Monday, November 27, 2017

The Accidental Veterinarian


I did not plan on becoming a veterinarian. In fact, when I was a child I was only dimly aware of what that was as we did not have any pets other than a gerbil, for whom professional medical care was honestly never a consideration. For many years I wanted to be a geographer or a historian at a university. Yes, I was a strange child. Then in high school my interest in animals and nature, which had always been there at some level, began to grow and I added research zoologist to the list. But veterinarian still wasn't on the radar.

My father was a practical man, and a man who had become cynical about academia. He was a physics professor at the University of Saskatchewan and he believed that academic jobs were becoming both increasingly scarce and increasingly unappealing due to university bureaucracy. Consequently he viewed my interest in pursuing an academic career in zoology, history or geography with growing apprehension. He was fond of the pithy German phrase, "Brotlose Kunst", which translates directly as "breadless art" - in other words a career or job that doesn't put bread on the table. He left the choice up to me, but made it clear that he recommended I pursue a profession instead.

I was a freakishly obedient teenager (mostly), so it came to pass that I spent a sunny Saturday afternoon in March of 1983, the year I graduated from high school, methodically going through the University of Saskatchewan's course calendar. The programs were listed alphabetically. I began eliminating them one by one - Agriculture (boring), Anthropology (Brotlose Kunst), Art (Brotlose Kunst)... and so on. As per the profered advice I paid particular attention to the professional colleges, but I steadily, inexorably, eliminated them all too - Dentistry (ha), Engineering (boring), Medicine (nope - sick people are gross) etc... I was comprehensively alarmed by the time I got to Theology (ha) as I had almost reached the end of alphabet without finding anything that made sense to me. There was only one program left. I turned the page and saw Veterinary Medicine written there.

Huh. Veterinary Medicine...

I couldn't think of a counter argument. In fact, the more I thought about it, the more appealing the idea became. This was essentially applied zoology! Moreover I reasoned that I had always liked dogs and cats, although I had never owned one...

In the impulsive way of 17 year olds I decided right then that, yes, this was Plan A. It also helped that the father of a girl I had a crush on was a professor at the vet college... But I knew absolutely nothing about the profession. I hadn't even read James Herriot. When I did find out more about it I began to waver (Herriot had the opposite effect on me than he did on most people) and completed a Biology degree first, but my faculty adviser echoed my father's advice - get a profession, go into veterinary medicine like you had planned. And so I did.

The great majority of my colleagues wanted to be veterinarians for as long as they could remember. In most cases they had to move a considerable distance to Saskatoon or Guelph to attend veterinary school. Their plan was clear and their commitment was strong. In contrast I still marvel at the accidental nature of my entry into the profession, a profession that has not only given me a wonderful career, but through which I met my wife and through which I moved to Winnipeg. What would have happened if the U of S hadn't offered Veterinary Medicine and the last entry in that course catalogue had been Theology...?

Some accidents are happy. This is one of them.

Thursday, November 16, 2017

The Anatomy Of A Vet Bill


Mr. Malloy was the type of jovial older guy who wore a camouflage coloured cap and red suspenders over an expansive gut. And the type of guy who loved cracking lame jokes. You know the type. Kind of annoying, yet also kind of lovable.
One day he was at the counter paying his bill when he said, "Holy Dinah! A hundred bucks? You gotta be kidding me? I must own a wing of this hospital by now!"
At the other end of the counter Mrs Chu was paying her $1500 bill and quietly exchanging knowing smiles with the receptionist.

If we had a hospital wing for every client who felt they had paid for one, we would be the size of the Pentagon by now. (Besides, veterinary hospitals generally don't have "wings"...)

But I get it. For a lot of people veterinary medicine is expensive.

Some in my profession push back against that statement and say that we just need to look at dentists and plumbers bills to see that we are not that expensive. No, dentists and plumbers are also expensive, just like us. A lot of modern life is expensive. For many people living paycheque to paycheque (47% of Canadians in 2017) a surprise $500 veterinary bill (or dental, or plumbing, or whatever) is difficult to manage, and a surprise $2000 bill is a potential financial catastrophe.

So now that we have established that veterinary medicine "is expensive", why is it expensive? The number one reason is that we have rapidly evolved to a point where our standards of care compare favourably to those for humans. The arguments about the rightness or wrongness and the whys and wherefores of this evolution are best left for another post, but the fact remains that we now practice close to "human level" medicine and consequently have some "human level" expenses. There are no special veterinary grade sutures, catheters, pills, computers, rent or education for that matter. In fact, for many of our supplies we pay more as we don't have access to the volume discounts the human hospitals do. It is interesting  to note that Americans complain about veterinary bills less often than Canadians because they know what human health care costs.

There are many scary expressions in a practice owner's lexicon - "audit", "lawsuit", "burst pipe", "crashed server" - but one of the scariest is "overhead". The others are avoidable, but overhead is unavoidable and in some practices it can gobble up almost all of the revenue. In my clinic I have calculated that it costs us $400 an hour to keep the lights on, the doors open, the supplies stocked and the non-veterinary staff in place. This is before any veterinarian gets paid. During the busy season this is easy to cover, but in the doldrums of January when you can hear the proverbial crickets in the waiting room you may see me obsessively watching the bank balance and line of credit. I might even be chewing my fingernails...

So, where does your money go? In our practice on a very broad average, for every dollar you spend about 25 cents covers veterinary salaries and benefits, 21 cents to staff salaries and benefits, 27 cents for variable costs like drugs, supplies, lab charges etc., and 15 cents for fixed costs like rent, computers, utilities, accounting, maintenance etc.. This obviously varies enormously from service to service, and it also varies a bit from year to year. Our veterinarians are on salary, so the 25 cents doesn't go straight to them, but in some practices vets are paid a percentage of their billings.

The mathematically astute among you will notice 12 cents missing. That is the theoretical "profit" or, more accurately, "return on investment", that is divided among the owners (there are seven in our practice) when we have kept a good eye on our overhead. I discussed this in a previous post, but in brief, those of us who own practices have to take out substantial loans to buy them, or, in the case of a new clinic, build them, so this money helps slowly pay those loans off. I suppose a theoretical non-profit clinic would be able to lower it's prices by that 12% and would have to somehow fundraise to build, expand etc.. It still would be expensive. Veterinary medicine is expensive. But - and forgive the self-serving nature of this comment - it is so worth it. What price can you put on health and love? Especially in a world where people are apparently buying thousand dollar smartphones...



Monday, November 6, 2017

Mook


Mook was my first "real pet". This statement may prompt hate mail from the gerbil lobby as I did have a gerbil named Bobo (http://vetography.blogspot.ca/2015/12/bobo-christmas-gerbil.html) when I was twelve years old and I suppose I loved him, but to be honest, only in the way I loved my favorite toys. I really wanted a dog, but there was simply no way that was going to happen. My parents didn't have pets growing up (it was worn-torn Germany after all - there were many other priorities, like survival) and none of the people they knew once they emigrated to Saskatoon had pets. It simply wasn't part of their world. They didn't view it as a bad thing necessarily, but it was something "other people" did, like line-dancing or cross-dressing.

Then while I was starting second year biology at the University of Saskatchewan, we moved to an acreage about 20 km southwest of the city. It had always been my father's dream to own land and live in the country. Experimental plasma physicist by day, gentleman farmer by night (and weekends and holidays). He began to collect tractors and outbuildings to house these tractors.

One late autumn day a black-and-white kitten appeared in the tall grass around one of these outbuildings. It was good mousing terrain I suppose. It was a boy and it was probably about 10 weeks old. My parents had no idea what to do. I was preoccupied with school and with being a young adult with a car and a social life (such as it was...), so I didn't pay too much attention at first. The kitten was extremely friendly. It would run up to you and immediately begin rubbing on your pant leg, purring at an improbable volume for such a small creature. And in the way of cats who hone in on the least cat friendly person in any given crowd, he took a special liking to my father.

Winter can hit quickly in Saskatchewan and it can hit hard. After gentle badgering from the rest of us my father allowed the kitten to come into the detached garage and began to feed him there. He did this himself, saying he was in there all the time anyway. Sure, it was a nuisance, but not much of one. But the kitten was only to be allowed into the garage, nowhere else. Certainly not the house.

Somewhere around this time the kitten acquired a name. We called him "Mook" because my mother said that that was the chirping sound he made when he head-butted your hand, "mook, mook".

I imagine that many of you have already worked out for yourselves where this story is going. You are absolutely right. As winter set in the garage became quite cold as well. My father said, "Ok, the cat can come into the house, but only the basement. Nowhere else." Our basement stairs had a door at the top, so in theory it was relatively simple to keep him down there. Mook would however cry pitifully from behind the door. So soon my father said, "Well, during the day Mook can come up on the main floor, but at night he goes down. And he does not go into the bedrooms or my study."

A few weeks later I came home early from a Saturday running errands in town. My mother and brother were still out. When I came in the front door I heard an odd sound coming from upstairs. It was a shuffling and scraping noise and the sound of my father chuckling, although he was home alone. I went upstairs and saw that the door to my father's study was open. I peeked inside and saw him on his hands and knees, playing with Mook, both of them delighted.

I started veterinary school two years after Mook came into our lives and he was my constant study companion. He knew exactly where to lay on my desk where I wouldn't shoo him off. He made some of the abstractions that were being taught seem more real and he was a source of comfort when I was stressed.

In 1990 I graduated and moved to Winnipeg. Although I called him "my cat", Mook was really more my parents cat, so there was no question that he would stay. He continued to have adventures on the acreage including being quite seriously injured when he was either hit by a car or fell out of a tree, we're not sure which. My mother was visiting family in Germany when this happened, so my father nursed him back to health, giving pills, changing bandages and phoning me frequently for updates and advice. My father had never phoned me any other time for any other reason. Something shifted between us when he did this. Two adults talking together, needing each other. He passed away in 1994 from a brain tumour.

Then in 2002 my daughter Isabel was born. Mook was quite old by that point - I suppose 18 when I do the math. During one of the first visits with the baby to Saskatoon Mook padded into our room and clambered up onto the bed, where I was holding Isabel, trying to settle her to sleep. Mook curled up beside her, purring. I remember so very clearly how grateful I was to him and how strongly I felt the connection from Isabel to my father through this cat. A living link. I couldn't stop myself from crying.



Thursday, October 26, 2017

A Duck Tale





    His name was Puddles. His photo still hangs on the wall above my desk. Our relationship began, like so many, with a phone call from a client.
    "Philipp, Mrs. Wickland is on the phone. She wants to know whether you'll see a duck."
    This immediately got my attention. To be honest I sometimes only half tune into what I'm being told as I attempt to catch up on my office work by ineptly multi-tasking. I put down my pen and turned to face the receptionist.
    "Did you say duck?"
    "Yup, a duck."
    I picked up the phone.
    "Hi there, Dr. Philipp Schott speaking. I understand you have a duck now?"
    "Yes! His name is Puddles! I got him from my daughter. The house was so empty after Al and Bandit died."
     Al was her husband and Bandit their dog. Al was an interesting guy and was one of my favorite clients. He was short and round and had a gravelly voice. He was probably in his sixties and you could tell he used to be quite muscular. He told me that he had once been a biker and that if I ever needed help dealing with a difficult client I should ask him because he "still knew some guys" who would straighten things out. I limited my response to a smile and a nod. He also wanted to know whether he could volunteer to walk dogs for us at Christmas. We didn't have any patients stay over that Christmas and then Al died of cancer the next year.

     It turned out that there was nothing wrong with Puddles and that Mrs. Wickland just wanted him to get a checkup. So I read up on ducks as best as I could in advance and then on the appointed day Puddles waddled in the front door, herded gently by Mrs. Wickland. Puddles was a standard white farm duck. Have you ever been up close to one? They are surprisingly large. He was easily ten pounds and when he stood tall he reached halfway up my thigh. Now imagine the scene in the waiting room. A half dozen clients, a couple dogs, a couple cats and in walks a duck. You could pretty much see the pupils of the cats eyes dilate from across the room. The one dog was indifferent while the other, a little Cairn terrier, began barking furiously until the owner settled him down. Puddles was as cool as a proverbial cucumber. He ignored everyone, let out a few soft quacks, strutted (a waddling kind of strut mind you) about the waiting room and generally assumed the air of having claimed the place.

    The examination went well, despite Puddles's clear indignation at aspects of it, and I was able to pronounce him healthy, although I was at pains to make it clear to Mrs. Wickland that I was far from being a duck expert. The years went by and Puddles came in regularly for his check ups and once or twice for relatively minor foot and skin issues. I always looked forward to his visits. I shouldn't play favorites among my patients, but he definitely was a favorite. He was treated like a rock star by the staff and the other clients and his arrival never failed to spark delighted gasps.

    Then one day Mrs. Wickland called to say that Puddles wasn't well. He had been eating less and less and his bowel movements were much wetter than normal. When I looked at him it was obvious that he had lost weight and he wasn't nearly as feisty as he usually was. Also, it became clear that it wasn't watery stool she had seen, but excessive urination mixing with the stool. We ran some tests and determined that his kidneys were failing. He was eight years old at that point, which is elderly for a duck. We struggled along with a few attempts at treatment as Mrs. Wickland wasn't ready to say goodbye yet, but nothing made any difference. With tremendous sadness one blustery March day we let Puddles go.

    Spring is a busy time, so despite his celebrity status I soon stopped thinking about Puddles until six months later when Mrs. Wickland phoned. I hadn't spoken to her since the day of the euthanasia. She had trouble keeping the emotion out of her voice, but she wanted reassurance that she had done everything she possibly could for him. She missed him terribly and she always would. Love is blind. It is blind to gender, colour, age, shape, religion, and it is absolutely blind to species.

    

Thursday, October 19, 2017

At The Very Heart Of It All


I've been in practice for 27 years. When I'm asked what the biggest change has been over that time I sit back, rub my chin thoughtfully, adopt my best wise old man tone, pause dramatically and then quietly say, "techs". Not all the new drugs - in 1990 we had hardly any pain medications we could send home. Not all the new in-house lab equipment - in 1990 we sent most samples away and waited a day or two for results. Not all the new diagnostic imaging equipment - in 1990 ultrasound was not generally available and xrays were developed in a dark room with dip tanks of stinky chemicals. Not all the new dental equipment - in 1990 I used a hacksaw blade to cut apart large teeth that needed to be pulled. Not all the new knowledge, not all the new techniques, not all the new computerization. None of that. These things are important, crucial even, but the most pervasive change that has touched every aspect of veterinary practice is the role of the veterinary technologist (aka RVT, aka registered veterinary technologist, aka animal health technologist, aka veterinary nurse, aka tech).

To put it simply, since I began in 1990 techs have moved from being overqualified, underutilized animal holders and kennel cleaners, to being at the very heart of almost every small animal practice. In 1990 many veterinarians simply trained people in house to perform whatever simple technical duties the veterinarian didn't want to do himself (and it was usually a himself, not a herself, in those days). The actual college trained vet techs did very little more than these informal techs, which was a demoralizing and frustrating situation that contributed to a high rate of turnover and burnout. Looking back it was a bizarre situation. As the veterinarian I took most of the blood samples, placed most of the IV catheters, took most of the xrays, induced most of the anesthetics and cleaned most of the teeth, even though the college trained techs were perfectly qualified to do all of this. I was basically an expensive (although not that expensive in those days...) tech for about half my job.

Today techs do practically everything except what the law reserves for veterinarians: diagnosing, prescribing and operating. Today, in our practice, techs take every blood sample, place every IV, take every xray, induce every anesthetic and perform every dental prophy and cleaning. Moreover, they command an in-house laboratory that looks like a miniature version of NASA Mission Control, they perform blood transfusions, they hook up ECGs, they monitor and care for critical hospitalized patients and they counsel clients on weight management, behaviour, post-operative care and a host of other subjects. And they do it all well. Very well. Each one is a medical nurse, an ICU nurse, an emergency nurse, a surgical nurse, a laboratory technologist, a nurse anesthetist, a dental hygienist, an xray technologist, a neonatal nurse and a palliative nurse... All of that, and more.

In 1990 I could do absolutely everything in the clinic. I knew what every knob on every piece of equipment did and I knew how to make it do that. I knew exactly how to get blood on every patient (well, almost every patient) and I could wield every instrument and administer every treatment. Today I am more or less useless. Ok, I'm exaggerating for effect. More accurate is that I am useless without my techs. Absolutely useless and helpless.

Most clinics are designed with a large room in the centre called the treatment room. This is where all the action happens. It is the physical heart of the clinic with the laboratory, patient wards, anesthetic prep area, operating room, pharmacy, dental area and xray suite radiating from it. And at the heart of this heart - at the very heart of it all - are the techs. Thank you Jen, Kim, Mela, Brandi, Marnie, Melissa, Jamie and Jasmine. Thank you for making me so much less useless. 

Thursday, October 12, 2017

The Firehose and The Pudding



Most people are looking at this title and are thinking to themselves, "That's weird. Firehose? Pudding? How do these relate to each other, or to pets or veterinarians?"
On the other hand, people who work in vet clinics are groaning lightly and facepalming because they know exactly what I am going to write about. I am going to write about diarrhea. And I'm going to try hard not to be too gross about it. It's tough for me, but I am going to try hard.

Even though it may seem obvious, let's start with a definition. From a medical perspective, diarrhea is stool that has enough liquid in it that it can no longer keep its happy log shape. A single abnormal one could be a fluke, but if it happens more than a couple times in a row, we can properly call it diarrhea. And if you want to get all nerdy technical about it you can refer to the "Bristol Stool Scale" and score the poops from 1 to 7:
https://en.wikipedia.org/wiki/Bristol_stool_scale
(Note that where it says "lacking fibre" for stools scoring 5, this just applies to humans. In animals I would consider 5 to be borderline diarrhea.)
6 is what we sometimes refer to as "pudding" and 7, if it is sprayed out, is "firehose". That's it for the gross bits! All done. You can read on safely now.

Once you know your pet has diarrhea there are really just two important questions we need to consider:
1) How long has it been going on?
2) Does your pet have any other symptoms, or is she otherwise happy and normal?

To the first question, we're only going to talk here about diarrhea that has been going on less than roughly two weeks. This is acute diarrhea. The word acute sometimes confuses people as some believe it means severe, but it doesn't, it just means recent onset. Chronic diarrhea is due to a whole other set of causes, needs different tests and has different treatments. Fortunately it is relatively rare, while acute diarrhea is extremely common.

If the only symptom is diarrhea and there is no vomiting, lack of appetite or lethargy, then you can follow the advice here or just phone or email your veterinarian for their advice. There is no need to rush Billy-Bob down for an urgent examination. If, however, any other symptoms are present, then it's best to get him checked over.

Before we get to what to do, a word about causes. Acute diarrhea in previously healthy pets with no other symptoms is almost always due to either a virus or what we like to call a dietary indiscretion. Even if your pet is not in contact with other animals, viral diarrhea is still possible as these viruses can be found out in the environment and be easily transmitted on their paws (dogs especially) or on your shoes. And dietary indiscretion simply means having eaten something their system doesn't tolerate, like five day road-aged dead squirrel, stuffed pizza crust, nasty random thing in the garbage etc. (dogs especially, again). Keep in mind that what they can tolerate will change over time, so just because Ellie-Mae did well on bacon chips for years, doesn't mean that won't cause diarrhea now.

Treatment for this is usually simple because the body has remarkable healing mechanisms. Often all we need to do is turn off the tap and power down the poop making machine. To do this we need to temporarily replace their regular diet with a low residue diet that produces very little stool and therefore allows the gut to rest and heal. For this you have two options. You can either buy a commercial prescription low residue diet from your veterinarian such as "Gastro" or "I/D", or you can cook for your pet.
For dogs the magic recipe is:

1 part extra lean cooked ground beef (boil or fry and drain until it's just dry meat with no fat), or if your dog can't have beef, use lean chicken breast.
2 parts (by volume, just eyeballing it is fine) boiled white rice, not brown.

That's it! Frequent small meals is best. And no treats or anything else other than water to pass their lips. For cats I usually recommend just a pure lean protein source without the rice, such as canned fish packed in water, or cooked chicken or turkey breast.

Feed this until you've had 48 hours without diarrhea. If it is still persisting after that, please call your veterinarian! There may be no stool at all during this period, but that is not constipation, it is just the result of the low residue diet producing very little waste. Once you're past the two days, mix the low residue diet 50/50 with their regular food for a day or two before switching back completely.

One final wrinkle is that diarrhea that has been going on for a few days, but is not chronic yet, may be persisting due to "dysbiosis", which is both a fun word to say and a useful one to know as it describes an imbalance in the normal gut bacteria. We are learning more and more how helpful the bacteria in our large intestine are. That dead squirrel or sidewalk virus can sometimes lead to a change in that bacterial population that impairs the gut's ability to produce normal stools. Consequently, if a couple days of low residue diet haven't done the trick, your veterinarian may recommend a source of pre-biotic, which is something that feeds healthy bacteria, such as canned pumpkin (weird but true), and/or a pro-biotic, which provide large numbers of the good bacteria. Years ago we used to recommend yoghurt for this, but fortunately there are much better, more dog and cat specific, pro-biotics available now from your veterinarian.

With any luck, ta-da, normal poop! (Ahem, Bristol Stool Scale 3 or 4....)



Thursday, September 28, 2017

Things I Am Terrible At - Part 1


The appointment looked innocent enough, "3:00 - 'Count Basie' Simmons - collect sample". I did wonder briefly what sort of sample, but figured it was probably a needle biopsy of a lump as the techs do all the blood draws.

I entered the room and introduced myself to the owners, an older couple, he sporting a Tilley hat and she clutching a red notebook with "Count Basie" written boldly on the cover. Smiles and solid handshakes all around. There were two dogs in the room, both rough collies ("Lassie" dogs, in case you're not sure).

"The Count has a friend along for moral support," I said, chuckling lightly. I crouched down and invited them both to sniff me.
"In a manner of speaking," Mrs Simmons replied, also chuckling lightly. "Ella is his teaser."

Uh oh.

'Teaser'... My heart dropped. I knew what I was collecting.

Ella and the Count seemed relaxed about the whole thing. Mr and Mrs Simmons smiled at me. Obviously it was my turn to say something.

"So. Um. I am just collecting for analysis then? Or are we... um... using it?"
"To analyze please. He's been a bit of a dud I'm afraid. Such good bloodlines, but no luck so far." Mrs Simmons said this in a pleasant, matter-of-fact tone.
"They said you were good!" Mr Simmons added enthusiastically.
I made a mental note to track down the comedian who told them this. It's not that I am in any way embarrassed by the procedure ("I am a doctor."), it's just that I am not good at it. In fact I am terrible at manually ejaculating dogs.
For example, there was that time with the pretty young woman and her toy poodle stud "Robert"...
God.

But I knew what to do. I excused myself to "get what I need", which in fact was mostly just a few deep breaths and a couple minutes to quickly scan the net and the books for tips. It is not, as the saying goes, rocket science. The procedure is essentially what you imagine it to be. Although a cool dog penis fact, if you didn't know this already, is that they have a long bone in their penis, the "os penis". For real. This makes things easier in some ways. I'll leave the obvious jokes to you.

I stepped back into the room. Gloves, lube, collection vials. Everything ready. I looked at Count Basie and he looked at me. Mr and Mrs Simmons smiled encouragingly. I made sure that Count Basie had sniffed Ella, who was apparently just coming into season, and then he and I began.

(Fade out for the sake of decency and decorum.)

It wasn't working.
Mr Simmons offered, "Maybe the white coat is putting him off?"
I took it off, vowing to myself that that was as far as I would go.
It still wasn't working.
I kept trying, varying rhythm and pressure from time to time, reapplying lube, trying to look relaxed and professional, but the Count just stood there, panting, not even glancing at me. My hand was getting tired.
"Oh dear," Mrs Simmons said, and wrote something in her notebook.
I was determined to succeed this time, but my hand was really beginning to cramp and Count Basie remained as unmoved as a deaf man at a symphony.
"I'm sorry, but this just doesn't seem to be the day," I said weakly.
"Don't feel bad, this happened to the last vet too."

I booked them to try again in a week when Ella was more in season. I knew I'd be away then so they'd have to see my colleague.
"He really is the best at this," I assured them, smiling a wicked little smile to myself.

This xray shows the os penis (running to the left from the point of the arrow, 
crossing the femur), and shows that it can be a hazard as well as a convenience. 
This poor dog has a bladder stone lodged at the right hand end of his penis bone.