Arthritis in cats

While I love my dog patients, cats are the nearest and dearest creature to my heart. Hence the obsession with bottle-raising kittens, I suppose. But I digress. Arthritis in cats is an interesting and complex subject that has only been recently garnering attention in the vet world. Mistakenly, for the longest time, it was thought that cats were physiologically extremely similar to dogs. In essence, cats were thought of as "little dogs." It has only been in the last 10ish years that this assumption has been challenged and recognized as completely wrong. Cats are NOT small dogs.

As a result of this thinking, as well as the fact that people are more likely to take their dog to the vet than their cat, there is a dirth of literature on the subject of cat diseases and illnesses. Arthritis is a great example of this. For dog arthritis, there is Rimadyl, Previcoxx, Deramaxx, and Metacam, all fairly safe for long-term use. There are dog supplements of glucosamine and chondroitin. The subject has been well-researched, and research is ongoing in every aspect of it.

On the other hand, there is only one NSAID approved for use in cats - Metacam. It is labeled only for one-time usage, unfortunately. Joint supplements are poorly researched, and not much is known on the topic. Cats are basically left out in the cold when it comes to to arthritis management.

This subject is near and dear to me because I have an old kitty with some of the gnarliest hips ever seen. Seriously, this is what I was told by my orthopedics professor. He actually said that my cat had the worst hips he'd ever seen. Unfortunately, once arthritis has set in, there is no cure for it. The disease is permanent and painful. No one really understands what causes it, other than old age with the contribution of obesity frequently noted. In dogs, there are many possible underlying causes: hip dysplasia, previous trauma, necrosis of the femoral head as a puppy, and the like. Cats just seem to get arthritis, for whatever reason.

The veterinary world is finally getting somewhat interested in this subject. As a vet student, I enrolled my cat in a study on a new NSAID (unnamed) developed specifically for cats. I'm not sure what the results of that study were (it was a controlled, double blinded, prospective trial), but it's encouraging that the research was being done!

In the meantime, these are the options that exist for kitties with arthritis. Most cats are treated with a combination of these medications and therapies:

Pain control
-Buprenex: this is a partial opioid liquid that can be given orally. Unfortunately, it needs to be given up to 3 times a day and is quite, quite expensive these days. It can be a good long-term solution when combined with other pain medications and life-style changes. It tends to make kitties extremely, extremely sweet (basically, because they're high).
-Gabapentin: this is an anti-convulsant that was also found to have good neuropathic pain control. It has recently been used in pets with a variety of different pain types. It is a liquid, fairly inexpensive, and seems to have good results. In some cats, it causes vomiting and sluggishness.
-Metacam: this is a non-steroidal anti-inflammatory medication. It is only approved for one-time use in cats due to the possibility of acute renal failure. Some veterinarians will use it chronically in cats due to intractable pain and an absence of other good options. Its use for this is controversial, due to the possibility of kidney damage.
-Tramadol: this is an opioid like drug that can control pain in cats. It is inexpensive, however some cats become intensely dysphoric on it - so it doesn't work for everyone.
-Amantadine: a drug similar to ketamine (called "Special K" on the street) that works on nMDA pain receptors. This is fairly new in the pain control arena, and again, there are no studies in cats yet. It is all experimental therapy. I have no experience with this drug personally.

Joint supplements
-Adequan: recently, veterinarians have started using the injectable form of glucosamine/chondroitin in cats. There are no studies evaluating it at this time, but anecdotally, it works. I use this in my old kitty. Subjectively, he seemed markedly improved with it.

Other, non-traditional therapies
-Acupuncture: this has recently made a big splash in arthritis treatment in cats. I have not personally tried it (yet), but many veterinarians swear by it for pain control.
-Cold laser therapy: another relatively new modality in the fight against kitty arthritis. I know practically nothing about it, but some practitioners are swearing by it for all manner of diseases including IVDD, trauma, and heart failure!

Surgery
-In cats with severe hip arthritis, there exists the possibility of either doingva total hip replacement (running thousands of dollars per hip) or femoral head osteotomies - in which the head of the femur is removed, thus stopping the bone on bone contact that makes hip arthritis so painful.
-For front limb arthritis, there are no good surgical options.

Other
-Fat kitties should undergo weight loss. This takes undue stress off of joints and helps with pain control.
-Dietary modification: Hill's has recently released a j/d diet specifically targeted at joint pain. It is supposed to reduce the need for NSAIDs (in dogs) by 25%. As an ER doctor, this isn't something I use much, but I have heard of very positive results with this diet.

This is the current state of feline arthritis treatment. It's a hodge-podge of different approaches, which is usually better than a single modality approach anyway. And now that veterinarians are realizing the need for better pain control in felines, perhaps the research will finally start to take off. In the meantime, if you have a kitty with arthritis, make sure your veterinarian is recommending multi-modality therapy - multiple pain medications, as well as possible acupuncture, laser therapy, joint supplementation, appropriate weight loss/management, and possibly dietary management.

Selling yourself

I had a request a while back on how to sell yourself to a practice as a newly graduated veterinarian. Naturally, I like to write about what you guys want to read, so I betook myself to the computer, confident that I could write this easily. Then I sat. And sat some more. Selling yourself is hard! So, I approached it from my own perspective. If I was hiring a veterinarian, what qualities would be important?

We were lucky as a veterinary class to have Dr James Wilson come and speak to our class about interviewing, contracts, resumes, and the like. We were also lucky to be provided with a huge, fat binder covering all of these things, including samples of cover letters and resumes. I have referred to it numerous times since graduation.

In this binder, Dr Wilson reviewed what experts have found that employers are looking for. It is NOT GPA. In order of most importance, an employer looks for 1) loyalty 2) stability 3) enthusiasm coupled with good judgement 4) intelligence and 5) technical skills.

So, when selling yourself to employers, here is what I recommend (again, just opinions!).

First, confidence, eye contact, and a professional appearance are absolute musts! Dress for success is a cheesy but accurate phrase. For men applying for veterinary positions, a suit and tie are perfectly appropriate. For women, there is a little more leeway. I usually wore suit pants, a button down shirt, heels, and some toned down jewelry. Appearance, while widely panned by our society as superficial and meaningless, is very important. Before I was hired at our clinic, they interviewed the #1 student in her class for my position. She had pink hair, a mohawk, and several facial piercings. She was also absolutely brilliant. The problem? Our clinic is in a small, poor town in NC. She would automatically have not been trusted by 80% or more of our clientele. Is this fair? Absolutely not, she was a phenomenal doctor and person. Life isn't fair however. As a doctor, you have to instill confidence in your clients. Physical appearance is a large part of that. As a result, dress like a professional and act like a professional when interviewing. As silly as it sounds, a firm handshake, eye contact, and a confident manner of speaking can make the difference between you and someone else being selected for a job.

Secondly, know your strengths AND weaknesses. This was a common question asked by interviwers. When asked about my strengths, I could readily spout off many of them. Weaknesses were harder, as who wants to admit to a potential employer the things that they dislike about themselves? Prior to interviewing, it is important to sit down, make a list of these 2 categories, and honestly evaluate yourself. Are you good at medicine but lack surgery experience? Are you shy and have a hard time being up front or strong with clients when you need to be? Are you bossy and aggressive (like I am?), or are you passive? The best way to present your weaknesses is to acknowledge them and to explain how you plan on addressing those weaknesses. Employers like to know that you are aware of shortcomings and actively working on fixing them.

A third important thing to do as a new graduate is to go ahead and root the chip out of your shoulder! I speak from personal experience. When you come out of the Ivory Tower of vet school, your mentation is that the university does it right and does it better. It takes years to rid yourself of this thinking (as I am going on 3 years out, and I still have a problem sometimes). Yes, you will know the most up-to-date way to treat something, and you should ABSOLUTELY use that knowledge to improve patient care wherever you go. But it's also incredibly important to remember that the vets that you work with who have been out for a while have a great store of knowledge and can be very helpful in helping you navigate the "real world" - where clients often have no money, seriously ill pets, and very limited means with which to treat them. When interviewing, the way to sell this point is to present yourself as a new graduate with many possible new ideas to improve patient care - and then make the point that you are also open to learning from people with more experience than you. An open, willing attitude with a desire to learn instead of dictate is incredibly important!

Another important thing when selling yourself is to remember those strengths. Explain to the interviewer what YOU in particular can bring to the practice. Did you win the Sr Award for ophthalmology? Make the point that you are very interested in eyes and would like to develop in that area. Were you the head of the Exotics club? Discuss your extensive experience with exotics and how the practice might expand into that area. Every applicant has unique abilities and talents. It is important to know yours and present them in a way that shows the interviewer that you can bring something special with you.

Become a team player - even if it's against your natural grain. It's against mine. I am very much a "loner" in that I tend to work best quietly and alone. This has led to me being seen as aloof and arrogant, when in reality, I usually just need time to think. It has often sometimes given my colleagues the belief that I don't value their experience or opinions. Learn to work well with owners. Learn to ask questions, be open to the answers, and try new things. There is no absolute RIGHT WAY to do anything in medicine - there are shades of grey in every single diagnosis and treatment. It took me a longer time to learn this lesson than some others, I think - and it is still a lesson I am daily working on. Learning to be a team player and showing your potential employer this willingness will make you a valuable addition to the team.

Enthusiasm will also go a long way towards helping you find a job and impressing an employer. If you love what you do, let it show. You don't have to gush, but let your potential employer see how much you enjoy small animal medicine or equine ambulatory practice. It is often easy to tell when someone is settling for a position versus when they actually WANT a position.

I think those things are the most important for me personally...but what do you guys think? Other important factors that I'm overlooking?

Drunk driving strikes again

A few months ago, I mentioned a case in which a dog was injured during a drunk driving accident. It actually turned out to be a really interesting case with a surprisingly happy ending (at least, for the patient - not sure about the driver).

We received a call very late one night after a very busy night in the ER. It was a police dispatcher, asking us if we could drive to the scene of an accident and pick up an injured dog. She explained that it was wedged under the dashboard, and no one could remove it. I explained that unfortunately, we had no pick-up service, but if they could get the car towed to us, we could help with sedating and removing the dog. She informed me she would call me back. Moments later, she notified us that the dog had been freed and was on the way to our ER.

When the patient arrived, we were confronted with a 90 pound German shepherd. "Cora" was lying on the stretcher, barely responsive. Her gums were pale, and she was obviously in shock. She'd also suffered head trauma, as evidenced by her minimally responsive state. Her eyes were open, but she barely responded to us. Her pupils were slightly unequal in size, another sign of head trauma.

More concerning to me was her posture. Cora's front legs were rigidly outstretched, while her back legs were flaccid. She would not lift or turn her head to look at us. Initially, I was concerned based on her posture that her back had been broken in the accident.

We started stabilizing her with IV fluids, oxygen, pain medications, and mannitol for her head trauma. Her mentation remained very dull. I quickly surveyed the rest of her body for signs of other injuries - lacerations, broken bones, evidence of internal bleeding. I found none, all in her favor. Then, I went to talk to her owner and deliver the grave news about possible spinal trauma. As the story unfolded, the owner's husband was driving drunk and hit a telephone pole. Cora was thrown into/under the dashboard and wedged there. The owner's wife had driven to the scene, then brought the dog to us. She was beside herself with grief and probably a healthy dose of humiliation, as well.

I carefully explained to her that I was very concerned about her dog's spine. The possibilities were a few - spinal fracture, severe blunt trauma to the spine causing "spinal shock," and a disc that had popped out of place and hit the spinal cord. Our diagnostics were limited to xrays, I explained. A disc would need CT or MRI of the spine. The owner elected to continue with testing.

To my delight (and a little surprise, I won't lie), the back was not broken. I was left thinking blunt spinal trauma or an acutely extruded disc. As the night progressed, Cora became more responsive. She wagged her tail when her mom came back to say goodnight, but she still did not lift or move her head. Even more curiously, she did not move her front legs, but she did move her back legs.

I was confused. Her front end seemed to be the badly damaged end, less so than her rear legs. When she initially came in, I thought she was exhibiting Schiff-Sherrington posture (rigid extension of the front legs, flaccid back legs), which is always an indicator of trauma to the middle of the spine. If that were the case however, her front legs would be working, and her back legs would not. As the night worn on, it became apparent that she did NOT have SS posture - as intermittently, her back legs would become rigid too. Cora remained unable to lift or turn her head.

My brain started to churn and I realized that she must have suffered injury to her cervical spine (neck, in layman's terms). That explained the reluctance to lift/move her head, the stiffness of her front limbs, and the intermittent weirdness in her back legs.

The next morning, Cora tried to sit up frantically. Her back legs would paddle, paddle, paddle - but her front limbs did nothing. This confirmed my suspicion. I recommended to the owner's that they take the patient to the neurologist for imaging of the spine. My suspicion was that a disc had popped out of place, damaging the cervical spine. An MRI of the spine would give the best image of the damage, as well as allow the neurologist to determine if surgery was necessary, and help with prognosis.

As it turned out, the patient did pop a cervical disc out of place - causing spinal trauma. Based on the kind of disc extrusion it was, surgery was not indicated. The patient was discharged home with instructions for pain medications and physical therapy. Her prognosis was given as very good with time.

The owner sent us a goody basket the other day stuffed with fudge and other delights thanking us for all we had done, and letting us know that Cora was doing great. It was nice to get a happy ending to a sad story for a change!

Dear baby

You have no idea how excited I am about your coming. My biological clock has been ticking for the last 5 years pretty steadily, so when we found out that after 2 short months of trying, we were expecting, well, I was thrilled. You are very much wanted and anticipated.

BUT...it is decidedly not ok that you have decided to make sleeping till 3pm, doing laundry, and cooking dinner for 2 the MOST that I can do without needing a nap. Seriously. I have to be able to function more than this, as I have a job and some serious responsibilities. So, if you could just put out a little energy for me, or stop emitting napitrons - whichever is fine - I'd seriously appreciate it.

Sincerely, your mom...the one that is so tired that 2 hours of laundry and dinner was unbelievably fatiguing!

Blood transfusions

Recently, I was confronted with this IMHA patient, and I realized it had been several months since I'd done a red blood cell transfusion. When running over the physiology in my mind, it became apparent that I was forgetting my book learning, so a refresher was needed. This post will share what I refreshed myself on.

So, just like in humans, we do blood transfusions for anemic animals. We also do transfusion of plasma, as well as immunoglobulin, and platelet rich cryoprecipitate (although this is very rare in the area where I practice). Each type of transfusion has its own nuances.

Dogs, just like all other animals, have blood types. The categories are a bit more confusing than people and include designations such as DEA 1.1, DEA 3, 4, 5, and 7, and DEA positive or negative. For the sake of brevity, I will not go into the differences here. Suffice to say that the most important blood group in dogs is the DEA 1.1 group, as it the most likely to cause severe reactions.

In dogs, it is generally considered acceptable to transfuse a patient once with red blood cells without blood typing them. Why is this the case? Dog red blood cells are identified by the designation DEA. This stands for dog erythrocyte antigen. A dog can be either DEA positive (meaning the dog has little immune system stimulating compounds on the surface of his red blood cells) or DEA negative (meaning there are no compounds on the surface of his red blood cells).

Antibodies are one of the killers that our bodies produce. Antibodies can be directed against viruses, bacteria, and even things like donor blood. Dogs are not born with any antibodies against different blood types. As a result, you can transfuse a dog without blood typing it once. Since there are no antibodies, there will be no immune reaction to the blood. BUT - once you have transfused that patient, you must blood type the patient before transfusing again.

Why? Well, let's say you have a DEA negative dog. There are no compounds on the surface of his blood cells, and his immune system recognizes these red blood cells as "self." You transfuse him with blood from a DEA positive dog that DOES have little compounds all over the red blood cells. The dog has no natural antibodies, so there is no reaction. The body does however recognize that this is not "self" blood, and the immune system makes antibodies to that type of blood. Next time you transfuse, the body will release those antibodies against that unfamiliar, non-self blood, and a severe "allergic" reaction will ensue. It takes 5-9 days for the immune system to produce those antibodies.

There is another interesting way to assess how a dog will react to blood. After blood typing, you can take a combination of the dog's own blood and blood from the donor and mix them together to see if a reaction occurs. If it does, then the blood is not safe for the dog. This is called cross matching and has nothing really to do with blood type. It is merely a way to see if a dog will react to a certain donor's blood. It is very useful in dog transfusions.

The perfect donor dog is DEA 1, 3, 5, and 7 negative, as these are the most likely to cause reactions. It is very interesting to me that greyhounds have a higher prevalence of ideal donors than other breeds of dog. While they make great donors, a high percentage of them (approx 50%) also carry a red blood cell parasite called babesiosis that can cause severe illness and hemolytic anemia. Thus, very careful screening of all blood donors is done before they are accepted as donors.

Cats are a whole different species. Cats have blood type A, B, or AB - similar to humans. Type A is far and away the most common (99% of cats), while Type B is very rare and is often found in purebreeds such as Russian Blues and Devon or Cornish Rex breeds. Cats ARE born with natural antibodies against other blood types. Thus, an A cat will have B antibodies, and a B cat will have A antibodies. Further, in the B cats, these antibodies are so strong that transfusing it with A blood will lead to almost immediate death from a severe anaphylactic reaction. Giving a type A cat B blood will also lead to a reaction, but it is not always fatal. As a result, cats must always, always, always WITHOUT exception, be blood typed. There are type AB cats, but these are <0.4%. They have no natural antibodies and can be universal recipients. I have never seen an AB cat (or a B cat), nor do I expect to.

A B cat given A blood will - within seconds - become restless, may stop breathing briefly, the heart will slow down and the rhythm become irregular, the cat will often vomit, and then collapse. Death is imminent. A milder reaction will happen if a type A cat is given B blood, but it can still be life-threatening.

As a sidenote, kittens developing in utero can have a different blood type than the mother cat. If this is the case, when they are born, the kittens will start nursing. Through the colostrum, they will receive the antibodies that the mother cat has against their own blood type. They rapidly deteriorate due to hemolysis of their own red blood cells. This condition is called neonatal isoerythrolysis and thankfully is rare!

Luckily for us and our patients, we have in-house tests that are (relatively) simple and quick to run that can identify both blood type and whether a reaction will occur to the donor blood (cross match kits). These are imperative for ensuring that our patients are receiving the right blood and make our jobs as veterinarians so much easier.

Hoarding. Where is the line?

Hoarding has become a very popular subject in today's society - especially in the realm of reality TV, it would seem. A couple of months ago, I was vacantly channel surfing, and I came across TLC's show "Hoarding: Buried Alive." The whole premise of the show is that hoarding is a mental illness and that the people depicted need intervention to live normal lives. While I think there is a whole area to be explored here (what is mental illness? if it's not hurting anyone, why should people interfere? whose business is it?) - I want to talk about animal hoarding.

I am very bothered when the government tries to intervene and set limits on how many animals a person can own. I have read of state and local laws limiting owners to a certain amount of pets. In the big city adjacent to our small town, there are laws about how many dogs one can own. This invasion of personal freedoms is infuriating, but that is not the topic of my post.

My question is this: what is the definition of true animal hoarding? When should outsiders get involved?

When asking this question, my mind automatically goes to Ms Spencer. Ms Spencer is a single lady that lives with her mother. She takes in cats and kittens as "fosters." None of us know exactly how many cats and kittens she has, but we can always tell she has been in the clinic because of the pungent odor associated with her, her clothing, her cat carriers, and her cats. It is the overwhelming reek of cat urine.

We see Ms Spencer at least 1-2 times a month with an ill cat. The last one to visit us I diagnosed with FIP - a fatal disease associated with high density cat populations (catteries). Ms Spencer is loathe to euthanize any cat and will do whatever is financially necessary to provide medical care for them. She is also well-read on subjects of cat health and knew that FIP is uniformly fatal. We did euthanize that cat.

Prior to that, she brought in a cat that she had very recently agreed to foster. The cat had a pyometra, because it was not yet spayed. She paid for surgery to spay the cat, as well as the long and expensive aftercare, as the cat developed complications and eventually died. Before that cat, it was a cat with severe neurological signs, seizures, obtundation, and an unknown diagnosis. She treated that cat for 6 days in the hospital (spending over $2000) before the cat started to recover (we suspect toxoplasmosis).

The point is, Ms Spencer will do whatever is necessary to care for these cats. They are not sick, they are not emaciated, they are all vaccinated, tested for feline leukemia and feline immunodeficiency virus, and they are free of ectoparasites such as fleas. She takes good care of them. Whenever she brings them to us for care, her trust in us is implicit, and she does whatever we recommend. She is the ideal client. She herself is a frail, tiny woman.

We suspect that she has at least 30+ cats based on how many we've seen. No one knows for sure, and she is not forthcoming with that information (none of us have ever asked, though). Now, would you call her a hoarder? Should someone intervene? She has the financial resources to care for the cats, they are well cared for and adopted out eventually. My contention is that she is a model owner, doing good deeds for these cats that would otherwise be euthanized, and that she should be left in peace to continue her cat good deeds. Others would argue that she has a mental illness and that someone should intervene.

I find that thought funny given some of the horrible things I see "non-hoarder" owners do - not vaccinating their pets, not spaying/neutering, and breeding dogs that are 10+ years old, to name a few. No one argues that those pets should be taken away from the owners, yet they are far, far less well-cared for than Ms Spencers million cats.

So, what do ya'll think. What is hoarding to you?

The cat in the wall

Prior to leaving town, we always do a cat check to make sure that no one is locked in the closet or in the bathroom. While preparing to leave for home on Tuesday, I scanned the cats in the house and could not find Mike Waszowski. My husband, her favored person, called and called. No sign of Mike. We checked all of her favorite spots. No Mike. We rustled cat food in the bag around, as well as cracked a can of moist cat food. No Mike.

We'd had people in the house on Tuesday afternoon, working on installing new fixtures in the bathroom/shower. They'd been in and out of the house several times. We figured Mike had lain in wait by the front door (as she normally does) and skittered out. We scoured the yard. No Mike. I checked with the neighbors. No one had seen her.

After an hour of searching, we had to assume that she'd escaped outside and would show back up. I wasn't especially worried. Cats usually do fine outside, although Mike did disappear once for 3 weeks. We had to leave, so leave we did.

When my technician called me the next night to update me on the pets, she told me that Mike was in the house, acting perfectly normal. I was perplexed. Where could she have possibly hidden that we couldn't find her? We know all her spots, and the house is very organized...so, where?

We came home on Thursday, and I set about changing the parrots' food and water. While in the bird room, I noticed that the new access panel that the plumbers had installed in the wall behind the shower was lying on the floor. Hmmm, I thought, guess they didn't do a very good job installing that panel, as it seems to have fallen onto the floor. I mentioned it to Jim as I came out of the room. He looked thunderstruck for a moment, and then said, "Oh my God - that's where Mike was!"

I realized he was right! The plumbers had left the access panel open and had made a trip to Lowe's, leaving the opening there with no cover for an hour or more. Mike had undoubtedly gone into the hole and decided to explore within the walls and around the shower. When the plumbers came back, she was probably deep in the opening, nowhere in sight, and they had gone ahead and placed the access panel and caulked it in place. Mike was sealed in a la the Cask of Amontillado.

Luckily, she was able to claw her way out and knock the access panel down without too much difficulty. She seems none the worse for the wear, but I'm very, very thankful that she was able to let herself out!

Weaknesses

Veterinarians are trained as generalists. Unlike MDs, we are not required to do an internship and residency, although those programs are available. As a result, we learn a little bit about everything. We go through classes ranging from large animal reproduction to exotic animal medicine. It can be extremely challenging to be a good veterinarian for this reason. Everyone has their strengths, and certainly, everyone has their weaknesses.

My biggest weakness is definitely orthopedics. I don't like bones - broken or intact. I don't like trying to localize vague lamenesses. Palpating for a cranial drawer sign (as found in a torn cruciate ligament) is a challenge for me. When I see a dog present for "limping" - I automatically get nervous. Unless it is an obvious, traumatic fracture, these can be very difficult to sort out. There are a variety of reasons for this. First, we are an emergency service. As a result, we do not have the time to do extensive, multiple views of legs as is necessary sometimes for complex orthopedic problems. Secondly, it can sometimes be very hard to sort out bony pain from soft tissue pain. There are fractures, tendon tears, ligament tears, muscle strains, tendon strains, and every variant in between. In the frantic pace of the ER, sometimes sorting this out is just not possible.

If I can't determine the source of lameness, I generally prescribe an anti-inflammatory for pain, as well as tramadol (Ultram) for pain control. I then recommend the owner cage rest the for X amount of days, then follow up with their veterinarian. After all, as an ER doctor, there isn't much I am going to be able to do unless the leg is broken and needs a splint. I don't do orthopedic surgery.

Tonight, I am relaxing on the couch with my orthopedic notes from vet school (how sad, I know!) and reviewing common orthopedic problems of the dog and cat. I'm then going to brush up on my blood types and the like, as I realized my brain is starting to forget a lot of the things I used to know. I'm not sure if this is "baby brain" or just "old" age.

The importance of a good oral exam cannot be underestimated!

I was recently presented with an interesting case. A woman called us, frantic, screaming that her dog was choking and that she needed directions to our ER. We obliged her, and after getting lost twice, she made it to our door. She handed over a tiny (less than 1 pound!) puppy.

Now, mostly when people call and tell us that their dog is choking - it's not. Usually, it's a severe reverse sneeze or kennel cough or heart failure. It is rarely ever choking. This puppy did appear to be choking, though. She kept stretching her neck out and gagging. Fortunately, her gums were pink, and she did not appear to be suffering severe oxygen deprivation. I examined her briefly - a wiggly, alert, tiny little puppy that fit in one hand. After my exam, I popped her in the oxygen tank and went to talk with her owner.

Ms Smith had obtained the puppy 1 week earlier. In that week, she had noticed no problems when the puppy ate. Tonight, she was in the middle of eating her dinner (dry dog kibble soaked in water) when she began to gag and cough. When it did not subside within a few minutes, her owner became understandably worried. Otherwise, there had been no other problems.

Since this happened in the midst of eating and quite suddenly, choking did seem likely. I looked in puppy's mouth as best I could, but she was squirming, screaming, and gagging. On very cursory exam, I saw no abnormalities. There was not a cleft hard palate, there was nothing at the back of the throat, and the mouth looked normal. We gave a tiny, tiny dose of butorphanol for sedation and xrays, as I was thinking perhaps some kibble had lodged in the trachea. Xrays were normal, however. Nothing in the trachea.

Perplexed, I went back to my tiny patient - who continued to gag and stretch her neck out intermittently. Loathe to do it, I gave her the tiniest dose of Propofol imaginable to knock her out enough to let me look down her throat. It's lucky that I did so, because the answer was there! Although her hard palate was normal, she had a cleft in her soft palate! I had never seen a cleft soft palate without a concurrent hard palate. But sure enough, there was a 3 cm slit in her soft palate, communicating with her sinuses. Every time she breathed, the opening flared open. I realized that she had likely snorted food up into her sinus cavities! We swabbed out the small amount of food back there and swabbed the cleft to ensure that it was not obstructed. I counseled the owner that surgery would likely be necessary, as this would not close on its own.

It was a potent reminder of why a thorough physical exam is absolutely necessary to figure out a health problem! Without the sedated oral exam, I would not have found the reason for the puppy's gagging behavior. Hopefully, his owner will have surgery conducted to fix this defect, and the puppy will live a long, happy life!

Sorry blog readers

I have been a bit flaky lately about the veterinary posts - so much going on in my life that work has taken a back seat. The wonderful news is that my mom DOES NOT have cancer. She was suffering uterine hyperplasia. This was likely what happened with my aunt. She was suffering hyperplasia and it went untreated for years, eventually transforming into malignant cancer. Had my mother waited, this likely would have occurred with her, as well. Luckily, the tissue is out. It's such a huge relief!

Now I have to keep my fingers crossed that my aunt's chemotherapy will go well. She had her first treatment today. She also received the not so great news that due to enlarged lymph nodes in her abdomen, radiation therapy will be needed. Her prognosis is good, from what I understand.

I'll work on some vet posts and get back to you guys ASAP, I promise.

A veterinary post - woohoo!

This weekend wasn't too bad at work. Saturday evening was inexplicably busy, while Sunday night was extremely slow. It's usually the opposite case. Everything I saw Saturday, with the exception of a pancreatitis case, was "treat and street." Minor wounds, laceration repairs, limping dogs, vaccine reactions, and the like. I both like and loathe this kind of night. It's nice not to admit a bunch of critical patients that need very close monitoring, but it's not very lucrative for our business.

We had a happy story this week with a very nasty disease. It doesn't usually have happy endings. On Tuesday, we were transferred a small, sweet Lhasa Apso named Maggie. She had seen her vet that day for lethargy, anorexia, and weakness. She turned out to have immune-mediated hemolytic anemia, a nasty, nasty disease in which the body turns on its own red blood cells and starts destroying them. She was young, she had not ingested any metal products that would cause this, and there was no other obvious underlying cause for her malady. Thus, we treated her as an idiopathic IMHA.

Idiopathic means "idiots don't understand the disease." Not really. It's just a term that means a disease without a clearly understood underlying cause. IMHA is frequently like this. It can be caused by many things - cancer, dogs eating pennies or other zinc containing objects, heartworm disease, and the like, but in most young dogs (especially of certain breeds), the cause is never found. Treatment is major immune suppression. Basically, shut down the bone marrow to stop it from attacking the red blood cells.

Unfortunately, the drugs we have to do this with all have a lag time of 2-5 days before they really start to take effect. Thus, the patient must be maintained and stabilized until the drugs can begin to work. This includes a blood transfusion (sometimes multiple), careful maintenance of hydration, the addition of low-dose aspirin (these patients are VERY susceptible to clot formation/thromboembolic disease), and sometimes oxygen therapy.

I usually give people a 4-8 day hospital stay estimate and a cost of $2000-4000 to treat. Prognosis is decent in the initial time frame IF people can financially go the distance. Unfortunately, the disease can relapse throughout the dog's life and it is likely the patient will stay on some sort of immunosupressant for the rest of its life. It's not a good disease. Many patients are euthanized for financial and quality of life reasons.

Maggie's owners wanted to go the distance. And they did. Maggie needed her first blood transfusion on Thursday, 2 days after diagnosis. She rapidly destroyed that blood as it was given to her, and she required a second transfusion on Friday night. Her condition looked dire. She was weak, extremely lethargic, and her belly, eyes, gums, and ears were all highlighter yellow (the breakdown of the red blood cells releases large amounts of bilirubin into the body, which is a yellow pigment). Her prognosis looked grim.

Still, we persisted. We placed a nasoesophageal feeding tube to start trickle feeding her and supporting her nutritionally (often overlooked in the critical patient!), continued her prednisone, cyclosporine, and aspirin, as well as fluids and gastroprotectants. We held our breath.

On Saturday, she rallied. Her PCV stabilized. Her skin began to look less yellow. She became more alert and licked food when offered. She walked outside and wagged her tail. Sunday, she was bright enough, eating enough, and her yellow color was almost gone. It was remarkable. I haven't seen an IMHA turn around quite that drastically or quite that fast.

Sunday night, she went home to her owners. They were thrilled, as they had confided in me Friday night that they "didn't have much hope for her." I had reassured them that this was a tough disease to control, but when owners were dedicated emotionally and financially, we could usually get remission. I was thrilled to be right - for whatever period of time! Maggie's owner promised to bring her back to visit us sometime soon. He was very grateful for our help and never complained about the expense of the blood transfusions and intensive care she had received. She was a wonderful patient, and he was a wonderful client.

It was a good end to this week. Oh, and we have our first kitten of the spring season. A 4 day old, blind, deaf, rat of a kitten. He sure is adorable...black with a white face, chin, and paws. He's quite scrappy.

Update on my mom

My mother wound up having surgery to remove abnormal, bleeding uterine tissue. She recovered well and has been discharged home. The doctor is concerned that she has endometrial cancer, as he described the tissue as looking "just like" the tissue he removed from my aunt (my mom's sister) during surgery 4 weeks ago. So now we wait for the biopsy results. They are supposed to be available as early as Tuesday or as late as Friday. Hopefully, whatever it is, it was caught in time to be curable with surgery, but we will see.

When it rains

So, my mom called me last night to tell me that she was having chest pains and getting winded walking from room to room. I hoped that it would turn out to be panic attacks as a result of her mother (my grandmother) and her sister (with cancer) - as well as the death of a long-time friend. Unfortunately, she went to the doctor today and was informed that her hemoglobin was 5. FIVE! My aunt that just had 8 units of blood - hers was 4.9. So, my mother is being hospitalized tomorrow morning for multiple transfusions, as well as further testing (I would assume). At this point, the cause of the anemia is unknown. Please keep our family in your thoughts. I'm staying here and working my weekend night shift with plans to go home on Monday morning.

Parrot help

A colleague's close friend recently died, and she left behind all of her pets rather unexpectedly. There are 5 birds that need good homes - 2 African greys, 2 Amazons, and a Pionus. I am waiting to get information - ages, sexes, handleability, and hopefully pictures. If anyone knows of anyone who would be interested, please let me know.

We have a troll amongst us...

Regrettably, I have enabled comment moderation, as a result. Keep commenting! Thanks for the support, I really appreciate you guys :)

Anonymous and negativity

This comment was left on my previous post. I deleted it because I wasn't interested in replying. My husband, however, thinks I should have left it. Since he is generally wise, I am reposting it here.

"Your are just the most negative person on the planet. Nothing good ever happens to you. Each night there's another person doing something to drive you crazy. Lighten up before your kid is born hard wired for stress like you are." (The typos are not mine, this is cut and paste).

I can assure you that's not the way to get stuff done

The other night, I was confronted with a woman in her late 30s/early 40s. Her small dog had been transferred over by the day veterinarian for overnight care. She required oxygen therapy and careful monitoring through the night.

When I stepped into the room to go over the plan for "Daisy's" care, the owner said to me, "now, you will be transporting Daisy back to her vet in the morning?" I regarded her with surprise. "No, ma'am, we won't. It's just me and my overnight technician. He has a 2nd job, and he leaves at 8am. That's not a service we provide." (It's certainly not something I do on a regular basis for stable patients. I have done it before for very ill patients when I was worried about them, but this patient was stable).

The woman went apoplectic with rage. She slammed her keys down on the table and went into a 20 minute tirade about how she has 3 kids, and her husband was out of town. She couldn't possibly be there to pick up her dog before 9am. I carefully explained that we closed at 8am, and there would be no one present to discharge her dog (or even let her in the building). She then threatened me by saying, "I'm just going to have to take her home! I'm not getting my kids up that early!!!"

She continued to rage. In the middle of her tirade, I simply walked out of the room and shut the door. At this point, I am sick of dealing with people. What right did this woman have to a) expect me to act as a personal taxi service so that SHE was not inconvenienced?? and b) what in my 8 years of school taught me that I had to put up with that? So, out I walked.

I called her veterinarian to relay the problem. He graciously offered to come pick the dog up in the morning. Great, I thought, pander to that kind of obnoxious behavior. I sent my technician in to tell the owner the "good" news, as I couldn't bear to talk to her (I was truthfully afraid of what would come out of my mouth). Naturally, the owner turned into sweetness and light, apologizing to my technician for her behavior towards me, saying, "I shouldn't have acted like that, the doctor didn't deserve it."

Want to bet had no one agreed to pick up her dog that she wouldn't have acted so graciously? I didn't see her again before she left, as I purposely hid in the office. My tolerance for BS is so low right now that I'm afraid I would have said something catty and unprofessional. Avoidance is sometimes the best solution.

Lovely email

When I got home last night, I checked my Homeless Parrot email address and was touched to receive a lengthy email from a reader. I'm not going to post it all here, but just bits of it. Honestly, the email could not have come at a better time for me.

"Your blogs about euthanasia are partly what inspired this rambling email--I was reading them last night on a long flight home. That you tell each dog, they are good dogs and they are loved as they slip away comforts me more than you can know...

So this missive is a heartfelt thanks to you for all you do (and in a way, to my vet as well, though I've told him many, many times) and all you put up with and how hard you work. The kindness with which I was treated by my vet during my dog's illness inspires me daily to be a kinder, more compassionate, and patient care-giver to my own patients and their families. You inspire me in this way as well."

Thank you all for your kind comments and your emails. This too shall pass, and I realize that. On the bright side, my OB visit on Friday was lovely. We got to hear the baby's heartbeat again...which is terrifying and awesome at the same time. Pregnancy has been wonderful so far, other than bouts of extreme tiredness. I feel as good as I've felt in my life. I hope it continues in this vein!

I feel repetitive

I think that if I post about how bad today was, ya'll will start to think I'm making all this up. I wish I were. Today, if possible, was worse than yesterday. I'm tired of whining about it. Really. Still, I feel that this day, this special, special day, should be shared.

First and foremost, waking up at 7am to a DARK room is not acceptable. Springing forward has always been my nemesis. It's just wrong. I was so poorly rested this morning that I was actually muzzy...to use a made up word. My thoughts were fuzzy, my eyes burned, and my tongue felt like a lump of lead.

Work started out slow and quiet. The first 2 cases of the day were manageable stuff. Then the proverbial sh*t hit the fan. And I mean HIT THE FAN. All at once, there were 4 groups of people in the lobby with 4 different animals. A woman wandered in off the street with a kitten crying in her hands. It went like this.

The kitten was brought back to me. Now, we all know what a sucker I am for a kitten. This little girl was about 3 weeks old. She weighed about a 1/2 pound. She was struggling mightily to breathe. The woman who brought her in "found" her in the parking lot. All Good Sams are required to fill out a brief bit of paperwork telling us where they found their animal, their personal information (so we can contact them if we have questions), and a signature. It's also a way for us to keep up with people who take to dumping animals on us. Well, this lady who "found" the kitten had been in our clinic a year earlier, also with a kitten that was in dire condition. She'd had no money at the time, so we'd euthanized it for free. The kitten she "found" that day reeked in a particular way that is only associated with catteries. So did the woman. Further, the kitten had milk around its mouth and chin, so someone had been bottle feeding it. I knew it was her kitten, and she was dumping it on us. I made a note in the computer and turned to examine the little grey kitten. She was so cute and sweet, rolling over to expose her soft belly when you stroked her with a finger.

She couldn't breathe and was struggling desperately. I decided to take the kitten on as a personal Good Sam, but I was super concerned about the breathing and suspected something very malignant. I xrayed her chest and my suspicion was confirmed - a megaesophagus was present. She had severe aspiration pneumonia. Her xrays were consistent with a condition called persistent right aortic arch. I've seen this once before in a kitten. Short of surgery, there is no cure - and the pet ultimately starves to death (or chokes to death). For whatever reason, I didn't accept it immediately, fed her some liquified baby food (which she frantically ate out of my hand), then put her in the oxygen cage while I turned to other matters. She slept peacefully.

Meanwhile, our exam rooms filled up. I stepped into room 1 and was confronted with a dog I had seen 5 days ago for a "pregnancy check." The owners knew nothing about normal dog whelping, had bred her accidentally, and were concerned. When they brought her in, she was doing fine, was not in labor, and had 6 healthy, live puppies on ultrasound. I told them to take her home and wait till she gave birth in a couple of days. Friday, she'd had 5 puppies fairly painlessly. Then she stopped. It was now 36 hours later, and the final puppy had not been born. Now, she was feverish (104), her heart rate was high, her abdomen was distended with gas, and she was vomiting. Her owners had $100 to fix her. Sighing, I left them with a CareCredit application and moved to Room 2.

Room 2 contained a Labrador retriever that had escaped from his kennel. He'd been gone for 3 days. When he came back, his front paw was devastatingly mangled. From the wrist down, the paw dangled, five times the normal size. It appeared to have been caught in a trap of some kind and completely, utterly destroyed. Now, it was rotting. Worse, the dog was lying on the floor - licking it and pulling strips of skin off with his TEETH. I nearly vomited at the sight. They had $150 to spend on his care. Leaving them with a CareCredit application, I moved to Room 3.

There I faced a nice Boxer dog with a fluid distended abdomen. He'd been diagnosed with a "heart problem" 1 year ago. The owner knew nothing about it. No treatment had ever been done. Today, he'd been lethargic, exhausted, and could not get up. His abdomen had also become tight and distended. I explained to the owner he was in right heart failure and discussed his options. The owner requested euthanasia. As we discussed, I was summoned urgently back to the ICU by my technician.

There I was confronted with a Shih-Tzu whose eye was dangling partway out of his head - the victim of a dog bite to the head. His owners had brought no cash or other way to pay for his care - but they wanted his eye removed (as it needed to be).

There I stood in the ICU dealing with a 1) septic dog with a dead puppy inside her 2) a dog in right-sided heart failure 3) a dog with a rotting paw that needed an amputation 4) a Shih-Tzu with a bloody, tramautized eye hanging out of its head and 5) tiny kitten depending on my decision whether to end or continue her life. Between all the owners, there was probably $300 to spend on these problems.

I wanted to go hide in the back and shriek until I was hoarse. Either that or cry hysterically. In situations like this, I will admit that I'll sometimes have a cigarette to calm me. I'm not a smoker, but occasionally - the stress requires that I do SOMETHING...ANYTHING...to alleviate the stress. Obviously, I'm pregnant - so even that respite wasn't an option.

So, I just sucked it up and we got 'er done. The proptosed eye dog's people came up with $700 (the estimate was $800-1000). I made it work for that amount of money because I couldn't bear not to. I was able to crush the dead puppy's skull in utero and help the Dachshund pass the puppy. She was septic still, and the owners were able to contact some family members and come up with money to hospitalize her. The Boxer's owner chose euthanasia. The rotting paw dog's owner also picked euthanasia.

At the end, I sat with the tiny grey kitten on my lap and fed her a touch of liquefied food again. This time, she choked terribly on it - gagging helplessly, as the food refused to pass down into her stomach. She was starving but unable to eat. This last episode of choking made the decision "easier" - although I still cried the whole time I did it. It was a combination of exhaustion, stress, and sorrow for my inability to help. In the end today, both of my patients in the hospital (the proptosed eye and the septic post-partum dog) are "discount" treatments - meaning I am doing treatment much cheaper than normal and without my usual diagnostic testing. I couldn't bear to euthanize them in the face of the past few days I've had. The pragmatic side of me just has to let that go for now.

By the time I made it home, I was nearly comatose. Thank God for my husband. He fixed me spaghetti, salad, and garlic bread for dinner. Then he sat on the couch and kept me company while I watched Chopped AllStars on the Food Network. I think I'll go to bed now and hope that someday soon, this curse on me will pass and that owners will again be able to care for their pets.

Bleh.

Today was no better, unfortunately. My colleague had a rocking night - including a gunshot wound dog, a GDV, and a nasty laceration repair. She reports that everyone was courteous, patient with the wait, and did what she recommended. She took the GDV to surgery, fixed the gunshot wound, and sewed up the laceration. My day, on the other hand, was "no, I can´t afford the $92 to see the veterinarian. WHAT, you don't LOVE animals? You're going to let Fluffy suffer??" and, "We can't afford that, we're going to have to put him down." Mix in the usual old, sick animal euthanasias...and it was the third day in a row that has been a downer.

It comes in waves like this for each of us. Sometimes we individually just have very bad times. Times where we don't communicate well with owners, times where no one listens to our recommendations, times when we want to quit what we're doing and go flip burgers.

I know it will pass, but it's demoralizing in the short term.

Double dud

Having just read about the earthquake and tsunami in Japan, my complaints seem relatively minor. Still, I plan on airing them despite their unimportance.

The last 2 nights have sucked. I don't know if it's the gas prices, the economy, or just people in general, but I have euthanized or discharged so many ill/injured animals in 2 days. No one has any money, and no one wants to do anything for their pets. Even the people that I *mistakenly* assumed had money did not. A woman threw an absolute fit at our check-out last night. Why? I didn't get approval for an additional $40 to reverse her cat's sedation and to place a bandage on its foot. And when I say fit, I mean fit. The woman was discombobulated with rage. My poor receptionist ran back to get me. Normally, I don't deal with that stuff. It's not my job. My receptionist was so cowed however, that I betook myself to the front desk.

The cat had come in for a gash on its foot. It was very painful, and in an awkward position, so I thought it best all around for some light sedation with Domitor and butorphanol for an exam to see what would be necessary. I couldn't tell if this was a glue, suture, or benign neglect situation. My technician went over the estimate. On the estimate was ONLY sedation, wound care, and wound repair. My tech clearly told her that it would be an additional amount of money for any sutures.

Once the wound was cleaned, I was relieved to see that it would probably respond well to a silver nitrate stick to cauterize it and a bandage to protect it. It took 5 minutes. We reversed the cat's sedation, and they were in/out of the ER in 45 minutes. Except, she got to the register and refused to pay.

I politely explained to her that I did not foresee it being a problem, that I reversed sedation so that they didn't have to wait an hour for the cat to wake up, and that I did what I thought they wanted me to do (namely - TREATED THE CAT!). She was LIVID and kept yelling me. At one point, she asked me why I sedated the cat, and why I couldn't have just held it down! I wanted to offer to shove a silver nitrate cauterizing stick in a wound on her body and see how well we could hold her down, but I kept my voice low and assured her that I did what was best for her cat. She then went off on a different tangent and accused ME of not faxing her cat's records last time we saw him. I explained that I had nothing to do with that, but we would certainly be faxing the records. She sullenly said, "You said that last time." Believe me, I was gnawing on the inside of my cheek in desperate effort not to say anything rude to this client.

She paid her bill finally and left. The rest of the night was no better. I saw a proptosed eye that needed to be removed. $180 to their name. Sent home with e-collar, eye meds, pain meds. I euthanized FOUR animals. I was berated on the phone for spending too much of a client's money on treating a diabetic ketoacidosis patient - one of the most expensive and difficult to treat diseases- BY THE VETERINARIAN WHO SENT THE DOG TO US AND WHO IS A REFERRING SHAREHOLDER. (Oh, and he's trying to treat the DKA on a "budget.")The night before, I dealt with a couple of women who adopted THREE puppies at one time, dewormed and vaccinated themselves, and had no money to help their vomiting, likely parvo positive puppy.

I'm over people lately. I empathize that gas prices are high and that pet care costs a lot of money. That doesn't change the fact that I still have to make a living to support my future baby, as well as help the clinic keep the lights on and the doors open. We're an ER. It's expensive. It sucks, but that's the way it is.

The only bright spot in the last 2 days is the fantastic news I got yesterday. The oldest of my younger brothers (1 year younger than me), his wife, and my niece are moving here to our town. She is pregnant with their second child, and she's due around a month after me. There is no describing how thrilled I am that they are going to live here! One of my few sources of unhappiness has been the lack of family near me, and now I can see my niece, and she can grow up with her cousins. It made my month.

How to find a job (maybe)

So, I had a request to do a post on how to select your first job out of veterinary school. It sounded like a breeze. After all - I have a great job. Then I sat down to write it, got incredibly long-winded, and realized I hadn't given that much good advice.

I'm going to post what I wrote, but I'm thinking this might not be my best post ever. Feel free to email or post specific questions, perhaps I'll be better at answering those. I'm happy to do this with the caveat that I am not an expert. True, I am extremely happy with where I wound up, but some of that might be attributable to luck. Who knows? With that said, this is my attempt to guide my fellow vet students into a job that is fulfilling. It is not an easy path, not everyone looks for the same attributes in a job, and these answers might not be right for everyone.

The most important thing for me was identifying exactly WHAT I needed in a practice to be happy. There are some things that are negotiable, and there are some things that are not. What matters most to you? Good medicine? Excellent support staff? Excellent pay? Good benefits? Long stretches of time off? Vacation time? High volume, low cost? Predominantly preventative health-oriented? Predominantly sick patients? ER v. GP?

Figuring those things out early on is crucial. I knew immediately upon graduating that finding a practice where I could do excellent medicine was the most important thing for me. Mentoring was not as important to me, as I'd been through a grueling internship and felt ready to start out as an ER veterinarian. I knew that going to a place that prescribes steroids and antibiotics without doing any diagnostics was not an acceptable compromise for me. Thus, I looked for practices with access to top-notch diagnostics (ultrasound, digital xray, full in-house bloodwork) and readily available and current therapies. Not necessarily because good practice isn't possible without these things, but because (to me), the presence of these diagnostics and treatment modalities indicates a willingness to stay current. As a result, I felt I could do the kind of medicine that I'd learned.

KNOW what kind of veterinarian you want to be. Figure out what things you can compromise on and what you cannot. Do you need an IV catheter for your spays and neuters? Do you want BP and SPO2 monitoring on all surgeries? Are multi-modal pain protocols important to you? Are you more laid-back and prefer to practice less invasive medicine - no catheters for neuters/spays? Less aggressive diagnostics and treatment? Find a practice that fits with YOUR take on veterinary medicine. Compatibility with your fellow doctors and their practicing methods is absolutely 100% vital. Every single friend of mine that currently is miserable in their job is miserable for one of 2 reasons: incompatibility with how medicine in that practice is done or financial compensation (which I discuss later).

Decide what kind of pace you can handle, and look for a practice that fits you. If you feel like 15 minute appointments are within your ability to handle, look for a high volume, fast-paced job. If you need mentoring, longer appointments, and more time to think, look for a practice that is interested in fostering a new graduate. The problem with this is that some places will say that they want to mentor a new graduate when really, they run a new grad mill. That leads directly to my next recommendation: the working interview.

A working interview for several days to a week is an absolute must. I would recommend doing it for more than 2 shifts. Everybody can be on their best behavior for 1 or 2 days. If you work in a practice for a week, the warts will show eventually. Red flags for me are running out of important inventory when it is needed, in-fighting and gossiping behavior between technicians, receptionists, and other veterinarians that is tolerated by management, a lack of camaraderie between veterinarians, and complaining clients. Appointments that are consistently too closely spaced, veterinarians that do not get lunch breaks due to overwhelming stress and responsibilities, and unhappy technicians are also signs that a practice is not a healthy environment.

Knowing turn-over and the whereabouts of previous veterinarians can be a good indicator of a work environment as well. If a place has a high veterinarian turn-over, that is usually an indication that there are problems. A good friend of mine works in a practice that has lost 5 vets in 5 years. She is miserable and now understands why the other veterinarians left. If you can talk to previous veterinarians, that's even better! They can tell you the good, the bad, and the ugly. Just because they don't work there anymore doesn't mean it's a bad job. Some people move on for family reasons, changing life circumstances, better salaries, retirement, and any other number of reasons. Contact previous veterinarians if possible and get the details on a practice.

Finding a salary with which you are happy is crucial, as well. We all know that leaving veterinary school, the majority of us have an enormous debt load. It just goes with the territory. Salaries can vary wildly. From the $40,000 range to upwards of $120,000/year, it is all possible for the new graduate. Pay is not everything - but it IS important. I personally derive a great deal of personal satisfaction from my earning power. On the converse, I have a friend who is brilliant, internship trained, and absolutely miserable that she only makes $65,000 annually. She took the job for reasons of family, husband-to-be, and location, but the fact that she is so under-valued in a practice that she basically runs really eats at her.

Other things a good practice should offer: membership to the state VMA, the AVMA, VIN, health insurance, licensing fees, some sort of savings plan/IRA/401K, a discount on pet care, annual CE (ranging from $1000-4000+/year), and a clear policy on maternity leave (whether paid/unpaid, time period, health insurance coverage during that period, etc).

Those are all good guidelines and served me well. There are however 2 really important things to remember.

First, give it time. No job is perfect initially. It can take a while to fit in and feel comfortable. It took me at least a year to really settle into this job and feel like part of the team, but it was worth the initial rough patch.

Secondly, and perhaps more important, give yourself permission to leave if the job isn't a good fit. I've had so many friends hate their first jobs, but they feel tied to them, obligated to their employers. Or they feel bad that they want to leave their first job, as it must constitute some failure on their part.

Dispense with this thinking. If a job isn't a good fit, you've done what you can to make it work, and you're not happy - move on. There are veterinary jobs all over the place. Going to school for 8 years, spending $100,000+ for that education, and sacrificing personal health and happiness for a DVM means that you should do what makes you happy. There is no martyrdom for staying in a job that you hate! I promised myself long ago that if I was ever truly miserable in a job and couldn't make it work, I was free to leave and do something else. Life is too short to be unhappy.

If you have specific questions about contract negotiation or a job - feel free to comment or email me at homelessparrot@hotmail.com. I'll be happy to try and help.

Really?

A few weeks ago, 2 of our phone lines rang simultaneously. The receptionist answered one, and my technician grabbed the other. I was sitting between them, and it was like listening to a conversation in stereo.

My receptionist, "no, we don't take payment plans. That is our policy. You can try to apply for CareCredit. Yes, that does sound very serious, and it sounds like your pet is in critical condition..."

On the other side of me, my technician was having the almost exact same conversation, "no, ma'am, we did not arrange payments with your cousin on Monday. No, ma'am, we do not take payments. If you would like to, I can give you the number for CareCredit, so you can apply. Yes, it sounds like your pet needs medical care ASAP..."

Over the next several hours, these people called back multiple times. They were describing a laterally recumbent, vomiting, incredibly lethargic female dog. They insisted they had not a single cent to their names. Finally, I told my receptionist to relay to the owners that they could bring the dog in, if her condition was extremely critical, I would euthanize her without charging them. They had to understand that they would not see or talk to me, but I would examine their dog and make a decision.

A few hours later, FIVE adults showed up with a very, very sick female dog that had never been spayed. She could not stand, her temperature was 105+, and she was having excruciating abdominal pain. Her condition was extremely critical. I gave her a large dose of fentanyl IV for her pain, then told my technician to relay that I would euthanize the dog, as she was dying in front of me and would shortly die without intervention. I then stood around the corner from the front desk and heard this,

"Well, can't the doctor give her a shot to make her better?" (If only!)
"Can't you take a post-dated check? None of us get paid till Friday."
"Is she really that sick? Can she make it to go to our veterinarian in the morning?" (The dog had never had any vaccines, intact, was not on HW prevention, and they had listed no referring veterinarian on their intake form.)

Between five adults, not a single one had the $92 it would have taken to pay me to come in and talk to them about their dog's condition? I could have been kind and gone out there to talk to him, but listening to these FIVE -- FIVE!!! -- adults go on and on about their lack of money, I got madder and madder. All of them had cellphones, yet no one could come up with $92 to talk to me.

In this case, I truly believe it was a matter of priority versus reality. They didn't WANT to pay for my expertise. They wanted to bully the receptionist until she caved in and summoned me - that was obvious. In the end, they finally left. I euthanized the poor dog, bringing to a close another frustrating situation. At least I was able to relieve the poor patient's suffering, which is some small measure of victory.

Update

Thanks all for your thoughts and encouragement. My grandmother is home. Her speech is improving, but we still have no answers. I tried to get her appointment with her PCP scheduled for today so that I could go with her and act as her medical advocate. Unfortunately, they couldn't get her in until tomorrow at 3:45pm, and our flight leaves at 1:30pm. It's unbelievably frustrating. I wish I could stay here for a bit longer, but I have to be at work Wednesday night (at which point I promise to return you to your regularly scheduled programming).

MDs versus DVMs

Having spent the last 2.5 days watching my grandmother's ordeal in the hospital, I have come to really ... dislike? ... our health system. It is inefficient and disorganized, to say the least. This is not an indictment of public health care versus private or that sort of thing. I am grateful that we have such good medical care in this country, but really, I found this disturbing.

My grandmother had a carotid ultrasound to rule out severe atherosclerosis/carotid stenosis contributing to her condition. She then underwent an echocardiogram to determine if any emboli foci were located in her heart. She also underwent a CT scan, supposedly with contrast - I assume to determine if a mass was present in her brain. She could not have an MRI due to her pacemaker.

In her 2.5 days hospitalized, she saw the hospitalist twice. None of the doctors who "read" her ultrasound and echocardiogram discussed the results with her. No diagnosis was determined. She was discharged with the vague determination that it might have been a TIA (transient ischemic attack), but that it could also be a mass in her brain. There was also the intimation that her blood pressure was poorly controlled and that this might have caused the "incident." As a result, she was put on a new, additional diuretic, as well as Crestor. No real explanation, no discussion of life-style modification (diet, stress, etc). Not a single doctor saw her the length of her Friday stay, only nurses and medical assistants. No one came around to answer her questions.

Further, she came home with all of her medical test results - the results of the carotid ultrasound, the results of her echocardiogram, CT scan, and her blood work. The echocardiogram report had not a SINGLE measurement listed. It had all of the parameters that were supposedly measured, but where her results were supposed to be, only an /E/ showed up. My mother theorized that it meant everything was normal. However, on reading the results and conclusions, she did have some abnormalities that would have led to abnormal measurements. Yet, nothing was recorded there.

Even worse, the conclusions and findings stated that the echocardiogram was of limited and mediocre quality - making interpreting it difficult! Seriously? It wasn't even done well, yet her insurance paid for it.

Then, I read the CT scan report. My grandmother was given IV contrast for a contrast study. She explained it to me when I went to the ER. She was lucid, but having difficulty speaking. I confirmed with my grandfather that they had indeed administered a contrast agent prior to CT. Yet, when I read the CT report, it was titled: "CT scan without contrast." The conclusions also stated that no contrast was administered.

I was horrified at the ineptitude and callousness indicated by this combination of things. Tests were run, no results were explained, some of them were recorded incorrectly (and the CT possibly interpreted incorrectly), my grandmother has no idea what happened to her, and we have no idea of prognosis or what to expect.

If I, as a veterinarian, provided this kind of service to my clients, you'd better believe that I would hear about it. Clients are often belligerent if they wait ONE HOUR for test results, let alone 2 days, and no answers. I would feel I failed my clients if I treated them in such a fashion. Sure, there are plenty of times when I don't have the answers, but I tell clients that - and I tell them of the ways (and refer them) we can find out.

With my grandmother, we have many questions, but no answers. Two months ago, she had an episode where she lost the feeling in her foot. She was dragging it and unable to manipulate it. She was seen at a different hospital and underwent a slew of testing, all finding nothing wrong.

And yet, something is wrong. The loss of the ability to use her foot (now returned), and her current aphasia, indicate a medical problem that is still present and needs to be addressed! Shuffled between her PCP, the ER, and the intermediary ward, she is being passed from hand-to-hand, and no one is really looking out for her overall health. Doctors are so specialized these days that they can't seem to step out of their boxes and look at a patient's total health. I am beyond frustrated and feel like my hands are tied. What can I do to advocate for my grandmother from 650+ miles away??

Meanwhile, I am extremely worried about her. Her speech is improving daily, and she was able to do a crossword puzzle, Sudoku, and a complicated word puzzle with me tonight, but as I watched her write, it was obvious her brain was still mixing up letters. She knew the word exonerate and stated it clearly, but then she struggled to write it. There is something occurring, and I am powerless to help!

Still no diagnosis, but my grandmother is due to come home tomorrow. Her speech has improved some - she can finish a sentence now, but she is still having trouble. We spent a few hours at the hospital today with her while she slept. I'm happy that she is coming home, but I am worried about her recovery.

Otherwise, it's been nice seeing my aunts and uncles. I am grateful that we have such a close-knit family. There is always someone at the hospital with my grandmother, and a great network of family all around us. I'm really lucky that way.

Bad week

So, we're here for a funeral, obviously. We flew down late last night, and my grandparents picked us up at the airport late (our flight was scheduled to come in at 12:15, but was delayed until 12:45am). We didn't get back to Lakeland until 2am. Neither myself nor my husband could sleep, and we were up until around 5:30am. At 9:30am, my grandfather woke us up, informed us that my grandmother had lost her ability to speak, and was on her way to the ER via ambulance (we heard none of this going on, mind you).

Today, we've spent part of the day with my grandmother in the hospital, part napping. The current consensus is that she had a transient ischemic accident (TIA) - or a "mini-stroke." I think an MRI would be helpful in diagnosing this, but she has a pacemaker, so it's not possible.

Right now, she is suffering aphasia - she knows the word she wants to say, but she can't actually get it out. When we first got to the ER, I had to fight back tears. My grandmother is a retired English teacher and always articulate. She has never really been ill in all the time that I can remember. Seeing her struggle so was extremely upsetting. Her condition is stable, but she is still struggling to talk. My grandfather is spending the night with her, and we'll take shifts tomorrow. She doesn't like being alone because she's having trouble communicating with people, and it's very stressful for her.

On top of that, my aunt was recently diagnosed with uterine cancer with ovarian metastases and has to start chemotherapy.

Our family is having a hard time lately, please keep us in your thoughts - we need them!

Parvovirus

I thought this might be an interesting post for ya'll (and an easy "cheat" for me, since I see it at minimum once a week).

Parvovirus first showed its ugly face in the late 60s. At that time, it was an unknown disease. It was incredibly deadly and killed most pets that contracted it. Eventually, its secrets were unlocked, and we began to understand parvovirus. A vaccine was developed against it, immunities were passed from mother to offspring, and the disease became less deadly.

We still see it extremely frequently here. It's a combination of living in a warm, temperate area and the fact that we live in a poor area in the South. Parvo lives in the soil for years and years, and it can be transmitted on the soles of your shoes, hands, or other fomites. Infected dogs shed it in their feces. Parvo incubates for about 3-7 days.

Many people here do not vaccinate their pets, often for financial reasons. Either that, or they administer the vaccines themselves often procured from Tractor Supply. There is nothing inherently wrong with the vaccines from Tractor Supply; they are legitimate vaccines. On the other hand, in the process of shipping, it is likely that they become over-warmed and inactivated. On top of that, I've had owners inform me that they "vaccinated the dog with the liquid - but what was that powder for??"

It is a crafty little virus. It attacks the gastrointestinal tract - wiping out the cells that are crucial for absorbing nutrients and water, as well as crucial for protecting your bloodstream from all the nasty bacteria that live in your intestines. With those cells gone, diarrhea, vomiting, and rapid dehydration rapidly set in. Worse, bacteria translocate across the thin GI wall and straight into the bloodstream. Sepsis rapidly sets in. And parvovirus isn't even done yet. It also attacks the bone marrow cells. Bone marrow makes all the white blood cells that fight off infection. So, when under attack, the white blood cells are not produced. Thus, nothing to fight infection with.

As a result, patients rapidly sicken. Puppies with parvovirus are often feverish, extremely lethargic, very dehydrated, with copious vomiting and very bloody diarrhea. The presentation is very classic, and we can usually make the diagnosis without testing (although we do test to confirm the diagnosis and distinguish it from others such as severe GI parasitism, etc).

Treatment is aimed at managing the sepsis that occurs due to bacterial translocation and neutropenia. Broad-spectrum antibiotics are crucial, as are very aggressive IV fluids to replace the losses through vomiting and diarrhea. Pain relief is also important, as these puppies are often very uncomfortable due to the GI inflammation and diarrhea. Further, the vomiting must be controlled to help prevent worsening dehydration, as well as to help the patient feel better. Unfortunately, the cost of this aggressive treatment usually runs at least $700-1000 for the first 24 hours, then $250-400/day. Couple that with the fact that most of these people didn't vaccinate for financial reasons in the first place, and I do a fair amount of parvovirus euthanasias.

We do offer outpatient therapy to the more stable patients - subcutaneous fluids, anti-emetics, and oral antibiotics to go home. Some patients pull through this way, but the odds are about 50/50.

It can take as little as 48 hours for a patient to turn around with treatment, or as long as a week or more. Yet, we manage to save about 80-90% of these puppies. Some still die - particularly Rottweiler, pit bull, and German shepherd puppies. For some reason, these puppies have a weaker immune system.

The bright side to all of this is that parvovirus is SO EXTREMELY preventable. Puppy vaccines starting at 6 weeks and continuing until 12-16 weeks, followed by a vaccine at a year, then every 3 years will virtually insure that your pet never contracts this disease. So simple to prevent, and yet I see repeat offenders at least once a month at work. No matter what you do, sometimes you cannot get through to people.

Oh well, whatever pays the bills, right??

RE: Curious Cat and perioperative antibiotics

A question was posed by a reader a while back on the post "The antibiotic war". If you will go back, I have added some comments to address your question, Curious Cat.