practice, and jump!