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Wednesday, August 28, 2013

Justifying Euthanasia

From death, to humor, back to death.  Some variety in the posts lately, eh?  Today's comes from a reader in Korea.

Hello! I am an aspiring veterinarian studying in Korea. Ever since I had to put down my dog after he got severely injured by a wild animal, the idea of becoming a vet just stuck in my head.
 However, what bothers me most about becoming a vet is how vets often have to perform euthanasia. Just by reading your blog I can get a good grasp of how many of those I have to go through each week. In no way am I suggesting that what you had to do was unreasonable, but the ethical issues regarding euthanasia bothers me to no end. I mean,
 So in what ways can euthanasia be justified? And does having to put down pets bother you much? 

Euthanizing animals isn't easy.  Doctors are trained how to preserve and extend life, sometimes through very extreme and heroic measures.  Our main motivation for becoming vets is to make sick and injured pets better.  So making the decision to end a life is often difficult.  And because it is an irreversible decision it isn't something to be done lightly.

I am 100% against "convenience" euthanasia.  Many times I have refused to euthanize a pet because a client couldn't keep it any more, was aggravated by it, was moving, and so on.  There are always other options for an unwanted pet and I'd rather an animal go to a shelter or foster home rather than be put to sleep.

To me euthanasia is completely justified when the animal is suffering and there aren't any other options.  It's a rather cold, sometimes depressing fact, but we can't fix everything.  There are some animals whose injuries are too severe for them to survive for long.  There are some diseases that we can treat and extend life, but at some point will be fatal, such as kidney failure and some forms of cancer.  The hardest cases are the ones that we're fairly certain we can help, but the clients cannot afford treatment.  Regardless of how it happens, there are pets that simply can't be helped and will die.

But most deaths aren't quick and quiet while sleeping.  Liver and kidney failure can cause a pet to linger for days or weeks, feeling sick and suffering the entire time.  Heart failure that leads to fluid in the lungs results in severe difficulty breathing.  Perhaps a dog is hit by a car and has multiple limb fractures that can only be fixed with surgery, but the client can't afford the procedure and their pet is screaming in pain.  I've seen many dogs who have such severe arthritis and joint disease that are generally healthy, but they literally cannot stand or walk and all attempts at pain relief have failed.

At these times we have to look at the best interests of the pet.  Is it the most humane, ethical thing to let them lay there, sick, painful, unmoving until they eventually die from thirst, starvation, or toxins?  I think most people would agree that this is not an ethical choice.  We want to stop suffering, not allow it to linger.  The pet can't make the decision or talk to us, so between the client and the animal we have to make the decision for them.  

When I agree to euthanize a pet, I make sure that there aren't other options.  I look at the case and think "What would happen to this pet and how would they feel or survive if we did nothing?"  If the answer is that the pet would die or suffer extensively I think the most ethical thing is to humanely end their life.  Then there is the quality of life question.  I'll ask the client if the pet is having more "good" days or more "bad" days.  If I know that the case will be terminal anyway and the bad days outnumber the good, why would I want the animal to suffer even more bad days before the inevitable outcome?

Yes, some cases bother me, but those are normally pets that I have seen for a long time and to which have become emotionally attached.  I've shed tears along with the client many times.  But the other cases don't bother me as much because I know that I'm ending their pain and suffering.  If I didn't have the assurance that I was fulfilling my oath to help illness and pain I wouldn't be able to do it.

I hope that explains some of the thoughts and justifications behind veterinary euthanasia.  As a would-be vet you'll be faced with these situations, and it might be a good idea to find a local vet and shadow them for a while to see these cases in the real world.

Monday, August 26, 2013

Not Always Right...At The Vet

I've mentioned it before, but the website is one of my favorite daily visits.  After a long day dealing with sometimes difficult people, it's nice to see what other people have to put up with.  Often it puts things in perspective for me and my own cranky clients don't seem as bad.  While most of the stories are related to fields other than my own, I still enjoy them and can relate.

Every weekend they do a themed "Weekly Roundup".  This week was the first time I've seen the Roundup be veterinary themed!  Since I don't have a lot else on my mind today to blog about, I thought I'd share the link.  Everyone in the veterinary profession can absolutely relate to these clients, and maybe the pet owners have seen people like this when they visit the vet's office.

Thursday, August 22, 2013

The Final Gift

This has been one of those "Dr. Death" weeks, where I've had to euthanize several pets.  All of them were severely ill and terminal, so it was completely justified.  But it still isn't easy for me or the clients, and I found myself teary-eyed more than once.

Euthanasia is hard.  But it allows an ease of suffering and a peaceful passing.  In many ways it's a gift, the final one we can give.  Our pets have given us so much life and joy, and we can help them end life peacefully.  This was brought to my attention in this way by one of my clients whose pet I put to sleep.  She has lost pets before and with her permission I'm sharing a poem she wrote about the experience.  I hope this can help those who have lost their own furry, feathered, or scaly loved one.

The Gift

It was Christmas of Nineteen Eighty Five
And my beloved cat Prince was no longer alive.
He'd died of pneumonia just three weeks ago
Prince was only three - it was a terrible blow.

That Christmas began just like any other -
Presents exchanged between sister, father, and mother,
But - surprise!  One final gift, sitting in Mom's lap
A teen week old bundle of fur, taking a nap.

She opened her eyes; they were a lovely amber-green,
Then, much to our delight, she started to preen.
She had a beautiful tail and long soft hair.
Cute white feet - a dainty lady most fair.

All she needed was a name, for she was all mine.
It had to be special for a kitten so fine.
Because it was Christmas, I chose Tiffany
It was appropriate, meaning "God's Gift" to me.

She was with me for many of life's trials.
My parents' divorce, a move of many miles.
A new school, new friends, my first summer job
She soothed me when all I could do was sob.

Then she had kittens - five months, two litters!
A total of ten, but they were cute little critters.
Mom said "Spay her!" so my first gift to her
Was no more worry about becoming a mother.

Then came college and yet another move
Tiffy took it in stride, like she had something to prove.
Then marriage, more moving, finally my degree.
And always Tiffany; her presence was her gift to me.

Many years passed and Tiffany grew older.
She didn't play as much, just wanted me to hold her.
Then an unexplained illness, and the dreaded answer.
My beloved gift was suffering from terminal cancer.

The veterinarian kindly explained there was no hope
After fifteen years together how could I cope?
So we took her home to love her while we could.
We gave plenty of treats, but not more than we should.

Finally, the time came, when she would no longer eat.
We took her to the vet and gave her one final favorite treat.
Never again to hear her loving, sweet purr.
No more suffering, eternal peace, my final gift to her.

Monday, August 19, 2013

The 2013 State Of Pet Health

Love it or hate it, Banfield Pet Hospital is the largest veterinary practice in the world and has over 800 locations throughout the United States.  Their computer databases can tally data from millions of pets every year and analyze it in many different ways.  For the last couple of years they have released an annual "State of Pet Health" using this data, showing how different diseases or trends affect pets.

In this year's report they break it down by state.  Now, there are certain limitations to their data as it is only from their clinics, but it's more than most other sources have so it can be educational.  Here are some highlights from my own state of Georgia.

Dogs average a lifespan of 10.9 years.
Cats average a lifespan of 12.1 years.
Dental tartar and ear infections are the most common diagnoses made in dogs.
Dental tartar and fleas are the most common diagnoses made in cats.
Bella and Max are the most common dog names.
Kitty and Tiger are the most common cat names.
Labrador retrievers and shih tzus are the most common dog breeds.
The most common pure-bred cat is the Siamese.

Other data....
Overall 1 in 4 pets is overweight or obese.  The highest rate of this in both dogs and cats is in Minnesota.
The highest prevalence for diabetes can be found in Iowa for dogs and Nevada for cats.
Louisiana and Mississippi have the highest rats of heartworm disease in dogs.
In both dogs and cats the rate of ear infections is highest in Mississippi and Florida.

All-in-all some interesting data and trends.  Though I don't find that anything here will change my personal way of practicing, looking at national trends can be helpful in seeing how well we as a profession are diagnosing, preventing, and treating given health problems in pets.

Friday, August 16, 2013

Kids, Reality, And Facing Death

My last case of the day yesterday was a difficult one.  A father came in with his two daughters and an injured hamster.  The oldest girl was about eight or nine years old and obviously very attached to the hamster, Sugar.  Earlier in the day they had noticed a problem with one of Sugar's back legs and had made the appointment to have her seen.

The hamster was in good overall health, very active, friendly and surprisingly sound for being over two years old.  That was the good news.  The very bad news was the left hind leg was badly broken and bone was protruding through the skin.  The fracture had happened in the tibia, and one of the broken ends had worked it's way through the skin, causing damage and infection.  I was actually very surprised that she was acting perfectly normal and had been eating well.  Somehow she didn't seem bothered at all by the fact that her foot was dangling by some skin and muscle.  Unfortunately due to the extent of the injury the only option was to amputate part of the leg.

This is actually something that I've done before.  I've amputated toes, feet, or legs on hamsters, lizards, chinchillas, and birds, all very successfully.  In some ways this is much easier than with a dog or cat as the bones and blood vessels are much smaller and therefore easier to remove and handle.  However, there is greater risk due to the size of the patient and difficulties in typical surgical precautions (IV catheters, endotracheal tubes, monitoring equipment, pre-anesthetic blood testing, etc.).  Even though Sugar was very old for a hamster she was in great condition and so I thought she was a good surgical risk.

The daughter was upset by this discussion.  She knew her hamster was badly injured and didn't like looking at the bone.  I could see her obvious nervousness and distress, which she also was quick to verbalize.  The idea of surgery worried her as there was concern about Sugar surviving.  However, as I talked she decided that she wanted to do the surgery.  In a way it was very sweet and amusing as she was adamant about the need for surgery.

The problem came when I had to start talking to the father about the costs.  This was not a simple procedure, and once I added everything together it came out to around $450.  This is definitely an expensive surgery for a pet that can be purchased for around $10, but is still about 1/3 of what it would cost for a dog or cat.  In this particular case there were really only two options...amputate the leg or euthanize the pet.  There was no intermediate option to bandage or fix it and allow it to heal.

I was trying to be careful how I worded things to the father since the girls were right there beside us.  I wanted to communicate to him the truth of the situation without upsetting his daughters too much.  Unfortunately there is no easy way to present euthanasia versus expensive surgery.  The older girl was still very certain that Sugar needed surgery and if it was up to her we would have done it right away.  But at her age she didn't understand the reality of the expense of doing so, or whether her parents could afford it.

I really hate being in these situations, and it happens more frequently than I'd like.  Kids become very attached to their pets and haven't learned to control their emotions as well as an adult.  They wear their feelings on their sleeves and it comes out quickly when discussing a very ill pet.  I've been in rooms many times when a parent and I have talked about a potentially terminal case while their child was next to us, and then have that child begin crying.  That's never easy, especially since I'm a parent.  We've lost several pets over the years and I've had to help my children through the grieving process, so when I see another parent having to do the same it really hits home to me.  Though I've learned how to handle being around upset and grief-stricken children, I can't say that it ever gets easier.  Often times the parent has an idea of the severity of the situation before they come to me and may have started the discussion at home.  But it becomes more "real" to the child when the doctor is the one talking about it.  And as hard as it is for them, this is a lesson that children have to learn at some point.

Any time I deal with terminal disorders and grief it makes me uncomfortable.  I'm not the kind of person who handles death well around others, whether it is human or pet death, and like many people I have a hard time knowing just what to do with a stranger's emotions.  That discomfort is multiplied when a child is involved as they are still learning how to process those feelings and cannot be consoled as easily.  In 16 years of being a vet I've been in these situations enough to learn how to handle most of them, and have learned that really anyone about to lose a pet just needs compassion and understanding.  And though I still don't like it, this is a reality of being a vet and something I can't ignore.  For the sake of my clients and their families I've had to learn how to balance truth, clinical detachment, and human compassion. 

In this case the father needed to go home and talk to his wife.  We started Sugar on antibiotics and tentatively planned the surgery for Saturday (I'm off work today and my associates aren't comfortable with this kind of surgery on a hamster...also there are virtually no other vets in my area who would even touch this case).  They were supposed to call this morning and let us know what they were going to do.  I won't find out until I get to work tomorrow morning, though they may come in today for euthanasia.  I might be surprised, but typically in these cases euthanasia is chosen for financial reasons, which I completely understand and don't begrudge the client.  But that can be another hard discussion and dose of cold reality for the daughter.

Nobody said that life lessons were easy.  And these are the things that veterinary students typically aren't trained for.

Monday, August 12, 2013

Free Time As A Vet?

Jessica emailed with the following....

 I'm an undergrad student at Allegheny College. I have wanted to be a vet for years, and after getting a work-study position working for a wildlife rehabilitation center, I can't see myself doing anything else besides working with animals.
However, I'm told that being a veterinarian doesn't allow for any free time. Is this true? I love being busy and consumed by what I'm doing, but I would like to take some vacations from time to time. 

This is a common concern of veterinarians, but I don't think that it's as bleak as you may have been told, Jessica.  Much of this opinion comes from older vets who are used to being on call day and night, putting in 50-60 hours per week.  And as a practice-owner and single doctor, it really is hard to take time off.  But I'd summarize the answer as "it depends".

One of the changes that has been discussed about the recent generation of veterinarians is that they are not driven in their careers as much as previous generations might have been.  Vets who graduated in the last decade or so will work very hard, but are concerned about the work-life balance.  They want to put in solid, busy days at work, and then have time to have and enjoy a family.  Newer vets want to work hard for 40 hours per week and then have time off.  They're not lazy, they just realize that there is more to life than work and want to have time to use their hard-earned money.

If you work in a multi-doctor clinic you can likely have the opportunity to take vacations and have regular days off.  I'm in such a situation and work four days per week, putting in 10-11 hour days.  That means that though I have long days, I get three days off per week, as well as getting over two weeks paid time off per year.  I do feel that I get enough time to have a life outside of work.

As I mentioned first, if you are a single doctor and a practice owner, your options are much more limited.  It will likely be years before you have built up to the point where you can regularly take time for yourself, though that certainly isn't always the case.  This is the more difficult route to go, but can lead to greater long-term rewards if you're a good business leader and manager.

How much free time you have also depends on how well you can leave your work at the office.  I'm always trying to teach younger vets to avoid looking up cases at home, researching things every night.  While that may be necessary at times, it can lead to burn-out if done too often.  Everyone deserves to have time for themselves to forget their job and be something else.  This is a learned skill and something that can take years to master (if you ever do).  But it's important to try and develop the ability to leave work behind.

So Jessica, whether or not you get much free time depends on your personality and circumstances.  Being a vet is hard work and often long hours, but it doesn't have to consume your every waking moment.

Saturday, August 10, 2013

Lord of the Rings YMCA

Keeping in mind that this blog is as much about an average vet's life as it is about veterinary medicine itself, form time to time I like to share about non-veterinary things that interest me or strike my fancy.  Today is one such time.

Regular readers know that I'm a big geek, with a long-time interest in fantasy and science-fiction.  So it should be no surprise that I love the Lord of the Rings movies.  My father just sent me a link to a video that amused me so much that I've shared it on Facebook and want to share it here.  The person who made this obviously had a whole lot of time on their hands, but the results are very impressive.  I hope this brings a smile to my readers.

Thursday, August 8, 2013

When Bad Vets Cause Major Problems

Ready for a long one?  No names are used as this will likely end up in a lawsuit.

I'm usually quick to defend my colleagues and point out that veterinarians are human and make mistakes.  I've even posted some of my mistakes on this blog, and they are certainly only part of them.  But as in any profession there are absolutely vets who simply shouldn't be allowed to work anymore.  Recently I ran into a situation regarding one of these doctors.

The client came to me last week, having brought in her young male boxer for an exam.  I had seen him previously for a minor issue when her regular vet was closed, and she had liked me so she wanted a second opinion.  The boxer was very sweet, but had lost weight since I had seen him a few months ago, and had an obviously distended abdomen.  The owner had brought him to me because at a vaccine clinic a vet had said that the fluid in the abdomen needed to be checked, so this was my main focus.  On the exam he was bright and alert, and at home had been eating well, drinking normally, and having good bowel movements.  In fact, he had been acting normally and would have seemed healthy other than the slow increase in the size of his belly over a couple of months.  With him being a boxer my first thought was heart disease, as this breed is prone to cardiomyopathy.  I also ran through  a few other possibilities, such as low blood proteins and liver disorders.  I recommended x-rays and blood tests, whether they were done with me or her regular vet.  She took the estimate home and was going to consult with her vet.

Yesterday she dropped off a copy of the x-rays because she wanted another opinion.  And this is where the story gets more interesting.  Apparently the dog had had a problem this past December (2012) and x-rays were taken.  According to the owner the vet had said he had a wire in his intestinal tract and gave him some oil to help it pass.  When I looked at the x-rays, I noticed a couple of things.  First, the image only had the upper (dorsal) half of the abdomen.  The bottom half was completely out of the view and hadn't been taken.  His body was rotated, so it wasn't a straight-on side view like we're supposed to take.  And then I noticed the metallic thread or wire in the abdomen, inside some kind of cyst or mass.  It was a very poorly positioned image and one that any of my radiology professors would have flunked me for.  And despite that "wire", the vet never did follow-up with the clients.

A slight aside.....This isn't directly relevant to the case, but talks strongly about the quality of vet they had.  There were a few dozen x-rays of different pets on the disc the owners brought to me.  Initially I didn't know which one was the boxer's, so I looked through all of them.  I repeatedly saw human hands and arms in the image, holding the pets.  This is a HUGE workplace safety violation, and a major problem.  The humans whose hands were in the field of the x-ray were getting repeated doses of radiation, and the owner of that practice is responsible for any damage or cancer risks.  X-rays are safe when done in small doses, but repeated frequent doses can be a health risk.  My jaw dropped a little when I saw so many repeated major violations of basic radiation safety.

Besides the disc from over seven months ago, the vet did x-rays two days ago and the owner gave me a copy of that.  This one was much better positioning, but the object from December was still in the exact same place.  What was more worrying was that there was almost nothing normal about how the abdomen looked.  In fact, I had a hard time making heads or tails of what I was seeing, other than displaced organs and this large mass with metallic thread in the center.  Her other vet had told her that the dog had swallowed something that was stuck in the intestines and needed surgery.  

Let's take a slight digression for those not in the veterinary field.  When a dog has an obstruction in the intestinal tract it is going to cause serious issues.  The dog typically will stop eating, likely will vomit, and won't be producing any feces.  This is something that develops obvious symptoms quickly.  Yet this boxer had none of these symptoms and was eating and defecating normally.  The lack of GI symptoms combined with the fact that the object was the same over a nearly eight month period made me significantly doubt this analysis.  

Back to our story....the client didn't completely trust what the other vet was telling her.  She had dropped her dog off for the x-rays, and then called later in the afternoon.  The vet answered the phone himself, but when she identified herself he put her on hold and had one of his assistants pick up the phone and talk to her.  When she came to pick up her dog the vet was at the front desk and as she walked in he went to the back of the clinic.  At no point did she get to talk directly to him about the situation, and in fact it seemed like he was deliberately avoiding her.  With that feeling she wanted my opinion on the x-rays.

I studied the images, trying to piece together what could have caused this particular problem and appearance.  Then a thought occurred to me.  I asked her if by chance he had ever had an abdominal surgery in the past.  She said that when he was a puppy he was cryptorchid (a retained testicle) and had surgery to remove it.  That strengthened my suspicions.  Many kinds of surgical sponges have a metallic thread woven into them so that if they accidentally get left in the abdomen they can be easily noticed on an x-ray.  My fear was that during the abdominal cryptorchid surgery a sponge or gauze had been left in the belly, which would explain all of the problems.  

To shorten the story just a little bit (yeah, I know...too late) I referred her to a local surgical specialty practice because if my suspicions were correct I knew it was going to be a bigger problem than I felt qualified to handle.  They went today and I talked to the surgeon this afternoon.  He said that the surgery was long and difficult, and the abdomen was "a hot mess" (direct quote).  The large mass was obvious, with lots of abdominal tissue around it and multiple adhesions within the abdomen.  About six inches of intestine had to be removed, even though the mass was outside of the GI tract.  And what was in the mass?  A surgical laparotomy sponge, obviously left in after the original surgery.  

The owners are obviously livid about this situation, and I can't blame them.  I had told them that if it turned out to be a sponge it was the liability and fault of the veterinarian who performed the surgery.  In this situation they have an open-and-shut lawsuit and I'm sure they will pursue this option.  One of the things that made me upset was the denial or evasiveness of this vet.  If I suspected a surgical sponge without first knowing there was an abdominal surgery, surely the vet who actually did the surgery and used those sponges would come to the conclusion more quickly.  If I had made this mistake I would have admitted it and faced the consequences.  Don't believe me?  I actually blogged about one of my mistakes back in 2009, and was very open with the clients.  In this current case it seemed like the vet was deliberately avoiding the client.

Now it gets really bad....This afternoon after I spoke with the specialist I was talking about the case with a couple of my staff who had overheard my side of the discussion.  One of them is very experienced and has been in our area for a long time, even having worked for a few different vets.  She really knows the veterinarians in the local region.  She asked me what vet had done the cryptorchid surgery.  I was trying to remember but was having trouble, when she asked if it was "So-and-So" clinic.  I recognized the name and told her that was right.  She became immediately upset because she was able to guess the specific doctor and office.  Apparently this isn't the first time this doctor has left behind surgical sponges in patients.  She told me that she knows that he has been sued several times in the past for the same kind of thing, one time leaving six gauze pads in a dog during a routine spay.  According to her he has had to change the name of his clinic several times because of these lawsuits.

Frankly, if all of that is true I don't know why his license hasn't been taken away or why any company would grant him malpractice insurance.  But if he pays out of pocket and doesn't report it to insurance, they might not know.  And if the client only sues and doesn't report it to the state veterinary board then no action is taken towards license revocation.  

We all make mistakes.  I've been open about mine.  But I can be confident that I learn from my mistakes and don't make the same one twice (at least in my wife might disagree about repeating mistakes in my home life).  But someone who repeatedly makes the same mistakes shouldn't be working in that profession any more.  As I said at the beginning of this blog, I'm quick to defend other veterinarians and give them the benefit of the doubt.  I never directly bad-mouth another vet just because I have a different opinion on a case.  But I also don't want to ignore true malpractice, and will strongly encourage these clients to look into options for a lawsuit as well as recommend that they contact the state board.

What about the dog?  He had major surgery that even a specialist had a hard time with.  There was also evidence of possible infection within his abdomen.  So he isn't out of the woods yet.  Though the surgery went as well as expected and the surgeon is hopeful, we won't know his short-term prognosis for at least another day or two, and then it will be another week after that before we can start seeing that he may fully recover.  If things go well he can likely end up living a normal life.  I'll certainly be praying for him and will follow-up with the client.

Wednesday, August 7, 2013

Snake Surgery

In early 2012 I posted about a surgery I did to remove a prolapsed hemipenis on a gecko.  Earlier this year I did a similar surgery on a chameleon, and last week I was faced with a California king snake with the same problem.  This was an interesting case because the snake was 20 years old and the owners had acquired him about 18 years ago.  They had cared for him well for the last nearly two decades without any problems at all.

When I examined him the prolapsed hemipenis was pretty obvious.  What they hadn't really noticed was the bruising on his tail beyond the cloaca (yes, snakes have tails).  The skin in that area appeared damaged and dying, as if it had been injured there.  A compression injury could have caused the lesion as well as prolapsed the hemipenis, but he wasn't taken out of his tank much and there was nothing he could have pinched himself in.  You can see the bruising well in these photos.

After being anesthetized it was easy to ligate and remove the hemipenis.  Since he was unconscious I decided to remove the dead and devitalized skin, expressing a large amount of clotted blood and bruised tissue.  The healthy skin was sutured together and the wound closed.

I expect him to make a full recovery, but I don't think we'll ever know how he became injured.  This was a fun case for me as I don't get to see snakes as often as I like and this was a nicely behaved one.

Tuesday, August 6, 2013

Fixing A Bulldog's Butt

Yes, I've been a bit absent from the blog recently, with only a few posts over the last few weeks.  I've been busy with other things in life and haven't had the motivation to blog.  However, let's make up for that with a couple of days of posting some interesting surgeries!

The first surgery is of a sweet female English bulldog who had a history of allergic skin problems.  We're working through what she may be allergic to, but there was another situation to deal with.  Bulldogs are one of the few breeds with naturally short tails that don't have to be "docked".  The tail should be short and slightly curly but not have really deep folds.  Unfortunately, deep depressions in the skin can happen as a consequence of how they grow and develop.  When the skin folds are very deep they can trap moisture and skin oils, leading to persistent infections.  This kind of infection can be very irritating to the pet causing significant itching and rubbing.  Such was the case with this dog, who was daily scooting and rubbing her bottom.  While this behavior can indicate full anal sacs, in her situation it was definitely the skin around the tail.

Here are some pre-operative pictures.  You should be able to see how deep the folds are and how inverted the tail itself is.  The third picture down shows me holding the folds back and pushing the tail out.  This was one of the deepest tail folds I've seen and could only be fixed with surgery.

The goal of a surgery like this is to remove the tail and excess skin, then closing the incision to make the hind end smooth with no folds.  In principle this is a simple surgery.  However, the process can be difficult because on a short tail like this you have to remove the tail as close to the sacrum as possible, usually leaving only one tail vertebra in place.  The challenge comes in that with the folds and fat around the hind end the surgeon is working deep in a hole with some limited visibility.  I was able to work by feel when I couldn't see due to my own fingers being in the way.   The vet also has to avoid damage to the rectum, colon, and surrounding muscles.

Here is the tail after it was removed.

And here is how she looked after the surgery was over.

When the hair regrows and the post-operative swelling goes away she'll have a smooth bottom and no further itching!  Now we just have to control the rest of her skin problems.