Health

The midwife at the end of life

Like many of you, I’ve been mesmerized by the bravery of Brittany Maynard, a 29 year old woman who is dying of Stage IV brain cancer. After hearing the course of the disease progression from her doctors and considering what the end of her days were likely to be like, she made the incredibly difficult decision to move to Oregon, one of a handful of states in which assisted suicide is legal, and choose the day and manner in which she will die.

brittany

 

While her story is compelling and awful, it is not so surprising a concept. For veterinarians, taking part in these sorts of heavy decisions is an everyday occurrence, and to the Maynard family I say: I am so glad you have the ability to make that choice.

As I travel to Indianapolis for the annual meeting of the International Association of Animal Hospice and Palliative Care (the mouthful acronym of IAAHPC), I find myself struck by the two most common things clients say to me when I come to their home to euthanize a sick pet:

  1. This must be so hard.
  2. I wish we had this for people.

Though we all wish for ourselves, and our pets, to die peacefully and unaware in our sleep, the truth is, that doesn’t always happen. Sometimes death is peaceful, but sometimes it is horrible and painful and agonizing and drawn-out. To say that is a fate worse than death is not a metaphor in this case. Death can be a relief. We don’t always get to choose the way in which we die, but when we know it is coming and it is going to be unpleasant, I am very grateful this is an option we have for our pets, and for some people.

I suppose in many ways veterinarians are leading the charge in normalizing people’s attitudes about this possibility, right in there with hospice workers and other professionals who deal with these realities. None of us probably gave that much thought when we signed the dotted line on vet school admission forms, but it’s there nonetheless.

There is a small but important distinction I wish more people made when talking about Brittany’s situation: they say, “She is choosing to die.”

This is not true. She wants very much to live. She has no choice in the matter. She is dying.

The accurate statement is, “She is choosing how to die,” and that is a vital distinction. I’ve seen differing views on this, people who genuinely believe that there is beauty in every moment of life, even in suffering an agonizing death with a ravaged body, and to that I simply say: I respect your view on it and your right to choose that end. I also respect those who choose as Brittany is doing, and I find beauty in that as well.

There are limits, of course. I do not show up at people’s homes and simply provide euthanasia on demand for pets who do not have a terminal disease. For my own emotional well-being I have very specific requirements and lines I do not cross. There are situations (such as a dangerously aggressive pet) where the lines about what is ethically acceptable are fuzzy, but my personal limits are not. I feel very proud and honored to be able to do what I do.

This is how I continue to do this every day: by reminding myself and the grieving owners that we are not killing a pet; the disease is killing him or her. We are simply aiding the process and making it more comfortable. I wish for the Maynards the same I do for my patients: comfort, peace, as much as can be gathered in a stressful situation.

I am the midwife at the end of life.

And I am OK with that.

Filed: Blog, Daily Life, Euthanasia/Hospice, Featured Posts, Health Tagged: , ,

Knuckle cracking real-time talk here.

This is not about Sophia Yin.

I feel the need to say that before launching into a discussion about suicide and depression in the animal community, because the horrible news that she took her own life and the ripples it is causing in the veterinary world is the reason I’m talking about it today. But it’s not about her or her situation, which none of us will ever really know; Dr. Yin’s legacy is the work she did during her life, and it should remain that way. This is not about one person.

Whenever a tragedy like this happens, I see the same posts over and over: “Shocking. Tragic. Hold your loved ones close and tell them you love them. If someone seems to be suffering ask if they are OK.” And so it goes for a day or two, as we hug our kids and our spouse and our dog and then go back to work and assiduously ignore the suffering of those around us. Not that we recognize it most of the time anyway, but I’ll get to that in a moment.

One of the biggest misconceptions people seem to have about stress, burnout, and depression is that it is inevitably obvious to those around the person. I blame Zoloft ads for making us think all depressed people walk around weeping with little clouds hanging over them.

YouTube Preview Image

I think a lot of depressed people look like this:

positive-people

Totally fine, I’m fine, I’m fine.

You know how we always say cats walk around looking like a million bucks with BUN levels through the roof until one day, way past the point it was an issue, it’s finally too much but you never had a clue? A lot of depressed people look like that. So maybe this is a little more accurate:

flesh-wound

They do just fine at work, and out amongst friends, and then come home and realize man I am not fine. But we’ve normalized stress in our lives to the point many of us don’t even necessarily recognize the signs of depression in others, and even in ourselves. I sat on the floor of the bathroom for four hours straight one day, when I was suffering from postpartum depression, and still had no idea that sitting on the floor of the bathroom unable to muster the energy to move two feet might be a sign something was wrong (protip: it is).

I don’t like talking about that time in my life, but I will because every time we censor ourselves from discussing these things we perpetuate the stigma that drives people away from seeking treatment. We are more scared of the consequences of admitting depression than we are the consequences of not being treated, and oh my god, how awful is that? I’m pretty sure the mental health professional community has been watching us in horror for years, waiting for us as a profession to finally say yeah, we could probably use some assists here.

So while asking someone if they are ok and offering virtual hugs is lovely and kind, I really think the time has come to try and do something a little more impactful. Open dialogue is a good place to start. So let me share some things that I have discovered over time, watching us wring our hands in despair over and over while we wonder what we could have done differently:

1. You would not believe how many other people out there are going through the same thing.

People at the top of their field, with lovely families and good jobs and beautiful dogs. People who seem to have it all together. And maybe they do, if they have good treatment.

2. I wish someone had told me about these things in vet school.

I thought I was the only person plagued by worry and self-doubt in school. In retrospect, ha! That was really not the case. Nonetheless, a little peer-to-peer support or support from people already out there would have been very reassuring. I believe we need to start letting people know at the start of their career, not at the middle or end, that stress/anxiety/depression/burnout are common, but solvable problems.

3. There’s support, although it’s hard to find.

Do you know what the hardest part was for me about getting through my depression? Figuring out who to call. My OB didn’t help, the psychiatrists she gave me the numbers for didn’t take on new cases, I wasn’t actively suicidal, and by the fourth call I was too tired to deal with it any more. So I laid on the bathroom floor for a few more days until I had the lightbulb idea to call my primary care physician, who was horrified and got me in that afternoon and life got a lot better after that.

I feel like our profession is still in the same place. Help should be very visible and easy to access, a rope already floating in the water instead of a life preserver someone has to yell for when they are drowning. Want to really do something to make our profession better? Help me figure out how to make that happen.

So you think you’re depressed/ burned out/ feeling off? Take a deep breath, you are in good company. You do not stop being a successful professional and accomplished person. Life can be good and you can still rock out and kick ass and laugh till your cheeks hurt. Here’s some places to start:

1. There is active peer support, through VIN, and on Facebook. A closed group has been started on Facebook for people dealing with these issues as well as their family and friends- to request membership, click here. Peer support is fundamental, though of course it is not a substitute for-

2. Calling your primary care physician, who if they cannot handle it themselves can at least get you where you need to go. I guarantee you every mental health professional out there is going “uh, of course,” at every thing I have said because they are experienced in these things, while we are not.

3. Stop googling. Seriously, all you will do is come out blaming yourself for not juicing enough and while it is a lovely way to get vitamins, it’s probably not going to be enough. Talk to a pro, just like we tell people to stop treating their dog’s ear infections with diluted alcohol that they read about on a yahoo group and go to the vet. Right?

4. VetGirl has offered their excellent webinar about suicide awareness available for free, for everyone. It is well worth the watch not for anyone who works in the field to help increase your understanding of the issue. You can find it here.

5. VIN is offering a webinar this Sunday at 9 pm PST to honor Dr. Yin and discuss “Dealing With You and Your Colleagues’ Stress and Depression.” My understanding is that this webinar will be made available to non-VIN members as well, so stay tuned as I get more information. Both webinars, by the way, are taught by mental health professionals who know their stuff.

I will be honest and admit I hate overly sentimental statements accompanied by soft-focus ocean pictures like “fall into my arms and I will catch you” and “the world is full of hugs if you just ask for them” and all that other stuff, so I will offer you my own personal unfiltered thoughts on this:

Depression sucks, and it’s real, a physiological crap storm of neurotransmitters, and if you are reading this experiencing a dawning sense of dread with unasked-for tears rolling down your face as you desperately say nonononononono I’m fine, you might not be. So call someone who can help so you can stop feeling miserable, ok? Do it today.

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OK maybe one overly sentimental picture. But just one, and only because kittens. And with that, I demand some good news so we can get back to our regularly scheduled program of fur removal device discussions and derpy dog pics.

Filed: Be The Change, Blog, Daily Life, Featured Posts, Health, Musings Tagged: , ,

Pet insurance- the good, the bad, the somewhere in between

I admit I am biased about pet insurance. I like it, mostly. Clients who had it were, in my experience, much more likely to approve necessary treatments. That dog with a case of happy tail who wagged it so hard and so fast he got a nasty deep infection that ended up necessitating a partial tail amputation? Insured. Hit by car? Insured. From my perspective, it allowed owners to focus on the pet’s immediate needs and get them taken care of.

I also liked it because I didn’t have to do anything to get it taken care of, other than fill out a brief form.  The owners paid me upfront, and were reimbursed by their company after the fact. If the owner and the insurer had a disagreement about what should or should not be covered, it wasn’t something I had to get involved in. It was nothing like human medicine. The summer before I started veterinary school, I actually worked the front desk in an internal medicine MD practice and good lord, those staffers spent probably 33% of the day dealing with insurance issues.

Source: Trupanion.com

Source: Trupanion.com

Just a few years ago, I could list three pet insurance companies, tops. Now there’s almost too many to count, with good policies and bad policies and fine print a mile long and exclusions even longer, especially if you have a bulldog in which case you might as well just get a second job.

Some pay a flat percentage of your bill. Others use benefit schedules, and specify exactly what amount they will pay per procedure. Most reimburse you, but I know of at least one that is rolling out a program that will pay veterinarians directly. Some cover preventive care. Some cover accidents. Some cover breed related illnesses, and others don’t. Tooth extractions? May or may not be a pre-existing condition. WHO KNOWS.

It’s gotten so confusing, even for me, that when people ask me what I think all I can say is, “Yes, go for it, but with caution.” Caveat emptor. But even then, even knowing all there is to know and asking all there is to ask, I’m hearing more and more people tell me they just spent five hours on the phone with an insurance rep trying to figure out how a newly diagnosed endocrine condition counts as “pre-existing.”

If this sounds familiar, that’s because that’s what all of us have done with our health insurers at least once, right? It’s confusing, and getting even more so the more players that enter the field. All companies are not created equal. I think most people completely understand the need for exclusions and limits, but for goodness sake let people know when they sign up what, exactly, they are signing up for.

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While lawmakers in California had hoped that pet insurance would fall under the auspice of state insurance regulators, it hasn’t happened, and people with complaints have found they were pretty much out of luck. Fortunately, a new bill that already passed the legislature and is headed for the governor’s desk should give consumers a good deal more protection.

AB 2056 will make California the first state in the nation to specifically pass regulations about the pet insurance industry, separate from its current designation as miscellaneous property and casualty. It specifies the need for clear language about co-pays, exclusions, waiting periods, and caps- all the stuff people run into issues with now.

This is good news for everyone: the excellent insurance companies out there whose reputation is being sullied by the shyster groups, veterinarians who are able to better care for pets, and most of all the clients and pets who stand to benefit from better access to care.

So let’s hear it: what’s been your experience lately? Have you been blindsided or pleased with your insurance coverage?

Filed: Blog, Daily Life, Health, Lifestyle Tagged: ,

Ebola, the real bogeyman, and you

Ever since I was 15, my sister and I have used “Ebola” as a short form derivative of every bad bug we’ve ever gotten. “Oh god, I’ve been laid up all day with Ebola,” “that taco from last night gave me Ebola,” etc, etc. We were able to say it with such offhand tone because we knew that really, Ebola wasn’t exactly a threat here in Southern California. It was simply shorthand for “really sick.”

After reading “The Hot Zone” I stopped saying the word at all. Faced with the visceral reality of what hemorrhaging out of every orifice is really like and the panic it engenders in local communities, it didn’t seem so funny a hyperbole. That stuff is scary. You should read the book if you haven’t, which will not only make you start washing your hands a little more, it will also help you appreciate the new role veterinarians are facing as the front line against emerging zoonotic diseases.

fotos-virus-ebola

 

Ebola is scary, very scary, don’t get me wrong. But we’re probably not about to be thrust into the middle of the next Zombie Apocalypse, which is what many people are expecting if my Facebook feed is any indication. If you’re in the mood to freak out, be my guest, but let me give you a better thing to be worrying about. The number of people losing their marbles over two US citizens being flown in within a self contained bubble is pretty silly when you look at all the other scary things facing us every day that, while less camera-ready than a guy in a space suit stumbling into Emory, are much more likely to truly mess up your day.

Remember: A person with a known diagnosis, held inside a containment unit, isn’t the problem here.

The guy coughing on the plane home from Heathrow who feels like garbage but doesn’t want to miss his daughter’s birthday party? That’s going to be the problem. The traveller who takes 4 Advil before hitting the thermal imaging cameras at the Shanghai airport to fool the system into thinking she doesn’t have a fever? Or the person who doesn’t even realize they’re sick until after he or she gets home? There’s the problem, at least so far as Ebola is concerned.

But Ebola isn’t the problem I’m so worried about, not really. As awful as Ebola is, there’s a much bigger tsunami lurking in the background and it’s already here.

pills

When the associate director of the CDC tells us, “We’re in the post antibiotic era,” THAT makes me panic. And it’s already happening.

The Real Losing Battle

We forget how recently antibiotics have developed in the annals of medical history- Alexander Fleming’s famous penicillin discovery only happened in 1928, less than a century ago. Before that, we were routinely felled by scrapes, coughs, childbirth, urinary tract infections. We’ve done a good job keeping apace of bacteria’s insanely effective evolution to defeat the antibiotic’s mechanisms of action, but we’re finally losing the battle.

It’s the result of a multitude of causalities: a slowdown in new drug development and approval. Misuse of antibiotics in both human and veterinary medicine. The ability for antibiotics to be used over the counter in food production facilities. The latter is now being removed thanks to the FDA’s Guidance 213- taking antibiotics back behind the prescription pad, where they belong.

resistance

But it may be too little too late. The last line of defense in treating drug resistant infections, carbapenem, is now itself encountering resistant bugs. THIS scares me. It should scare you too, more than Ebola, even if Ebola makes people bleed out of their eyeballs. Bacterial infections can be gruesome too, CNN. Is that what it’s going to take?

In the meantime, I do not want to get a fever. Because if I get a fever someone is going to think I have Ebola thanks to the current media frenzy and then I’ll have to go to a hospital, where the real enemy is waiting to kill me. I’m avoiding hospitals like the plague (which is another disease that responds to antibiotics and might not in the future.) DANGIT, we just can’t win, can we?

Filed: Health Tagged: ,

Clean bill of health…

Can we talk about the fainting schnauzer video? We need to talk about it, because if there’s one thing I don’t get in this world, it’s the current trend for pets with a myriad of medical malfunctions or genetic issues becoming internet sensations.

You’ve seen the video, I imagine. A dog is surprised by the owner she hasn’t seen in a year or two, and after freaking out for a few seconds she loses consciousness briefly.

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Attempting to head off criticism, Carson Daly helpfully interjects “CLEAN BILL OF HEALTH GUYS” into the video. No problem, dog is great, everyone can go home, right?

Syncope, Part 1

Now without knowing the dog or what went down at the veterinary clinic, I can’t really tell you what happened, but I can tell you in general that fainting episodes (what we term syncope) are not normal, no matter how excited a dog is. There is a pathology there, whether it’s cardiac or seizure activity or something, but “she just got the vapors” is not a diagnosis.

Let me share with you the general arc of a visit when a patient brings a dog like this- and I’m including both seizure activity and syncopal episodes here- to me. Because the episode itself is short lived, by the time the dog shows up to the clinic he or she often looks fine. After taking a history and keeping in mind things like the age and breed of the pet, we begin the examination.

“Well, the physical examination findings are normal,” I say.

We could end things right here, and you could read that as saying “The pet has a clean bill of health!” But that’s missing the fact that while physical examinations are wonderful tools, they are limited in what they can tell us. The causes of syncope are rarely evident based on physical examination alone.

Syncope, Part 2, 3, and 4

“If we want to figure out the underlying cause of the issue,” I will say, “We should begin with some bloodwork and a urinalysis.” The client may or may not agree, mentally calculating the cost.

“If that’s normal, and it often is, we could proceed next to a cardiac workup: an EKG/cardiac echo/24 hours on the Holter monitor and have a cardiologist review the results.” Now we’ve definitely ventured into “need to think about it” territory.

“If the heart is fine, and we’re more concerned about seizure activity being what’s going on here, a neurologist is your best bet. Unfortunately, diagnosis usually involves costly procedures like CSF taps or CT scans. Epilepsy? Well, we don’t have a definitive test for that at all, so we just have to make the diagnosis based on ruling everything else out first.”

Many owners, especially after a first time episode, go as far as the bloodwork and decide to wait and see if it gets worse before moving to the next step. I don’t blame them- it’s expensive, and you have no idea if the dog will have an event a day later or a year later- but I just want to emphasize that unless they actually performed all of those diagnostics I just listed, it’s hard to definitively say the pet truly has a clean bill of health.

There’s a reason “The dog’s fine!!” is in the Today show headline and Carson makes sure to tell you “the dog’s fine! Someone said so!” and that reason is, we all intuitively know things aren’t fine. Just because you haven’t found the problem doesn’t mean it’s not there. It just means you haven’t located it yet. And I imagine somewhere in that visit, between answering calls from the Today show and counting YouTube hits, the vet did say just that.

 

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Filed: Blog, Daily Life, Dogs, Features, Health Tagged: ,

Cures what ails ya

In the olden days, people used to turn to carnival medicine men or the back pages of Look Magazine for the latest way to solve all of their problems. People don’t change, just the technology. Now we have the internet to turn to. If the web is to be believed, and it always is for some reason, there is a new cure for all the world’s ills. That cure is coconut oil.

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It’s good for your hair, your skin, your GI tract, your dog, your mental health, and your aura. It’s anti-inflammation and pro-synergy. You can rub it on your scalp, then scrape it off and use it to cook, or sit on the leather couch and make it more supple. I don’t think there is a single malady out there that someone has not suggested coconut oil can fix:

Dry skin? Coconut oil.

Dry face? Coconut oil.

Yeast infection? You guessed it.

Alzheimer’s? Eat up.

Athlete’s foot, acne, depression, hemorrhoids, anxiety, UTI, weight loss, heartburn, autism. I guess what I’m saying is you could nuke your local CVS and be just fine as long as there was a Whole Foods next door, because coconut oil’s got you covered.

I’ve done a Whole 30 challenge, which is a no-processed food crossed with a tinge of Paleo, so I’m no stranger to coconut oil. I’ve cooked brussels sprouts in it, stirred it in my coffee, used it to make paleo pancakes. They were good.

Sadly, at the end of a jar I have to say my life has not substantially changed. Everything broken in me before is still broken. Coconut oil, while delicious and no doubt healthier than, say, margarine, has not eliminated my need for my allergy inhaler. I asked my doctor if I could try shoving coconut oil up my nose instead, just for a little while. It’s way cheaper than Dymista. She didn’t think much of the idea. When I told her I was just joking, then she sighed and said, “I get that question a lot.”

While coconut oil is unsurprisingly gaining steam in veterinary medicine, we have an equivalent that already enjoys legendary status in the home remedy category: pumpkin.

pumpkin

Long treated as the pet pepto-bismol, pumpkin is the go-to far various GI maladies spanning the range from constipation to diarrhea. It’s a great thing for the colon. It’s a great source of fiber and most pets will eat it. Pumpkin is Metamucil in a more holistic package.

What pumpkin is not is everything else, like an anti-emetic or anti-inflammatory or something that will teach your dog to talk. Like, it’s no coconut oil or anything.

On a friend’s Facebook page, she recently asked if it was possible for a pet to develop an allergic reaction to a food they’ve been eating for years.

10 people chimed in (correctly) that yes, this happens. Then someone said, “Why do you ask?”

“Because my dog’s been throwing up every time he eats all of a sudden.”

As a veterinarian, my mind immediately collates a list of the differentials when I hear something like this. 3 year old pit bull, history of being a destructive chewer, clearly the problem is “pumpkin deficiency.”

Which is exactly where the comment thread went.

“OMG! You need to give your dog some pumpkin.”

“Seriously! My dog loves it.”

“Pumpkin cured my dog’s farts.”

“Pumpkin is a great source of electrolytes.” And so on and so forth.

Don’t get me wrong, I like pumpkin. As far as advice on the internet goes, it’s one of the more benign things I’ve read and unlikely to cause harm. My only concern is that people recommend this in lieu of something that might actually work, such as starting with a correct diagnosis. Fortunately this person has multiple veterinary professionals on the thread, and somewhere in between pumpkin recommendations she got some solid advice.

A couple of weeks ago, my neighbor came over with her adorable 6 month old Golden Retriever. She hopped back and forth on her toes before asking me if I had any thoughts about her dog’s diarrhea.

“How long has it been going on?” I asked.

“Two days.”

“Go to the vet.”

“We’re going tomorrow,” she said, “but in the meantime……do you have any pumpkin I can borrow?”

I did. It’s on the shelf next to the coconut oil. Hope springs eternal.

 

PS The dog improved dramatically … once the vet diagnosed Giardia and started Flagyl.

Filed: Blog, Cats, Daily Life, Dogs, Health, Musings, Picks of the Litter Tagged: , ,

Dog: World’s Worst Coach

I am training for a half marathon.

I thought about training for a full marathon, but then the reality what that was like the last time I attempted it kicked in and I remembered that oh yeah, I don’t like to run. I think you can do a full marathon once when you don’t like to run, just to say you did (Rock n Roll 2001 for me), but after than there’s really nothing to prove other than, “oh yeah, this hurts.”

A half marathon though, is doable. Still not fun, but manageable. I have decided, along with my friend from the gym who I kind of hate because she keeps inviting me to things such as “Summer Boot Camp!” and “Half marathon! It’ll be fun!” and I keep saying yes, that should we complete this without killing ourselves, maybe, just maybe, we will try and tackle a triathlon before our 40th birthdays.

Do they let people leisurely triathlon these days? All my competitiveness gets used up in my professional life so I have none left over for this.

Anyway, the point is I am doing this and it’s a grind, but I keep remembering that health is a gift and blah blah blah; I’m training with a group because it’s the only way I will drag myself out of bed at 6 am for the long Saturday runs.

Brody doesn’t come with me on those. He can manage shorter distances, but he’s made it clear he’s not yet ready for anything over 3 miles, tops, despite his summer cut. I appreciate that.

This Saturday I ran (‘ran’?) 9 miles, which sounds alternatively fantastic and psssshaw depending on where on the running spectrum you fall. To me, this is the longest distance I’ve done in a single day since I staggered off Mt Meru a few years ago, and that was because I had to since there was no oxygen up at the top.

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I’m hunched over because I couldn’t straighten up, not because I voluntarily felt like standing that way. Teri is hanging on for dear life.

So after 9 miles, at the end of which I realized my entire body was numb from the waist down, I came home and sat on the floor to stretch. Soon enough I was laying on the floor, like one of those crime scene outlines.

020 0120 7141 023 0123 7173 Small is Beautiful Floor Black Still Life

020 0120 7141 023 0123 7173 Small is Beautiful Floor Black Still Life, by Steve James on Flicker

I began to appreciate why dogs do this, this splat sort of positioning. The wood was cool. Soon I melted and became one with the floor. Why don’t I do this more often? I wondered, and when my daughter asked me why I was doing that I realized it was not really possible for me to make it onto the couch at that particular moment.

Brody was excited I was in his domain, plopping down nose to nose and looking at me like, “Hey! What are you doing here?” He stared at me for a while, and then I decided I needed to stretch if I ever was to have hope of standing up again.

It went about as well as you’d expect.

Dogs don’t understand why we would come into their territory for any purposes other than play, and Brody was having none of it. He laid on my foot, licked me in downward dog, and dumped a soggy tennis ball on my stomach when I tried to stretch out my hip. It’s clear I’m not alone in this.

Dogs are awesome at many things, but sitting quietly by while you sit on the floor and bend into weird shapes is not one of them. If you’re going to goof off, they figure, might as well let me in on the fun.

Anyone else have a dog who simply won’t let you on the floor by yourself?

 

 

Filed: Blog, Daily Life, Fit Life, Goofball Antics, Health, Musings Tagged: , ,

Good health is a revelation

When I took my son in for his first routine eye exam, I had no idea he needed glasses. Neither did he. He seemed fine, wasn’t running into things, was reading fine in school, but nonetheless the optometrist suggested glasses. OK, I said, let’s give it a shot.

One week later, his glasses arrived and we went into the office to pick them up. He picked them up dubiously, slid them over the bridge of his nose, and stood there for a moment, blinking as the refracted light hit his retina in new and improved ways.

ralphie-broken-glasses

He spun, slowly, taking it all in. His lips twitched, burbling with something important. When he could no longer hold it in, he opened his mouth and shouted, “I CAN SEEEEEE!!!!”

Boy did I feel like a horrible mom as the assorted clients turned to see this blind boy get his sight back.

abfab.jpg

Later that week I was sharing this story with a friend. As we were talking, her daughter picked up my kid’s glasses and put them on just for fun to see how weird things looked.

She came over and tugged on her mom’s sleeves. “Hey mom. Things look pretty good with these things on. I think I can’t see too well.” Then I felt less bad. It happens to us all.

We thought things were fine, my kid thought things were fine, and then someone with tools I didn’t have access to and the ability to evaluate things said, “Actually, life can be even better.” And it was.

I think of this all the time when people say, “Oh, Buster’s doing fine, he doesn’t need an exam or meds or anything.” To a client’s eye, he is fine. His gait is the same it’s always been. But I can pick up things they don’t, that slight crunchy feeling in the knee, a stiffness when I extend the leg. It took some doing, but we convinced that lab’s owner to try some Rimadyl.

Or the dachshund who came in for a routine dental. “He’s fine,” the owner reported. “He eats kind of slow but he’s been that way since we adopted him two years ago.” When we opened his mouth, the fetid odor of eight rotting teeth hit my nostrils, teeth held in by tartar more than by tissue at that point. It took some doing, but we convinced the owner to let us remove them.

In both cases, we got a call about a week later to marvel about this new dog in the house. “He’s like a puppy again! I can’t believe his energy! Who IS this dog?” Like my son spinning around in the optometrist office, they had a problem they didn’t even realize existed lifted from their shoulders, and got to experience something better for the first time.

In the year since their last eye exam, both kids seem to be perfectly fine, but I took them in dutifully anyway. Both of them need new prescriptions. This time, I don’t feel so bad. Big things we notice- small ones? Not always.

It isn’t my job to evaluate such things in my kids, or to be able to recognize the more subtle signs of something needing help. All I need to do is get them to someone who can, on a regular basis. Next stop: orthodontist. Lord help us all.

Just a little reminder to everyone that there is a reason we recommend yearly (twice yearly, for older pets) checkups at the vet. We’ll probably find things you weren’t aware of, and that’s OK. That’s what we’re here for! Every pet deserves the revelation of improved health. :)

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Filed: Blog, Health, Mother of the Year, Musings Tagged: , ,

Do we need pet care advocates?

In the depth of my despair when Apollo was dying, the medical resident at the specialty hospital made a comment I will never forget.

He was dying of a blood clot, a sequelae of hyperthyroidism and heart disease. I was in shambles, having come home from the gym to find him immobile on the couch, and rushed in straightaway, sweaty and spandex-y. I scribbled his medical history as quickly as I could, which the resident pored over with her intern as I sat in the room planning to say goodbye. I knew at that point it was coming, I was just waiting for confirmation of the diagnosis.

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I had checked ‘yes’ to allergies, in the interest of being thorough.

“What allergies?” the resident asked.

“Food allergies,” I said. “Chicken.”

She paused, and shared a knowing glance with the intern. “And how do you know this?”

I blinked. “I’m sorry?”

“How do you know he has food allergies? Did you just assume, or did you actually test him?”

“I….I did an elimination diet, 10 weeks…not the full 12…. but it was obvious by that point,” I stammered, though what I really wanted to say is “WHAT THE HECK (ok maybe another word) DOES THAT HAVE TO DO WITH THE PROBLEM AT HAND?? WHO CARES HOW HE WAS DIAGNOSED WITH AN UNRELATED MANAGED CHRONIC CONDITION A DECADE AGO??”

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But you know, I just sat there because what are you going to do.

OK sure, let's talk more about Hills z/d and then can you please get this cat some morphine?

OK sure, let’s talk more about Hills z/d and then can you please get this cat some morphine?

Now, I understand that a teaching hospital is going to teach, but from the patient perspective I suppose I would appreciate the teaching being limited to the issue at hand instead of using an emergency cardiac event to make a point on dermatology. I don’t know if it was that, or the way she asked the question as if she were sure I was going to give the wrong answer, that rubbed me the wrong way. I also had to tell her not once but twice that I didn’t want to hospitalize him on the off chance his clot might dissolve enough to give us another month at home. We didn’t hit it off.

Fortunately I didn’t see her after that and was turned over to the lovely cardiologist who looked and talked like Oberyn Martell and understood when I said, “Please confirm my suspicion so I can give him a peaceful goodbye at home”, but it really reminded me, from the other side of the table, how hard it is to be a patient advocate for our pets. I knew what I was doing and I still had to push a little. It was a lonely experience.

It’s even worse in human medicine, as this ER physician who was hit by a car will attest to. Without someone who knows what’s going on to oversee the process and keep the focus on the overall wellbeing of the patient, things fall through the cracks. Flustered and underinformed family members get confused. Specialists focus on this problem or that problem and not the patient. How can we do better?

Um, no, actually.

Um, no, actually.

In human medicine, many hospitals now have designated patient advocates who serve as an invaluable liaison between a family and a healthcare provider. In veterinary medicine, it’s not something I’ve ever heard of, so we’re stuck with ourselves, the vet clinic, or the internet to help us make sense of complicated issues, to understand why the vet wants to do this or that and to empower clients to make informed decisions, including “No.” It’s not the ideal system, clearly.

I wonder if people would benefit from a neutral third party patient advocate group in veterinary medicine. I think things are only going to get more complicated from here on out, and as both a patient and a vet I think that sort of thing could only help. Food for thought.

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Have you ever felt confused and not sure how to proceed with your pet? Would it have been helpful to have a pet care advocate to serve as a liaison?

 

Filed: Blog, Daily Life, Euthanasia/Hospice, Health, Musings, Picks of the Litter Tagged: ,

One Twenty Over Eighty

A few years ago I ran away from my job.

At least, that’s what I called it at the time, that is how I framed it in my head. I couldn’t hack it, I was a failure as a vet. My mind was wrecked, my physical health was wrecked, and my stomach curled up into knots every time I pulled into the parking lot. It wasn’t only me who suffered; I knew my heart was not where it needed to be for my patients. They deserved for me to want to be there. It was a bad place to be in.

With the gift of perspective, I know now I was dealing with some pretty significant burnout. I didn’t know that was what it was at the time; after all, don’t you have to be in it at least a couple of decades for that to kick in? Or be a practice owner? This is how it works, I was told. No one really talked about it, or it was code for ‘bad vet’, not for a defined type of stress reaction. Old Doc Johnson who treats everything with pen G and steroids needs to get put out to pasture, he’s old and burned out.

No matter the reason, I knew I needed to leave and take a breather. I am very fortunate that my husband was supportive of the decision, even without knowing how it would play out, or when I would be back. Although I saw it as a failure on my part at the time it was the best thing that could have happened to me.

I have learned to let go of a lot of destructive ideas in the past few years:

  • that taking care of yourself is an indulgence;
  • that saying ‘no, I can’t’ means you are a slacker;
  • that being a veterinarian means you put your work above all other things.

I had to practice those sentences a couple years before I really truly believed them, but I do now. I listened to a wonderful VetGirl webinar today on the topic of veterinarians, depression and suicide and was kind of taken by surprise when our wonderful presenter said, “self care is an ethical obligation- to yourself and to your clients.” She’s right.

If you recall, one week ago today this happened in my neck of the woods:

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A few days after the smoke had cleared, I had a girls’ weekend getaway that we had been planning for almost half a year. Girls weekends aren’t really something I’ve done much of- too busy, other priorities- but we randomly decided at a Christmas party that we should plan one. I didn’t know how much I would be needing it at the time, but man, I’m so glad it happened the way it did.

I flew far, far away from my blackened streets and up to the land of one of the world’s finest philosophers: Santa Rosa, home of Charles Schulz.

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We ate, all weekend. Really, really good food.

2011-onetwenty-over-eight_webWe tasted some wine. Really, really good wine. Our personal favorite was a wine by Ehlers Estate, which was founded by a man with a deep philanthropic interest and is now owned by a trust that funnels all its profits into cardiovascular research. (I tell you this not to try and sell their wine, though if you ever get a chance you should absolutely try it, but because it ties into the rest of this story.)

The wine we sampled is called “One Twenty Over Eighty,” in honor of an ideal blood pressure. We liked it, so we bought a bottle to share that evening.

We all came on this journey with our own piles of stresses and stuff going on, and one of those things involved a friend taking a spot check blood pressure monitor, just to kind of keep an eye on things.

“I feel really relaxed,” she said later in the afternoon. “I’m going to check my blood pressure, just to see how it went today.”

She took it, looked at the numbers, shook her arm a little, and held up the monitor.

“One Twenty…Over Eighty.”  OK, maybe closer to 125/82, but nonetheless, it was pretty darn good. Magic, almost.

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On the last morning before we left, we bumped into Kenny G in a bistro. All I have for proof is a surreptitiously snapped picture of the back of his gloriously curled head, but it was confirmed that yes, we lunched with the G himself. Seriously, if ever you were waiting for a sign from the universe that you needed to kind of chill out for a few, there are few signs more blatant than running into the king of smooth jazz. This may top the time I ran into Weird Al at Disneyland (story for another time).

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Good friends, laughter that makes you snort in the most unfeminine of ways, and maybe a sip of an exceptional wine if that’s your thing. It may not replace all the medicines in life you might need, but a little self care now and then does wonders, it really does.

Here’s to your One Twenty Over Eighty, whatever that might be. Cheers.

Filed: Adventures, Blog, Daily Life, Health, Musings Tagged: , , , ,

A place of passing

“I’m never going back,” I have heard more than one pet owner say. They are talking about the office of their veterinarian, a person with whom they have built a relationship for years, someone they like and trust. But their pet died there, and the painful memories are too strong. So strong for some people that they go and find a new vet, even if they liked their old one just fine.

It’s one of the reasons I like having the option that I offer, of performing in-home euthanasia and pet hospice with Paws into Grace. Because I know more than anyone that as much as the client hated the office that one time, many pets hated it every time. That can be pretty upsetting for some families.

Which leads to the next concern, one I hadn’t thought of until a client voiced it to me. “I don’t want to go to the vet office, but I can’t euthanize my pet at home,” she said. “I can’t have that memory associated with my house.” So sometimes those clients end up decamping to a third party location, a park or a beach. And I respect that decision, though I would encourage those who feel that way to think on it a little while before making up their minds. Here’s why:

1. The precedent has been set in human hospice for staying at home.

The gold standard in human hospice, for those who have adequate support systems in place, is for people to pass at home whenever possible. That is by far the most comfortable place for a patient, in familiar surroundings. I was with my grandfather when he quietly died on a rented hospital bed in the living room he called his own for 40 years. He hated hospitals and I’m pretty sure had we put him in one, he would have haunted us all.

2. Moving an ill pet can be a challenge.

Pets who are very ill can be nauseated, painful, disoriented, and uncomfortable. This goes for people, too. How many times have we been down with the flu and known that we should probably go to the doctor but we feel too rotten to move? Same goes for pets. Add in mobility issues and it is just one more stress for owners, especially with very large pets or very upset cats- no matter the destination.

3. Your home is deafeningly, loudly, overwhelmingly a place of comfort.

This is the place Kekoa died:

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But unlike a vet office where I might only have a handful of memories, I see this place every day and I don’t look at it as the place my dog died. I look at it as my living room, the place we opened Christmas presents, the place Brody plops down while I’m writing. It also happens to be the place Kekoa chose to settle down and leave this earth, because she knew as well that this is a happy place.

And you know what? It still is. I am glad she chose our sun dappled living room. At home, when I administer a pet’s sedation, they choose where they want to be: outside, in the kitchen, in mom’s lap. People find comfort knowing their pet selected the place they are most at home.

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I’ve only been in this house a year and it’s had more than its share of sadness. I am looking at the floor where Kekoa died while sitting on the couch where Apollo died. I actually drove him home from the specialty hospital as quickly as I could- after he got lots of pain meds, so he could curl up on my lap after everyone got a chance to say goodbye.

But right now, it’s the place my dog is chewing up a toy and my son is doing his homework. This is our home, where life happens. And I feel good about that.

Want more info or to know if anyone in your area provides this?

Not all veterinarians even know this service exists, and information can be hard to come by. Here are two national databases of veterinarians that offer this service:

The International Association of Animal Hospice and Palliative Care

Association for Pet Loss and Bereavement

Here in America’s Finest City of San Diego, you can of course reach me or my wonderful colleagues through Paws into Grace.

Filed: Blog, Cancer sucks, Daily Life, Euthanasia/Hospice, Health, Musings, Picks of the Litter Tagged: , , ,

Awesome App Alert: Pet First Aid

You’re on a walk with your dog. He looks tired. You don’t know if he’s just tired from the walk or if he’s showing early signs of hyperthermia. What do you look for?

Unless you have a lot of experience with dogs or happen to have an emergency medicine textbook on you, you might not know. But thanks to increasingly cooler and better apps, you can get some immediate reassurance from your smartphone.

The latest must-have app for dog and cat owners just came out, and at $0.99 there’s no reason not to download it right now. The Pet First Aid app from the American Red Cross was developed in conjunction with the vets at Penn, and offers concise, easy to navigate info that you can access in seconds. It’s worth the price just for the 18 second CPR videos covering three sizes of dog and a separate one for cats. (There have been some awful CPR videos out there on YouTube, just sayin’.)

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I just bought it and put it on all the smart apps in the house. The pictures (dog with bee sting!) and videos (bulldog in respiratory distress!) are ones you can use to educate yourself, or for the vets out there serves as a quick and easy resource to show clients in the exam room. And it has quizzes (thank goodness I passed all the ones I took, that would have been embarrassing.)

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Thanks Red Cross for another great- and affordable- resource!

Pet First Aid at itunes

Pet First Aid at Google Play

Filed: Blog, Cats, Daily Life, Dogs, Health Tagged: , , ,
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