Overpaid My @$$!!!

Please excuse my crudeness but my ire is a bit up right now.  A reader posted a link on a comment about yesterday's post which has ticked me off.  She already had her say, but I felt the need to put in my two cents' worth.  Hey, it's my blog.  Deal with it.

Over on Salary.com there is an article about the "8 Most Overpaid & Underpaid Jobs".  And what a bunch of hogwash!  The author introduces the topic as follows:

In this article I’ll compare eight overpaid jobs with eight underpaid jobs. My methodology? None. I realize that some jobs require a certain level of training and education, while others are merely the victims of supply and demand. While I feel that all the jobs on this list have merit, they simply represent -- in my humble opinion -- jobs that are paid more or less than they are worth given day-to-day responsibilities and duties.  (Emphasis mine)

So this article on a supposedly respectable site is making an analysis based only on opinion without a shred of facts?  And that's supposed to be GOOD writing?  Here's what she says about veterinarians:

Becoming a veterinarian takes years of education and training, and ensuring the health of man’s best friend is a noble profession. Believe me, no one was more willing than I to fork over $450 when my dog, Sunny, ate 3 lbs of coffee grounds and had to be hospitalized. Yet veterinarians, for the most part, work in clean, well-lit environments with domesticated animals. While they may be on call for emergencies, their hours are relatively predictable and the pay is above average as well.

I call 100% BS on that one.  She obviously has no clue whatsoever about what goes on in a veterinary practice.  "Clean, well-lit environments"?  What about all of the vets who work in the large animal industry that are out in the fields, chicken houses, barns, and pig pens?  None of those are clean or well-lit.  "Relatively predictable" hours?  Yeah, tell that to us vets who have to stay late unexpectedly because a last-minute emergency comes it.  "While they may be on call for emergencies"?  She says this in passing like it's not a big deal.  Tell that to those of us who have had to wake up at 2am, throw on some clothes, rush to the clinic, treat the emergency, and then be back to work by 9am.  "Pay is above average."?  WHAT?!?!?!  Where in Hades is she getting that rationale?  We have a salary crisis in veterinary medicine where the debt burden is becoming so high that new vets are going to have a hard time just surviving and paying back their loans.  Vets have the highest debt-to-income ratio of any medical profession in the US.  On paper a $95k salary may seem great to most people, but a large chunk if that is merely repaying for the training used to get to that point.

The rest of the article is in a similar vein, and judging by the comments the author is equally off the mark on other professions.  No profession just says "I want to make $X per year" and then charges that.  Salaries are based off of many factors, including the cost of doing business, the cost of education, the rarity and demand of the job and so on.  This is one of the worst-written articles I think I've ever read and filled with so many false assumptions and lack of real knowledge.  It's sad that someone approved this going up as other than a personal blog.

Overpaid my lily-white tushy!

Dodgegoo!

Being a veterinarian requires more than just intelligence, training, and compassion, though all of these traits are certainly important.  It also requires often lightning-fast reflexes.  The most obvious application of a quick response time is dodging the claws and teeth that often come at us.  But many people don't think about how often we have to avoid spraying fluids.  It's not dodgeball around here....it's dodgegoo!

Yesterday I was getting a rabbit out of his kennel to look at an eye problem.  As I was trying to remove him from the small kennel he started urinating, spraying directly on my lab coat.  Kind of failed my dodge on that one.

That afternoon I removed a rather large mass from a dog's abdomen.  After I was out of the surgery I cut into the mass to see what it was composed off and get a sample to send to our lab.  It had felt very solid and initially seemed that way when I first started incising, so imagine my great surprise when a slightly bloody thin liquid came shooting out of the center under pressure.   This time I was lucky and managed to jump back in time to avoid getting more than a couple of drops on me as it sprayed out a good foot or so.

Today I had a small female dog that presented for difficulty urinating.  We took abdominal x-rays and saw a very full bladder (which I had felt on abdominal palpation) and a rather large stone stuck in the area of her urethra, likely causing a partial blockage.  I needed to catheterize her, which is never easy on a female and was more difficult since she was only nine pounds.  After some sedation I got her in position and tried to pass the catheter.  The first attempt didn't work, so I used a larger catheter, trying to push the stone back into the bladder where we could deal with it easier.  Though tricky, I did get the larger catheter through the urethral opening and started gently pushing it in.  All of a sudden a spray of bloody urine came shooting out of the end, thoroughly covering my lab coat.  I was successful in moving the stone, but at the expense of a dirty coat.

Veterinary medicine is rarely glamorous, and is far dirtier than most people realize.  On a daily basis I have to avoid urine, blood, feces, and pus coming at me at often rapid rates.  Large abscesses under tension?  Yep, you can get a good several inches of distance when you lance it.  Full anal sacs?  Express one of those in the wrong direction and you can get hit.  Even though you never like it, after a while you tend to get used things like this and it becomes part of your daily routine. In the above circumstances I tend to just sigh and calmly strip off the dirty clothing (if I can without flashing everyone or becoming indecent...I've had to deal with "stuff" on my pants many times), then move on with whatever I'm doing.

Anyone with dreams of becoming a vet still want to do so?

Flea Control Revisited

It's been about 18 months since I had any discussion on flea control, in large part because I had done so many exhaustive posts on the topic.  Then I received an email from Jon, and felt it was worthwhile briefly revisiting the issue.

I saw your blog and you post "It's NOT The Flea Product...Really!"  Well, I have to tell you I'm confused.  I live in Washington, DC, and five weeks ago I rescued a feral kitten that was running in traffic on my street.  I brought her into the house and things have gone well (she's now quite tame), except for fleas.  Just so you know, she's been spayed and checked out by my vet.  

I have two other cats and I gave them all Advantage II after I realized there was an infestation.  Within three days I noticed the scratching was continuing, so I waited another week and gave them all a second dose.  The same thing happened again (fleas returned).  I don't even know if they went away.  So you know, I'm applying it as directed (getting to the skin).  Yesterday I bought a flea comb and found six fleas on the kitten, and a few on the other two cats - and that was after only a minute or so of combing.  The Advantage site says they should die when coming into contact with the animal.  But these were very healthy fleas.  

I know they are likely still in the environment, but given that I just gave the cats the treatment, something doesn't seem right here.  They shouldn't be so happily ensconced on the cat.

Do you think I got a bad batch of Advantage II?  Something else going on?  

For anyone reading this I STRONGLY recommend looking at the post Jon read since it lists all of my previous blog entries on flea issues and will take care of most of the questions people will have.  In fact, I won't answer questions that could be covered by reading these posts.

First, let me say that I don't work for Bayer, get paid by them, or own any stake in the company.  Heck, I don't even carry their flea products in my clinic!  But I have a lot of respect for them as a company and like their flea products.  Bayer checks for resistance every year by collecting flea populations from around the world and testing their products against these fleas.  So far no resistance has been documented.

Yes, fleas will die when in contact with Advantage.  However, it will take hours for this to happen.  If you have fleas in the environment then you are continually having new fleas jumping on the cats.  So let's say that you are having 5 fleas per hour land on the cat, and it will take 2 hours for those fleas to die.  Then do the math.  At hour 0 you have five fleas.  At hour 1 you have 10 fleas.  At hour 2 you see the first 5 fleas die, but you have 5 new fleas as well as the fleas alive from hour 1, leaving 10 alive fleas on the pet.  At hour 3 you see this pattern continue.  So as long as you have new fleas in the environment you will continue to see fleas jumping on the pets even though the product is killing them.  And if you go by the above example, you will always average 10 fleas on the pet until there are no more in then environment.  Why five per hour?  Simply easy math and it may not be that many (or may be more, depending on the environmental infestation).  But I think you get the point on how a flea product can work even though you are seeing new, "healthy" fleas.

A couple of rules of thumb....adult fleas are only 5% of your total flea population, the rest being other life stages.  And for ever flea you see there are about 100 that you don't see.  By the time you see adult fleas in these numbers on the pets you have a significant problem in the house and yard.  If you're not using products designed to treat the environment you will find it much harder to get it under control.

So how long does it take to get an existing flea population under control?  A minimum of 2-3 months!  And that's assuming proper, ongoing treatment of the pets and the environment.  All of that has to do with the flea life cycle:  eggs can become adults in as quickly as three weeks, or can take as long as 6 months, so during that time period you have the risk of new fleas hatching out daily for many months.

Jon, I hope you can now understand why the Advantage II isn't giving you immediate relief.  Make sure to continue to use it every month on all of your pets, treat your house every 3-4 weeks, and have patience that you probably won't see significant results until closer to Thanksgiving.  And make sure to treat throughout the winter, since fleas can live inside year-round!

Euthanasia Nightmares

One of the toughest parts of our job as veterinarians is euthanizing pets.  Even if we know that it's the best thing for the animal and is humane, there are still a lot of emotions running through the situation.  Owners are sad that their pets are leaving them and may be questioning their decision to euthanize.  Some are bawling and breaking down in tears while others are very stoic.  Even with our experience it can also be hard on us and emotinally draining. 

That's with everything going smoothly.  And things don't always go smoothly.

On the surface it's pretty easy...you put a catheter or needle in the vein, inject the solution, and in a few seconds brain activity stops.  The huge majority of the time it really is this quick and simple and the pets fall asleep quietly, not waking up.  But when you're dealing with physiology and chemicals you can't predict every single outcome.  Every vet can tell you stories of routine euthanasias gone horribly wrong. 

Today my associate saw a cat we had been treating this week for renal failure.  She wasn't getting any better and the client elected euthanasia.  They placed the IV catheter since the owner wanted to be present, which wasn't an easy task considering that the cat was aggressive, severely dehydrated, and had poor blood circulation.  In the room she gave the injection into the catheter in front of the owner.  Nothing happened.  So she gave some more.  Still nothing.  She ended up giving enough euthanasia solution to kill a 60 pound animal, and this cat was only 8 pounds.  And it wouldn't die!  As this was happening the husband was becoming very upset and even irate that it wasn't happening quickly.  My associate came to the back to get an intramuscular sedative (not deemed necessary at first because a catheter was in place) and the husband came into the back, grabbed her arm, and said that she needed to find someone "who knows what they are doing."  I was busy so she eneded up giving the sedative and then once the cat was out giving an injection directly into the heart.  Definitely NOT a smooth procedure, and it resulted in a very mad client.

There was nothing she did wrong and this was an unusual outcome.  The catheter was placed properly, the solution didn't come out of the vein, and she used far more than is typically necessary.  She has been practicing for longer than I have, has worked at emergency clinics, and is a very skilled doctor.  We think that the cat's circulation was just so poor due to the disease that the solution was having a hard time reaching the brain.  It was tragic but not something that could be helped.

I've had similar things happen to me.  One time a cat lept into the air screaming as I gave the injection, then landed hard on the table dead.  I've had pets suddenly jerk, causing the needle or catheter to pull out, necessitating further pokes.  Sometimes the calcuated dose isn't enough and the pet doesn't pass away quickly, requiring additional dosing.  In rare cases there will be significant disorientation, causing the pet to cry out or thrash as the drug takes effect.  These situations don't mean that the doctor did anything wrong or is somehow incompetent.  They are rare and bother us as much as they bother the client.  It's also hard for us because we have both our own discomfort as well as the client's obvious sorrow to work through. 

Thankfully these "nightmares" are rare even though every vet can tell you times when they have happened.  Almost every time it will be quick, smooth, and easy with a very peaceful, painless passing.  I also don't want to discount the cases where the doctor does make a mistake or do something they shouldn't (I'm sure I'll get comments about those).  But there are times when everything is done correctly and it still goes wrong.  Those things are bad enough normally, but it's even worse of an emotional impact when someone is going through the passing of their pet.

Fragile Birds

Birds are surprisingly fragile creatures, especially when it comes to illness.  Anyone who has worked with them medically knows how quickly they can seem to be come sick and how serious that is.  That was reinforced today.

A cockatiel came in for breathing problems and bubbles from the nose.  The owners had just noticed it last night, so they didn't wait to see if it would improve.  The bird was alert when it came in, but I could hear some "clicks" when it beathed.  I started doing my exam and heard a lot of fluid in the lungs and air sacs.  It seemed to be getting stressed, so I started to put it back in its cage to prevent further handling.  As I did so it started to act strange, and in less than a minute had died in my hands.  All of this was right in front of the owner, so they know that I didn't handle him roughly, but they were also surprised.

Why did that happen so quickly?

Birds hide their symptoms better than just about any animal.  Once a bird acts sick it actually means that the illness has progressed to the point where they can no longer hide it.  "Sudden" onset of symptoms is actually the last part of a bird that has been sick for at least a few days, rather than a true actue illness.  So when a bird acts sick, they should be brought in right away rather than waiting.

When a bird is this sick even gentle and appropriate handling can push them over the edge.  In this case there was so much fluid in the lungs that even mild handling caused a rapid breathing and difficulty getting enough oxygen.  The bird would probably have died in 24 hours anyway due to the fluid in the respiratory tract; the stress from handling just hastened the disorder and happened so quickly that there was no way to intervene.  This is only the second time I've had that happen to me, but I was trained that this was a possibility and am careful to always try and warn the owners about this possibility.

It's sad, but it's part of doing medicine on birds.  They are fragile little creatures and don't give us much warning before they become seriously or critically ill.  Again, the lesson here is to bring a bird to a qualified vet at the first sign of illness; but even then some patients can't be saved.

Vaccines, Side-Effects, And Brain Damage?

Here's one from Stefanie...

I just came across this blog that mentions vaccine induced meningoencephalitis.  Apparently this occurs with the rabies vaccine.  Have you ever seen this in your practice and how common is it?  

http://petblogsunited.blogspot.com/2012/09/what-would-you-do-to-save-your-dogs-life.html

Let's begin by saying that ANY medication or treatment can have complications.  Go pick up any over-the-counter medication in your medicine cabinet and read the small-print.  I'll bet you never realized how potentially dangerous aspirin and cold medicine can be.  If you want a real scare, go onto WebMD and put in any symptoms you might feel every week.  You may come out of that thinking that you need to update your will.

My point in bringing this up is that most of the anti-vaccine people quickly point to death and other serious complications of vaccines.  However, the actual incident rate of such things is very small.  On average a serious side-effect happens less than 1 in 10,000 times, so a dog or cat has less than a 0.1% chance of a significant reaction.  Can bad things happen?  Absolutely.  But they are the exception rather than the rule and vaccines are overall considered very safe for the majority of patients, as well as being far better than the diseases we're trying to prevent.

In my 15 years in practice I have given countless thousands of doses of vaccines.  Figure that I see around 100 patients per week and half or more of those receive vaccines.  A little quick math...50 work weeks in a year...2500 x 15...so I've given somewhere around at least 35-40,000 vaccines so far in my career.  Out of all of those I've seen 4-5 truly anaphylactic reactions that almost resulted in death.  More common reactions are vomiting, facial swelling, and hives, but even those happen less than 10 times per year (still great odds) and are normally just uncomfortable without being life-threatening.  Being sore, lethargic, or running a low-grade fever are all normal for a day or two after vaccines and are not considered "reactions", instead being "responses" that are normal for the immune system.  With proper precautions such as pre-treating with antihistamines or antiinflammatories, these mild reactions can be prevented.  In fact, one of my own dogs had facial swelling after her first adult vaccines, but I continue to vaccinate her with no problems by giving her diphenhydramine injections before and after the vaccines.

So what about the meningoencephalitis that Stefanine mentioned?  This is a serious inflammation of the tissues surrounding the brain and doesn't show up immediately after the vaccine.  It seems to happen more commonly in very young dogs that are given a modified-live vaccine, while rabies are killed vaccines.  In fact, in my searching it seems to be more common after a distemper vaccine than any others.  That being said, it's probably the rarest of all vaccine reactions.  I've never seen one in my career and have never talked to any colleagues who have mentioned this.  It's certainly nothing I ever worry about in my patients or my own pets.

Most of the time you'll see effects like this one and others brought up by people who are against vaccines and are into holistic or homeopathic therapies.  Yes, they can show incidents of such problems, but they are overwhelmingly the minority of cases and are statistically rare.  They are also impossible to predict ahead of time.  Make your own decisions but realize that most vets continue to use vaccines on their own pets without concern.

Do We Love It?

One of the comments on yesterday's blog was an interesting one to me.

I'm starting to question whether most vets love what they do or not. A great majority of the ones I talk to do not. 

Several years ago I saw a survey in a veterinary journal stating that around 80% of practicing veterinarians loved their job and would choose to do it again.  I had a hard time relating to that study since I was in the 20% that didn't feel the same.

I think that most professionals reach a point in their career where they question their choice.  What was once a dream and a passion becomes routine and just a job.  When I first graduated from vet school I loved my job.  I was eager to put my knowledge to use and took pleasure in going to work every day.  As I practiced longer I began to feel the stress of the duties and responsibilities.  I also kept seeing the same kinds of cases day in and day out, which was not very exciting or interesting.  Fast-forward a few more years and I hated what I did and dreaded work every day.  Now the pendulum has swung back and I don't mind work most days, even though it is still a job.

As I mentioned yesterday there are a lot of stresses that come with being a vet, especially when you start realizing how many serious decisions you have to make on a daily basis.  For the most part I would say that it is a rewarding career, and I've gotten so I actually like what I do most days.  But would I do it again?  No.

As is typical, hindsight is 20/20.  My interests have also changed over the years to where I enjoy other sciences and history more than I did when I was younger.  I also discovered a love for teaching.  So if I had to do it over again I would likely go for a PhD in history and become a college professor.  Knowing then what I know now would have completely changed my future.

Would I recommend a career in veterinary medicine to someone at this point?  Possibly, yes.  The circumstances are different than when I applied almost 20 years ago, mainly in regards to the financial picture and debt load.  I do think that someone could really enjoy themselves and it's a stable career. However, the salary and hiring prospects are the worst they've been my lifetime with no signs of getting better.

All of this being said, I doubt that veterinary medicine is alone in these feelings and outlook.  

Fatigue

Though today was busy, it wasn't the worst day I've had.  Yes, I'm tired but have been far worse in the past.  Even so, it brings to mind just how hard we work sometimes.  I think that most clients don't realize that working at a busy veterinary practice causes fatigue in different ways.

Most obvious is simple physical fatigue.  I work from 9am until 7pm and on days like today I don't stop for the entire 10 hours.  I eat lunch while I'm typing medical notes or am calling clients.  It's not uncommon for me to barely sit down all day, leading to some sore feet and legs by the time I leave work.  Constantly going and going at that pace will really wear a person out.

Next is mental fatigue.  Much of the day I'm having to juggle cases, switching from well pets to sick ones in an instant, and having to keep track of which set of lab results goes with which patient.  Then there is the challenge of difficult cases.  When symptoms don't make sense or when lab results don't give answers you really have to work the ol' brain muscle to try and figure out what's going on.  Such rapid flip-flops between cases and such continual stress can burn out brain cells.

Then there is compassion fatigue.  This is a legitimate phenomenon among many health-care professionals as we have to show caring and feeling to man different people in often difficult situations.  Just today I had to euthanize three pets and all were crying.  I have to counsel them and help them through their decision all while maintaining a professional, clinical demeanor.  I also have to work with people faced with tough financial situations and how that affects their pet care.  Then there is my staff, each of whom may be going through problems and trials on their own.

Most vets love their jobs and find them very satisfying.  But that doesn't mean we don't get worn out.  This is a very, very difficult career for many reasons.  Sometimes it's nice to help clients understand the realities of doing what we do.

Necessary Dental Work

I received this email from Barbara,

My family owns a small mix breed that needs her teeth cleaned, however the vets around my area are instantiating on extensive dental work. They are telling us that there is no point to just clean her teeth and will not do the basic care. Is it true there is no point in the basic because there is more extensive work that must be done?

Well, it's a little hard for me to give a precise opinion without knowing more details about the case, such as exactly what is meant by "extensive dental work".  However, I can imagine that there may be receeded gums, periodontal disease, loose teeth, and so on.  If such is the case, then simply cleaning the teeth isn't going to help.

Let's say that you have a car that isn't in the best of shape.  The floorboards are rusting, the tires are balding, and the bumper is hanging at an odd angle.  So you decide to spend a hundred dollars to get it professionally waxed and detailed.  Does it look better?  Sure!  Have you don't anything to fix the car?  Nope.  You may still have a bumper fall off, tires that aren't safe, and might put your foot through the bottom of the car.  So what have you really done to help your car be safer?  Nothing.  What was the purpose of spending the money merely to make it look better?

While not a perfect analogy, you can use it to describe teeth.  When there is periodontal disease, especially with loose teeth or erosion of bone, doing a basic dental cleaning isn't going to help.  That's like washing and waxing a rusting car.  In order to fix the problem you have to get below the gumline, extract infected teeth, and treat the problem.  If you merely clean the tartar away and polish the teeth you haven't actually fixed anything.  In fact, you've ignored the real problem that is brewing where you can't easily see it.  Since you're putting the patient under anesthesia with those associated risks, you are doing a procedure that doesn't really fix anything.  Sure, the teeth look a little better but that's a false sense of security.  The problem is still there and you've spent the money without truly fixing anything.

In similar situations I have also refused a basic dental cleaning.  I don't know if that's the case with your dog, Barbara, but I hope this explains it a little better.

Dragon*Con 2012

Just got back from one of the biggest multi-genre geek conventions in the US, Dragon*Con.  I'm very tired, but had a great time.  Here are a few choice pictures of me and my family in a couple of our costume sets.  All costumes were made by my wife, who runs A Touch Of Magic Costumes.

These are pictures of us as Snow White, Prince Charming, Emma, and Henry from the TV show, Once Upon A Time.

These are pictures of us as steampunk versions of the Thundercats, which I guess you can call "Steamcats".

Yes, we're a bit crazy and geeky, but at least we can do it as a family!  Not your typical family, but we have a lot of fun.