Spayded, an update

Perhaps you remember the story of the yorkie pyometra. How excited we all were that she lived. Well...seems we spoke too soon.

Given how long she'd been sick prior to surgery, and how toxic she was at surgery, we kept her on antibiotics for a long time. She came in for suture removal at 2 weeks and looked good. Shortly after that, she finished her antibiotics. Our staff called for a follow up call and we were told she seemed a little dull, picky about food but she's always been a picky eater. Maybe pickier than normal, not as energetic, more dull than when she was on the antibiotics. Recheck appointment? Well, gee, how much will that cost cuz, see, we're kinda out of money again.

A few days later, we received a fax from the emergency clinic that she had presented with septic abdomen and was euthanized.

Could we have saved her (again) if they'd come in a few days prior? Obviously we'll never know but it would have been nice to have gotten the chance to try.

:( RIP little girl. This one I feel badly about.

Career Fair

About a week or so ago, I attended a career fair. It was put on by a local service organization and hosted some very official attendees. And then there was us, Awesome Critter Clinic. We had a table mostly due to Dr. Old's relationship with the service club. We were the most popular table there, because we had a puppy.

It was really hard, because I love my profession. However, I don't love the $12-15,000 I see fly out the door each year in student loan repayments. Graduates these days with debt between $150-200,000? I don't know how they live, especially if they're single.

Afterwards, the Army guys told me I should be a recruiter. Because, see, every time a kid asked about vet school, I said - you better figure out a way to pay for it. Don't do it on loans. If you really want to go to vet school, join the Army & have them pay for it. Otherwise you're going to be busting your @ss for the next 30 years working at a semi-thankless job and watching 40-60% of your salary go out the door to repay loans.

It was painful, sure, to discourage kids from attending vet school. But someone needs to tell them the truth.

Shredded, Part 2

A few days later, they bring in Dog #2. See, this dog had "only" ripped up his mouth, so they thought he didn't need to be seen. The sister "who works at a vet clinic" was bringing over medicine, so proper veterinary care wasn't necessary. Until it was.

I'm kinda surprised they actually paid, but pay they did to collect dog #1. Dog #2, upon initial inspection, did not appear as bad off. However, he was less cooperative, and required a muzzle to anesthetize. Yay.

Once under, it was decided that, yes, he did need a drain tube in the gaping hole in his chest. He also had some of the larger wounds on his lips stitched. Due to the wounds on his face, however, he had developed a very nasty case of cellulitis along his entire lower face. There was no distinct wound or abscess, instead, his entire face oozed pus. There were rips & tears in his tongue that had begun to turn necrotic, again, nothing that could be stitched.

And, the coup de grace, he fractured his upper canine almost in half, with the full extent of the fracture running up under his gum line. Pulp was exposed, and the tooth would bleed when touched.

This dog is patched up now too, with a bill very similar to the first dog. Even with the fractured canine, had we seen the dog the day it all happened, we might have been able to save them  a bit of money, I suppose. They didn't want us to do anything that wasn't necessary, but it was all necessary!

The best part of this whole story is that, when we walked into the room to talk to them about Dog #1, it was like walking into a wall of alcohol & marijuana. And perfume/cologne. I'm not sure who they thought they were kidding with the cover-up, but we had to air out the space after they left.

Shredded

Strike 1: You own 2 intact males & 1 intact female pitbull dogs, who have never received veterinary care unless its an emergency.

Strike 2: You call me at 11am (we close at noon), to tell me that the males got into a fight over the female, and you need to bring them in ASAP.

Strike 3: I find out when you arrive that the fight actually happened last night. But you called the emergency clinic and they were too expensive.

One wonders, however, why you wait until 11am to call when the clinic opens at 7am? And the dog whose face was literally ripped off (to the point where, among other things, I was forced to "amputate" the third eyelid because it was shredded) - I guess he just sat there all night & morning in pieces because you were...??? Hung over? Drunk? Getting your new tattoo?

Yes, I'm judging. Because I'm the one who had to look into the dog's eyes (one of which I was attempting to put back into his head) and see his pain.

Phone Etiquette Part 4

Ring back tones. I hate them. I hate them with a burning passion.

I hate the "classical" music Verizon plays, I hate the snippet of the country music song some people select. I hate the slice of Black Eyed Peas, Miley Cyrus, Brittany Spears or any other musical artist. You know what I don't hate? Hearing the phone ring.

People pay money for this crap.

Honestly, if I call you & you have a "ringback tone", in my head I picture a junior high girl. And I'm not going to take you seriously. And I'm unlikely to call you back if you don't answer. Ball's in your court, because I don't wanna listen to your crap music.

Private cremation

We offer private cremation for our clients. Its one of many "end of life" services we provide. Each client who euthanizes a pet at our clinic, long time or brand new, get a personalized, handwritten card signed by each of us. We often do clay paws, and will also send personalized memorial stones. Those are costs we absorb in our clinic, we pay for those items. Private cremation, however, those costs are borne by the clients.

Enter deadbeats...

I'll confess. Sometimes we do payment arrangements. Personally it drives me nuts, but Dr. Old has been doing this for 40+ years, and started taking payments back in the day when people actually paid their bills. So sometimes we still run bills for people.

There was a client who didn't pay his last bill, and was told that he had to pay for any services rendered on subsequent visits. He wanted me to operate on his dog's necrotic, rotting tumor. I refused. He elected euthanasia. I said, fine, but you have to pay for it today. And it would be nice if you could pay on the $300+ you already owe as well. He claimed to have $100 cash and would pay the rest tomorrow. Uh huh. He wanted private cremation. Then left without paying the $100. I called him, he did turn around and pay the $100. But I tagged his dog as a "hold" in our freezer. Four months, many calls, returned registered letters, and failed contacts later, I finally sent his pet for non-private cremation. I also subsequently reduced the debt (removing the charge for private cremation) from the amount he owed to our collection agent.

Repeat situation today - semi-deadbeat ran up a $1000 bill, finally the pet was euthanized and they wanted private cremation. First, someone explain the logic to me - you can't afford your vet bills but you are going to pay $200 for a private cremation? Well, we're fast learners I guess because the pet was euthanized on Wednesday and today we went a registered letter basically saying - listen, you owe us $1000. We're not sending your dog for private cremation until you pay your bill in full. We're happy to send for group, reduce your bill accordingly and you still owe us. But if you're having trouble paying, maybe spending $200 on private cremation isn't the best plan. And you're sure as hell not getting your remains back until you pay your bill.

I can't hold alive pets hostage to people who don't pay their bills. But I'll be damned if I'm going to pay for you to have your pet cremated when you won't pay your bill.

Tax Day

I'm not very political. I'll admit, I get most of my news from The Daily Show and The Colbert Report. Oh, and Facebook. One can never forget Facebook when discussing reasonable and accurate sources of political information.

But I think today, Tax Day in the good, ole, U. S. of A. - almost everyone has a political opinion, at least about taxes.

Last year was the first year my husband and I owed money. It was pretty shocking. This year, we owe again as well, more than last year despite increasing our monthly with-holdings.

Tax time makes me think of student loans, and how much my education cost me. Mostly because part of my student loan debt is tax deductible. A laughable part. Here's my tax story, as it pertains to my student loans.

These numbers are hypothetical, kinda. They closely resemble my situation, close enough to get my point across.

I, like many vet school grads, have 6 figures in student loan debt. I'm working part time in small animal practice, and I am well compensated. Like, well above average for my area. But let's crunch some numbers. I work off production and average $25,000 a month production. My 20% commission on that is $5000. But I lose 1/3 right off the top to taxes. So my take home is $3300. I pay $1000 each month in student loans. (My actual payment is just under $900 but we round up to an even $1000.) So that leaves me with $2300. My mortgage is around $1300 a month so I'm now left with $1000 to pay my phone, gas, insurance, electric, food, water, etc, etc, etc. And people wonder why I'm still driving a hand-me-down Subaru with 220,000 miles on it! Because I can't afford a car payment!

Okay, fine. But then tax time rolls around and I get that student loan interest statement. Seems about 1/2 of what I pay each month goes to interest. Close to $6000. And when I plug all that in to Turbo Tax, I get the super helpful message Congratulations! You've reached the maximum deduction of $2500 for student loan interest! So fully 60% of the student loan interest I pay each year is NOT tax deductible! 

To recap, I'm taxed like I make $60,000 a year, I live on approximately $15,000 a year and only 40% of my student loan interest is tax deductible. 

Is it any wonder we get a little grumbly at tax time?

All I can say is Thank God for my husband, his complete lack of student loans and his good paying job. I honestly don't know how people getting out of school now, or those who are single or the sole bread-winners do it.

Charging what we're worth

Money is always a hot topic in veterinary medicine. Since very few people have insurance (and those that do usually require the client pay up front & then they are reimbursed), they are left to bear the burden of the entire medical costs for their pets.

The other day, I was working solo. An older cat had come in the day prior, basically just not doing right, with abdominal pain. Blood was drawn & sent to the lab, and an abdominal radiograph was taken. The radiograph shows a marked lack of detail in the abdomen. The cat was hospitalized overnight with supportive care while we waited for the bloodwork to come back, and for me to be there to perform an abdominal ultrasound. Bloodwork came back normal but the ultrasound showed pockets of free fluid in the abdomen. Not a huge volume, so I was fairly uncomfortable blindly tapping the abdomen for fear of hitting intestines.

Communication at our place can be tricky sometimes, what with one doctor admitting the patient and the next day another doctor takes over their care. We try really hard though, for the sake of the clients, and so Dr. Old called the owners on his day off and told them the news, receiving permission to perform the abdominocentesis and for fluid analysis if we got anything useful.

The cat was sedated (he was too painful and became fractious during the ultrasound, there was no way he would sit nicely while I shoved a needle in his belly and have it all stay sterile) and surgically prepped. I picked a spot again using the ultrasound. I chose a 22 gauge catheter, and once I felt the stylet pop through the body wall, advanced only the catheter and removed the stylet, thereby basically eliminating the risk of puncturing intestines in my search for fluid.

We obtained a diagnostic sample and, sadly, the cat had cancer. The owners elected euthanasia instead of searching for the exact source.

I tell this story because that was a lot of work. Safely sedating an old & sick cat. Using the ultrasound to find the fluid, prepping the patient with a sterile field, using sterile technique and a little but of a different approach to reduce the risk of contamination or sepsis. Collecting and analyzing a sample. The knowledge needed to perform these tasks draws from many different portions of my veterinary education (which, believe you me, I paid dearly for. Am still paying dearly for!) When I talked to Dr. Old about the charges I put in, I was almost apologetic. I said I wasn't sure what he'd quoted them, so if he needed me to discount my fee, I could do that.

Turns out my charges, the ones I was almost embarrassed about, were a full $200 less than he'd quoted them. Which would be about $6-800 less than a larger "specialty" clinic further south.

Why can I not wrap my head around charging what I'm worth?

Smartest person in the room

There is a meme going around Facebook that reads "If you're the smartest person in the room, you're in the wrong room"

I confess, I don't know what that means? That you should strive to be the dumbest person in the room? In all seriousness though, are they suggesting one should aim for surrounding oneself with smarter people to better your own intellect? I can get behind that.

However, technically, I spend a large majority of my day being "the smartest person in the room". Not that my clients are idiots - far from it - but they're visiting because there is something wrong with their pets and its my job to figure it out. I'm guessing both my clients and my patients, in those moments, are pretty glad I'm the smartest person in the room.

(Although, sometimes I'm still in the wrong room, but that is usually because I'm too busy to pay attention to which appointment is in which exam room and walk in on our other doctor examining a patient...)

It is in the name of the disease...

I don't often speak ill of other veterinarians. At least not publicly, and never, ever, ever, ever, EVER to the client. If you send us a patient, or if a patient transfers to us, in general, I've got your back. (Instances of gross misconduct nonwithstanding...) Cuz, you know what, we all make mistakes. I'm sure some day I will, and I hope that whomever sees the pet next won't throw me under the bus.

But this one, I've gotta get this off my chest.

An extremely overweight, 11 year old Aussie-type dog, owned by a long time client, presented to us on a Monday morning as a transfer from an ER/Fancy-pants clinic. Not a referral clinic, as its not staffed with specialists, however they like to consider themselves a referral center. They're not. But they think they are. Not the hugest fan of this facility...but I digress. Anyway, the dog presented to the ER and was eventually diagnosed with severe pancreatitis, so severe, in fact, that this dog's glucose was the highest reading I've ever seen...4 figures. WOW!

Extensive workup and supportive care ensued in the form of bloodwork, IVs, ultrasound, antibiotics, double run of 5% dextrose and IV insulin and extensive analgesia because they just could not get the dog comfortable, based on her panting. Despite excessive doses of opioids, the dog continued to pant. Was almost comatose, but continued to pant. And because she continued to pant, they continued to dose her with fentanyl.

When she arrived at our clinic, happily her glucose was in an acceptable range - that appeared to have been stabilized. The owner was concerned, however, because it seemed to her that they could not get her pain under control despite the excessive amounts of fentanyl and the dog was getting worse, not better. In her words, "You guys have never had problems making my animals comfortable." So, despite dire warnings from the ER facility (which had clearly wanted to transfer this patient to their in-house day service) that the dog was too unstable to transport, the owner brought her in.

She presented depressed and panting. I'm reading the discharge paperwork and I come across the line at the top: Suspect diabetic ketoACIDOSIS secondary to severe pancreatitis [my emphasis]. Then I quickly flip through the rest of the paperwork and note two very striking omissions in the pet's treatment at the ER. First, no one performed a blood gas to CONFIRM the acidosis and, second, no one treated said acidosis.

Now, I get that acid/base work is not for everyone. The mere mention of Henderson/Hasselbalch can still give some vets seizures with flashbacks to horrific fluid therapy lectures. But, guess what folks, its important.

Sadly, I've yet to convince my boss I need an iStat machine (I desperately wish for one about 4 times a year). But, drawing on my work with dairy calves with diarrhea, I made a base deficit estimate for this dog, immediately started her on bicarb containing fluids and - guess what - within 2 hours the panting had stopped and she was alert. Still sick, yes, but no longer panting and no longer obtunded. Although I probably can't take too much credit for the later - the fentanyl had likely finally metabolized out of her system.

Seriously though - you tell me you think the dog has acidosis, but you do nothing to address the acidosis? Do you not remember that carbon dioxide is an acid and animals will increase respiration in an attempt to compensate for a metabolic acidosis? I have never worked emergency medicine (outside of my time as an intern and a resident) but I really feel like this is something that ER clinicians should be aware of. Am I wrong?

Phone Etiquette Part 3

When I come in the room, get off your damn phone. When I'm in the room, don't answer your damn phone.

If what is happening on your phone is more important than your pet's health, leave my office so someone else can use the space you're currently occupying.

And, for the love of God, don't you dare threaten to complain to my boss because I walked out of the exam because you chose to answer your phone mid-conversation. Don't tell me I'm not respecting your time, because, lady, it's you who aren't respecting mine!

Spayded

"Well doc, we thought it was mean to have our dogs spayded."
"Yeah, and we thought we might want to breed them. They're such nice dogs, and we wanted our kids to experience the miracle of birth."
"Plus, it was expensive. That vet wanted a whole $150 to spay them!"
"We didn't know not fixing them could make them sick!"

Double whammy - a pyometra AND mammary adenocarcinoma (presumptive) in an 11 year old Yorkie. Who, thankfully, was either actually nice, or too sick to bite me when I put the IV catheter in.

"Will she make it?"

Well, I don't know. See, maybe if you'd brought her in one-and-a-half weeks ago when she started feeling ill, she'd be in better shape now and more likely to survive the emergency surgery she's about to have.

Epilouge:
The dog lived. Yay!
They are bringing in their other dog to be "spayded" next week. Double yay!
They applied for Care Credit, were approved, but paid 50% deposit cash anyway because they wanted to be sure we knew they were going to pay their bill. (New clients) Triple yay!
That last statement is not a reflection of our role as greedy, money-grubbing veterinarians, but excitement at gaining new clients who actually understand that pet ownership and veterinary care COST MONEY and don't expect us to do everything for free because "we love animals."

No, I won't lie for you

Mrs. Bully (the breed, not the social tyrant) brings in 2 dogs with recurrent, but manageable, condition. They've been able to keep the dogs comfortable at home, but it seems Mr. Bully is out of town and both dogs had a relapse.
No problem, I can take care of that for you. We'll fix them up today, and home tomorrow.
Well, now it's tomorrow and the repair from yesterday didn't hold. Sure, I can fix it again and be more aggressive this time in the repair.
Wait, hold on. Mrs. Bully just called and may want to put one of the dogs down. She is difficult to manage at home, won't easily let the owners fix the problem on their own and can not live with her defect left as-is. From a medical standpoint, I do agree this may be the best thing for the dog. Sad, but reality is what it is.
Mrs. Bully makes an appointment to be with her dog while we put her down.
Appointment time rolls around and paperwork is readied... Apparently during this conversation with my staff, Mrs. Bully confesses she's not telling Mr. Bully she's euthanizing his dog. She plans to tell him that she died under anesthesia.  

Um, excuse me, WHAT?!?!?!?!?! I don't think so!!!!!!!

So I'm faced with the marvelous task of 1) determining if this woman even has the legal right to request euthanasia on this dog and 2) informing her she may not blame me for killing her dog. Turns out, Mr. Bully isn't actually out of town. He's in jail. For another 2 months, and they're not allowed to communicate. Yes, please, tell this man I killed his dog while he was in jail. That sounds freaking fabulous!

Thankfully, she is actually a really nice woman, just didn't understand that there were paper trails for euthanasia, and under no uncertain terms would I be willing to lie for her. We did determine she was able to make these decisions, and humanely euthanized the dog.

But, wow, that could have ended badly.

No 'Obamacare for dogs', no accountability for owners

I don't know how many of you saw this article:

No 'Obamacare for dogs'...

In a nutshell, the story goes like this. Couple takes dog in for spay. Dog discharged same day. Later that evening, dog is having problems. Owners call veterinarian, who is closed and the recording directs them to the nearest ER. Dog goes to ER, ER DVM decides dog is bleeding internally and needs emergency surgery. Couple can't afford estimate, and is declined for Care Credit. The cold, heartless bastard of an ER vet actually expects to be paid* and therefore is unable to perform the surgery when the owners inform him of their lack of finances. The owners also decline humane euthanasia. Despite warnings that the dog will likely not make it through the night, the owners take her home where she dies.

*Please note the extensive use of the Sarcasm font

Then, as if that's not enough, the owners post on Facebook how this mean, nasty, horrible vet overcharged them for the estimate and wouldn't save poor Fluffy. The ER vet in question is now getting hate mail, emails and phone calls. Awesome sauce! 

BUT - the reason I share this is because of the comments on the bottom. I think some of the commenters must frequent one of my favorite vet blogs, Veterinarians Behaving Badly because they are about 75% awesome. The lame-brains are saying "He should have treated the dog regardless of money!" and the awesome folks are out in force saying "Why? Because who else do you know works for free? Grocery stores? They want to get paid. You're hungry? Too bad, come back with cash." 

Typically I don't read the comments on articles like this because they raise my blood pressure to dangerous levels but these restored my faith in humanity.

Yes, I love animals. No, I will not work for free. If you want to own a pet, you should have a savings fund or a back up plan for financing an unexpected large bill. I'm a veterinarian, not a bank.

Phone eitquette Part 2

Let's say you have some questions and call your (human) doctor's office. The changes of getting a call back the same day are slim to none (at least, in my experience at a busy, multi-doctor practice). The chances that your actual physician will call you back are, again, in my experience, even slimmer. Usually its a nurse (nothing against nurses) who is parroting back whatever the M.D. told them to say and can't answer any additional questions.

Now let's say you have a question for your veterinarian. You call, demanding to speak to your DVM, and won't tell the staff what you're calling about. With no additional information, its hard for the DVM to triage phone calls, and so yours gets pushed to the bottom of the stack. Irate at a lack of a phone call, you call again. Sorry, the doctor is with other patients or in surgery, if this is an emergency I can see if I can pull her out of the room. Can you please tell me what this is about? Finally, after 4-5 calls to the office, the vet finally calls you back to discuss corn meal being listed as the first ingredient of your dog's food and your having just read on the internet that corn is bad for dogs. Sigh...was this really worth multiple irate phone calls to the staff?

Finally, I understand the anxiety that comes along with your pet being hospitalized. But when you call and demand hourly updates, and I spend that time on the phone with you, you know what I'm NOT doing? TREATING YOUR PET! And as hard as it is for you to comprehend, yours is not my only patient for the day. So between treating your pet, I'm seeing appointments every 15 minutes and doing surgeries too.

Try to keep that in mind next time you call your vet and demand an immediate call back. You might get it, but you're not dong yourself any favors in asking for it.