A Vet's Biggest Daily Problems

This interesting question comes from Alex.....

As a veterinarian, what are the biggest problems you face on a day-to-day basis?

There many, many problems we face daily.  Some of them relate to efficiency, some to staffing and training, some around client interactions, some around cases....you get the idea.  Day-to-day some of these might change.  For example, this past Sunday one of my techs had a major family crisis and couldn't come to work.  We normally have two receptionists and two techs for one doctor on a Sunday (yes, we're open every day).  It was too last-minute to call anyone in, so we had to make it work.  We don't face that situation daily.

Here's a list of some of the biggest things I can personally think of as relatively daily problems for vets, in no particular order.  I encourage my readers to add to the list!

• Having time to take lunch.  Sometimes we're so busy that I go from 9am to 7pm (or later) without a break, eating while I type medical notes.
• Explaining complicated medical cases to clients.
• Clients not having enough money to do proper diagnostics and treatment.
• Clients refusing to do simple preventative care such as heartworm prevention, even when we clearly tell them the risks of not doing so.
• Scheduling enough staff to be efficient, but not so many that we are putting too much into payroll.  This is a delicate balance, as we loose profits if we have too many people scheduled for the workload of a day, but if we have too few we can't work quickly and do quality work.
• Pets that want to bite and scratch!  People don't realize it, but vets and their staff risk bodily injury every single day.  Sometimes it's a minor scratch, but we also work with animals big and strong enough to cause severe, life-changing injuries.
• Not being able to diagnose a particular case.  Some case are extremely complicated.  We may run every test available to us and still have no answers.  Sure, we might have narrowed the possibilities but that doesn't always lead us to a correct treatment plan.  I get more frustrated by these cases than by any others, but I am more of a surgeon at heart than an internist.
• Having to deal with interpersonal conflicts between staff.  This is mostly in the hands of managers, but since I have that responsibility it comes to my mind.  Conflicts between staff can ruin the flow and morale in a hospital, as well as potentially even affect patient care.
• Lost records!  My clinic has computerized medical records but many vets still rely on hand-written files.  Having worked in these situations before, I know that sometimes a patient's medical record simply goes missing.  Computerization is the best solution to this problem, but some vets haven't made the switch.
• Clients who think that we charge way too much and somehow have the impression that I must drive a BMW and live in an estate (reality....2008 Nissan Altima and a 1500 square foot split-level house).
• Training staff to be efficient, accurate, and high quality.
• Being able to work in urgent cases that really need to be seen today when we have an already full schedule.
• Clients who have to come in RIGHT NOW because their pet has been vomiting for two weeks.
• Finding appropriate and comforting ways to help a client through the loss of a pet.

Those are the the things that come to my mind and I'm sure I've missed some obvious ones (I'm counting on readers to point them out).  Yes, a lot of it revolves around clients, something that anyone in the profession would be quick to support.  Honestly our jobs would be a lot easier if clients had less limited funds and would agree to everything we wanted to do to help their pets.  But I also can't blame all clients because many of them are in situations beyond their control.

Alex, hope that helps!

"If It Was Your Pet...."

One of the most common questions asked of a vet is "Well, what would you do of this was your own pet?"  Yes, admit it.  As a pet owner you've asked this of your vet at one point or another.  And if you're in the veterinary field you've heard it more times than you can count.  Believe it or not, this is tough to answer.

Everybody has different perspectives on pets and different life situations.  Someone who is pregnant may make different decisions than someone who just had a baby.  And both may make choices different than a grandmother.  An unemployed teacher may spend more money on their pet than a wealthy lawyer because the teacher sees the pet as her biggest joy in life and the lawyer knows he can just buy a new one.  (By the way....I'm not commenting on attitudes of teachers, lawyers, or anyone else.  It's just a random example, folks....)  There rarely is a "right" or "wrong" answer as many circumstances depend on many factors.  

Just take a look at yesterday's blog.  Pam decided to pursue a full diagnosis and then authorized chemotherapy for her cat.  She's happy with her decision and the case turned out quite well.  In a possibly similar situation I made different decisions which ended up with euthanizing my cat.  I don't regret my own actions.  Two people, two cats, different outcomes.  Neither one was "more right" than the other.  Each decision was right for that person.

That's why that question is so hard for a vet.  It's usually asked in difficult cases, especially prior to euthanasia.  Because these are hard decisions people want some guidance.  I'm happy to share my opinions, experience, and knowledge, but that's different than "Here's what I would do".  Sometimes I'd run tests that clients can't afford.  Sometimes I would stop treatment before another person would.  My own thoughts, beliefs, and history guide my decisions.  And since nobody in the entire world has my specific combination of these things, my decisions are really only applicable and appropriate for me.  My financial situations are also different than many clients, where sometimes I have more money than them and sometimes I have less.

Rarely do I give a direct answer to this question since there are so many variables and the reason why I may pick a course of action can be quite different from why a client may go in the same direction, or even the same reason may lead them to opposite actions from me.  I try to word my answer in such a way as to allow the client to make their own choice and not rely on me.  While it may not be as satisfying to some people, it would be better and easier to ask "Well, what are the benefits or problems with options A, B, and C?"  That's a question I can handle.

Why Didn't I Treat My Cat?

Okay, time to try and get through the emails I've received over the last few months.  I'll mix these in with new posts related to work and my life.  Here's one from Pam.

I was researching feline lymphoma this morning and found your blog entries about your 16 year old cat. I was curious why you did not do exploratory surgery or needle biopsies on the cat. I have an 11 year old cat who got diagnosed with small cell feline lymphoma about 1.5 years ago. He had done well with a chemo protocol. It has not been inexpensive, but since he continues to have such a good quality of life, we continue on as conservatively as possible.

Thanks for your insight and help.

I'm still tweaking my computer, re-installing software and files.  And for some reason when I pull up my blog page I can't see the search function.  The reason I mention this is because I can't search for the post to which Pam is referring.  So let me summarize.

A few years ago I had a cat who became sick.  He was vomiting, losing weight, and just not doing well.  I ran multiple blood tests, x-rays, and just about every test I had available and that made sense to run.  Everything kept coming up normal.  As he wasted away I had to weigh my options and chose euthanasia.  That was not an easy decision as he had been my friend since he was about three months old.

So on to Pam's question....It really came down to money, as well as whether or not I wanted to put him through everything.  Intestinal lymphoma was definitely on my list of possibilities but there were no obvious signs on exam or blood tests.  He never developed any masses, enlarged lymph nodes, or thickened intestines.  Any of these (especially the latter) can happen in this type of cancer and help direct the diagnosis.  It's also not uncommon to see high blood calcium levels or changes in the white blood cell count and percentages.  However, there were no abnormalities on exam or lab tests to give me a better idea.

It could still have been lymphoma.  If there is diffuse cancer in the wall of the intestine, a needle biopsy isn't going to be accurate.  Needle biopsies or aspirates are sometimes inaccurate, and you really need to make sure that the needle goes into the tumor.  Even with ultrasound guiding you, a needle into the abdomen will pass through intestines and may never actually hit a cancerous portion.  This is really a bad way to diagnose this kind of cancer.  The best way is a surgical biopsy, taking full-thickness samples from multiple locations.  However, that's an major surgery with an open abdomen, and he was in poor condition by that time.  He would have been a much higher anesthetic risk.

Let me take the time to bust a myth or two about veterinarians.  We do not get medical care for free for our pets.  Someone who owns their own practice might be able to simply not invoice out a major surgery, but they are still paying for the supplies, drugs, and salaries out of the practice's money, which in the end is their own money.  For someone like me who manages a practice rather than owning it the situation is even more different.  If I didn't charge for care of my own pets it would be essentially stealing time and products from the owner.  Yes, I do get discounts, but I still have to pay.  An abdominal surgery with intestinal biopsies may cost an average owner around $1500.  With my discounts I might pay around $1100.  Yes, a substantial reduction, but it's still a big chunk of change.  And that's where the other myth comes up....vets aren't wealthy (well, most aren't).  The average veterinary salary in the US is around $85,000 per year.  If that's a single income in the family (as in mine) it's firmly middle-class and not rich.  Considering that I'm still paying off my student loans almost 17 years after graduation, bills to pay, and two pre-teens to raise, I don't have bundles of money lying around.

Do the math in this case.  Let's say around $1000 for the surgery and we get a diagnosis of lymphoma.  It may be another couple of thousand for oncology consultation and chemotherapy, depending on how long it takes.  I don't have or use credit cards and even as a vet with personal and professional discounts I don't have $2000 to spend at the drop of a hat.

Then I had to weigh the likelihood of improvement.  He was 16, pretty old for a cat and at or beyond the life span for most feline patients I've seen in my career.  His was a good, long life without any serious hardships.  The diagnosis of lymphoma wasn't guaranteed, so I may have done surgery and biopsies and come up with nothing or something untreatable.  Pursing invasive diagnostics was a gamble and one I wasn't eager to take.  While lymphoma is often treatable and cats can live a few years past diagnosis, this isn't always the case.  At his age would I really be doing him a favor to give him another six months and then be right back at the same point?  After going through surgery and chemo?  If he was five or even 11 years old I may have made a different decision.  But 16 is far older and he may not have had much time left anyway.

I don't think there was an absolute right or wrong answer in my cat's case.  If one of my clients had wanted to do surgery and chemotherapy I would have completely supported their decision and followed through to the best of my ability.  This was a personal decision where I weighed the financial costs with the likelihood of recovery.  The scale tilted towards full recovery being less likely, so I decided to end his life peacefully.  This was my decision and even a few years later I don't regret it.

This ties in with another question vets are frequently asked...."What if it was your pet?"  But I'll talk about that tomorrow.

Where Has Dr. Bern Been?

I started this blog way back in 2008 and for the next five years I managed to consistently average at least 3 blog posts per week.  Not bad at all considering that I started it without a strong plan in mind.  And then just as I was nearing the big anniversary...

PFFFFT....

Several things contributed to the longest absence from blogging that I've had in five years.  Most of it revolved around a play that my wife directed and in which I was an actor.  It was an amazing show and I'm so proud of how she brought together a cast of over 20 people to put on a musical set in 1941.  But not only did I have the stress of being an actor, I also ended up helping with set building and decoration.  During that time my wife also started having some health concerns, and I had to rely on strength in God to be able to help her through that stressful period.  Once the play was over we had to start catching up on activities, responsibilities, and other things that had been pushed to the back burner for a few months.  Then there was a break for Christmas, during which my computer went rather glitchy with a driver that somehow locked up my computer to where even a boot in safe mode wouldn't start it.  So it's been in a local computer service store for the last nearly two weeks, finally being in working order today.  

Probably the best part of the last few months is a "good" reason why I haven't had as much time to blog.  Some days at work would be slow, giving me time to whip out a blog post from time to time.  But for several months we've had surprisingly strong business, leaving me no spare time at all.  As a manager of a veterinary practice I'm certainly all for that!  But on the other hand I wouldn't mind a breather now and then.

So now I'm back.  I've actually been contacted by a few people who have wondered if I'll do more blogs, and I certainly plan to.  Life is quickly getting back to normal and I'm finding myself with some much-needed free time, at least at home.  I feel that I still have stories to tell and advice to give, as the veterinary profession is constantly changing and evolving.

So that's what's been going on in the life of Dr. Bern for the last several months.  Time to get back to the job of letting everyone know what the life of a veterinarian is really like.

Another Bulldog Tail Issue

Lynda sent me this email....

I was googling about options for my (child's) dog's tail and came across your blog post on the tail surgery. I have an amazing 2 month old English bulldog who has had a few tail infections over the past year.  It seems to be getting more regular and worse.  I took him to the vet to get x-rays this week but they said his tail is too hard for them to do the surgery in-house so we should wait on the x-rays until I see a specialist and try to clean it and treat it aggressively first. I thought I would be ok with waiting and trying the culture and more antibiotics but I am having a very hard time cleaning his tail and more so keeping it dry. He is obviously uncomfortable and the smell is taking over the house.

I saw that you went to NC State and that you are in Georgia now. I went to UGA, got my dog in Athens, and my first dog spent a lot of time at NCState vet school with Addison's disease and muscular distrophy.  I will do anything for my dogs.

I heard that there are multiple options for Geno's tail, but don't know who to trust or listen to. I heard they could seal up the folds with surgery without removing any part of the tail, I heard they could remove part of the tail to make the space less crowded and easier to keep clean and then I've researched the full amputation (which seems dangerous and risky). Can you tell me what options there are, (though they may not actually be options for us if he isn't a good candidate)? Is there anyone you would recommend that is a specialist in this specific area here in the Raleigh/Durham area?

I cried when I thought he was going to get x-rays so I can only imagine how I will be with surgery. But bottom line I want him to be happy and comfortable. Thank you in advance for any help and guidance.


Lynda was referring to a post I made earlier this year (click here).  This is certainly not a simple situation, but here is my reply to her.

I'm curious as to why they would take x-rays for a skin infection.  Were they worried about infection in the bone?

Doing an amputation of a bulldog's tail is certainly NOT easy, and if they don't feel comfortable with it I wouldn't want them to try it.  I also have some surgeries that I won't do because of lack of proper skill or abilities.  However, a skilled general practitioner should be able to do it, and it isn't necessarily something that can only be done by a specialist.  It all depends on the vets at that clinic or in the area.

One of the problems we see with infections in skin folds is the recurrent nature.  This can happen in deep folds around the face, tail, vulva, and just about anywhere else.  Yes, you can typically cure the infection for a time with appropriate antibiotics, topical medications, and cleansing.  But often these infections have yeast and not just bacteria, so you have to use multiple methods.  And because the reason for the infection is at least in part the deep folds themselves, it's likely to keep coming back until you fix that particular problem.  Many times you'll also find an underlying allergy disorder which needs to be addressed.  Even so, most sources I've seen agree that the best long-term management involves eliminating the deep fold itself, which requires surgery.  Facial fold removal, vulvoplasty, and even tail amputation are not uncommon surgeries for severe skin fold infections.

In my experience, the really deep folds around the tail in a bulldog make amputation the best option.  In order to remove the skin of the fold you have to cut so deep and extensively that you're just about amputating the tail anyway.  Personally, I find it easier to remove the stub of the tail (which they don't need) than to try to get the skin off the bone and then close the defect over the stub.  I would also question the idea of a partial amputation on a bulldog.  The problem isn't so much the tail itself, but the very deep skin folds around it.  Yes, you could remove the outer part of the tail, leaving the deeper bones and skin.  But is that really resolving the issue?  Is that taking enough of the fold away to keep the problem at bay?  If you remove ALL of the tail and skin fold, then you simply don't have that problem at any other point in the future.  The few cases in which I've recommended amputation have been so bad that a partial surgery wouldn't have fixed the problem.

If done properly and with a skilled surgeon, tail amputation is not a highly risky surgery.  You're not in danger of affecting the nerves or muscles of the rectum in most cases, and any bleeding or pain can be controlled.  I've done many partial and full tail amputations for various reasons, including everything from short bulldog tails to long, whip-like tails.  I've never had any serious complications and once they are healed the patients have always been better off than before the surgery.

As far as recommended referral practices, there is one in Cary that one of my former surgery professors, Dr. Gary Spodnick, left the vet school to help found. It's Veterinary Specialty Hospital of the Carolinas (http://www.vshcarolinas.com/), and they have multiple locations in the Triangle. I don't have much personal experience with them as I haven't lived or practiced in that area in over seven years, but I think they would be considered high quality.  Although if you're in that area the vet school is always a great option.

If you still have questions about the best option, I think it would be worthwhile to spend the money to get a couple of opinions.  Talk to your own vet about your concerns, as they know the case better than another doctor and may have very good reasons as to their recommendations.  If you're not quite satisfied, find a high-quality vet in your area and go for a second opinion.  If both doctors agree (which happens commonly), you'll have more assurance in your decision.  It may also be a good idea to consult with a veterinary dermatologist, looking for non-surgical options first.

Hope that helps!

More Ethical Challenges With Euthanasia

Ryan emailed this to me....

As a second year vet student, one thing I often think about is euthanasia.  I want to make sure that when I perform a euthanasia it is for the right reasons.  In regards to convenience euthanasia, I was wondering how you deal with the clients that you turn away.  I've read many blog posts about euthanasia (both yours and others) and I have heard that owners often threaten to kill the animal themselves.  This seems like a very troubling moral dilemma.

So, I guess my question is how do you react to different types of euthanasia requests and the clients behind them?  If an owner gets belligerent or threatens to harm their animal do you call animal control?  Warn other veterinarians that this client might be coming?  And I know this varies by location, but what can animal control officers do to owners that threaten to kill their animals?  Is merely trying to get a convenience euthanasia done grounds for calling animal control?  

This is not an easy or black-and white issue as it deals with often subtle differences as well as possibly varying systems of morality.  I've been a vet for over 16 years now and have learned to treat each euthanasia situation as a separate incident, dealing with the emotions and reasons individually.  I can't predict a person's feelings or reactions before I go in the room, so I have to be a bit flexible in how I handle them.

Let's look at each question separately.

1.  "How do you react to different types of euthanasia requests and the clients behind them?"

On either side of the spectrum the decision is easy.  If a client wants euthanasia because their pet is in the process of dying I gladly agree.  If someone wants it because they decided they don't want their otherwise healthy and happy pet anymore, I quickly decline to perform the procedure.  But the further away from the extremes you get, the trickier the decision can get.  What about the healthy 6 month old golden retriever with a badly fractured leg that the owner cannot afford to treat?  Do we euthanize a very sweet, young, healthy dog with a serious but very treatable problem when the barrier is money?  After all, if treatment can't be done the pet is going to suffer horribly.  Or what about a completely healthy cat that has been showing increased aggression to a member of the family, resulting in a few visits to the doctor to treat bite wounds?  There are many difficult decisions and you have to take them one at a time and judge the merits of each one separately.

2.  "If an owner gets belligerent or threatens to harm their animal do you call animal control?"

In general, no.  I've had many people threaten to go home and just shoot their pet after I've refused to treat due to lack of funds or I've refused to euthanize because I didn't think it was justified.  I really believe that very few of those people every followed through and were using the threat as a way to try and guilt me into doing what they wanted.  If I actually witnessed the person being violent or abusive to their pet, I would first sternly warn them and if it continued I would absolutely call animal control.

3.  "Warn other veterinarians that this client might be coming?"

This is a stickier moral situation.  Another vet might have a different viewpoint than my own, though in my experience it actually ends up being the other way around (they feel as I do).  I'm not going to tell another vet what they should or should not do in a situation like this, since euthanizing a healthy pet isn't illegal.  Also, while most vets in an area at least know of each other, the degrees to which they regularly communicate or are friends varies greatly.

4.  "What can animal control officers do to owners who threaten to kill their animals?"

I'm not a lawyer or police officer (which is what animal control falls under), so I have incomplete knowledge of the laws.  I don't know that a mere threat to kill an animal is sufficient grounds to arrest someone and confiscate their pet.  I also don't believe it's illegal to kill your own pet or livestock, as long as it's done in a recognized humane way and the animal doesn't suffer.  After all, domestic animals are legally a special form of property, and it's not illegal to destroy your own couch or car.  The AVMA does recognize guns as being a humane method of euthanasia, as long as it's done in the proper way.  But for a more complete answer you'd have to talk to some one in that profession.

5.  "Is merely trying to get a convenience euthanasia done grounds for calling animal control?"

I firmly believe that the answer is "no".  Part of this answer goes back to the things I've discussed above.  But making the inquiry alone isn't illegal.  In fact, I WANT clients to ask about that if it's on their mind.  Having a conversation with them allows me the chance to give them other options and convince them that what they are seeking is the wrong thing.  If I called the police merely because someone asked about it I would be losing that chance to save a life.

Ryan, I hope that helps!

What's Up With The Skin?

Here's a question from Victoria...

I have a 10 year old pure bred lhasa apsa who seems to be experiencing some kind of dry skin condition on his lower back. I initially brought him to our vet when he presented with what appeared to be cuts on his lower back,to my knowledge he hadnt injured himself so i was concerned. The vet explained he may be hypo glycemic and that can cause thinning of the skin. I.proceeded with the blood test to confirm this and when the test came back negative the vet concluded the dog must have cut himself on something without me knowing. I,thinking that was a totally plausible situation took my boy home and kept an eye on the healing of the cuts. The cuts have now healed but his skin seems to be blackening all on the lower back and almost 'flaking' off. The vet has said it is likely dry skin but hasnt really offered any reasons this skin condition would arise or how i can go about treating it. Any advice or insight you could offer would be much appreciated.

While diabetes can cause skin problems, it's not my first thought when dealing with a dermatology issue, especially if there aren't other symptoms.  The single most common symptom that leads to a diagnosis of diabetes in pets is an increase in drinking and urinating.

Victoria, a full exam and questioning would be necessary for me to give you a good answer, but here are some of the things I would consider in a case like this.  Are there any signs of fleas?  Has he been noticeably scratching or rubbing his skin?  Has he been going under low furniture such as beds, low tables, etc.?  Has he been anywhere new?  Has he been exposed to anything different recently?  Has he ever had any skin problems in the past?

The next thing that I would normally consider would be the trifecta of skin tests:  a skin scraping, skin impression, and fungal culture.  Every dermatologist will do these tests on pretty much every case, even if the referring vet has already done them.  A skin scrape looks for mites, the impression looks for bacteria and yeast, and the culture looks for ringworm.  If none of these are noted then it may be skin irritation or an allergy.  Unfortunately, many disorders can look the same and it make take several tests or treatments to make the proper diagnosis.

When dead skin scabs, it can look black and start to come off.  Also, chronically irritated skin will develop a dark pigment, though the pigment itself is normal and harmless.  Excessive flakiness is not normal and may be related to changes in the skin, nutritional deficiencies, and so on.  If the problem persists it should be further evaluated until appropriate treatment is determined and used.

I would first start with talking to your vet and asking more details.  The vet may actually have other ideas or directions to pursue when it becomes evident that the problem isn't simply some scrapes.  If your vet still doesn't want to look into it further, I'd look for a second opinion.