Geek Family, Geek Pets

My daughter decided that it was time to get another rat after the loss of her beloved Adara earlier in the week.  So today we went to a local pet store and found one that she found irresistible.  On the way home we started talking about different possible names for the newest family member.  After several suggestions my daughter decided on Princess Leia.

A little later this afternoon my wife pointed out that all of our pets are named after something rather "geeky".  To anyone who knows us this shouldn't come as a surprise, as you can quickly see by reading this blog for any length of time or looking at my favorite links.

Inara--Our lab mix, named after one of the main characters on the show Firefly.  Thinking back we probably should have named her River since she's rather quirky.

Yvaine--Our yellow lab, named after the female lead in the movie Stardust.

Ash--Our oldest cat (on left), named after Ash Ketchum from Pokemon.  My son wanted to name him Pikachu, but I nixed that and we settled on Ash.

Tristan--Our middle cat (on right), named after one of the knights of King Arthur's court.  It was a happy coincidence that this is the name of the male lead in Stardust.

Pippin--Our youngest cat, named for one of the main hobbits in the Lord of the Rings trilogy.  He is our most affectionate pet and our most mischievous one, living up to his namesake.

Falcor--Our three-legged bearded dragon, named after the luck dragon from The Neverending Story.

Silvermist--Our female Betta, named after the main water talent fairy in the recent Tinker Bell movies and stories.

Princess Leia--The newest addition to the Bern family, our brand new rat.

Most people name their pets after things interesting to them, and I've seen geeky names before.  But it was a bit of a realization to notice that our pets' names really do reflect our hobbies and personalities.  We're geeks and proud of it!

Not About The Benjamins

I thought the title of today's blog was cool, though for my non-US readers I will probably have to explain it.  Here in America our money has portraits of previous Presidents on one side.  Each denomination has a different portrait, with Benjamin Franklin being on the $100 bill (even though he was never a President!  Being an important Founding Father is enough).  So when someone says "it's all about the Benjamins" they mean that it's all about the money.  Okay, caught up now?

When I went into work today there was a note for me to call one of my regular clients right away.  Apparently their shar-pei, Sally, had been hit by a car in the early morning and was taken to the local emergency clinic.  When I called and spoke to the owner she was crying and obviously having a hard time keeping herself calm.  Sally had dislocated one elbow and one hip, had a few very large lacerations, and had one eye with an unresponsive pupil.  Though she was alive the prognosis was very guarded. We talked through the case and I told her that right now the best thing was to follow the recommendations of the emergency clinic doctor.  I promised that I would call and check on Sally later that day.

A few hours later I touched base with the ER, talking to the doctor in charge of her case.  Sally was doing okay despite the extensive trauma, though the dislocations were a problem.  After talking to the doctor I called Sally's owner and went through the prognosis with her and reviewed what the other doctor had said.  Sally is her "mommy's" pride and she wanted to do everything she could to help.  At the same time she didn't have unlimited funds and didn't want her dog to suffer.  It was decided that she would allow the surgeon to anesthetize her dog and attempt to replace the dislocations without incisions (a "closed reduction") and if that wouldn't work she would euthanize Sally since she couldn't afford full surgery.

I was starting to look at packing up near closing time when I realized I hadn't heard back about Sally in around seven hours.  So I called and spoke to the doctor at the emergency clinic, learning that Sally had just come out of anesthesia and the surgeon was successful in fixing the dislocations (as well as repairing the lacerations).  I then called and spoke to Sally's owner, expressing my happiness at her condition and reviewing what would happen over the next few days.

That's when the owner said something that surprised me and prompted the topic for this blog.  She said that she sincerely appreciated my concern and repeated follow up since I wasn't making any money on the case.

I was quite taken aback!  It had never once occurred to me that this would or would not bring in any revenue.  I was just concerned about a regular patient and what her outcome might be.  I was also very sympathetic toward's the owner's worry and sorrow.  The idea of the case making money never entered my mind.

Of course I expressed this to Sally's owner, and she said that she knew that and could tell that I cared, which was why she kept coming back to me.  But as I talked to her I had to wonder how many people think like this about their vet.  It shouldn't have come as a surprise to me considering some of the comments and discussions I've seen on this very blog over the last four years.  Many people really do think that the vets are only concerned about the bottom line and how much they can charge a client.  When people see their bills many will come to the conclusion that the doctor is trying to pad the bill just to empty their wallet.

For most vets this simply isn't the case.  It costs money to run a business, especially a medical one.  Our education, equipment, and facilities don't come cheap, and I can promise you that most vets are firmly middle-class and aren't driving luxury vehicles.  We went into this field because we truthfully care about pets and their owners and we want to see the best medical care for them.  For better or worse, quality medical care costs money, and we do have to charge.  But to us the charges are simply what we have to do and we focus on the necessity of our services and products.  The money involved is almost incidental, yet we can't ignore it without going out of business.

I'm very glad that Sally's owner realized that my main concern was for her pet and family.  But I do wish that it had never been a thought in her mind, because that means she has considered it with other vets.

And yes, I will be calling to check on her when I get to work tomorrow.

Children And Pet Deaths

We had a very unexpected tragedy in our house today.  For the last few days my wife's brothers and their families have been in town for the Thanksgiving holiday.  Friday night and into Saturday my daughter's girl cousins had a sleepover at our house, making a grand total of five girls ranging from ages 7 to 11.  One of the things they all really liked was my daughter's rat, Adara.  They had her out a lot, handling and playing with her.  Adara has always been well cared for and is used to being played with, but this was more than she usually has.

After church we went out and spent a few hours going to lunch and doing some light shopping as a family.  When we returned we hung some pictures around the house, including in my daughter's room.  I looked over at the rat tank and saw that Adara appeared to be sleeping, which was very unusual considering that she's always active.  I tapped on the tank and she didn't respond.  A quick look confirmed my fears.  She was dead.

She was a little less than two years old, and though that's relatively old for a rat she was in good condition.  In fact, I had helped clean her cage earlier in the week and had purposefully given her a quick checkup, finding nothing worrisome.  My daughter was a great rat mommy and was adamant about feeding her, making sure she had water, and keeping the cage clean.  Honestly, I'm a bit perplexed about what may have happened, unless she was unintentionally injured with the extreme handling she had gotten by all of the girls.  Just yesterday morning she seemed fine, so this happened within the last 24 hours.  It also appeared that she had passed away while sleeping, as she was in a sleep position and her eyes were closed.

I knew that breaking the news wasn't going to be easy.  My daughter had saved her own money to buy all of the equipment for the cage and Adara herself and was deeply in love with the little rat.  She was very responsible in caring for her and played with her every day.  I knew this was going to be devastating.  

As a vet I sometimes have to talk to pet owners about euthanasia while their children are in the room.  I've also been asked how to talk to kids about the death of pets, such as what to tell them and if the parent should just quietly replace the missing hamster.  I'm certainly not a child psychologist and am always a little nervous about giving advice.  But I think that honesty is always the best policy.  I don't think that we should lie to anyone, including children.  They will have to learn about and face death at some time, and doing so from a loving adult is often the easiest way in a difficult situation.

That doesn't make it easier.  I really hate seeing children crying their heart out over the loss of a loved pet, as it reminds me of my own kids.  I'm also a little uncomfortable around human grief, not really knowing how to handle it.  Seeing the sorrow in kids is even harder. It's important to help them through the grieving process and respect their honest feelings.  This isn't being too juvenile or pouting over something they can't have.  This is a real sadness over the death of a loved one.

So I steeled myself, sat my daughter down on my bed, and gently told her that something had happened and Adara had died.  As expected she started crying as I could see her 10 year-old heart breaking.  Adara hadn't been sick so there was no preparation for what might happen.  Just yesterday she was playing with her rat, and today she was dead.  It's hard enough to watch someone else's child crying, but it tore me up to see my own daughter going through it.  It wasn't long before I was crying along with her, more at her sadness than from the loss of her rat.

I don't want anyone to say "eww, it was just a rat."  Rats make great pets and are very social and intelligent. My daughter loved her rat and took great care of her.  The species doesn't make a difference when it comes to love and attachment.  This was as much a part of my daughter's heart as any of our dogs or cats.  Maybe a little more so because Adara was completely her responsibility.

We buried her tonight behind a tree stump we have made into a fairy house and garden.  My daughter asked that the cage be taken out of her room because it was too hard to see it empty.  And she has asked to sleep downstairs in the family room for a few nights because it will be hard for her to be in the room knowing Adara is gone.

When she is ready, we'll get her another rat, but we're waiting for it to be her decision.  Until then we will love and support her.

Tea Tree Oil Toxicity

Today's blog was sparked by a comment a friend of mine made on Facebook (we'll call him "Bob").  A mutual friend had said that his dog had some irritation on her skin that she was scratching at.  "Bob" suggested applying tea tree oil to soothe the skin.  I had to step in and caution that this substance was actually potentially toxic to pets and shouldn't be used.

"Bob" was likely thinking of the benefits that tea tree oil has in humans.  It is known for having antifungal and antibacterial properties, as well as potentially decreasing inflammation and itchiness.  Sounds great, right?  Well, in humans that's okay.  But this is a situation where we can't make extrapolations across species, as pets can actually die from tea tree oil.  Yes, it can be fatal.

Using as little as seven drops of the 100% oil has caused severe poisonings, and using 10-20 mls (2-4 tsp) has caused death.  Symptoms can include a low body temperature, weakness, walking as if they were drunk, not being able to walk, tremors, increased liver enzymes, coma, and sometimes death.

Once again, people should not use any treatments at all unless they first talk to a vet.  While many over-the-counter medicatons are perfectly safe for pets as they are in humans, others are not.  Avoid a tragic situation and talk to your vet before doing anything to treat your pet at home.  If you do use a human drug or supplement and see potential side effects, immediately call a veterinarian, or if you're in the US you can also call the Pet Poison Helpline (800-213-6680....no, they're not advertising and I'm not associated with them...you can also find their link in the sidebar).

Being Thankful

Here in the US and Canada it's Thanksgiving Day.  In our countries we set aside this day to get together with friends and family to celebrate what we're thankful for.  Of course, we also use it to eat a lot of food and prepare for the after-Thanksgiving sales.  But primarily it's supposed to be a day to reflect on the things in our life that are good and a blessing.

I'm thankful for my wife, who is my best friend and the best thing I've ever had in my life.

I'm thankful for God and Jesus, who have changed me and my life and who guide me through tough times and have helped me overcome so many problems.

I'm thankful for my kids, who are better than I deserve, and even though they can be aggravating (hey, they're kids) are still a great source of joy.

I'm thankful for my job, which even though it's not what I'd most like to do, it's a good career that affords me  a salary that lets me be the sole provider for my family and has gotten me the respect of my clients, staff, and peers.

I'm thankful for living in the United States.  Even though there are many things imperfect and wrong about parts of it, it's still a great place to live.

I'm thankful for food in the fridge, a roof over our heads, electricity and running water, and paid bills.

I'm thankful for our pets, who can be more aggravating than the kids (like the kitten who is making it difficult to type by laying on my lap and arms, purring loudly) but also bring unconditional love.

I'm thankful for loving parents who raised me to be independent and confident, plus instilled in me a sense of morality and honor.

I'm thankful for comic books, cartoons, and the Muppets, all things that bring a smile to my face.

I'm thankful for Star Wars, Firefly, Star Trek, and other sci-fi settings that make me want to live in their worlds.

I'm thankful for imagination and creativity, things that can let my mind venture into realms I'll never actually see.

Even if you're not in North America, I hope you can take this day to sit down and list out your blessings, giving thanks for each and every one.  There's nobody out there who can't find at least one thing to be thankful for.  Take this time to do so.

Happy Thanksgiving, everyone!

Veterinary Pharmacy

Erin emailed me with this very timely question...

Anyhoo, the presenter discussed a concern by vets of pharmacists erroneously changing drugs or dosages based on their human knowledge. I have to say, this blindsided me. Amox 1gm BID x 14 days yields a double-take to nary a pharmacist, and it embarrasses me that a pharmacist would think, "oh, I'm sure Dr. Smith meant 500 mg BID x 10 days, I'll see fit to change it myself." I've been in the field of pharmacy and/or general healthcare for about a decade and have worked with more pharmacists than I can count. I've found them to be much more hesitant about dispensing for animals than even the oldest old lady with CKD, so his mention of this was surprising.

The point of this ramble was to see if you've ever had experience with this or known of someone who has. Similarly, is there a good resource for veterinary pharmacy? Any insight would be greatly appreciated, and I appreciate your time.

A few weeks ago when I was at a continuing education conference this very topic was the subject of an entire lecture.  Historically human pharmacies have not stocked anything related to animals, concentrating only on human medications.  At the same time veterinarians used their in-clinic pharmacy as a potential profit center, prefering to fill things in-house rather than write a prescription.  In the last few years we have seen a big shift in medicine dispensing.  Many large pharmacies offer common medications at a substantial discount or even free, something that a vet can't compete with.  We're also seeing a shift to some veterinary medications being carried in human pharmacies, such as Wal-Mart now stocking heartworm preventative.

There are certainly medications used in common with humans and animals, such as amoxicillin and cephalexin.  However, there are also plenty of drugs that are found only in veterinary medicine and don't have a human equivalent.  Sometimes we may use a human drug but at a much different dosage than for people.  Let's look at levothyroxine, a supplement for low thyroid levels.  In humans the highest dose you'll find is around 0.2mg, but in dogs that would only treat up to 20 pounds.  For larger dogs we will use 0.8 or 1.0mg which isn't even available for humans and many pharmacists would be astounded as these dosages.  I've also run into problems when clients have wanted me to write a prescription for amoxicillin plus clavulenic acid.  In veterinary medicine this is normally sold under the brand name Clavamox, and in humans it's commonly known as Augmentin.  The problem is that the ratio of amoxicillin to clavulnate is different in the veterinary and human compounds.  I usually have to work with a pharmacist to find something equivalent with what they cary, and it's usually no cheaper than what I can sell.  So in many cases it's not as simple as writing a prescription and having a client fill it.

Human pharmacists have been known to alter prescriptions, especially with pet medications.  The lecture I attended talked about a case where a pharmacist received a prescription for a certain kind of insulin, then recommended a different one that was cheaper and based on their knowledge of humans should have worked as well.  This was an absolutely wrong choice and resulted in severe hypoglycemia that caused the dog to have to be euthanized.  It was a very tragic example of how you cannot extrapolate knowledge of one species to another. 

Currently human pharmacists get little to no training in veterinary pharmacy.  In fact, there are only a few pharmacy schools that even offer a course in this field.  Pharmacists are highly trained in toxicology, medication, physiology, and how these drugs interact with each other and with their patient.  They are an essential part of medical care and can be relied on to discuss the ins-and-outs of medications with expertese.  But they don't know much about animal physiology, which can be significantly different from humans.  Even between dogs and cats there are significant differences, where medications safe to one may be toxic to another.

Let me be firm in saying that pharmacists changing prescriptions are the exception and not the rule.  In fact, to my knowledge it is illegal for a pharmacist to change a medication or instructions without first consulting with the prescribing doctor.  So these cases have happened but the pharmacist doing so is breaking laws and their ethical duty, something that the large majority of the profession is certainly not doing.  But there are going to be bad apples in any job.

This is a great area for pharmacists and veterinarians to work together.  I've had wonderful experiences with pharmacists where we learn from each other and both respect the other's knowledge.  I also think that pharmacy schools need to see this growing trend in pet medications getting filled outside of the veterinary office and include appropriate courses in the training.  If nothing else pharmacists should be aware that there are significant differences among species, and should be even more cautious with veterinary prescriptions than with human ones.

Great question, Erin!

Disappearing Murmurs?

Valerie asked these questions....

My cat who is now about 2 years old was diagnosed with a heart murmur. At the time, veterinarians who I trusted and shadowed told me nothing about the dangers of a heart murmur. She was spayed by one of the vets at the same clinic. Since then my husband and I have moved, and during an exam I asked the veterinarian if she could hear the heart murmur, and she said that she didn't. Do cats "grow out" of heart murmurs? Could she have been misdiagnosed? Could it also be possible that the heart murmur is very mild and that's why it wasn't heard by the newer vet? 

Murmurs are interesting things.  While they indicate that there is an abnormality with the heart they say nothing about the severity of the problem.  All murmurs should be investigated further, but not all murmurs are dangerous or even require treatment.

What is a heart murmur?  As most people will know, there are four chambers in the heart and therefore four sets of valves.  When the heart contracts, valves close to prevent blood from flowing backwards and to keep everything moving in one direction.  If a valve doesn't close properly a doctor will hear a "swish" kind of sound meaning that some of the blood flowed backwards.  The "lub-dub" sound of the heart is actually the sound of the parts of the valve striking each other.  If we don't hear a crisp, clean sound then part of the valve didn't function properly.

In veterinary medicine we grade murmurs on a scale of loudness.  Most vets use a 1 to 6 (or I to VI) scale, with 1 being the mildest and barely audible.  How well we can hear the murmur depends on the ambient noise around us when we're listening as well as the direction of the blood flow.  If the "jet" of the backflowing blood is pointed towards the chest wall it will sound louder than if it's pointed away.  So a Grade 1 or Grade 4 murmur could both be due to an equal amount of valve failure, but one is louder because it's moving towards the stethoscope.  This principle also means that the "grade" of the murmur doesn't mean anything about the severity of disease, as a Grade 2 may be due to a more serious problem than a Grade 4.  And that's why you should never treat a patient based only on the grade of the murmur.

The severity of the murmur can also vary from exam to exam.  When the heart beats faster a murmur will become more obvious.  I have seen patients that have no audible murmur when they are calm, but when they get excited the murmur can be heard (I've actually had chances to hear this happen as I was listening, the murmur coming and going).  A mild murmur might be worsened if a pet is dehydrated.  And I'm sure there are other factors involved that aren't immediately obvious.

Many things can cause murmurs:  birth defects, tumors, and bacterial plaques are probably the most common reasons that would have true consequences.  Dehydration and anemia can cause a temporary murmur because of a reduction in the amount of blood flowing.  Very young pets may have a transient murmur because the heart walls are growing at a different rate than the valves themselves; if this is the cause it should always resolve within a few weeks to a few months of being first heard as the heart catches up with itself.

There can also be "false" murmurs.  If a pet is breathing hard or loudly I will sometimes start to think that they have a murmur.  Experience and careful listening usually will bring me to the conclusion that it's only respiration and not the heart.  I have initially heard arrhythmias and murmurs because the owner or my assistant was tapping on the chest or rubbing the pet's body, causing sounds to transmit through the pet and then my stethoscope.  On the flip side you can miss a murmur because you are hard of hearing or don't have a good quality stethoscope.  Barking dogs and talking staff can also interfere with the ability to hear a Grade 1 murmur.  When I have a question about whether or not I hear a murmur, I will take the patient into a quiet room and try to listen again, eliminating ambient noise.  I will also listen for a minute or two rather than 30 seconds or less, trying to follow the heart sounds and mentally eliminate causes other than valvular disease.

So what does that mean with Valerie's cat?  Well, we can't completely ignore the possibility that either the first vet misdiagnosed it or the more recent vet didn't hear it even though it's there.  However, I generally chose to believe my colleagues when they say the did or did not hear a murmur.  If the cat was very young when it was first diagnosed, she could have indeed grown out of it.  The recent vet may have had a noisy room when listening, making it difficult to hear a very soft murmur.  The cat may have been calmer or otherwise in better health on the latest visit, making the murmur less evident.

So let's say that a patient has a murmur.  What then?  I have attended lectures by two different cardiologists over the last 18 months, and both were in agreement on further testing.  If possible both a chest x-ray and an ultrasound of the heart (echocardiogram) should be performed.  The x-ray does a better job of showing changes in the shape and size of the heart, the surrounding blood vessels, and any changes to the lungs.  An ultrasound can show each individual valve and valve flap, as well as measure the contraction of the heart, the thickness of the walls, and the flow of blood.  They compliment each other and a full picture of the heart needs both.  But if that is not possible due to finances or logistics and you can only do one of the two, specialists agree that the x-ray is the test of choice.  And that's something pretty much every vet will have.  

If the patient isn't showing any outward clinical signs and there are no changes to the heart or lungs on an x-ray, the current consensus is that treatment isn't necessary, but follow-up is.  Those patients should have a repeat of the x-ray in six months and then annually as long as there aren't any progressive changes.

Valerie, I hope that helps try to explain the mystery!

Plan B

Kayleigh emailed me with a follow-up to yesterday's post...

I read your post about vet school debt on the rise, and job offers declining, and it was a bit discouraging. I've always had such a passion for animals, and have dreamed of being a veterinarian, especially after working in a vet hospital. Working there made it feel just like it was the right fit, I can't imagine working in any other field. So here's where my question comes up, did you have a back up plan just in case? If so, what was it?

My journey is actually a bit atypical.  I started wanting to be a vet when I was nine years old and everything I did from then until college was to get into veterinary college.  However, I discovered by my senior year that I wouldn't be able to get in immediately after undergraduate college.  I had two classes required for admission that I wouldn't complete by the application deadline.  I was bummed and really fretted over what I would do.  I was left with basically two choices:  take a year off from school, work a job, and then apply, or I could take two years off and get further education. 

At the time I had taken an animal behavior class and found that I really liked the subject.  I started to think that maybe instead of a DVM I would try for a PhD.  So I elected to take the second route and went into graduate school for a Master's degree in ethology.  About half-way through I realized that a life of research was not my cup of tea and that I missed the idea of being around animals as a vet.  So I applied to vet school and was accepted, beginning after I left graduate school.

At that time I didn't have a backup plan.  In fact, deciding to go to vet school was sort of Plan B or Plan C.   Unlike many people I only applied to one school as I knew I wouldn't be able to afford out-of-state tuition.  So I had kind of placed all of my eggs in one basket.  If I hadn't gotten accepted at that point I probably would have gotten a job and tried again the following year. I didn't have other ideas or plans and couldn't imagine doing anything else.  

But the financial situation and job prospects at that time were much different than they are today.  If I was a high school or college student nowadays and was following this blog, I'm not sure what choice I would make.  It's not a great time to enter the profession.  But if someone still really, really wants to they should know full well what they're getting into and what their financial situation will likely be after graduation.

More Bad News For New Vets

Anyone getting ready to go into or graduate from vet school probably shouldn't read this.  You'll just get depressed.

Today I read the results of a survey conducted annually by the American Veterinary Medical association.  The data was not encouraging for anyone entering veterinary medicine.  Here are some of the highlights....

*  61.5% of graduates received a job offer or an offer to pursue advanced education and training. This has come down considerably over the last two years, having been 74.3% last year and 78.9% in 2010.

*  Starting salaries (excluding internships and residencies) averaged $65,404, down 1.6% from $66.469 in 2011.  And that was down from 2010.

*  Average debt burden was $151,672, a 6.4% increase from $142,613 in 2011.

YIKES!

For two years the job offers and starting salaries have decreased, while debt load has increased.  This means that newly graduated vets are having harder times finding jobs and making enough money to even survive and pay back loans.  And while the problem of jobs and pay is getting worse, two states are wanting to open new veterinary colleges, adding around 200 more people to the workforce every year which will further drive down salaries and make it harder to find work.

I'm not sure why I keep blogging about this topic since every new report makes the picture bleaker.  I guess it's kind of like not being able to turn away from a car accident.  Industry leaders and the AVMA are supposed to be meeting to work on developing a plan to help the problem, but I'm not sure what they can do.  One of the solutions they are considering is making it easier to repay loans, but this still doesn't help with the decreasing pay and difficulty finding jobs.  That's determined by the market and in current economic times it's hard to overcome.  If the clients aren't bringing their pets in and aren't able to pay for services, we can't make enough money to pay higher salaries and hire more vets.

Most established vets like myself are doing okay, if not great.  Veterinary practices as a whole have seen a decrease in revenues, though there are still some (like mine) that continue to grow.  The problem is new graduates and their rather disheartening and debilitating debt load.  When I graduated I had maxed out on subsidized and unsubsidized student loans, ending up with a total of around $40,000 in debt, below average even 15 years ago.  I cannot imagine having $150k in debt to repay.  Keep in mind that this is the average, which means half of debt-laden graduates have a higher repayment!

This is depressing because most people who become vets have a real passion for animals and medicine.  They know they aren't going to be wealthy and do it because they genuinely love the animals, owners, and the profession itself.  When they realize that they can barely make ends meet and have a hard time finding work, it not only hits them financially but also emotionally.  This job that they have dreamed of and worked so hard for is suddenly out of reach.  Broken dreams are never easy to handle.

I would hate to be entering this profession nowadays, and have great sympathy for anyone doing so.  For those thinking about starting vet school, I can't say that I currently recommend it unless you can make it through school without any debt at all (and apparently about 10% of students do).

Talking To The Kids

This evening I left work a little early and went to a children's museum in Atlanta to give a talk on veterinary medicine and pet care to kids.  I met a guy from a local therapy dog group who brought a very sweet pit bull, Rayne, to work with us.  For about 45 minutes I talked about what a vet does, what kind of care pets need, and used Rayne to demonstrate how to perform an exam and how to approach a strange dog.  They were young, with the oldest age being around 8-10 and most of them closer to preschool age.  At the end I handed out coloring books and plastic toy stethoscopes.  The kids seemed to like it and I had a blast talking to them.

I started doing talks like this when I was in vet school.  Several of my classmates and I made ourselves available to go to schools and give presentations on animal care.  I quickly discovered that I liked doing it, and actually was pretty good at it.  Over the last almost 20 years I have gone to museums, libraries, and schools, talking to kids from preschool age to pre-veterinary college.  My favorite ones tend to be older grade-schoolers, as they are pretty interactive and surprisingly knowledgeable.  

One time I was giving a talk to a Fourth Grade class and asked about characteristics of birds.  I was looking for things like feathers, eggs, and maybe even something as advanced as hollow bones.  One of the nine-year old boys raised his hands and then began discussing how the shape of a bird's wing allows air to pass differently over the top than the bottom...he gave me a great definition of the principle of lift.

Talking to kids is sometimes challenging, especially the younger ones.  They often want to tell their own stories, taking the discussion away from the scheduled topics.  They also have short attention spans and it can be tricky to keep them interested for more than about 30 minutes.  So I've learned how to make things as interactive as possible and try to recognize when their attention is wandering.  But it can be rewarding since rather simple things fascinate them.

Besides my love of teaching and public speaking, I look at this as a way to help develop a new generation of pet owners.  If I can catch them young and help them learn how to take care of pets, I'm helping extend the influence of veterinarians beyond the small group in front of me.  And since parents are normally there I end up educating them as well.  It's a win-win for everyone.

Standing Your Ground With Clients

Today I saw a seven month old kitten for a routine spay.  My associate had seen her back in June for initial vaccines and had noted a heart murmur at that time.  This is always concerning in a young pet, but especially in a cat because murmurs are much less common in that species than with dogs.  The client was told about the concerns with the murmur, and if it didn't resolve we would have to send her to a cardiologist for evaluation before doing her surgery.  The client didn't bring her back for her last set of boosters, but over four months later she comes in today, in large part because the owner was worried that she might be pregnant (it's amazing how a possibly pregnant female or a male starting to mark suddenly reminds a client that they need to spay or neuter their pet).  We always do pre-anesthetic exams on every pet, and when I did hers I immediately noted the very loud murmur.  In fact, it was louder than what my associate had noted in June.  Back then it was graded as a 3 out of 6 (the standard scale for most vets, with 1 being the mildest) and today I marked it as a 4.  

I didn't proceed any further.  Any good vet will tell you that the loudness (or grade) of the murmur doesn't necessarily coincide with the severity of the disease.  A soft murmur may be part of severe cardiac dysfunction while a loud one may not be associated with any significant change in the size or function of the heart.  But even with this in mind a murmur is significant and should be investigated, especially in a cat.  We don't want to risk a pet dying under anesthesia for an elective procedure.

I called the client and explained the situation, making sure that she remembered the conversation she had in the Summer with the other vet.  I then told her that there were significant risks for surviving anesthesia if the heart wasn't functioning properly, and the only way to be 100% certain was to have her referred for a cardiac work-up including an ultrasound of the heart (echocardiogram).  Though she knew about the problem from the earlier visits she didn't seem happy about what I was saying.  

The owner asked if we would go ahead and do the surgery if she gave us authorization to take the risk, as she was not likely to go to the referral.  Without hesitation I said no.  We would absolutely not do the surgery without having her evaluated first to make sure it would be safe.

Why not?  The client said she wouldn't hold us responsible if the pet had complications and was willing to sign papers stating this.  So since she wasn't going to sue us and needed the pet spayed, why didn't I agree to it?  We had warned her and wouldn't be to blame if the cat died.  Right?

Wrong.

These kinds of authorizations don't hold up in court. I've read far too many similar situations where the client ended up suing the vet anyway and winning, despite giving the go-ahead.  In these cases the client usually says "Well, they knew the medical situation better than I did and shouldn't have listened to me."  The courts usually side with the client's logic at this point, regardless of what the owner had said to the vet previously.  Don't believe me?  Go find reports from any medical liability insurance company and you will see it happen again and again.  Veterinary licensing boards also can easily consider this malpractice and a vet could face disciplinary action and even loss of license for proceeding in a medically inappropriate way, even with client consent.

Sorry, but I'm not willing to lose my license and livelihood over a single cat spay.

It also isn't fair to the cat and I think would be morally questionable (at best) to proceed against better medical judgement.  A spay is an elective, non-emergency procedure, so continuing a surgery that we know is very high-risk under such conditions is not warranted.  We are putting the life of the pet at risk because the owner can't or won't go for one round of noninvasive diagnostics.

This is not the first time a client has pushed me and I have refused.  I can never force a client to do a treatment or procedure against their wishes.  At the same time, they can't force me to do something against my wishes or better judgement.  I am the one with the medical knowledge and skills, and I would be immoral and committing malpractice if I violated my instincts and training merely to appease a pet owner.

That doesn't mean that I don't compromise.  Later in the day I saw a dog that had been limping and I isolated the pain to his hip.  I really, really wanted to take x-rays, but the client couldn't afford it.  So I agreed to conservative therapy with pain medicine and rest, even though I discussed why the diagnostics were needed.  That's fine.  But prescribing medications without a proper exam, giving antibiotics without evidence of an infection, or performing surgery on a pet with a severe heart murmur are not areas of compromise.

My job is to look out for the best interests of the pet, not the owner's wallet.  I don't gouge clients or have unnecessary charges.  But in the end I have to do what is medically best, even if that means the client and I come to an impasse.  I have had owners literally yelling at me because I wouldn't prescribe medications without at least basic testing, yet I have learned to stand my ground and keep to my principles and medical quality.

I know there are many veterinary students and new vets who read this blog, so take this as a lesson (as I taught the new graduate I'm currently mentoring).  Don't agree with a client if it goes against sound medical practice, no matter what they say or threaten.  Regardless of their words or any signed papers, in the end YOU are the only person responsible for the outcome, and you will be the one held accountable if things go bad.

And to clients who have placed their vet in such a situation, please understand that we're not being mean or trying to get money out of you.  We truly have your pet's best interests at heart, and are trying to protect their health as well as our license and quality of medicine.

Reflecting On The Next Generation Of Vets

Now that I've been in practice for 15 years I'm starting to creep into the "old fogey" category of veterinarians.  I don't think I'm lazy with my cases but I'm about half-way through my career and can see a difference in how I practice now compared to how I did right after graduating.  Having a newly graduated vet working with me makes me reflect more on where I have come and how green I must have been.

Over my career I have mentored dozens of vet students and newly minted vets.  I have helped guide them through the transition from student to doctor and the realization that now the buck really does stop with them when it comes to cases.  I have tried to pass on my knowledge, especially all of the mistakes I have made, in the hopes that they will turn out better than myself.  I have seen people from multiple different veterinary schools in the US, Caribbean, and the UK so I have a broad basis of comparison.  Like most of humanity you have some who are really sharp and catch on quickly, while others seem to have cotton between their ears.  I've had new vets that I've had to reign in because they were too gung-ho to leap forward, and those that I've had to virtually kick in the pants because I knew they were ready to tackle things and they didn't have self-confidence to realize their own skills.  Though everyone is different, there are certain things that I see across all new graduates.

*  Fear of surgery--I can't blame someone for this, as doing surgery is literally the closest to death that we are willingly putting a patient.  A small mistake can have a big impact.  But if someone is going to be in general practice they have to get over the fear quickly, as they'll be doing spays and neuters daily.

*  Slow surgery time--A professor once told us that "time is trauma", meaning that the longer a pet is in surgery, the higher the complication and infection risks.  You want to develop fast surgical skills to minimize anesthesia time.  But that only comes with experience.  When I first graduated my average time for a spay was around an hour.  Now I can do the same surgery in 15-20 minutes, sometimes even a little less.  It takes time to develop the confidence and muscle memory that allows you to get through a surgery quickly.

*  Embarassment at not knowing--It's impossible to remember everything you are taught in medical school, and things frequently appear different in the real world compared to the classroom.  That's okay!  There is nothing wrong with having to look things up and I do so every day.

*  Awkwardness with clients--Unfortunately most vets tend to be introverts and learning to comfortably talk to clients can be difficult.  Like medicine and surgery this is a skill that can be developed with practice, as long as the doctor is aware of the need and seeks help.

*  Eagerness--One of the biggest characteristsics of most new graduates is an energetic eagnerness to starting putting lessons into practice.  Yes, they are nervous, but they are also excited to be a doctor.  At this stage they haven't developed the cynicism that most of us eventuall do.

Yes, I fit all of this when I was also a wet-behind-the-ears veterinarian.  Maybe I was a bit cockier than most and have always had self-confidence, but otherwise all of that applies to how I was.  Looking at new vets makes me think of how I was at that stage in my life, and thankfully I can let them know that they too will get through that.  I like giving back to the profession by mentoring people like I was mentored early on.  And I often learn from them as well!

Past And Present Meet Via Vet School

This past weekend I went back to my hometown area to attend the North Carolina Veterinary Conference.  It was also the 15th anniversary of my veterinary class.  I haven't attended this particular conference in several years.  I've also been really bad about keeping in contact with anyone in my class...okay, I haven't kept up with anybody in my class.  At first that may be a bit surprising, but when you spend four years of intense time and long days with 70 people you end up getting to know each other pretty well and develop relationships and friendships.  For some people those friendships persist, and I know of at least two classmates who opened a practice together.  But not me.

Let me set the stage.  Back when I was in vet school I was a very different person than I am today.  I was moody and petty.  I was deceitful and enjoyed trying to manipulate people just to see if I could do it.  I treated many people poorly, especially my parents.  One of my friends gave me an earring (back when I used to wear one) with the drama happy/sad face masks because she never knew what kind of mood I'd be in.  Though I've never been perfect and still am not, during those four years I was the worst person I could possibly be.  I'm ashamed of who I was and how I acted, and though I've been forgiven and changed by my relationship with Christ, I'd rather not remember those times.

So the idea of seeing my former classmates actually gave me a sense of dread.  These were not bad people and all of them treated me well.  But I feel awkward around them now because it's a reminder of who I was and a past I regret.  Remember those bad things I did?  And remember the many hours per day and per week in close proximity to other people?  Looking back I realize that people in my class probably knew more about my sins than I wanted them to, and that I wasn't as smart in hiding things as I thought I was.  Revisiting those times in my mind, I wonder what people really thought of me and if those memories would influence their perceptions today.

As luck would have it, I saw several of my classmates and ended up briefly talking to at least a few of them.  All conversations were brief and superficial, as I haven't said any words to any of them in 15 years.  We were all polite and pleasant and concentrated more on where we are now rather than where we were then.  Even so, I deliberately tried to avoid much contact...not because of them, but because of me.  I didn't dislike any of them but I certainly dislike my old self.  And I wondered what they remembered about me and if they could tell that I was changed.  I was unintentionally awkward and distant, which probably didn't help perceptions much.  

Our past can never be erased, and even if we've changed in the present we are the result of our experiences and actions.  My shameful past led me to a point where I put my faith in God, which lead me to my wonderful wife and great kids.  Even though I regret my past, it is no longer who I am.  That's something I should keep in mind the next time I run into someone from that time period.