Metanoia

Metanoia is a theological term for repentance. It has a very specific Christian meaning: turning from the bad, embracing the good. A complete life is filled with these moments (whether you are religious or not), moments in which we turn and face the right direction…it may be an old direction but it is filled with that hope and substance which characterizes much of our childhood but is lost thereafter. In many cases I think that this turning involves simply remembering. Whether it be a passion, an emotion, a thought, or an inspiration. When I was a young boy there were few relationships I felt more closely than our family pets. When they died, we were in mourning. We gathered around the graves and said kind words, even thanking God for the gift of companionship he had graciously given us through the life of this His creature. These moments of connection were a huge part of my decision to become a small animal veterinarian. It is very simply a privilege to be in the same room with this sort of bond day after day and to have a small part in preserving and enriching it. As with all things though, we can become jaded. We can, and so often do, forget quite easily our joy and inspiration. Our experiences become heavy with responsibility, guilt, or fatigue, prohibiting accurate or original perception. If we are blessed, however, moments arrive unbidden that baptize our imaginations with a sort of Metanoia.

The little dog standing on the exam room table when I walked in was unremarkable. Her owners were a middle aged man and his daughter. The daughter was likely 4 or 5 years old. As I approached my patient I subconsciously cycled through a list of possible responses. Fear, aggression, oblivion, and disinterested delight (the kind of delight which leads a Labrador to knock you on the ground and mercilessly drub you with their tail not because they love you but because they are physically and mentally incapable of doing anything else) are the most common. I was not prepared for affection. The little female looked up at me and then immediately put her front paws on my chest. I was stunned and not prepared for what happened next. After the examination, the little dog proceeded to walk all about the room on her hind legs repeatedly pawing the air. She refused to desist after being petted by everyone in the room except for me. It became obvious that she wished for me to pet her. I did so, and she stood by me until I had discussed her case with the owner and they were turning to leave. The little girl showed great interest in the proceedings and, being 4 or 5, was continually squirming with a mixture of delight and pent-up energy. Her father spoke to her impatiently and repeatedly made her sit quietly in her chair. After they had left, the scene replayed in my mind. In the midst of a moment in which the inexplicable and unearned affection of a beast warmed my heart and restored some humanity to my soul, I watched as one human being was degraded (not abusively in any way…but damagingly nonetheless) by another. I hope that the little girl will not lose her interest or spirit, and I am glad that should this occur there is a very definite chance for metanoia and redemption of that spirit in the form of a little dog who can walk on two legs.

Assassins

Vet enters room and begins examination.
-So how is Coconut Ms. Smith?
-He’s fine. Although he did take a fall the other day because our little dog tripped him up.
-Well that’s too bad, but it does look like he’s doing well.
-He seems to be. You know we just had a dog die.
-Oh no, I’m sorry to hear that.
-Yeah, that little dog tripped him too…but he didn’t get up.
Stunned silence.
-What?
-Yeah, that little dog just trips them up all the time, and this last time our old dog didn’t get up. Just died right there.
-You should have named him Assassin.
-Hey, that’s pretty good. Yeah maybe we should rename him.
Vet finishes exam, and chalks up another first.

Sampson and Solomon

The term “biblical proportions” is used quite often in our culture. Oddly enough, given widespread biblical illiteracy, it is still very commonly understood. It means large, unmeasurable, and cataclysmic on the scale of a tornado or a tsunami. It means the opposite of George Bush’s intellect or Bill Maher’s like-ability. The world of our clinic is not inhabited by dogs and cats of biblical proportions. As with most urban practices, small dogs are usually selected by owners because it is much easier to sit on the sofa next to your Miniature Schnauzer than to peer over the lounging profile of a Great Dane. Solomon and Sampson were exceptions to this rule: Rottweilers, both over 120 lbs, and truly dogs of biblical proportions. I had seen Solomon and Sampson for various things over the past few months, none very serious. The most interesting thing about the visits had been Ms. Dawson. A middle aged black woman with great optimism and bonhomie, her sentences were always punctuated with prayer. While it is quite common to hear the Lord’s name taken in vain, Ms. Dawson’s usage of “God” and “Jesus Christ” was very much in the form of prayer and supplication rather than expletive. She spoke with all the enthusiasm and fervor of an inspired minister. Conversations usually went something like this: “Well Ms. Dawson it appears that Sampson has an ear infection.” “Oh Lord Jesus, Sampson you gonna break me. Solomon get in here, stop lookin’ at that cat and stop pullin on me. Alright…less do what we need to do.” At the end of each visit, Ms. Dawson would reattach leashes to her 100+ lb charges and allow (not that she had a choice) them to pull her down the hallway at great pace and in the circuitous route necessitated by investigation of the various animal curiosities that presented themselves along the exit route.

The 10:30 Monday morning appointment for Solomon that is the subject of this post was different. Solomon  could not lift his head, he quietly mounted the exam table without protest, and with doleful eyes awaited our examination. Ms. Dawson related that he had not been eating for days, had been drinking large amounts of water and urinating frequently and in large amounts (not something an owner is likely to overlook in a dog whose normal urinary habits can be enough to put fear into the hearts of small rodents if caught in a deluge). He had also been generally depressed for that same time frame. A little red flag went up in my brain. Leptospirosis is a disease that we hear about quite a lot when coming through veterinary school. The Kansas State CVM faculty had made a point of hammering into our overfull skulls all zoonotic disease (disease which can infect people), and this was no exception. In animals, Leptospirosis is a particularly nasty spiral bacteria that enters through mucosal (mouth, nose, etc.) surfaces and can quickly cause acute liver and kidney damage and/or failure. In people, Lepto can manifest as meningitis and flu like symptoms or, in a more severe manifestation known as Weil’s Disease, can progress to liver and kidney disease, jaundice and, in 5-10% of those infected, death. Fever with symptoms of kidney infection (drinking and urination of abnormal amounts) should be enough to make any attentive clinician sweat a little when found in large breed, outdoor dogs. I was sweating now. Our dutiful technicians had collected a urine sample, and thus were potentially exposed, before I entered the room. I quickly instructed everyone to don gloves and prevent contact with urine as much as possible for the remainder of the visit. We started Solomon on Amoxicillin at a screamingly high dose and instructed Ms. Dawson to go see her physician immediately. We bleached the hospital up and down, I instructed technicians who had been in contact with urine to seek medical attention, and ran over in my own mind again and again all possible exposures that I myself could have experienced. All in all I felt that the risk to our staff was fairly minimal, but caution was best here.

So feeling a little shaky and with a much higher level of respect for human doctors who, after all, deal with things they could catch from their patients every day, I prepared for my next case. Reviewing the lab work for the next patient, presenting for a “spot on the foot,” my blood ran cold: There on the culture results in front of me were the words Methicillin Resistant Staph. It did not matter that it, in the end, turned out to be a fairly wimpy species of Staph…my foray into the world of human infection had been exciting, and long, enough already and I did not wish to go any further. Duty called, however, and my technician and I courageously gloved up, sedated the rangy labrador, took a tissue sample of the lesion via a somewhat medieval device called a punch biopsy tool, and submitted it for culture. The owner took some convincing that it was not, in fact, a good idea to have her pregnant daughter in close proximity to a potentially flesh eating infection even if antibiotics had been prescribed. No, it did not change our mind that the planned vacation was more for the dogs than for the people accompanying them.

It is one of the little ironies of life that the culture returned several days later as a nasty, but quite treatable, E. coli infection. The intricacies of a fecal pathogen causing tissue infection on the foot are too much for my simple mind…however it did re-enforce an axiom which I try to live by: Don’t step in dog poop.

New Death and Old Life

Ok, I admit I chose the title because it sounded mysterious and paradoxical. Life and Death in the teeny world of Vet med are never too far from my mind, though. It is an interesting fact that while becoming detached from every episode is much easier on the veterinarian, total detachment will not only render them useless to the clients they seek to help but will also cause them to miss a substantial insight into humanity that comes from the relationship between owners and their companions. Poetic moments in life are not to be missed, and few things are more potentially moving than a farewell said to an old friend.

Mrs. Chance is a middle aged woman with a squeaky voice. You know, one of those voices that you just know would benefit from some wd-40. She is the kind of person with whom you could become quite annoyed if your relationship were permanently restricted to phone conversations, as she constantly calls with questions about every detail of whatever case is at hand. Once you have met Mrs. Chance, however, this sort of irritation becomes an impossibility. She is possibly the most diminutive person I have ever met. Her questions are polite and her commitment to following our recommendations unwavering (thus the plethora of phone calls). She is delightful to work with. Over the last few months Mrs. Chance had lost her two most faithful cats, both over the age of 18.  Intestinal cancer claimed the first, and chronic kidney disease the second. I have been there for the final moments in both cases. Mrs. Chance is not emotional. She quietly says her goodbyes and then unobtrusively leaves when all is said and done. After the last visit, when Mrs. Chance’s cat Celi was finally euthanized after battling kidney disease for some time, I did not expect to see Mrs. Chance for some time.  To my surprise, I was called to the front desk first thing the next morning to see Mrs. Chance. She was smiling sheepishly and holding a picture taken with her cell phone up for me to see. It was a picture of two chics and one unhatched egg in a sparrow’s nest. She said,” I just thought this was neat. You know after Celi.” That was all. I thanked her and said that I was very glad she had stopped by. She left contentedly…I hope she comes back soon with a new kitten.

The Divine and the mundane

Everyone has it. That day when time stands still and the grey hue of repetition overshadows every moment. The things which bring us out of these moods are quite variable. A favorite song, a good memory, a loved one or family member, the list goes on. For me today two things happened almost simultaneously to chase the doldrums away; they were separated only by the thin window of time between afternoon appointments.

Summer is here, and with it a welcomed influx of appointments. Most of these are yearly examinations. Pets are examined, vaccinated, tested for various parasites and laboratory discrepancies, and clients’ questions are answered in as timely a manner as possible. While there is a great deal to be learned and to know about vaccinations and physical examinations, and one of our greatest joys is seeing clients and helping pets, we as veterinarians are not immune to the stagnation of appetite and enthusiasm that accompanies repetition. I was in just such a mood when I entered the first exam room and found two owners, one technician, and one very large frightened black laborador awaiting me. The clients had already drugged the animal heavily before coming in. And yet, with enough sedative on board to anesthetize another dog of similar size, Ace was watching the exits, as well as his antagonists, with hawk-like precision and anticipation. My technician and I began the arduous task of hoisting Ace onto the table where he proceeded to run in place for the next 10-20 seconds, and evacuated his bladder to boot. When a 107 lb dog wants to get off a table and is willing to do almost anything to accomplish that feat, even small animal veterinarians start using words like “snubbing post,” “casting ropes,” and “dart gun.” Nonetheless we soon had Ace subdued, and I believe his sedative began working a little more potently. He quietly submitted to the rest of his yearly appointment without resistance. As I talked to the owner, an exquisitely pleasant client, we reached the subject of work places. She indicated that she worked at the local hospital for the mentally disabled and said that when someone complained about anxiety she just told them that they had nothing to worry about because they could be nowhere near as anxious as her dog. A firm belief in Divine irony and good humor creeps up on a bad mood like a tonic after such encounters.

As I rounded on my next appointment my mood lightened further still as in the office door walked one of the most fascinating clients I have yet encountered. She was a short woman of wide stature. Her dog was a young female Tibetan Terrier. My previous encounter with the woman now standing in the examination room had ended in her confiding to me that the last time she had picked up her dog from the groomers, she (the dog) had purposefully placed her head along side her owner’s and very audibly said ,”Hot” in response to her (the owner’s) queries about her time at the groomers. I was filled with optimism about what this visit might hold. As I examined the dog, I realized something. Listening to the owner for any length of time was very much like listening to a person with a secret they desperately wish to tell you and yet also desire to keep a secret. Perfectly normal phrases and topics would role off her tongue one after another and then, without warning, she would inform me that she and her beloved Tibetan had been discussing the weather the other day and had decided that rain was in the forecast, she even repeated the,” HOT” story that I remembered from before.  The phrases that a listener might consider abnormal were carefully hidden in and amongst long and painfully normal conversation. I decided that it was much like the hidden world of Narnia: A whole world awaiting behind a very normal piece of furniture. It is also the only cure for boredom and repetition with any lasting effectiveness: finding the Divine and supernatural in the seemingly mundane.

An Episodic Day

Have you every felt like a day was made up of individual episodes. Most days, it seems, blend together into one long phrase. There are days, however, when so many strange, bizarre, or mentionable encounters occur in an 8 hour workday that instead of blending together, they all seems to stand out and remain fresh and clean. Today, there were three notable encounters:

First, an old black man whose dog we have been treating for non-specific gastrointestinal symptoms came to pick up his now healthy pet. Actually, his mother’s now healthy pet. Typically, at the end of a drawn out hospitalization and diagnostic marathon a veterinarian can feel and be treated a little bit like a credit card company who forgot to mention the “hidden fees.” It does not change a thing that these fees are typically “hiding” on the estimate sheet you printed out for the client before they left. Mr Dire and his family were quite different. They never even mentioned cost. Nor are they an obviously affluent family. Mr. Dire’s mother very simply loves her dog Tiny. Tiny is a lanky husky mix whose voracious appetite was so notable to the Dire’s that when he stopped eating, they rushed him in immediately. When I first spoke with Mr. Dire about Tiny’s symptoms he said,” You know doc I knew something was wrong. He usually eats everything in site. He’ll even eat tissue papers right out of my mothers hand. You know, she has to hide ‘em. I just can’t help but wondering if that’s got something to do with it?” This became a recurrent theme in our conversations. Every time I called the Dire’s with an update on Tiny, Mr. Dire would manage to mention that voracious appetite, the dog’s attraction to kleenex, and his mother’s crafty efforts to keep them from Tiny. All the while, plying me with the constant suspicion that that had something to do with this.  Happily, we never had to find out if Tiny had kleenex, or anything else, in his intestines as he recovered. I called the Dire’s when Tiny turned the corner. Mr Dire volunteered immediately,” you know Doc, I do wonder if him eating those Kleenex had something to do with this. He just has such a good appetitis.” I was happy to indulge any hypothesis as the conclusion did not change: Tiny was better. This brings us to today, when Mr. Dire arrived to collect Tiny. He was triumphantly ushered into an exam room where I joined him shortly. We talked through instructions on reintroducing Tiny to food, standard preventative care needs, and what to avoid in the future. Mr Dire began,” You know we have a pecan tree out back. Now Peaches, Peaches don’t eat no Pecans so when I found them hulls up on the porch, I sure knew that it was Tiny eatin’ those things. I just wonder if that had anything to do with this. You know Momma called all her friends and family and they been praying for Tiny. Losing a person is bad enough, but when Momma loses a dog that really upset her. You know Doc, Tiny has such a good appetite, that was how we knew something was wrong. He sho do love to eat those Kleenex from my momma. I just wonder if that had anything to do with this.”

The second episode was much less involved. A middle aged woman brought in her cocker spaniel mix for a recheck of her skin. The puppy was happy and bouncing about with very little resembling any sort of problem at all. I quickly examined the pet, asking questions all the while. The answers I received came as through a fog. The woman slurred her words, made irrelevant and incoherent answers, and frequently avoided my eyes. It was then that my keen perceptiveness, sharpened by years of practice, noticed the full limb cast on her right leg. The pain medication she must have been taking was so effective in removing her from the here-and-now that she informed us that she did not wish her puppy to grow any more and thus was feeding it less and that she would have to endure a mammogram on her knee next week. We very delicately correct her dietary management of her puppy and sent her on her way for her doctors to clear her knee of breast cancer.

Finally, as the clock made its merry way towards closing, and soon after I had treated a poodle for Brillo pad ingestion and subsequent regurgitation, been abused by a Bichon, and placed a rubber drain in a rather large and oozing cat abscess, our breathless receptionist rushed back and handed me a file with a number scribbled on the front.  ”She says her dog is still shaking its head and wants you to call her,” she called, beating a hasty retreat to the front desk. There are few things I enjoy less than calling a client to hear about my failures, usually in a rather meticulous narrative form. Nevertheless, I plucked up my courage and dialed the number.  A rather dazed voice answered. I quickly checked the client name and number to ensure I had not interrupted the mammogram of our earlier client. It all looked right, that is different, and so I proceeded. I asked after young Maggie and her ears. The woman became somewhat shrill and said,” I thought you said Maggie was fine. Please don’t tell me something is wrong with Maggie” I replied that I had thought Maggie fine as well, only to return to my desk and find her name and number and a note to call. ” Well,” she said, ” Maggie’s doing fine, don’t worry about it. You guys are great.” I am still not sure what happened. Miscommunication is one explanation…body snatching is another.

The Lesser of Two Evils

I consider myself a clean person. Some would call me obsessive. When my wife contracted the norovirus at a baby shower, I quarantined her to the bedroom, cleaned all smooth surfaces in the household with clorox-wipes…several times a day, and visited her only enough to give moral support and collect breast milk for our child (with rubber gloves). I allowed her to leave quarantine only after 3 asymptomatic days (the suggested CDC time period for allowing infected workers to return to serving food in restaurant environs). You be the judge.

I was recently reminded of the extreme irony of this propensity when I visited Barnes and Noble over a lunch break. Public places are necessary in an evolutionary sense I suppose, as only those with a strong immune system are likely to survive, but I confess that I do not terribly enjoy them. Nonetheless, I ordered my coffee and sat down to read my book. I was just trying to figure out how to wash my hands without braving the public restroom and before drinking my coffee (hand sanitizer is notoriously unreliable as a disinfectant)  when I happened to glance down at my pant leg. Dog hair, blood stains, and something whose (used in a personal sense intentionally) identity I am still not quite sure of met my gaze. I brushed off my pants and drank my coffee, feeling vastly superior and more contaminated than anyone in the place.

The Burrows

One of the most difficult skills to master as a new veterinarian is the skill of listening and working at the same time. This is not always possible as some situations require focus on one task at a time. Frequently, however, there is a level of listening that can at least decipher the essential from non-essential pieces of a conversation. Thus, when an essential piece of conversation comes along you can stop and listen, if you must. There are times, though, when you simply stop and listen because what you are hearing has nothing to do with the current situation and everything to do with a very interesting human being(s). The Burrows were clients that frequently provided such opportunities. As you listened to them talk, there was a very human fascination which became unavoidable. It was more than what they were saying. It was the synergistic combination of topic, tone, interaction between the two of them, and their general appearance during the whole exchange. Mr. Burrow was a tall dignified sort of person, obviously worn and whittled down from a previous personality type which might very accurately have been described as aloof. The instrument that had done the trimming was Mrs. Burrow. She was small, tiny even, with an exquisitely shrill voice which was paradoxically somewhat “throaty.” She was quite literally an unceasing stream of information: not always relevant, not always interesting, but constant and almost invariably good natured…and constant. There were times when Mr. Burrow would sally forth in an attempt to interrupt or correct his wife; these always ended badly for him. She would respond with varying (except in their success) techniques: usually, her volume would simply increase, her stream of conversation completely drowning and dwarfing her husband’s objections, and Mr. Burrow would return to his corner muttering discontentedly; sometimes, if his point was particularly good, she would gaze up at him for a moment from her 5 ft even vantage point through her inch thick glasses with something like pity in her eyes before returning to her previous topic. The result was always the same. In his own way, I think that Mr. Burrow must have enjoyed the game, having stuck around so long to play it.

I saw the Burrows in the context of their cat Baby. Baby had intermittend vomiting that had been going on for some time (1-2 years). She had been on every imaginable medication. Some had worked for a while and some hadn’t. Understandably frustrated, the Burrows wanted answers and something that worked. Unfortunately, cats with Baby’s symptoms are rarely simple cases. Inflammatory Bowel Disease, Cancer, a host of non-gastrointestinal problems, and/or rare intestinal parasites are a few problems which populate the differential list for such patients. The diagnostics required are expensive, the treatments and diet trials labor intensive, and the results (sometimes) disappointing. It was a mark of the Burrows devotion to Baby and their general bonhomie that they proceeded with my recommendations. In the end, after weeks of testing, diet trials, and treatment, the diagnosis of inflammatory bowel disease was reached. In the course of our time together, I learned that Mrs. Burrow had almost died from liver disease, that Baby still possessed enough vigor to attempt sexual advances on their female cat…daily (a fact that Mrs. Burrows would relate at the top of her shrill voice at every office visit), and that Nestle (the company) was attempting to corner the bottled water market slowly but surely, forcing the Burrows to purchase water from Florida.

They don’t teach this stuff in Vet School.

Supply and Demand

Pharmaceutical companies are the devil. They are also the life blood of medicine of any sort, as they are the only entity with enough wealth and resources in general to produce the many and varied products that have caused the coinage of the phrase “better living by chemistry.” They are still the devil. The most pronounced example of this that I have recently encountered involves the production of insulin. Here, they are cruel in an artistic sense. Imagine an incredibly complex problem, any problem will do. Imagine further that you have slaved over various scenarios that will solve this problem and none quite fit. Nothing will quite solve the dilemma as you want it to be solved, that is, as it should be solved. Then picture a well dressed respectable and trustworthy professional offering you a perfect solution to this problem that has been eating years off your life and adding cortisol to your blood stream. Imagine that you try it, because after all they are well dressed and professional, and it works. It works well, flawlessly, unbelievably. You like it so much that every time you encounter this problem, and even sometimes when you encounter other problems, you use it. Things go along in that “honeymoon” euphoria for a while…for a while. And then, without warning letters appear in the mail with words like “formulation error ,” “production halt,” and “FDA inspection.” Suddenly the “solution” is no longer available and the world comes crashing in. It happens little by little at first, and then all at once. No one blames the drug company of course; only you are exsanguinated slowly and inevitably by angry clients who, like you, have come to depend on this product. Well that’s insulin and diabetes in veterinary medicine in a nutshell. Every time they come up with a great product it is always snatched away when most needed.

As I said, I was recently reminded of this at a veterinary conference in which a boarded specialist in internal medicine spent 45 minutes of my birthday (yes I had to attend continuing education on my birthday) trying to plug the newest catastrophe-waiting-to-happen of the veterinary insulin saga. As temptresses go, she was pretty good. She used phrases like ,” oh don’t worry, this technology is different” and “well you CAN use that old insulin if you want you’re client’s animals to seizure and die, but this one is perfectly safe.” We all fell for it. We always do. We believed her because we wanted to believe her before she ever started talking. Just like children want there to be a Santa Claus, veterinarians want insulin that WORKS. It probably will work, seductively well more than likely. In the end, though, it will be withdrawn, the supply will become limited, or a production error will prompt an FDA investigation. We’ll be angry, stupefied, and outraged…until the next time.

Makes sense…

“So what’s wrong with Mig,” I asked. “He’s had bloody diarrhea for 3 days,” his young owner answered. “And doctor, “she continued,” I just have to tell you everything ’cause it might make a difference. When he was little, he had parvo virus. I went to that emergency clinic but it was just too expensive. So me and my friend, we experimented We got home and asked ourselves what works to kill parvo virus?” I began to sweat. “Yep,” she proudly announced,” we just gave him bleach and gatorade. And you know what? He got better.”