Wednesday, September 7, 2016

Why Hasn't The Doctor Called Me Back Yet!?!?

My father was dying of brain cancer. He had a glioblastoma removed from his left prefrontal cortex and was given months to live. He was a physicist and his intellectual capabilities were unimpaired but his judgment and social graces, such as they were, had been annihilated. Told by the surgeon that they removed the tumour using suction my father delighted in pointing to the large scar on his forehead and loudly telling strangers that his brain had been removed by a vacuum cleaner. There were other surprising moments of levity, but otherwise this was a bleak time. He was too young for this and we were not ready to lose him. Not nearly.

A few weeks after the surgery an issue arose regarding one of his medications. I don't recall which or why, but I do recall being quite anxious about it. It was not an emergency by any stretch, but the problem was beginning to spiral in our minds, so I phoned his oncologist to ask about it. He was unable to come to the phone, so his receptionist took a message. Ten minutes went by, then twenty, thirty, forty, fifty... By the time a full hour rolled around I had checked twice to make sure the phone was working (dial tone? yes) and my pacing had become obsessive. I couldn't read. I couldn't listen to music. I couldn't concentrate on chores. I couldn't think about anything except a recursive loop of 'Why hasn't he called me back yet!?!?'
'It would only take a minute!'
At the two hour mark my tone had darkened . I was much quicker to anger in those days.
'I can't effing believe this! He can't find a minute to help a dying man?'
'The arrogant prick!!'
I was beside myself. I left another message, trying to make my voice sound like cold steel, gleaming with sarcastic fury.
But at least another hour passed before he called. When he did his tone was disarmingly pleasant and empathetic. He took the time needed to properly answer my questions and the problem was sorted.

All these many years later I still cringe when I think of how I reacted that day. I cringe in part in recognition of the different person I was then and I cringe in part in imagining how my own clients must sometimes feel when I am slow returning their calls. I know that most people are reasonable and understanding, but I know that some must be just like I was - in a vulnerable and slightly irrational emotional state or perhaps even just unaware of the workflow in a busy clinical setting.

So for the latter group, it is probably worthwhile explaining the "type of busy" that we often are. In some jobs you can be very busy doing one thing. You have a single important task in front of you that is fully occupying your time, but you can take regular breaks from it to quickly address other matters as they arise. Veterinary (and presumably human medical) practice is not like that. We generally have numerous simultaneous demands on our attention throughout our entire shift. We are constantly in triage mode, figuring out in what order to do things so that the least number of people with urgent problems are left waiting the least amount of time. Moreover, for telephone messages specifically, in some cases it may be a few hours before we even see the message, let alone try to fit it into our triage. Another factor is that estimating the length of a phone call is notoriously difficult, for either the client or the doctor, so we are sometimes unwilling to take the risk and will leave it until a gap opens in our schedule or to the end of our shift. This is almost certainly what happened with my father's oncologist. It was closer to ten minutes than one and he was wise enough to leave it for the end of his day.

So, "How To Contact Your Veterinarian":
- By all means please phone if you have any questions.
- If you feel the question is urgent, tell the receptionist so.
- Ask for a realistic guesstimate on when you are likely to hear back.
- Please make sure the receptionist knows which phone number you can be reached at. Many files list multiple work and cell numbers for multiple family members in addition to the home landline.
- Please make sure you specify if there are times you will not be available to be called back.
- Please use email sparingly and only if you are ok with waiting for a day or two for a response. Sometimes we're quick with email, but sometimes we're not. For a variety of practical reasons it is not given a high priority.

(my dad and my brother, ~1970)

Monday, July 25, 2016

He Ate What...??? (Part 1)

This will be the first in an occasional series of short posts detailing the bizarre things pets will eat. Of course they will also eat terrible and harmful things, but I will stick to the more amusing stories that have a good outcome, so you can happily read without fear of needing to keep a box of tissues nearby.

The most recent entrant into the "He Ate What...???" Hall of Fame was Bouncer Rodgers. Bouncer is an aptly named young black Lab cross who was actually seen by one of my colleagues in the practice rather than me, but I was there and heard everything and I know she won't mind me using this story.

Bouncer was rushed in by Mrs. Rodgers one otherwise quiet Monday afternoon.
"I don't what's wrong with him! He was fine this morning and then just now I found him staggering, barely able to stand!"

Sure enough, although Bouncer could walk, he was extremely wobbly and kept falling over. His pupils were dilated and he had a facial expression that could only be read as pathetic confusion. As Bouncer was young and otherwise healthy my colleague immediately suspected poisoning and told Mrs. Rodgers that the next step was to induce vomiting. Mrs Rodgers readily agreed and the hapless Bouncer was taken into the treatment area to have his stomach emptied.

It's not always that easy to induce vomiting (nor is it always recommended - check with a veterinarian before trying to do it yourself), but with Bouncer it was gratifyingly easy and gratifyingly productive. Out came an enormous wad of green plant material and a small shiny tan coloured object.

Marijuana and a condom.

My colleague debated briefly how to present this information to Mrs. Rodgers, a conservative looking middle aged woman, but decided that the direct approach is always the best. There was a moment of silence as Mrs. Rodgers processed this. After being reassured that Bouncer would quickly make a full recovery her facial expression changed from concern to bewilderment to dawning realization to anger in a matter of seconds. It was like watching time lapse video of weather systems.
"My son! My son's room is in the basement. Bouncer was down there this morning..."

An hour or so later a very tall, very skinny, very ashen faced red-haired teenager came in to check on Bouncer. He didn't say anything to his mother and he studiously avoided making eye contact with any of the staff...

Thursday, July 7, 2016

Be Kind To Your Veterinarian

I came into this profession because of the animals and I have stayed because of the people. Not that the animals have become any less enjoyable, far from it, but because the people have become more enjoyable. Or perhaps more accurately my capacity to enjoy the people has improved. Regardless, it is the interaction with clients that "makes or breaks" most veterinary careers. So in aid of this, here is a list of the top seven ways clients can be kind to their veterinarian and improve that key interaction (listed from silliest to most serious):

1) Please do not talk to me while I am using the stethoscope. It is a listening device. I cannot listen to two things at once and make reasonable sense of either. 1 + 1 = 0. For the play along at home version, try following what your friend is quietly saying on the telephone while your toddler simultaneously tries to tell you a story about a problem in the bathroom.

2) Please do not take personal offense if I tell you that your pet is overweight. A client once threatened to punch one of my partners for saying this. It is merely a statement of objectively measurable fact. I am not judging you. I have a volleyball shaped cat. I get it.

3) Please avoid introducing multiple chronic medical concerns in an appointment you have booked for a simple check ear. My schedule is generally full and the receptionist has booked enough time for you for what she understood the visit to be about. Normally I am delighted to discuss the multiple chronic medical concerns, but we do need warning at the time of booking so that enough time is set aside. The domino effect of falling behind because of this can turn a pleasant day (sunshine! bunnies! roses!) into a hellish simulation of a combat zone (darkness! terror! chaos!).

4) Please do not show up at random hoping to catch me "when I have a minute" to ask me some questions. I never have a minute that is not scheduled (see above). And we are too polite to tell you that, so I will squeeze this conversation in and fall behind in my appointment schedule (see above again). Please make an appointment, leave a phone message or email if you have a question.

5) Please do not ask me why I can't figure out what's wrong with your pet moments after you've declined most of the tests I've recommended. For every set of symptoms and physical exam findings there are dozens of possible causes. My crystal ball is broken today. In fact, it is broken every day and I see little chance of it being fixed any time soon...

6) Please do not confuse anecdotes with statistics. Making decisions about your pet's health based on anecdotes would be like me taking up heavy drinking and smoking because my grandfather drank an entire bottle of wine by himself every day and smoked steadily and lived in great health to 93 years of age (a true story actually). So when I say, "vaccinations are proven to be very effective at preventing disease" (statistic), do not reply with "our farm dogs never had shots and they got pretty old" (anecdote). Statistics get a bad rap when they are used to mislead, but without them we'd still be chanting and sacrificing chickens whenever anything went wrong.

7) Please do not bring me your pet when you've already made up your mind to euthanize, telling me that you've "tried everything" when what you've actually done is "tried everything you and your neighbour whose daughter used to work at a kennel could think of and everything on the first page of Google hits". Maybe I could have helped if you'd contacted me much earlier before things went this far, or maybe not. We'll never know now will we? This makes me very sad.

And who wants to be sad?

Fortunately the above applies to a small minority of clients, so I'm not sad very much. And I've never been punched by a client. And I only drink part of a bottle of wine.

Monday, June 20, 2016

When The Sky Goes Boom

Eddie sat beside Mr. Parker and looked at me expectantly. Expectantly because I had already give him three of his favorite liver treats. 'If three, why not four, or even fourteen?' he seemed to be thinking. Regardless, he did not look especially nervous or anxious today.  However, two days prior this 30 kilo lab border collie cross put a dog shaped hole in the Parkers' kitchen screen door. Then he ran flat out for at least four kilometers, through the hammering rain and deepening mud. The Parkers found him several hours later, limping down a grid road, panting, bedraggled, exhausted. They brought him in to get him checked over because he still had a bit of a limp and because they didn't want this to happen again. Eddie had a storm phobia and it was the start of the summer storm season.

Many dogs have storm phobias and noise phobias. These are actually two different things, although there is considerable overlap. About 90% of storm phobia dogs also have a noise phobia to sudden loud sounds such as fireworks and cars backfiring. Curiously, the reverse is only true 75% of the time (noise phobia dogs who also have a storm phobia). Many also have other anxieties such as separation anxiety, but certainly a large number, like Eddie, do not. There is evidence that storm phobic dogs may also be reacting to the change in atmospheric pressure and to the flashing light in addition to the noise of the thunder. It is well known that dogs can hear the thunder approaching long before we do. This is a key part of the problem as many anxieties are worse when there is a wind up anticipatory phase.

I talked to Mr. Parker about three types of solutions: training, tricks and drugs. Most of the time you have to use at least two out of the three. Eddie needed all three.

Training is the best long term solution if you can get it to work. The chances of success are higher if you can consistently put the time needed into it. That said, I don't judge people who are unable to. My own dog still chases cars, steals entire cakes and barks at the vacuum like its the anti-Christ. There are a few training approaches, but the one I like best is counter-conditioning. For this find a long thunder storm sound clip. Start to play it very quietly and briefly while feeding your dog treats or his meal. Keep it below the level that sparks anxiety. Over time gradually increase the volume and duration, but always backing off immediately if he shows any signs of being worried. You are trying to create a deep association between a temporary bad thing, storms, and a permanent good thing, food. For most dogs the goodness of food will overpower the badness of storms, just so long as you take an extremely careful and gradual approach. This is best done well before storm season.

The tricks are fun. Get out you credit card and start surfing:
There are Mutt Muffs to block sound:
There are ThunderHuts, also to block sound:
There are Doggles in case the lightning flashes are part of the problem:
And there are ThunderShirts, to calm by creating a secure feeling "hug":

Of these I have only seen the latter in action. My observation has been that the ThunderShirt seems to help many dogs, but that's it's unusual for it to be the sole answer. Looks cool though. Especially when matched with doggles and mutt muffs. A cheap DYI solution is to let the dog tell you what reduces the noise and flashes for him. This means leaving all your (inside!) doors open and letting him find a bed to crawl under or closet to stuff himself into.

And then finally the drugs. Some clients glaze over for all the above and radiate a strong "just give me the drugs" vibe. There are several but none are perfect and all require you to be very watchful of the weather forecast as they won't work once the anxiety is already building up. It is good to have some medication on hand for when you know that a storm is predicted later in the day. Most drugs are given an hour or so before the expected onset of anxiety. In severe cases it may even be worth having anti-anxiety meds prescribed to be given on a daily basis right through the storm season. Regardless, talk to your veterinarian as there is definitely no "one size fits all answer".

Ultimately some counter-conditioning, a ThunderShirt and an alprazolam prescription were the ticket for Eddie. He had a great summer until they went camping in an aluminum trailer and were caught in a hail storm...

Monday, June 6, 2016

An Open Letter To The Client In The Park Whose Name I Forgot

Dear Client,

It will come to me. Just give me a little longer and it will come to me. But in the meantime I do apologize. It was clearly awkward for both of us. You saying a friendly and hearty "Hi Dr. Schott!" and me an, I hope, equally friendly but unfortunately slightly less hearty "Hi.....!".

I recognized you for sure. I just couldn't remember your name. Or that of your pet. Or pets. Or their species. Or whether they were still alive. So I had to substitute "How's insert name of pet(s) here doing?" with "How are you?", which is ok, but not as good. I wish you had your dog(s) with you. That would have helped jog my memory. Should that have been a clue? Maybe you don't have dogs?

But the awkward bit was when it was obvious after you stopped to chat that I should introduce my family. This is when I could tell from your face that you realized I didn't remember your name. You're a kind and understanding person so you weren't hurt or disappointed, rather you felt bad that you put me in the position of having to try to remember. And I felt bad that you felt bad on top of the feeling bad that I couldn't remember. And now you probably feel bad that I felt bad that.... Never mind.

So here's the thing. I'm sure that you are smart in addition to being kind and understanding, so you know this already, but it still bears explaining. The thing is that you have a box in your brain marked "veterinarian" and another marked "dentist" and another marked "piano teacher" and so on. Each of these boxes contains one, or perhaps at most a handful, of names and faces. Pretty straight-forward to connect those names and faces. I have a box in my brain marked "clients". It contains upwards of 6,000 names and faces.  I have a decent memory, but... Well, you get it.

What you might not get though is that you don't even necessarily want to be one of the names I can connect to faces. Just like with a newspaper where far more bad news gets printed than good, far more names connect to faces when they are associated with something bad. It's just more memorable.

So, if I do remember your name it often means one of two things:
(a) You are one of those wacky clients staff talk about all the time.
(b) Your pets are way too sick way too often.

In other words, you should feel really good that I didn't remember your name. But give me a bit more time and I will remember. It's on the tip of my tongue. Just like when you're trying to remember that actor who was in that movie with what's-her-name who use to be married to what's-his-name in that other movie, you know? Right? Yes, that one.

Once again, my apologies.


Dr. Philipp Schott BSc DVM

Thursday, May 26, 2016

There Are Worms In My Heart

Ok, not technically right in the heart itself, but more on that later. And not technically my heart, at least probably not, but more on that later too.

It is "Heartworm Season" in Manitoba. Yes it is. If you work in a veterinary clinic it is unmissable, unmistakable, unforgettable. It's not that our wards are packed full of dogs sick with heartworm disease, rather it's that the testing for and prevention of has to occur in a fairly narrow calendar window. Compounding this, for most people it's convenient to get all the other annual stuff done at the same time since they've dragged Fido in anyway (incidentally, no actual dogs are named Fido, or Rover, or Rex, or Spot; some cats are though). Consequently most of us see as many patients in a week in the spring as during a month in the winter.

I don't want to waste time spewing Basic Heartworm Facts. You can get those from, gulp, the internet (try or, better still, from your friendly neighbourhood veterinarian. Some of you even are "your friendly neighbourhood veterinarian", in which case said spewing would be even more time wasting. Instead I want to touch on a few of the more unusual Cool Heartworm Facts (ok, some of you will consider these Gross Heartworm Facts, but I think they're cool).

Cool Heartworm Fact #1
Heartworm has probably been around forever (or a very long time that may as well be forever) with possible reports in the 1500s. It was first positively identified as such in 1847 in South America and then 1856 in the southeast USA. It has gradually been spreading north and west since, arriving in Manitoba in the 1980s.

Cool Heartworm Fact #2
However, despite that spread, large areas such as Saskatchewan, the Arctic and the West Coast do not have it. Not necessarily because of a lack of mosquitoes, but because of a lack of positive dogs already there. Mosquitoes are just flying syringes moving heartworm from one dog to another. This is why the mosquito paradise of northern Manitoba is heartworm free.

Cool Heartworm Fact #3
Heartworms can be huge, up to 35 cm / 14 inches. And they can be numerous, with infestations of over 100 worms reported.

Cool Heartworm Fact #4
The above reported size and numbers are very rare, so most of the time "heartworm" is a misnomer. Most of the time the worms are hanging out in the pulmonary arteries leading away from the heart. Only if there are more than about 25 do they actually back up into the heart. But pulmonaryarteryworm is so much more unwieldly. Unless you are German like me, in which case you prefer more accurate long unwieldly words.

Cool Heartworm Fact #5
Wildlife can get heartworm. Logically foxes, coyotes and wolves are most at risk, but it has also been reported in bears, raccoons, leopards, sea lions and, oddly enough, beavers. Cats and ferrets are at some potential risk as well depending on where you live, but that is a big subject best addressed separately.

Cool Heartworm Fact #6
Perhaps the coolest fact. Humans can also get heartworm. Heartworm positive mosquitoes bite us all the time and release microfilaria (baby heartworms) into our bloodstream all the time, but fortunately we are not good hosts so 99.9%  (and probably a few more 9s after that) of the time they die. However, there have been at least 80 cases reported in humans in the US, mostly in the lungs but occasionally - shield your eyes if you are squeamish - the eyes and the testicles (!). These have mostly been mild infections. The main problem is that on lung x-rays a heartworm lesion looks very much like a tumour, prompting further invasive tests. Radiologist call it a "coin lesion". So if you overhear the interns whispering about this while they shoot sideways glances at you, ask about heartworm...

Thursday, May 5, 2016

So You Want To Be A Veterinarian

Veterinarians love animals. This is a fundamental axiomatic truth, much like pilots loving airplanes, chefs loving food and librarians loving books. Given that the love of animals is widespread, the ambition to become a veterinarian is widespread as well. This spawns tremendous competition for the few spots in the veterinary schools, meaning that very high marks are required to get in. Consequently, and quite logically, it is animal lovers with excellent grades who populate the ranks of future veterinarians. But sometimes a third essential ingredient is missing. In fact, this ingredient is rarely even discussed, but it is the one element that more than any other determines whether these keen and idealistic students ultimately become happy veterinarians who maintain some of that keenness and idealism or whether they become disillusioned veterinarians who burn out and succumb to cynicism and regret.

That third essential ingredient is a love of people. The same high marks would easily get any prospective veterinary student into human medical school, but for many this is ruled out not just by the pull of their love for animals but, unfortunately, by the push of their, shall we say, discomfort around people. This is a problem. I tell every prospective veterinary student that comes through our clinic that veterinary medicine is not an animal business that happens to involve people, but a people business that happens to involve animals. I tell them that the sooner they understand this and accept this and embrace this, the sooner they will come to love their profession.

And why is that? The answer should be obvious. Until the dogs and cats and guinea pigs and rabbits and all others come marching in on their own replete with the ability to talk (and pay) we will have to work through their owners and keepers and guardians. You can only help animals by communicating clearly and empathetically with people. Moreover, even when this miraculous Dr. Dolittle day arrives we will still have staff to deal with. And staff are most assuredly people.

I have been chair of our professional disciplinary body for a number of years and can attest without a flicker of hesitation that far far more veterinarians come to grief through an inability to connect with people than through any failings in their surgical skills or medical knowledge.

And once you "get it" you see how fabulously interesting people are in all their freakish variety. And you see that we are a privileged profession as we are permitted to help people who are ironically often at their most human around animals. I remember with startling clarity the specific moment when this dawned on me. I was just about to enter the clinic through the back door. It was a sunny summer morning and as I opened the door I realized for the first time that I was looking forward to seeing the clients who were starting to become my regulars as much as I was looking forward to seeing their pets. It was at this moment that I decided to stay in practice and not go back to school to pursue research, which had been my original plan.

But all that said, the love of animals is still at the heart of things. I often think of a card we got many years ago from a young child who boldly wrote "I want to be a vat!" Yes, I too once aspired to be a large container, but I became an animal doctor instead and I have never regretted that decision.