Your Pet's Best Friend

Offer everyone your best.

I learned some years ago to always offer my best to the client.  While it is certainly possible that they may not desire or be able to afford Plan A, they surely won't ask for it if they don't know what it is.  With every patient, my job is to offer what I believe to be the highest standard of care.  Offering anything less is a disservice to the pet and to the client.  You certainly cannot judge by a person's clothes or the car they drive.  People who are well-to-do may decline complete care and people who appear near destitute may make whatever sacrifice needed to care for their pet.

Sometimes it's a little difficult to get fired up about treating the pet's dental problems when the owner's smile reveals a few scattered green snags passing for teeth.  If their own dental hygiene is not a priority, how important will the pet's mouth be?  On the other hand, their own dental problems might make the pet's dental situation more real to them.

You might think that the pet's previous care would be a pretty good indicator of what folks will do in the future, but you can certainly be surprised there, as well.  When taking the history, I tend to get less optimistic when I find that the pet runs loose, hasn't had a checkup in years, doesn't take heartworm preventive, and the condition is long-standing or brought on by what appears to be egregious neglect.

You never know, though. Sometimes it's the guilt factor, sometimes people really were meaning to do all that stuff and just didn't get around to it.  Tonight we had a big pup who had been accidentally (how else?) run over in its own driveway.  She had lots of fleas, ear mites, no heartworm preventive, and no puppy boosters.   Not good, I'm thinking. Yet, her folks stepped right up to the plate and are doing what it takes to make her right.  "I guess we've been neglecting her."  Man, we've just got to go on from where we are now.  That's all there is to do. If beating up on you would take us back in time and fix it, I'd be all for it... but it won't, so pat yourself on the back for doing the right thing, and let's get on with Plan A.

Grief upon grief

Old Yeller Alert

It's always hard to give bad news, but sometimes it's harder than others.   Today I had two old patients with kidney failure.  Everybody's pets are special to them, and saying goodbye is never easy, but today...

The first one was a cat whose kidneys were so large and misshapen that I could feel them like a couple of tennis balls when I picked him up.  When I mentioned this to the owner, she simply replied, "You're going to fix him.  This is my boy."  Pretty clear instructions.  Unfortunately, his ultrasound and lab-work make it pretty clear that we are not going to fix him.  We may make him feel better for a while, but with both kidneys cancerous, we're not going to fix him.  His time is short.

The second patient was a dog whose mama did not need another loss this year.  After major emergency surgery on herself, she lost her father in the winter.  In the spring she lost her adult son to an industrial accident.  There's no question that she cares about her dog and would not wish to confront it's passing,  but this latest link on her chain of losses was a cruel blow indeed.

We all suffer losses and deal with it as best we may, packing the experience away in our emotional garbage bag.  We put them behind us, but we don't totally get rid of the experience.  Each similar loss forges a new link on the chain, and in the process pulls the whole chain of losses out to wrap around your neck.  When we confront the impending loss of a pet, it is not uncommon to have to do so through the haze of a lifetime's sadnesses: all the griefs of lost loved ones, animals and people, from our last dog to grandma.  Usually it's not so obvious as it was with my poor client today, but it is an undercurrent that runs through every euthanasia I have to perform.  I have to recognize that and acknowledge it. 

Clients frequently say they are "ashamed to feel this way about a dog".  Not only must they deal with their grief, but they feel as though they are abnormal into the bargain.  "I'll never have another pet.  I can't stand this again."  Again, I have to acknowledge their feelings, but also let them know that they are not abnormal, and far from alone in their feelings.

Those who can feel no loss cannot feel anything.  As hard as these bereavements are, who would wish for a life where he cared so little for anything that he could not feel a loss?   So we go on, and open our hearts again when the time is right. 

Pet Guardianship

When we welcome a new client to our practice, part of the process is a questionnaire about their pet's health history and environment.  The last question is: "Do you consider your pet to be a member of the family?" and most people answer "Yes". The human-animal bond is very strong.  It's very common for people to say that the pet is like a child to them.  Cat-lovers often say that the cat owns them, rather than the other way around.  Certainly many (most?) of us consider our pets as companions, as opposed to property. Thus it would seem that referring to ourselves as the "guardians" of our pets is just a nice way of saying how we really feel.  [Trade Secret: the real key question is "Where does your pet sleep?"]

I can't argue much with that kind of warm feeling, but I do believe it's a different story when that language gets written into laws and ordinances.  It would seem that the terminology is designed to achieve a higher legal status for our pets.  That sounds pretty good until you think about how litigious our society is.  As you are probably aware, anybody can sue anybody for anything.  The suit need not have merit, and you may not win anything, but we have a society that appears willing to tolerate a lot of bizarre actions. People over-eat and sue the restaurant to take responsibility for their resulting health problems.  (And everybody's favorite: the lady who spilled hot coffee in her lap and sued McDonalds. I know that must have hurt, but did she order hot coffee or cold coffee?)

Aside from the abundance of eager attorneys who feel that everyone deserves representation, there is also the issue of folks who may use this foothold to advance an agenda that is far from friendly to pet-owners.  Just google "A rat is a pig is a dog is a boy".  ( This is a site I like, even if has been assembled by bioscience researchers)  These folks want to stop animal research (including that which would benefit the animals), and make you a vegetarian, but that's not all.  There are a bunch of them who also don't think you have any right to keep a pet, much less ride a horse.  How dare you exploit that pet just because you both enjoy the companionship?

The Missouri VMA put together this little brochure considering the ramifications of adopting "guardianship" as the legal terminology for our relationship with our animal friends.  It may seem a little far-fetched at times, but ... maybe not.

It is certainly food for thought.  We need to be careful that we don't just accept this "Guardian" business for the warm, fuzzy feelings it gives us.  We also need to think about the foothold it gives to the wacko extremists.  I doubt that any of my readers would condone pet neglect, dog-fighting or other forms of animal abuse.  On the other hand, a lot of us eat meat, wear leather, and own pets (who also eat meat and wear leather). 

What ELSE can we do?

When I was a kid there was a TV show called "Let's Make a Deal".  There were lots of appeals to greed in the program and many ways to make a fool of oneself.  The BIG deal of the day always involved three doors (evoking that great short story "The Lady or the Tiger", by Frank R. Stockton).  Behind one of the doors would be a terrific prize like a brand-new car!  Behind another would be a pretty okay prize like a new home entertainment center (which would be a console stereo, or maybe even "hi-fi" in those days. If you were thinking home theater with surround sound, you are the age of my children).  The remaining door would have something pretty useless, like a pile of popcorn or a stuffed moose-head (although, personally, I like a stuffed moose-head...maybe not as much as a new car, but better than a "hi-fi").  This was known as the "zonk".  Part of the enjoyment of the show was seeing some poor devil pass up the car and choose the door with the zonk.  What could be funnier than the misfortunes of others?

In real life (as opposed to game shows) the zonk is not funny.  It is especially not funny when there is a zonk behind all three doors.  No brand-new cars, just moose-heads.  Not cool moose-heads, either -- old ratty, moth-eaten moose-heads with no ears.

What, you may well ask, am I talking about?  I'm talking about medical problems where I cannot offer an attractive solution: problems that are either insoluble, or where the solutions are not within the client's reach, or where the client doesn't consider the risk acceptable (in view of the expected benefit). 

For instance, today my client brings in his ancient Labrador retriever, once black and now gray (literally).  "His breath is really bad. What can we do about it?"  In this case, the bad breath is not from some terrible illness; in fact, his bloodwork is good. It's just a case of teeth that are totally encrusted with tartar (which we know to be half bacteria by weight: "the germs that cause bad breath").  The only way to make the bad breath go away is to clean the dog's teeth.  Owner hates the bad breath, but fears anesthesia for the dog.  In this case, I think the risk is low, but there IS always a risk.  If anesthetics were good for you, you wouldn't lose consciousness.  Two choices: accept the risk and clean the teeth, or accept the bad breath (and the health hazards associated with a nasty mouth).  "What ELSE can we do?"   

The little (and I do mean little) girl Boston Terrier was bred on her first heat.  She's only about 3/4 grown herself, a little young to be having babies (like a thirteen-year old girl: she can have a baby, but all concerned would probably be better off if she grew up herself before  becoming a mommy).  We could do a hysterectomy (Nope, they do want puppies later), hope for luck (she might not get pregnant on the first date), abort the pregnancy (yuck!), or see her through the pregnancy (and likely Caesarean section to deliver).   That looks like plenty of choices, but they don't like any of them.  "What ELSE can we do?"

These may seem trivial, but how about this one (and these were all today, mind you)?  Abby is a 12-years old, too fat, but very sweet Labrador Retriever.  She's had a series of episodes where she just gets weak and feels crummy, rebounding fairly quickly.  After doing some pretty nifty diagnostic work, we've determined that her problem is most likely to be a bleeding tumor in her abdomen.  We know that something in her abdomen bleeds until she's about a quart low, then stops. This is when she's weak and feeling crummy.  She reabsorbs the blood into circulation and feels okay again.  It's probably a tumor, but it's too small to see clearly with the ultrasound (not like some big whacking tumor on the spleen, for instance).  Here are Abby's doors, and there is no car:   

Door Number One:  Keep letting her have internal bleeding episodes until one kills her.

Door Number Two: Send her to the specialists for $300 to $1,000 in additional testing to see if surgery can either be avoided or more closely targeted.  If they do surgery, they estimate a cost of $2,500 to $3,000.

Door Number Three: Open her up here (still several hundred dollars, but probably about $2,000 cheaper than the specialists).  The incision will have to be "stem to stern" (or xyphoid to pubis, as we say in the profession, or "crown to groin" as they say in the Conan books), as you could have more than one spot bleeding, and it (or they) could be the size of a pin-head.  Even if you find it (them), it could be something malignant (or inoperable) and you've gone to all that trouble for something that's not going to get fixed.

I can explain it all really well, but I don't have an attractive choice for my client.

"What ELSE can we do?" Zonks are not funny in real life.

Nobody likes being stuck with a needle.

You might be surprised to find that many pet-owners feel compelled to comment when their pet protests an injection.  Some sympathize: "Did the bad old doctor stab poor 'ittle 'oo?".  Some are less sympathetic: "Welcome to the house of jabs."  And then there are those who apparently feel like the pet should just suck it up and be tough: "I don't know why he acts like that.  That doesn't hurt so much."  Personally, I tend to agree with the pet.  Being stuck with needles hurts.  Some injections don't hurt so badly, some are more painful, but gee whiz, none of them feel good.

Just as the owner feels compelled to comment, naturally I feel compelled to reply (people who blog like to hear themselves talk, and I'm no exception). My standard reply is that "You can hardly blame him. Nobody likes to be stuck with a needle." Usually this just gives the impression that I care, which is correct.  You've got to realize that nobody goes to veterinary school because they want pets to hate them.  Alas, almost every visit will involve something that is painful, frightening, or at least annoying to the pet.

Today I made the usual response ("Nobody likes being stuck with a needle."), but I didn't get the usual reaction from the owner.  Instead he said, "Gee, I dunno... I was thinking about people with piercings."  At this point I notice his large earrings, though no other piercings were visible.  So, does this gentleman enjoy getting stuck with needles, and if so, how am I getting out of this one?  I feel like honesty is always the best policy (though my father used to tell me that "...you don't have to tell everything you know.").

"Well, I really don't know much about it.  I just assumed that people got piercings so that they could display the ornaments, not because they enjoyed getting the holes poked in them.   Sort of like (again just speculating) my idea that people get tattoos because they want to display the pictures, rather than just enjoying the big scabs.  I mean, if you just wanted big scabs, you could skate-board naked, right?"

At this point we have wandered about as far from the dog's medical needs as we can reasonably get in such a short time.  Sometimes I amaze myself.  Even more amazingly, we managed to get back on topic and have a successful visit.  When things don't go according to plan, it's always good to keep the original objective in mind when devising plan B. 

Don't You Wish Dogs Could Talk?

I don't think it would improve the situation much.  People frequently ask me that and my reply is that "I wish they could roll up their sleeves." [Drawing blood from a vein hidden under an inch of hair is quite a trick.]  I can make friends with animals. The problem is that I then immediately betray their trust.  Everything I do ranges from merely annoying to frightening to downright painful.  If they could talk to me, I think I'd be hearing mostly a lot of cussing.

Oh, sure, there are a lot of times I would really like to know how some bizarre injury occurred.  That's what brought on this discussion.  I looked at a dog who has a history of intermittent lameness for about a year, and now he has a swollen, draining wound below his elbow.  Actually, it's below where his elbow used to be.  On his X-ray, the lower end of his humerus and the upper ends of his radius and ulna (the parts of the bones that make up the elbow joint) just aren't there.  Of course, after a year, who the heck knows what has been going on?  It's a mess now, though.

I think that most of the time talking to a sick pet would be like talking to a sick two-year old (human).  "What's wrong?"  "I don't feel good."  "Where does it hurt?"  "Everywhere." Yeah, okay, that helps...NOT.  I don't envy pediatricians.

And what about the unconditional love and affection that those pets bestow on us, talking only with their eyes and their expressions?  If they could talk, I'm afraid we'd hear a lot of stuff like "You smell like popcorn.  I love popcorn. You smell good.  I'm gonna lick you now...  Yeah, popcorn."  That would really deflate my ego.  I prefer to think that my dog worships me.

Generally speaking, I think that pets understand us better than we understand them.  Two of my favorite people-pet communication cartoons are from Gary Larson's "Far Side".  The first is a neighborhood of dogs, some on leashes, some in fences, some loose.  The caption is "If we could understand dogs" and every dog is yelling "Hey!".   They're just yelling for the heck of it.  The second is the old "what we say and what they hear".   The owner is bawling out Ginger, who hears "blah, blah, blah, Ginger, blah, blah".  I have that one in my exam room.  Sometimes it makes people really mad.  "My dog understands every word I say!".  They understand a heck of a lot, but that's not the point.  The point is that they don't learn anything from being bawled out.  For them to understand what you want, you have to show them.  Sometimes you show them without meaning to.  Think how many pets can spell B - A - T- H.  They can learn an amazing number of words, but they don't get it from a lecture.

Oh, yeah? What about Lassie?  She's really smart.  Stay tuned for my thoughts on Lassie.

People who think Vets like animals more than they like people

are mostly mistaken.  Many times I have had a client tell me that they "should have been a vet, 'cause I like animals and I don't like people."  Get a grip, kid.  This is not a job for someone who can't get along with people.  If you're a real animal lover who just can't stand people, you might be able to make it cleaning out the kennel... but how do you think the animals are going to get to your kennel?

We close at noon on Thursdays.  Since we're open until seven Tuesday and here on Saturday morning, I've got to have some errand-running time.  My wife comes in while it's quiet and does the bookkeeping.   Today she buzzed my cell-phone and asked, "Before I let this little dog who snuck in the door go outside again, you aren't missing a patient, are you?"  "Does he look like a sawed-off Golden Retriever or a Golden/Dachshund mixture?"  "Why, yes he does."  "That's Sunny. He just comes to visit."   Sunny belongs to a neighbor and he's quite the little escape artist.  He likes to come to visit us, oddly enough.  When it's hot, he likes the air conditioning.  When it's raining, he likes to get dry.  He waits outside the door, then sneaks in behind a client.  You'd think he might run around and make a nuisance of himself, but he doesn't. He just heads back to the kennel and waits by the door until someone opens a cage for him.  At the end of the day, we call his folks and they come get him.  He likes to come see us, and he comes often, but he never brings any money.

Sunny is unique in his desire to visit our hospital on his own. If he brought in a "to-do" list and a credit card, he would be truly unique -- you'd be seeing him on Animal Planet.  The fact is that animals do not come to the veteinarian without their people.  When you want to know what's been happening with the animal, you have to ask his people.  If you want to stay in business, it's not enough to do a good job for the animal.  You have to please his people as well.  In fact, if his people are really pleased, the animal can be pretty ticked off and he'll still be coming back to you.   

You have to develop a relationship with the people.  It doesn't matter how smart you are and how much you care for the animal, and what a great job you do in restoring his health.  If you are not communicating and relating to his owners, they won't be happy.

If a guy builds chairs for a living, you can see that his product is finished chairs.  What is my product?  It's a healthy pet with an enthusiastic owner.  I like meeting people, visiting with them, hearing about their pets and lives, and teaching them what they need to know about their pet's problem.  I like working together with them to solve those problems, which is good, because I only have a short time with the pet.  I depend on his people to do most of the work.  I can send home the medicine, but good nursing care from the people is essential to getting well.

If you don't like people, veterinary medicine is not the place for you.  Sunny likes you, but he never brings any money.

Spin Doctor of Veterinary Medicine

Every profession has its own technical jargon.  This is necessary in some cases because you deal with concepts that don't come up in every-day conversation.  Sometimes it's necessary in order to be precise, especially in communicating with another professional. It's a lot easier to just say "intussussception" than "you know, that thingy where the bowel kind of telescopes on itself for no particular reason and causes a blockage" when you're hobnobbing with your fellow wizards.

Of course, there are many times when it is NOT necessary.  You might do it out of force of habit, like a newly graduated doctor using the technical lingo that was required while in veterinary school.  I used to have to correct my associate (when I had one).  She would start talking about "renal insufficiency" (kidneys not working well) when a lot of people are pretty fuzzy on what kidneys do in the first place.  Most of the time, you can use common terms to explain what's going on. 

On the other hand, jargon is sometimes used to let other people know that they are not "in the club", which is understandable, though pathetically petty.  The worst use of jargon is to cover up the fact that you don't know what is going on.  Use enough made-up words and the other person will think that he is the dumb one.  That's really despicable.

I just love seeing a patient as a second opinion for a long-term skin problem.  "What did Dr.X think the problem was?"  "He said it was dermatitis."  Well, he wasn't wrong there.  Since dermatitis is a generic term for messed up skin, the client already knew that: that's why he brought in the patient.  "We have some erythema" equals "It's red". "Excoriation" equals "he sure has scratched this hard enough to hurt himself". "Pyotraumatic dermatitis" equals "his skin has been scratched so hard that it's oozing pus".  These are all things that are technically correct, but are just obfuscating descriptions.  They are not telling you anything about what is really going on or why.  Sounds scientific as all get out, though, doesn't it?

There are times when it just makes you feel better to use a euphemism.  Sometimes  it's obvious that there is some major problem, but you can't find anything out of the ordinary on physical examination and you don't know what is going on.  It makes me feel a lot smarter to write up the record with "physical examination is unremarkable and diagnosis is open" than "Man, I couldn't find anything and I have no idea what's going on here."  In either case, my next step is to work out a plan for diagnostic testing.  However, it should be obvious that a scientist with an unremarkable physical exam and open diagnosis is going to have a better plan than some quack who couldn't find anything and doesn't have a clue. 

That's my story and I'm sticking to it.

Understanding your Doctor

In James Thurber's charming fable "Many Moons" [Are there ever fables that aren't charming?  Yes, to wit: "The Bird, the Mouse, and the Sausage" from the brothers Grimm.  I love it, but it's not charming.], the Princess is ill and won't get well unless someone brings her the moon.  The King summons all his wise men, advisers and courtiers to address the task.  None can bring him the moon, but all hasten to list the many things that they have done for the King.  The court magician's list includes a cloak of invisibility.  "That didn't work.  I kept bumping into things, same as always." The mage replied, "It wasn't supposed to keep you from bumping into things.  It was supposed to make you invisible."   "All I know is, I kept bumping into things."  Yeah, me too.

This came to mind last night when I was visiting my mother, who has a number of medical problems.  Her doctor had prescribed a medication for her which she did not intend to take.  She had looked up what it was for, and the insert information showed that it was approved for a different condition than the one she is suffering from.  As it happens, it also happens to be the best medicine for the condition she suffers from, despite the fact that it isn't on the labeling.  When I spoke with her doctor, he was a little dumbfounded, as he was certain he had done a good job communicating to her why the medicine was being prescribed.

Two weeks ago, I saw a dog with long-standing skin problems and a complicated history, having been to two different veterinarians previously.  I carefully outlined what seemed to have been going on, and what I believed the different possible underlying scenarios were (skin problems in dogs, often having multiple underlying causes, ALL of which must be addressed for relief).  Then I lay out the diagnostic and treatment plans.  Proud of my careful explanations, I then asked if the client were clear on what was going on. "Well, I heard you say allergy a lot."    That was discouraging, I can tell you. I started over, using words of one syllable where possible.

When the client doesnt "get" the explanation, it doesn't mean they are stupid.  It means that I have used a word they don't fully understand, or skipped from step one to step three without mentioning step two.  That's like watching a movie in a theater where they get the reels out of order.  It's interesting in a way, but it doesn't really make sense.  It's my job to help you make sense out of the puzzle, not leave you stuck in an additional mystery.

If I had neglected to ask my client about her understanding, I wouldn't have known she was still clueless.  She probably wouldn't have followed the plan (which, by the way, has been very successful), and she'd be moving on to doctor number four.

Sometimes people look so smart (or I get in so much of a hurry) that I neglect to ask if they have questions or concerns.  That's bad, because they may walk out and not help the pet at all.  We've called people back to ask how the pet is getting along and find that they were completely unable to medicate the animal.  They didn't call back for an alternative, they just gave up and watched them deteriorate. 

Even if I forget to ask (or your doctor forgets to ask), if you are still "bumping into things", call me back and let me know.