A Little Patience, Please

Sometimes I just don't understand the impatience of people.

Today we had a client call us saying that her dog was sick, wasn't acting well, was dehydrated, and hadn't urinated in over a day.  That sounded pretty bad, so we told her to bring her dog in.  All of our appointments were booked up and we were still finishing up morning surgeries, so we told her to drop the dog off and we would look at it and call her back. My receptionist told her that it may be a few hours before the doctor could look at the dog but we would call as soon as we knew something.

Between surgeries I peeked in on the dog, a shih-tzu around a year old.  He was wagging his tail and barking, and certainly didn't look sick.  So I finished my morning drop-offs and procedures, took lunch, and came back a little early to check him out before afternoon appointments started.  His physical exam was completely normal and he urinated several times while with us.  Overall, I couldn't find anything wrong with him.  My plan was to call the owner and discuss the case with her to see if there was something else going on.

The afternoon started with some pretty big cases.  A Yorkshire terrier was limping, and on exam I thought he might have a dislocated hip.  A stray kitten that someone brought in had abnormal sounds in her chest, and I thought she might have a herniated diaphragm.  While starting this the shih-tzu's owner called.  I had my receptionist tell her that her dog appeared perfectly normal, but I wanted to talk to her and would call her as soon as I could.  Frankly, I thought that would be that.

The little kitten did have abdominal contents in her chest (I'll try and post about this later this weekend with pictures), and the owner couldn't afford the very expensive and risky surgery necessary to fix her.  So in the middle of getting ready to euthanize this kitten (with kids crying in the exam room), the shih-tzu's owner comes in, irate that nothing had been done with her dog.  I wasn't about to stop working on a very sick kitten and had my receptionist explain to her that we had some serious cases come in, her dog was fine, but I wanted to talk to her.  The client couldn't wait the 15 minutes it would have taken me and insisted on taking her dog, leaving in a huff.

Okay, somebody please correct me if I'm wrong here.  The client's dog had been with us for not quite 3 hours when she came back in.  During that time I had examined the dog and found nothing abnormal and nothing to support her claims.  Because the dog was very healthy and stable, I moved on to more serious cases, planning on doing them first and then calling the shih-tzu's owner. Sounds reasonable, right?  Apparently, not to some people.

Taking It In The Face

I've already talked about how gross veterinary medicine can be sometimes.  But what I didn't mention is where all of the fluids and other things can end up.  Often, it's right in the face.

Last week I was flushing out a dog's anal glands and had some of the fluid splash back into my face.  A few months ago I was looking at a problem with a dog's rectum and narrowly missed being squirted in the face with explosive diarrhea.  It's pretty routine to have a dog sneeze kennel cough vaccine back on us after we've given it (it's an intranasal spray).  I've had arteries arc towards my face after being cut during surgery.  Frankly, I'm glad that I naturally wear glasses and have some built-in eye protection.  But the worst case I've ever heard of was about 11 years ago with a guy named Earl.

Earl was a veterinary assistant at the practice I started at after graduating from vet school.  He was a laid-back, easy-going guy and a lot of fun to work with.  He had incredible compassion for the animals, and was a very hard worker. 

One day we had a dog come in with a horrible skin infection and maggots crawling over it.  When moist dermatitis happens during warm, humid months, flies may lay eggs on the diseased skin.  When the eggs hatch, the maggots will emerge.  There's nothing quite like seeing a mass of squirming white worm-like creatures wriggling over a dog after you've cut off the mats.  And this dog was pretty severely affected.

Once we did the initial cleaning, Earl took the dog to the kennel to bathe it and wash both the maggots and the dirt off the pet.  He was back there for several minutes when suddenly we heard a loud, horrific scream.  We rushed back there to see what was wrong and found Earl almost wretching into the tub.  Apparently he had the water on too forcefully when he started washing the dog and when it hit the skin the spray rebounded into his face...carrying maggots with it.  To make it worse, when the maggoty spray reached him he happened to have is mouth open.  Yes, he ended up with a mouthful of little maggots.  Frankly, we could all understand his scream.

Just one more escapade in veterinary medicine!

Volunteers Needed!

Richard, a veterinary student from Ross University, sends in this email....

First off, thank you for taking the time to read my email. I've been reading your blog for a while now, and not only do I enjoy seeing the practitioner's side of some issues, it is a great example of how to communicate with the public at large. I know that you encourage questions from your readers, and you may be able to help me with a little dilemma I have. I need to build a portfolio of case studies for my pharmacology class. The idea is to put together short videos of a variety of cases, before and after medical treatments, along with some basic information about the medications they received. Then I have to provide a narration discussing the method of action, pharmacokinetics, adverse effects, etc. based on lecture material. Where I find myself in a bind is that our teaching hospital does not permit photography of any kind inside the facility. I understand where they're coming from, and it is an interesting discussion for another day, but it leaves me in a bit of a bind. Do you have any thoughts or suggestions? Would any of your clients be interested in volunteering their animals, anonymously of course, to help a student?

Richard, I'll certainly try to help here. This is an official shout-out to my readers around the world. If anybody is interested in helping out, please email me (DrChrisBern@gmail.com) and I'll pass on the information to Richard (I don't want to share personal emails in a public forum). This may be a way to get a bunch of cases together in a way that you couldn't otherwise do, and will go beyond my own clientele. If you're on VIN (Veterinary Information Network) I would recommend seeking the help of other vets there, as you'll find a wide spectrum of people.

I remember having to do projects when I was in school, though nothing so fancy. My senior project was on Helicobacter pylori, a bacteria found in the stomach and implicated as a causative agent in stomach ulcers. In some parts of the world it's a major health concern, and it's found in the stomachs of some animals (ferrets carry it, and are used in research on this organism). My presentation was one of my first forays into PowerPoint, and I was so excited that I found a small animation of Helicobacter moving. This was back in '97, so I was pretty proud of my computer skills. And I actually won an award for that presentation.

Richard, I hope this may help a little, and maybe I can send some interesting cases your way!

Bragging Rights

To me client service is extremely important.  In an economy like our current one it's difficult to drive business and succeed strictly on price.  To truly win, you have to have excellent customer service.  Though I'm far from perfect, I pride myself on creating this kind of environment in the practice I manage.  And sometimes you do win.

Today I had a client pay me one of the biggest compliments I've received.  She was friends with another one of our regular clients who apparently has had nothing but great things to say about us.  The new client had come to us specifically because of her friend's recommendation.  And the greatest part is that she drove an hour and passed numerous other vets to get to us.  The word of mouth was so good, that she went out of her way to bring her pets to us.

You simply can't buy that kind of advertising.  Good word-of-mouth is the best way to develop a business, as well as the most cost-effective.  When you have people speaking well of you, word gets around.  The same thing is true of complaints and bad word-of-mouth.  If you're doing the right thing for the pets and clients, the former will outweigh the latter.

One of the most important parts of treating clients in the right way is the team you work with.  As good as a vet might be, they can't to their job without their techs, receptionists, and other assistants. My team deserves the credit for such success at least as much as I do.  Without them, I wouldn't be able to do my job and the clients and patients wouldn't get the treatment they need and deserve.

So yeah, it's time for a mild bit of bragging.  Next challenge?  Do even better!

Not Expecting The Unexpected

Today I neutered a three year-old boxer.  He had recently been seen at my practice for testicular pain, with the suspicion of an inflammation or infection in or around the testicles.  He responded well to antibiotics and pain medication, but on the recheck exam I noticed that the firm swelling had not resolved.  Suspecting other problems, including cancer, I convinced the owner to have him neutered with the possibility of a biopsy of any suspected tissue.

Normally a routine neuter takes me around 10 minutes to do.  Since I was expecting some masses attached to the testicles I thought it might add an additional 10 or so minutes to the surgery time.  After having been in practice for almost 13 years, I should know better than to expect things to go smoothly in cases like this.  The more I was involved in the surgery, the more I realized that the abnormal tissue extended much farther than I had initially thought.  I could feel irregular, firm tissue extend along the length of the epididymis (just off the testicles) down to where the tissue attached to the scrotum.  I found myself in a surgery unlike any I've done before, and ended up doing the procedure for just over an hour.

One of the things you learn as a vet is that the unexpected can happen at any time.  The bad part is when this happens during a surgery, because suddenly it becomes difficult to do it part-way and stop the procedure.  You have to trust in your abilities and experience, knowledge of surgery and anatomy, and hope for a little good luck.  In this case I knew that I had started to remove the affected tissue and couldn't very well close up the pet with the job only partly done.  So in the end I ended up removing his scrotum to make sure I removed all of the abnormal tissue (this is sometimes done for cosmetic reasons in large, adult dogs who are neutered, as the empty scrotum tends to hang down and is unattractive).

The dog recovered normally, and we sent some of the tissue to the diagnostic lab or a pathology review.  If we're lucky we'll end up with merely a severe inflammation or a benign cancer.  Unfortunately boxers are prone to cancer, so the report may give news of a malignancy.  We'll know by next week.

Now the final lesson came when the owner picked him up.  I was explaining the surgery and findings as well as the possible outcomes.  She asked me if this could have been prevented by having him neutered when he was a puppy.  I don't like to brow-beat clients, especially ones who are trying to do the right thing.  But I had to be honest with her and tell her that if he had already been neutered this would never have happened.  Testicular disorders aren't common, but they do happen.

So make sure to have your dogs spayed and neutered.  I will help to prevent many types of health disorders later in life.

Canine Couch Potato

I have come to the conclusion that one of my dogs, Inara, is a fan of TV.  However, it must be certain programs or movies.  She is around a year old and is a yellow lab mix.  Normally she's pretty active and loves to play, though thankfully she has calmed down a bit once she reached adulthood.  Television normally doesn't interest her, and she will lay quietly on the bed or couch, chewing on one of her toys.

Until a show comes on involving dogs. 

Right now we have Homeward Bound on TV and she has been watching it intently.  Whenever the animals come on she will turn and watch it, even leaning closer to the TV.  In a few scenes she has even growled a little.  When scenes have only people, she will turn away and not seem to care.  It's been very interesting studying her and watching how her attention waxes and wanes depending on what comes on the screen.  The animals really fascinate her.  Our other dog, Guinevere, could care less and doesn't even seem to notice what the TV does.

It makes me wonder what is going through Inara's mind.  Does she recognize that these are real animals?  I have to think so, otherwise she wouldn't have the interest.  Does she wonder where they are and why she can't smell them?  Does she wonder why they don't respond to her?  How much does she really perceive and understand?  We'll probably never know.  But it's interesting that some dogs can have interests in TV like people do.

Other people have hoped to cash in on the pet TV watcher market.  You can find videos of fish, birds, and other animals that are designed to keep the interest of your cats while you are away.  I can't say how well they work, and it's probably marketed towards the owners as much as the pets.  But watching my own dog I have to say that there is probably some validity to it.

Hmmmm...Maybe I should get one of those videos for Inara.

A Real Mess

Anyone who thinks that veterinary medicine is glamorous has obviously never spent time working with a vet.  I was just talking with some friends of Facebook about this, and I don't think people realize what we have do deal with in the course of a day.  I'll often say to people that if I don't get bodily fluids on me during the course of a day, I obviously haven't been to work.  Most days I'll come into direct contact at least with feces and blood.  Urine and pus are not uncommon.  And anal gland secretions are a necessary risk; I have my finger in the rectum of multiple pets per day.

Large animal vets have it even worse.  They walk around in barns or fields with an inch or more of manure.  Much of their day is spent literally up to their shoulders in the back-end of a cow or horse. Vets who work on dairy farms may have to rectally palpate several hundred head of cattle each day.  Often such work is done in freezing cold or blistering heat.

Then there are the smells.....Expressing anal glands are bad enough.  But a nasty abscess can really clear a room.  Swine vets carry the odors around with them for days, even with showers (I certainly remember my brief forays into a swine barn and how hard it was to get the stench off me).  Parvo has a very distinct, rather nasty smell.  As a vet you have to develop a strong stomach, and you become rather immune to many harsh odors.

And despite all of this, most vets love their jobs!  Yes, we're a bit of a strange bunch.