Thursday, February 22, 2018

The Naming

One of the unsung minor perks of being in small animal practice is the exposure to the ever-changing landscape of pet names. This might not seem like a "perk", but I enjoy learning the names and, for the unusual ones, asking how they came up with them. For obvious reasons people allow themselves far more latitude for creativity with pet's names than with their children's. That said, there is also a lot of overlap and there has been more than one family where I have had to be very careful not to refer to the dog by the daughter's name because, honestly, Bailey is a far more common dog name than human name (with all due respect to you wonderful human Baileys out there).

The range of pet names is breathtaking. I normally change all the names in the blog, but for the purposes of this discussion I'm sure nobody will object if I just list the names of all the animals I saw at work yesterday as an example of what I mean:
Tikka, Snerkle, Junie, Gunner, Silvester, Kayne, Kirby, Annabell, Maggie, Milkshake, Poppy, Stewie, Ben, Wimbley, Rico and Castle.
This is absolutely typical. Nothing crazy, but clearly a lot of thought and some creativity there. And each of them an individual perfectly suited to their name.

Some common names are presumably easy and quick to give - Tigger for a tabby cat, Blackie for a black Labrador - but many probably involved a lot of debate in the family. For those of you for whom this was the case, isn't it interesting how a name that was so difficult to come up with, and that you were a bit uncertain about at first, now seems so inevitable and perfect in retrospect? This even happens for objectively inappropriate names. I had a cat patient named Bob for a number of years. Bob was a girl. They had been told that she was a he when they got him/her and didn't think to double-check. I had to break the news to them when they brought Bob in for the first shots, at which point the name had already stuck. They didn't try to feminize it to Bobbie or Roberta, saying that she still "looked like a Bob". And you know what, they were right. I now can't imagine her being called anything else.

My own dog's name of Orbit came about after trying on several others that just didn't feel right. One day we were watching him rocket around the house in circles and we started saying Sputnik. Yeah, I know, that would have been wrong so many ways, but it did get us going on that theme, from which Orbit emerged. It also helped that he ate everything in sight and that roadside trash containers in Manitoba when we were growing up were called "Orbit", as in "Put your trash in Orbit!" (see photo above). Our one cat, Lucy, was named by my daughter after a second cousin in Germany who had made a strong impression on her. We got the second cat shortly after and Isabel though she should have a German human name as well. For fairness and symmetry you know. Many were considered and rejected until she settled on Gabriella, which instantly became Gabi.

But of course the best part of discussing pet names are the weird ones and the funny ones. Unfortunately although my memory is generally really very good, it has a glitch when it comes to names. They appear to reside in the mental equivalent of a sock drawer. So, while I originally intended to present something like a "Top Twenty Fun & Wacky Pet Names I Have Encountered", sitting here right now I can only come up with three... In no particular order then:

1) Russell Bertrand - As in, the cat's name was Russell and the owner's last name was Bertrand. The fact that this amuses me speaks strongly to my geekness. The reverse, Bertrand Russell, was an important English philosopher, writer and Nobel prize winner who lived from 1872 - 1970.

2) Maximillian Samba-socks - Another cat. I don't know why, but this one still cracks me up years later. Even this bizarre name suited him perfectly. Maximillian Samba-socks could only be Maximillian Samba-socks.

3) Satan - They thought it was hilarious naming their their little black poodle Satan. At least they thought it was hilarious until they found out that he had a habit of disappearing deep into their big yard at night and often had to be loudly and repeatedly called back to the house, "Satan! Satan come here!"

As I can only offer you three of these right now, I will crowd-source a longer list and invite any of my colleagues, or really any readers, to submit their favorites in the comments below!

Thank you!

Thursday, February 8, 2018

Fiddling With The Dials

I remember clearly the first time it happened. It was about two years ago when a good client who I had known for a long time told me that she had heard I was retiring. I was touched that she looked concerned, but disconcerted by the question. Since then I have been asked at least a half dozen times about my alleged imminent retirement.

First things first, no I am not retiring soon. Quite aside from any question about how long I want to work, the plain mathematical fact is that I am very unlikely to be able to afford it for at least another ten years. If I retire now we are moving into a trailer and the kids, and possibly the pets, will have to find jobs. Also, I am only 52 years old after all! Yes, that's right, I said "only".

At first I was quite taken aback by these rumours, thinking that they related to my grey hair and my admittedly at times somewhat haggard appearance. It honestly feels like no time elapsed between the last time I looked too young to be a doctor and the first time I was asked whether I qualified for a senior's discount at Shoppers Drug Mart (to be fair to myself, the clerk was so young that I'm sure anyone over 30 looked impossibly ancient to him). From Doogie Howser to Marcus Welby overnight. And before anyone makes any snide remarks, no, I am too young to have watched Marcus Welby MD on TV - I just happen to know who he is.

But when I calmed down I realized it probably wasn't my appearance so much as it was my schedule. Two years ago I cut back to three days a week. At the same time I adjusted the shifts so that in those three days I work 70% of full-time. I had gone to working four days a week a long time ago and back then the transition from five to four hardly attracted any comment, but at three I seem to have crossed a line. Now it looked to some like I was beginning the process of easing my way out of practice.

That is, however, not the case.

The reason has far more to do with my work-life balance than with my career trajectory. When I worked four days a week the one day off was designated for errands, appointments, housework and childcare. Although both children are teenagers now, both have some special needs that require additional attention. Consequently this day off is as busy as my work days. Therefore I took the additional day off when I turned 50 to have a day to pursue other interests, such as writing, and to go for long walks, and to have delicious stretches of unscheduled unplanned hours. I am well aware that a "me day" like this is a luxury that few people enjoy, and I am very grateful for it. And this finally brings me to my point. My point is that one of the great beauties of veterinary medicine as a career choice is the freedom to chose your hours and thereby also, to a limit, chose you income.

It's like there are two linked dials: one for hours and one for income, and in many multi-doctor small animal practices you have the ability to fiddle with these dials. You want to work less? You turn the hours dial down and the income dial turns down automatically. You want to earn more? You turn the income dial up and the hours dial turns up automatically. In theory you could work as little as eight hours a week or as many as eighty. Not many people have that sort of freedom. To be accurate though, some veterinarians don't either. In smaller practices you may be forced to work full-time just to be able to keep all the shifts covered and for many large animal veterinarians freedom and flexibility, or the lack thereof, is tied to the dramatic seasonality of the practice. But many of us now work in practices where flexible scheduling is possible. For those wanting to start a family this can be very attractive (so long as the spouse earns enough...). And for those greyhairs like me who want to do the things they put off for decades but don't want to (or can't) leave the profession, this can be very attractive too.

Thursday, January 18, 2018

In The Dark

This is not a metaphor. I mean it literally. Ok, I'll confess, sometimes it would be an appropriate metaphor, but that's not what I'm writing about today. Today I'm writing about the curious fact that I now spend roughly half my time at work in a dark room.

After ten years in general small animal practice I could begin to see the rough outlines of burnout approaching on the distant horizon, like a cloud of dust way down a gravel road. I didn't know whether that cloud of dust signified a puttering tractor or a careening semi-trailer truck, but I didn't want to wait to find out. It wasn't anything I could put my finger on, just a growing sense that I needed a different challenge. Don't get me wrong, general practice is extremely challenging, but it is made up of thousands of individual challenges, case by case, that keep you running like a proverbial hamster on a treadmill, but for me there was increasingly no sense of progress on something "bigger".

At around that time we were starting to find more and more uses for ultrasound, but no small animal veterinarians in Manitoba were doing it routinely, so we had to get a human ultrasonographer in who moonlighted going from vet clinic to vet clinic with her portable machine. She was great, but the limitations of that set-up were obvious. Moreover, I found the technology fascinating, so whenever I had time I would peer over her shoulder and annoy her by saying, "That's liver, right?" and "What's that grey bit there? Beside the other grey bit?"

I was not a partner yet, so I approached my boss at the time with a proposal to buy an ultrasound machine for the clinic. It was a very big ticket item and even with creative math I could not make a solid financial case for it, but Bob was a remarkably wise man and could both sense the implications to the practice of my restlessness and see beyond what the immediate numbers showed.

So in 2001 we bought an ultrasound machine and I went to Calgary for a course. It was a revelation. Here was a world I could deep dive into that combined a fun technological toy with live anatomy, physiology and pathology, the subjects I loved in school. Blood tests and urine tests and xrays are cool in their own way, but they are static and removed and abstracted from the animal. Ultrasound was more like an extension of the physical exam. It was a live real-time exploration of the interior of my patients. Another exciting thing about ultrasound for me was how it was turning one of our weaker senses as a species, sound, into one of our stronger senses, vision. With ultrasound I was becoming like a dolphin or a bat and was seeing with sound. The hand-eye-brain coordination was going to take time to get consistently right, but the first few times that that grey mess on the screen automatically crystallized into a 3D organ in my mind were exhilarating. Furthermore, because it is done in a dark room, and because I drone on in a monotone, the animals were usually calm and the whole experience felt soothing and peaceful to me. I was hooked.

Over time I took more courses, in California and New York, but it became clear early on that the key to becoming proficient was case load. You just had to practice a lot. It was more like learning to play a musical instrument or a new sport than anything else I had encountered in practice. So I began to set aside time to scan healthy patients who were in for spays and neuters. This also helped me build up a strong sense as to what normal looks like, as well as how much variation there is in normal.

And then the first referral came in. Another practice across town had heard I was doing this and wanted to send a patient over. I was terrified. I agreed on the condition that the pet owner understood that I was still learning. But it went well and I failed to humiliate myself as expected. And then there were a few more referrals from that practice and then some from a second practice and then from a third and....

In the last fifteen years I have done over 12,000 ultrasound studies for close to 40 clinics from southern Saskatchewan through to Northwest Ontario. Now there are many veterinarians as well as an excellent human ultrasonographer doing it, but I am still busy enough with ultrasound that it takes up about half my time. And I still love it and it is still helping keep the burnout at bay.

Wednesday, January 3, 2018

Begins With The Letter "A"

This post carries a mature content warning. Seriously.


Yes gentle readers, today we are going to talk about your pet's anus. Frightened yet? If so, it's not too late to bail out and check if anything new has happened on Facebook in the last fifteen seconds. But if you're still with me, you're in for a special treat, because we are not just going to be talking about the anus generally. Nope, we're going to be specifically talking about anal sacs.

Most people call them anal glands, but technically they are not glands, so veterinarians are taught to refer to them by their correct name: anal sacs. However, most veterinarians soon encounter the situation I did after just a couple years in practice.
"The problem is with Bella's anal sacs," I said.

The client raised her eyebrows and said with a smile, "You have to be very careful how you pronounce that..."

Indeed.  Naively, I hadn't considered this before. I don't often blush, but this was an exception. Not long after that a colleague told me that he had decided to start an explanation of why there was inflammation around a dog's hind-end by first describing the basic anatomy: "So, your dog has anal sacs..."
Outraged, the client interrupted, "He most certainly does not!"

So be very careful how you enunciate that "a". Or just call them anal glands.

And why do they have these bizarre little structures you ask? They have them primarily to use for scent marking. All carnivores have them. Skunks have the most famous anal sacs, having turned a communication device into a weapon. But for our dogs and cats the stinky secretion contains information about them. What specifically we don't know, but we can guess gender and perhaps some individual identification markers. This is why dogs in particular will sniff poop. They are not necessarily interested in the poop itself, but rather in the bit of anal sac material that it is on it.

This then leads to the question of how they normally empty. They empty when the animal has an appropriately sized bowel movement. The pressure of this passing through the anus squeezes the anal sacs. When this does not happen, perhaps because there has been diarrhea or unusually small stools or just at random in some individuals, then the material can gradually build up and lead to problems. Typically a dog or cat with full sacs will lick at the area or begin to "scoot" in an unmistakable fashion whereby they sit down and then drag their bottom across the ground by pulling themselves along with their front legs. Note: scooting is not caused by worms! This old myth is remarkably persistent.

If they are successful in emptying their sacs by scooting or licking you will know - the smell is memorable. Gram for gram anal sac secretion is one of the most potently vile substances on the planet. However, if they are unsuccessful, you should call your veterinarian. One of the more glamorous parts of our job is to put on a latex glove, apply a little lubricant and "manually express" full anal sacs. And here's the cool part - if your dog has frequent issues with full anal sacs we can teach you how to express them at home!* No medical degree required! It's clearly not for everyone though...

If the sacs remain too full for too long the material can thicken and become difficult to express. This thickened material can also become infected, leading to the formation of an anal sac abscess. Some dogs do not give clear warning signs like scooting so unfortunately the first thing you may notice is blood near the anus when the abscess ruptures. Luckily this is usually easily treated with antibiotics, but it can be an alarming mess in the meantime.

Prevention is of course always better than treatment. There is no fool-proof way to prevent anal sacs from filling up, but adding fibre to the diet can help. A source of fibre, such as metamucil, oat bran or canned pumpkin, can increase the bulk of the stools and thus encourage the sacs to empty naturally. Appropriate amounts vary with the source of fibre and the size of your dog, so check with your veterinarian. Incidentally, we generally do not add fibre to a cat's diet but cats fortunately are much less likely to have issues with their anal sacs. One final note is that in some animals food allergies may play a role in anal sac disease, so ask your vet about that possibility.

I got through that without even telling my grossest anal sac story! I'm proud of myself.

 *What a bizarre world we live in. The "For Dummies" series actually has a tutorial on this:

Thursday, December 21, 2017

Elwood Regrets Nothing

Although he looked dejected, and although he would clearly rather be somewhere else, in his heart I am sure that Elwood was defiant. He had done it before and he would do it again. If his people left a Terry's Chocolate Orange lying in reach again, by George, he would snarf it down again before you could say, "Elwood! Drop it!!" No question. Foil and all. It was so worth it for the three seconds the chocolatey goodness was in contact with his taste buds. Furthermore, it was his Christmas tradition and tradition was clearly important to Elwood. Actually, I'm kidding - just access to anything remotely resembling food was important to Elwood. Forget tradition.

I showed the Sykes the chocolate toxicity calculator* which told us that 157 grams of milk chocolate in a 10 kg beagle translated into 35 mg/kg of the active toxic ingredient, which was in the "mildly toxic" range, likely to produce vomiting, diarrhea, shaking and an increased heart rate. Fortunately we had only seen the first symptom, in part because the Sykes knew their Elwood and had rushed him in immediately after the futile "Elwood! Drop it!!" so that we could induce vomiting and get as much out of him as possible. As an aside, I want you to know that although veterinary clinics can be awash in a potpourri of vile smelling substances, chocolate vomit holds a special place near the apex of the devil's perfumerie. I mention this only so that you know that the veterinary staff also suffers when you allow your dog access to chocolate. But I digress.

So chocolate is poisonous to dogs, this much most of you know. But do you know why it is poisonous? The aforementioned active toxic ingredient is theobromine, which is in the same methylxanthine class of stimulants as caffeine. What makes dogs different is that they metabolize it much more slowly than humans. Cats do too, but they are almost never interested in eating enough chocolate for it to matter as they can't appreciate the sweetness. Because it is a stimulant, at a high dose it can cause severe heart rhythm disturbances and potentially fatal seizures. At about 200 mg/kg of theobromine 50% of untreated dogs will die. Theobromine content varies between types of chocolate, with milk chocolate having the least and baker's dark chocolate having the most. As a general rule of thumb, 28 grams (1 oz) of milk chocolate contains approximately 60 milligrams of theobromine, while the same amount of dark chocolate contains about 200 milligrams and baker's 400 mg.

It may be of interest to note that a recent study of 230 vet clinics in England indicated that the risk of chocolate poisoning was four times higher at Christmas than any other time of year except Easter, when it was two times higher. Curiously, there was no increased risk on Valentine's Day or Halloween (although, mind you, the latter is a much smaller chocolate event in the UK than over here and the former usually involves more expensive closely guarded chocolates).

Incidentally, it is theoretically poisonous in humans as well, although we are much less sensitive. A person my size would have to eat about 4.5 kg of baker's dark chocolate, or an impressive 32.5 kg of milk chocolate to be at significant risk of Death By Chocolate. I would imagine that an array of increasingly distressing feelings would precede the fatal overdose and prevent you from getting to that point. But imagine the obituary...

* Here is the play at home version:
I caution you to please please call your clinic or emergency line regardless though, rather than relying on the online calculator. If you are in a remote location or otherwise unable to reach a clinic you can try to induce induce vomiting by administering 3% hydrogen peroxide at the rate of 1 teaspoon per ten pounds. You will probably need a syringe or a turkey baster to get the poor guy to take it. But he will regret nothing.

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...