When Darkness Overwhelms

(Updated from the original August 2016 post.)

This essay is going to be a departure from my usual lame attempt at a lighthearted tone. This essay is going to be about suicide in the veterinary profession. Statistics are not available for Canada, but in Britain two separate studies found the suicide rate among veterinarians to be four to six times that of the general population and double that of dentists and physicians. The American Centers for Disease Control did a survey of 10,000 veterinarians and found that a shocking one in six had considered suicide. I personally knew two colleagues here in Manitoba who took their own lives, and in 2014, a prominent and very well-liked behaviour specialist killed herself, drawing some media attention to this little-known aspect of the profession.

To the casual outside observer this will be unexpected and possibly even slightly bizarre news. Aren’t veterinarians generally well respected? Isn’t it a secure, interesting and rewarding career? Isn’t it a dream job for so many people? Isn’t it wonderful to heal innocent animals and get paid to play with fluffy kittens? All of that is true. Except the part about the fluffy kittens. Why, then, does darkness overwhelm so many of my colleagues? There are three significant reasons.

The first reason is that veterinary medicine attracts a disproportionate number of idealistic, introspective and sensitive people. Sensitive to the point of neurosis. This is true of all of the health professions, but it is even more so in veterinary medicine. Some of these introspective people are more comfortable around animals than around other people. They do not fully understand that it is actually a people job that happens to involve animals rather than the other way around. Grappling with this reality can be very problematic for some. Add to this the fact that competition to get into veterinary college is extremely high, and success favours perfectionists who can produce high marks. Perfectionism and idealism are fated to be brutally ground down by the chaos of reality in practice. And then their innate sensitivity lays them wide open to the second reason: the inherent and often surprising multi-factorial stress of the job.

Of immediate relevance to sensitive people is the fact that a veterinarian is at times marinated in death and grief. There are weeks — many weeks in fact — where I perform one or more euthanasias each day. Sobbing, crying, wailing, grief-stricken people, some of whom we’ve known for many years, are a routine part of our day. And for those of you who think this is simply a question of overwrought crazy cat ladies or frou-frou poodle people who too much resemble their dogs, I have two things to say to you. The first is that if you have not experienced a deep bond with an animal, then you are missing out on a key human experience, one shared by people from all walks of life, all backgrounds, all levels of intellect. It is one of the richest threads we weave. The second is that you have no more right to judge the grief of someone closely bonded to their pet than a blind man has to judge a photography exhibit. Simply trust me that these are normal people with legitimate and intensely felt grief. Additionally, a veterinarian is expected to be competent across a range of species and a range of disciplines, from dentistry to radiology to dermatology to . . . you name it, wedging the door wide open to so many opportunities to fail. And remember: “sensitive.” Mix sensitivity and failure and see what happens. And I haven’t even mentioned the financial stress of trying to be affordable to clients yet still able to service sometimes enormous debt burdens and meet payroll, etc. Or the stress of being a manager when you went to school to be a vet, not a manager. Or the angry clients. Or the angry spouse, upset because you’re stuck late again.

The third reason is that we know how easy it is. How easy it is to die. Those daily euthanasias are consistently peaceful, painless, quick and reliable. One hundred percent reliable. We know the dose. We know the delivery methods. We have the drug right there. Can you see now why it happens too much?

And to make things worse, this is clearly an iceberg situation, where the suicides are only the visible tip of a massive mental health problem in the profession. According to an exhaustive American Veterinary Medical Association survey, just under a third of all veterinarians have experienced depression at least once since graduation. A smaller Canadian study found that 1 in 10 veterinarians were currently classified as having depression, and another 15% were borderline. Also, a third of veterinarians in that study were suffering from anxiety, and a shocking 47% scored high on measures of emotional exhaustion. Clearly the problems run deep and run wide.

Fortunately, our professional associations are beginning to take notice, and mental health support is increasingly being incorporated into the services they provide. And what can you, the reader, do? You can’t do much about the first and third reasons listed above, but you can definitely do something about the second. If your friend or family member is a veterinarian, do not trivialize their stress. Understand that the real job is far more complex and serious than you imagine. Offer to listen with an open heart. And if you are a client and your veterinarian has done something to make you angry, please recognize their human fallibility and frailty, and try to find a calm and respectful way to address your concerns.

And what about me? Well, fortunately I had a “happy optimist” chip deeply implanted at birth. The zombie apocalypse could roll into town and I would say, “Cool, this will make for some excellent photos!” And, “Maybe brains are better with a bit of smoked paprika?” I have painted a bleak picture when in fact most veterinarians are fine — even better than fine — but burnout is very real, and depression is very real, and, for a small, tragic minority, suicide is very real too. Not only in veterinary medicine, but in society at large, we must work to demolish the stigma that still surrounds mental health. If your leg is broken, everyone wants to talk about it, but if your brain is broken, hardly anyone does. This is wrong, and it is doing so much harm.

This is for Terry and Craig and Sophia.

Snoopy's Magical Digestive System

When I'm in exam room #2 around Christmas I sometimes still think about Dixie Pawluk. I sometimes still think about her even though this was close to twenty years ago, and even though the display of "odd things removed from pets" that we kept in that room appears to have been thrown out, probably by staff tired of being grossed out every time they dusted the jars.

Dixie came in on the first day we were open after Christmas. She was normally a very lively little Cairn terrier - lively even by the peppy standards of the breed - but that day she was quiet. Normally she would run up to me and cock her head with that so, are you giving me a treat? facial expression if I went anywhere near the treat jar, but that day she just lay by Mrs Pawluk's feet and did not look up at me at all. Mrs Pawluk was a widow and none of her children lived in Winnipeg anymore. Apparently she had some friends who she played poker with every Friday night, but otherwise Dixie was by far her best friend and closest companion. She had had a succession of Cairns over the years, but she told me more than once that Dixie was the best of the lot. She often wore sweaters with pictures of Cairns on them. She had a new red one on that day sporting a large tartan applique Cairn.

"So, Dixie's not looking too well today. When did this start?" I asked.

"The day before yesterday, on Christmas Day, she did not want to eat, not even her favourite treat. I thought maybe she just ate too much on Christmas Eve so I didn't really worry, but yesterday it was the same thing." Mrs Pawluk had Parkinson's and her hands were shaking as it was always worse when she was anxious.

"Ok. Has she vomited at all?"

"No, but she does this." Mrs Pawluk mimed a dog opening its mouth open wide, as if to yawn, while stretching her neck out. "There's no sound at first and then a little gag at the end. Do you think something could be stuck in her throat doctor?"

"It's not likely, but it's possible. Did you feed her anything unusual on Christmas Eve?"

I know that a few of my colleagues read this blog and that most of them will immediately recognize my error. Perhaps they're even sticking their arms in the air and saying "oh, oh, oh" like Horshack on Welcome Back Kotter when he knows the answer to a question. In my defense I will remind them that this was a very long time ago and assure them that I definitely learned from my mistake. But back to Dixie.

I was about to ask a few more questions when Dixie stood up and retched a couple times in very much the fashion that Mrs Pawluk described, although the sound at the end was louder, wetter and more violent than I expected. I picked her up and put her on the exam table. Her lungs sounded clear and her belly felt soft and empty, but she had a slight fever. The only other abnormality was that by palpating her windpipe I could get her to cough a little. To allay Mrs Pawluk's worry about something being stuck I opened Dixie's mouth and looked in as far as I could, which was not very far. I put her back on the floor and then sat down on my stool to deliver the verdict.

"I'm pretty sure Dixie has a form of kennel cough. It's unusual for them to go off their food with this, but she has a bit of a fever too so she may have some bacterial complications. It will clear up with time and antibiotics."

"Thank you doctor, I'm so relieved it's nothing more serious!"

Cue ominous music.

I saw Dixie again four days later on New Year's Eve. She still hadn't eaten and she had become increasingly depressed, hardly moving at all now. Mrs Pawluk would have come in sooner, but the weekend had intervened and she wanted to wait for me rather than go to the emergency clinic. Now I was worried too. This was obviously not kennel cough, or any other sort of respiratory infection. We ran blood and took x-rays. One of the nurses grabbed me and said, "Philipp, come and look at this x-ray. There's something weird in there."

Indeed there was. In Dixie's chest, slightly ahead of and above the heart, was a very dense, irregularly shaped object, perhaps half an inch across. It was a piece of bone and it was lodged deep in her esophagus, the tube that leads from the mouth to the stomach. Mrs Pawluk had been right, sort of. Certainly more right than me.

As we were closing for New Year's, and in any case are not set up to provide the overnight care she needed, we transferred Dixie to the emergency clinic. I don't think enough of you are interested in the gory medical details to warrant a complete telling, so I'll summarize what happened next by saying that they ultimately decided to try to remove the bone with a scope. They got the bone, but unfortunately they found a large tear in the lining of the esophagus that could not be repaired. Poor Dixie struggled along for another couple of days, but it was hopeless and Mrs Pawluk had to make the heartbreaking decision to let her go.

A week or two later Mrs Pawluk came in with a thank-you card, that I was not sure I deserved, and to talk. I felt terrible that I had missed the diagnosis initially and she felt terrible that she had fed Dixie pork ribs as a treat. She said that Dixie got rib bones regularly. It was her usual treat for special occasions. She never had a problem before. She had told the truth when I had asked her whether she had given Dixie anything unusual to eat.

Before she left she handed me a small object wrapped in brown paper. It was the bone. I put it in a jar and set it up on the shelf in room two, beside the giant stone that had filled Guido the tiny Pomeranian's entire bladder, and beside the rogue's gallery of pickled parasites. Dixie's bone was there to remind me that I should always ask, "Could she have eaten anything other than dog food?" rather that "Did you feed her something unusual?" It was also there to remind me to tell people that Charles Schultz, bless his soul, did the dog owning public a grave disservice by depicting Snoopy powering through a stack of bones like they were Pringles. But then Snoopy is clearly a magical dog. When your dog starts fighting the Red Barron and decorating Christmas trees we can talk about feeding him bones. Until then, know this: bones can be so dangerous, especially pork and poultry.

To be honest, the bone in the jar was kind of gross, so I understand why it's gone. And I remember these things anyway.

p.s.
Some of you reading this will protest that the dog you had growing up on the farm ate nothing but bones and lived to be 103. Or something like that. This was likely the same dog who never saw a vet, not even once in his unnaturally long life, and the same dog who ran twenty miles through a blizzard to get help when grandpa got his arm stuck in the snowblower. All I can say to you is that I guess they don't make dogs like they used to.

p.p.s.
A small but measurable percentage of you will now have the Welcome Back Kotter theme looping through your brain for the next two days. No, there's really no need to thank me.

Monty's Story

Little gets a veterinarian's attention faster than a person running in the door screaming, "Please help me! My dog collapsed in the parking lot! I think he's dead!!"

One of my colleagues and two of our nurses jumped up and ran out to help. A minute later they came back in carrying a medium sized mixed breed dog on a stretcher. He was not dead. His name was Monty Jacobs and while he was not dead he was clearly in trouble. His breathing was laboured and his gums were pale. Mrs Jacobs was freaking out. My colleague is a very calm person and she was able to reassure her that we would do our best to stabilize Monty and get to the bottom of whatever was going on as quickly as possible. 

Sure enough, 15 minutes later we had a chest xray. The heart looked enormous. 

"Oh no, it's another right atrial hemangio," I said when I was asked to look at it. I was referring to a common cancer that can cause bleeding on the outer surface of the heart. The blood becomes trapped under the pericardium - the membrane that wraps around the heart - which causes the entire heart shadow to appear enlarged on xray.

"Do you have time to do an ultrasound to confirm?" my colleague asked.

"Yeah, I can squeeze it in. Sadly for the dog it's going to be quick as these are really easy to see."

But I was wrong. It was not quick and Monty did not have a bleeding cancer. Monty had dilated cardiomyopathy. Dilated cardi... what? I'll break it down for you. Dilated means what you think it means - stretched out. Cardio means heart, myo means muscle and pathy means disease. Put it all together and you have a disease of the heart muscle causing it to become so weak that it becomes baggy and stretched out.

This made no sense. We only see DCM (the easier to remember abbreviation) in a small handful of specific breeds because it is a genetically determined disease. Monty was maybe terrier, mixed with maybe husky, mixed with maybe German shepherd, mixed with maybe... who knows? A classic "Heinz 57". I was stalling for time by describing some of the less important things on the screen before getting to the inevitable 'why' question when suddenly a little (metaphorical) bell rang inside my head. Bing.

I turned to the owner and asked, "What do you feed Monty?" She named a brand of food I hadn't heard of before and said that it was grain-free. Now I knew.

Last year reports began to bubble up of dogs developing something that looked like DCM but who did not fit the usual breed profile. Individual private practitioners did not detect a pattern because they would only see one or two cases, but cardiologists did see a pattern. All of these dogs had been on "BEG" diets - "boutique", "exotic ingredient" or "grain-free" diets. 

To expand on this a little, by "boutique" we mean relatively small batch foods produced by companies that do not have a certified animal nutritionist on staff and who are not able to do proper scientific feeding trials. "Exotic ingredient" refers to lentils, chick-peas, fava beans, tapioca, alligator, kangaroo, ostrich, pomegranates etc etc. Please know that this is a tiny sample from the list of exotic items that are popping up in pet foods. Unfortunately until this gets figured out everything that was not traditionally fed to dogs needs to be considered "exotic" and viewed with suspicion. "Grain-free" is self explanatory, but read on. 

I know that grain-free diets are enormously popular at the moment, but I have no hesitation in saying that this is a fad built on two fallacies. The first fallacy is that allergies to grains are common. In fact, allergies to grains are quite rare in dogs. Moreover, when there is a grain allergy it is usually to a single type of grain, such as wheat for example, not to all grains. The second fallacy is that dogs are essentially wolves and therefore should not eat grains. Your dog is no more a wolf than you are a Neanderthal (mind you, I'm making an assumption about you). We now know that evolution works much faster than we used to think it did. A lot has changed in their and our biology since those good old wolf and Neanderthal days.

I apologize for the digression. Back to BEG.

Many theories have been put forward as to why some BEG diets are damaging the heart, but as of now (February 2020), nobody knows with absolute certainty yet. Is it the absence of a key nutrient that is in the traditional foods? Is it the presence of too much of something new that was put in to replace the traditional ingredients? The leading theory currently is the latter. There does seem to be an association between high levels of peas, lentils or potatoes and this problem. These have been put in to balance the protein and carbohydrates when the grain is taken out, but may be throwing off the metabolism of specific amino acids.

We expect that only a small number of BEG diets are involved, however that list is growing so we cannot be sure yet that any specific BEG diet is safe. So although there may be many fine diets under the BEG umbrella, at this time we have to recommend that you feed a traditional diet from a well-established company that has a solid footing in nutritional science. Ask your veterinarian for a list of these companies. And please don't panic if you are feeding a BEG diet, this problem is not that common, but you really should talk to your veterinarian about switching. And please don't feel guilty either, many of the BEG diets are particularly good at marketing in a way that appeals to our desire to do the right thing. 

There are good drugs for DCM and most patients can be stabilized if it is caught early enough, but the terrible thing is that there can be no warning signs. Monty had just been a little weaker for a few days prior to the collapse and had been breathing a little harder. This is typical. We expect that by changing his diet we can stop further heart damage from occurring and we hope that maybe even some of the damage can be reversed. 

I have seen a few dozen more cases since Monty. Two tragically didn't survive, but Monty is doing ok. And he likes the new food.

The Envelope Please

As in, "Oh God, please please please let this be the envelope." Yes, that envelope.

It's May of 1986 and I'm standing in Dr Bruce Murphy's laboratory on the second floor of the biology building at the University of Saskatchewan and I'm pipetting mink serum into tiny vials when the phone on the far wall rings.

"Philipp, it's your mom!"
My mom never phones me at work. Never. Either dad died or the envelope arrived.

"Yes mom?" (Cautiously, in German.)

"There's a letter for you from the veterinary college!" (Excited, in German.)
It's the envelope! Or, more accurately, it's an envelope.

"Is it thick or thin?" I ask.

"Thin. Is that good or bad?"
Bad bad bad I think. Shit, it's thin.

"Um, neither I guess. Go ahead, open it"

Ripping sounds at her end of the line. Panicky breathing sounds at my end. Long pause and then...

"You got in!"

I got it! It was the envelope!! It's hard to describe how this feels. Like winning the lottery (although I have never done that). Like getting an Oscar (never done that either). Like having your marriage proposal accepted (did that one!). Elation. Validation. Magic. In one instant your previously murky future suddenly comes into crystalline focus. And this coming from someone who only decided to become a veterinarian a few years prior (see: http://vetography.blogspot.com/2017/11/the-accidental-veterinarian.html). Imagine how this feels for all the people who have wanted to become a veterinarian from before they even knew the word.

This coming spring fifteen Manitobans will have that feeling. In 2020 possibly only ten will. The Manitoba government is considering a plan to drastically reduce the number of students permitted to study veterinary medicine. And this is an extraordinarily bad idea.

Let me explain.

First of all I should clarify what I mean by "permitted to study veterinary medicine". Manitoba is far too small to have it's own veterinary college. Prior to 1965 all Canadians who wanted to study veterinary medicine went to Guelph, Ontario, but the profession was expanding so rapidly that this was no longer tenable, so a regional system was set up. The four western provinces banded together to select a reasonably central site for a joint Western College of Veterinary Medicine. Lloydminster not having a university, Edmonton and Saskatoon were considered, with the latter ultimately getting the nod. After 1965 Guelph would only take students from Ontario east and all western students would go to WCVM at the University of Saskatchewan. Each participating province funded a set number of seats. Manitoba currently has 15.

There are a handful of veterinary colleges in North America and the Caribbean that permit non-residents to study there, but at full price, which is five to ten times what one pays at WCVM. As a nation we decided that post-secondary education is essential to our future, so we subsidize it. We recognize that it is better to keep the system open to talent than just open to deep pockets. So if Manitoba cuts the seats it funds, the five prospective students who could have gone to WCVM - to our college that we built - will have to move much further away and go even far more absurdly into debt to follow their dream. Very very few will be able to do this.

This is a problem. A big problem. The demand for veterinarians continues to grow. Animal welfare, biosecurity and food safety are all hot topics that are not going away any time soon. In Manitoba especially we have a hard enough time attracting people from out of province (due to weird and unfounded biases, but that's another subject...), so we count on Manitobans coming back. Yes, some students who go to vet school don't come back to Manitoba, and by the same token many med and law and dental and engineering students who study here leave Manitoba - that's life and it is after all a free country - but if we send less, even less will come back. It's a downward spiral.

I get it, the government wants to balance the books. Let's assume for a moment that you don't give a rat's hindquarters about young people's dreams or pet doctoring or prudent antibiotic use on farms or exotic diseases jumping to humans. Let's assume that. Let's assume that you just care about the economy in the most narrow sense of the word. Well, guess what? Veterinarians are also small business people. This government is supposed to love small business people. In very rough figures we contribute 180 million dollars to the economy every year and that's growing at about 5% a year. We employ large numbers of skilled people and pay taxes, lots and lots of taxes.

And then there's the question of fairness. If you really feel you need to balance the books by cutting postsecondary education funding, then cut evenly across all programs. Is the law faculty funding being cut by 1/3? Dentistry? I doubt it very much. The cost of those five vet school spots represents a rounding error in the government's budget, but for our small profession it has a huge impact.

In survey after survey children list veterinarian as one of their top ten dream jobs. And not just children feel that way. So many people want to become veterinarians at the supply end and so many jobs are open for veterinarians at the demand end, but there is a very tight bottleneck jammed between that supply and that demand. This bottleneck is your government. And this is a democracy, so your government is you. Do something about this.

The Life and Times of George Ramirez

George Ramirez lived a long full life punctuated by adventure and surrounded by love. Given the relative nature of time and how subjectively its speed of passage is felt, I'm sure that in his admittedly minuscule mind he lived the equivalent of a hundred human years. We don't know where or exactly when he was born and we don't know who his parents were, but every aspect of his subsequent life was lavishly documented by his companion and guardian, a ten year old girl. It is astonishing that something weighing only 45 grams could live such a rich life. And it is perhaps astonishing to some that something weighing only 45 grams could be loved so deeply and loved so truly.

George Ramirez was a teddy bear hamster.

His full name was actually George Ramirez Penner, as he was owned by the precocious Chloe Penner. I say precocious because the first time she brought George Ramirez in she was in the exam room by herself. Her parents had decided that as he was her hamster she should be fully in charge of his medical care, so they sat out in the waiting room. (I think they still paid the bills though.) To be frank, sometimes this type of arrangement is irritating to the veterinarian as it can effectively double some of our work when we have to repeat everything to the parents later. But not in Chloe's case. She was attentive and sharp and clearly capable of following my advice. Such as it was. Really, she was fully on top of things, so on that first visit when George Ramirez was brought in for a check-up my role was primarily to confirm for her that she was doing everything correctly. She showed me pictures of his cage, from which sprouted an elaborate network of clear plastic pipes leading to various chambers, including, if memory serves, one made to look like a little space capsule. George Ramirez was going to have a good life.

At this point I should offer up a confession. I love all types of patients. I do not favour dogs over cats (or vice versa), or rabbits over guinea pigs, or budgies over canaries, nor do I shy away from snakes or rats or hedgehogs or ferrets, to name just a few that sometimes elicit bias. But I was long a secret hamster skeptic. It's funny because my wife had hamsters when she was young whereas I had a gerbil, so we would sometimes engage in hamster versus gerbil debates. I felt I had solid facts on my side. And I had been bitten by more hamsters than all other rodent species put together, so that might have biased me a little as well. But then George Ramirez came along. He did not bite. He was clean. And he was cool. This was a hamster I actually looked forward to seeing.

Normally hamsters do not go to the vet. There are no vaccines for them and we do not need to (or even want to) spay or neuter them. Moreover, they are really pretty rugged, so not all that much tends to go wrong in their short lives. But perhaps the most common reason that they don't go to the vet is that unfortunately many people view spending money on their medical care as silly, putting them more in the goldfish category of pet than in the dog and cat category. I wonder why this is? Is it because hamsters are cheap to acquire? But then so are many dogs and cats (and heck, human children come into the world free). Is it because they are so small? If so, then does that mean that Great Danes deserve more care than Chihuahuas? Is it because they are loved less? I suppose that must be it. But that was happily not the case for George Ramirez.

I think I saw George Ramirez five times in his three years. Once for the initial visit, twice for annual check-ups and twice for medical reasons. The first time was for what is referred to as "wet tail". "Wet tail" is a euphemism. The tail is not wet with water, it is wet with liquid poo. Much like diarrhea in every other species "wet tail" is not a single specific disease but rather a symptom that has a range of causes. These little creatures can dehydrate quickly, so it can be serious, but fortunately George Ramirez revived right away when we sorted out why it was happening.

The second time I saw him sick was when Chloe brought him in with what she thought was a tumour on his face. She was clearly really upset, but trying hard to be brave. George Ramirez had an enormous irregularly shaped lump in his right cheek and he had stopped eating. Hamsters are prone to cancer, but this was not a cancer. When I palpated the lump and pried his tiny mouth open to peer inside I was as surprised by what I found as Chloe was. He had somehow filled his right cheek pouch so full of food that it had become impacted and bulged out to roughly equal the size of the rest of his head. And because he had jammed unshelled sunflower seeds in there it felt very odd and lumpy on the outside. We both knew that hamsters had large cheek pouches, but had no idea that they were this large or that food could get so badly stuck in there. The solution was gratifyingly simple. I simply turned the pouch inside out like the pocket in your jeans. He was weak enough that he let me do this awake.

I know you're expecting a sad ending, but the cheek pouch incident isn't it. George Ramirez bounced back yet again. Just like with wet tail. Just like when he did an EVA* from his capsule and was found three days later in the heating ducts. Just like when the Penners got a cat and the cat knocked over his cage. Eventually Father Time caught up with him and he died peacefully in his bed at the ripe old age of three and one third years. I found this out when Chloe came in with Edna von Trapp, a new young female hamster. Edna von Trapp had an evil glint in her eye and proceeded to bite me savagely at every opportunity, thus proving, in case proof was needed, that hamsters are not interchangeable. There are a lot of stories of parents sneaking out to the pet store without telling their children to get a look-alike replacement when a hamster dies. I suspect that the child almost always knows, even if they don't let on. Sort of like a Santa or Easter Bunny scenario. And Chloe definitely would have known.

*Extra-Vehicular Activity. It's an outer space thing.

Three And A Spare

"See that bright white line? That's normal bone." I was showing Jake's x-ray to the Folsoms. "Then see here?" I pointed to an area of the humerus that was both wider and fuzzier looking, as if someone had smudged the picture there with a cheap eraser. "This is abnormal bone. I'm really sorry, but I'm afraid this looks like bone cancer."

Mr and Mrs Folsom said nothing for a moment while Jake, a slender 7 year old yellow Lab cross, wagged his tail and looked up at them.
Then Mr Folsom said in a flat, very controlled voice, "So he's done then. You're sure?"

"We should do a biopsy to be sure because the way this looks it could be something else, but I doubt it. I'm sorry, I know that this must be a terrible shock for you. However, if the biopsy confirms cancer that doesn't mean he's done. In that case I will recommend amputation and..."

Mr Folsom cut me off, "No way. We're not doing that. We can't let him suffer."

Mrs Folsom put her hand on his arm to shush him and turned to me, "We'll talk about it doctor. Let's get the biopsy first and then we'll see."

So this is what we did. Within a week we had the diagnosis confirmed - osteosarcoma, malignant bone cancer. We also did a series of tests to check for visible metastases, or spread of the cancer to other parts of the body. Finally some good news - these tests were negative. They wanted to come down to discuss the options in person with their teenage kids present.

After introductions, plus cookies for Jake, I began, "If Jake were my dog I would amputate. He is still young enough and healthy enough that he is a good candidate. Without amputation he is at a high risk of breaking that leg because the cancer has weakened the bone so much. If we do nothing his life expectancy at this point is about 6 to 8 weeks on average."

"Is that it? Just 6 to 8 weeks?" their daughter asked.

"Yes, that's the average, some shorter, some longer, but none very much longer. This is why I want you to think about amputation. That immediately gets rid of the pain and obviously eliminates the risk of a fracture. With surgery plus chemotherapy the average jumps to almost a year, with 20% of dogs living longer than two years. And a year is a really long time in a dog's life. Also, chemo is usually much gentler in dogs and has far fewer side effects than in people."

"But how's he going to manage on three legs?" Mr Folsom asked, his arms crossed, his expression clearly skeptical.

"That's the beauty of being a dog or cat. They do so well on three legs! You'd be amazed. In 28 years I honestly have never had anyone come back later and say that they regretted doing it. Obviously we have to make sure that his three remaining legs are in good shape, but otherwise it's just not a barrier."

"It's like he has three and a spare!" the daughter said. Mr Folsom was staring straight ahead.

Exactly. I couldn't have put it better myself. Three and a spare. It can be such a hard procedure to convince people to do, but it's one of the ones that brings the most obvious and immediate benefit to the patient. It's not just helpful for scenarios like Jake's, but also for some complicated fractures. I liken it to pulling a bad tooth. At that point the tooth is just a liability. It no longer provides benefit, only pain and risk.

Clearly this is not for every dog or cat with bone cancer. I don't want any of you who may have been through something like this and chose not to amputate to feel bad about your decision. The age of the pet can be a significant factor. For every year beyond middle age the decision becomes more complicated. And the bigger the dog, the faster they age. Also, as I mentioned, the other legs need to be healthy, and if it is cancer, it can't have spread. And finally, to be honest, I wish it didn't have to be about the money, but sometimes it does have to be. Surgery plus chemo runs into the thousands.

Incidentally, this general principle of being able to remove prominent parts of the body to benefit the patient goes for the eyes too. In some cases of glaucoma, which is high fluid pressure in the eyeball, the medications stop working and the eyeball painfully swells. At that point it is a liability, like a rotten tooth, or like a cancerous leg. People are sometimes aghast when we recommend removing the eye (a procedure called enucleation), but just like with amputation, once the owners get over the psychological hurdle, nobody ever regrets having the eye removed. Nobody.

This is one of the beautiful things about animals. They have very little in the way of body image hang-ups. They just do not seem to care how many teeth or eyes or legs they have. Terry Fox would be proud.

As I'm sure you guessed, three of the Folsoms ultimately out-voted the fourth and they opted for surgery, and Jake, being an above average dog in a lot of other ways, lived an above average length of time. He had 16 good months before we had to let him go.

Love

"I've been spending the nights with him on the living room floor, by his favourite spot. I keep worrying he's going to stop breathing, so I'm not sleeping much. I know his time is coming soon. I didn't want to bring him today because I'm so worried you're going to say I have to put him down." Mrs. Gagnon's eyes were red rimmed and her voice trembled as she said this.

I looked down at Edwin, an elderly black cocker spaniel. He was wheezing a bit, but at first glance he did not appear to be on his last legs. I crouched on the floor and offered him a liver treat, which he happily took, wagging his little stub tail. As I dug around in the treat jar to get another one I thought about Mr. Wilson who had taken the day off work to sit with his cat Parsnip while he was being treated for complications from diabetes. Parsnip would be in all day and Mr. Wilson would be there the whole day too, reading a little, patting Parsnip and generally just being there with him. I thought about Mr. Wilson because Mrs. Gagnon reminded me of him. She reminded me of him because they were both here for the same reason: love.

I am in a very privileged profession. What other professionals are you primarily motivated to visit because of love? Family doctor? No. Lawyer? Ha. Accountant? Double ha. Dentist? Triple ha. The list goes on. In fact, the only other similar profession I can think of is pediatrics. I have often joked with my kid's pediatrician that I practice furry four-legged pediatrics, or he practices hairless two-legged veterinary medicine. For sure many veterinary clients (and parents of children?) are also motivated by a sense of duty, a desire to do the right thing or even feelings of guilt, but the basic driver is usually love.

This is where the conversation can become awkward around people who don't have pets. Love? Really? Isn't that a bit overblown? Too sentimental? A sign that they are lacking human love? No, no and no. Forgive me if I am, as the saying goes, preaching to the choir, but the following is for the benefit of the occasional non pet owner (can I call them muggles?) who stumbles on this blog and thinks, "wtf?"

Part of the problem is language. English is a wonderful, rich and expressive language, but it has some gaps. We have an exhaustive list of words to chose from when it comes to describing and naming objects, but rather less when it comes to relationships and emotions. Think for example about the word "uncle". In English this can describe your parent's brother, or it can describe the random dude your parent's sister was briefly married to. It can even sometimes describe an older male family friend. There are many languages that have distinct titles for each of these, but may not have separate words for all the different kinds of car shapes or shoes styles or couch configurations. I'll let you draw your own conclusions regarding what this says about our culture.

In any case, so it is with the word love. There should be more words to describe all the kinds of love. Does your love for your parents feel the same as the love you feel for your spouse? Or your children? Or your siblings or best friends? They are all closely related emotions, but they are not the exact same. So it is with the love many people feel for their pets. If we're stuck with this one word, "love", then it has to be big and it has to be inclusive. Comparisons between the different flavours of love are not useful. Sure, in a "Sophie's Choice" nightmare scenario all of you would chose to save your child at the price of losing your dog or cat (or almost all of you... most of the time...), but that is never a real life choice.

With respect to it being sentimental, yeah, I suppose it can be. So what? Isn't the appreciation of much of what makes life worth living often somewhat sentimental? Good music, movies, art and literature all make use of emotional response to draw you in and involve you. Loving and appreciating the company of a pet is broadly similar. Can you imagine a world where sentiment was banished and everything had to be cold and practical?

And as to the love people feel for their animals indicating the need to fill a void, this has been amply proven false for the majority of cases. There certainly are many lonely people who find solace in the company of their pets, but pet owners represent the widest cross-section of society, including many of the most gregarious and outgoing "people people". In fact, my experience has been that the more capacity a person has to love an animal, the more capacity they often have to love people too.

Both Edwin and Parsnip did ok. I won't say that it was the power of love that made them better, but it certainly didn't hurt either.

"We can judge the heart of a man by his treatment of animals."

-Emmanuel Kant

Dr. Goliath Inc.

It may be a cliche to say so, but change is inevitable. In few aspects of life is this as true as it is in the world of work. Every job and every profession is changing, and the pace of that change is accelerating. In veterinary medicine we have seen great technological change and we have seen an enormous change in our understanding of many diseases. We have also seen the profession change from being male dominated to female dominated in a single generation. These changes are evident to most pet owners, but today I want to talk about an equally important change that is occurring behind the scenes. I want to talk to you about the creeping corporate takeover of veterinary medicine.

Practice groups consisting of locally owned hospitals with a few satellite clinics have been around for a long time, and the larger ones may blur the lines with corporate practice, but I'm not talking about them today. What I'm talking about started in 1986 when Veterinary Centers of America (now Veterinary Clinics of America, or VCA) was founded in California and began buying private practices and practice groups across North America one by one. VCA now owns over 800 animal hospitals directly in 43 states and 5 provinces, and it operates another approximately 1000 (!) under it's Banfield brand name, which it acquired in a 2017 merger. VCA is a publicly traded company listed on the NASDAQ stock exchange (under the cloyingly cute stock symbol "woof"). Other corporations include National Veterinary Associates with over 400 clinics and Vet Strategy with close to 100 clinics.

Winnipeg is always the last place for any trend to hit. We were the last to get Starbucks, the last for the microbrewery revolution and we are the last major market to be targeted by corporate veterinary medicine. Up until very recently all the practices in Winnipeg were locally and privately owned. Then two years ago a large corporation began to buy clinics, owning four now and with a rumoured fifth deal in the works.

Change can be good, change can be bad and change can just be change. On the good side corporations bring deep pockets to the profession that make it easier to upgrade to the newest technology and to present sparkling, professionally decorated practices, but with ample respect and affection for my colleagues who now work for corporate, I am going to argue that this particular change is on balance bad for the profession.

The fundamental problem is that large corporations solely exist to make money. Of course small private practices also have to make money, but the difference is that if my clinic has a bad year financially we tell ourselves that it was bad luck, or the weather, or the economy and we'll hope for a better year next year. We only answer to ourselves, not to shareholders or investors. In contrast, if revenue drops in a corporate practice, management from Los Angeles or Toronto or wherever will put pressure on the veterinarians they employ to meet quotas, or else. Some corporations track remarkably specific metrics.  For example, in the US one looks at the number of xrays a veterinarian should take relative to the amount of respiratory disease they see. The corporations do not dictate the management of specific cases - that would actually be illegal - but they will set general benchmarks for numbers of specific tests and procedures and they certainly make specific financial goals clear to their employees. On one hand more tests can be "good medicine" and, as in the above example, it can be hard to argue against precautionary "just in case" xrays for a cough, but on the other hand this does diminish your pet's doctor's freedom to use their professional judgment and make sensible decisions without having to worry about what management is going to say about their numbers at the end of the quarter.

Another problem is vertical integration. Mars Corporation has recently bought a controlling interest in VCA. Mars is massive. It had $33 billion in sales in 2015, and only a fraction of that was chocolate bars. It is now the world's largest provider of pet health products and services. In addition to VCA it owns  Royal Canin food, with their prescription diet line, and a whole series of non-prescription pet food brands, such as Pedigree, Whiskas, Eukanuba, IAMS, Nutro and more. It also owns the largest chain of veterinary specialty and emergency centers, the second largest veterinary laboratory company, one of the largest veterinary ultrasound companies, and the number one canine DNA analysis company. Oh, and a chain of 130 boarding and doggie daycare facilities. All that's missing from their portfolio is a pharmaceutical company. The fear here is that veterinarians will be increasingly required to use only the products and services under the same corporate umbrella rather than picking and choosing from all the options based on their professional judgment of their patient's needs. I mostly love Royal Canin foods, but only mostly. I would not tolerate being told that that is the only prescription diet I can offer my patients.

At the end of the day the important relationship is the one between you and your pet and your veterinarian. Who your veterinarian works for is hopefully not all that relevant most of the time. It's just sad for us within the profession to see the freedom and independence we enjoyed gradually be eroded. And it's sad to think about the coming generations of veterinarians who will have less opportunity to enjoy the sense of pride that comes with owning your own practice and making all your own decisions.

Postscript:
Since posting this I have been asked how these corporations have been able to buy clinics. There must be willing sellers. Of course there are. I should explain this and introduce some balance to this story. The large veterinary corporations can offer older veterinarians a relatively straight-forward way to ease into retirement. Moreover, they are able to make these offers very generous. I am fortunate in that I have younger veterinarians working for me who are keen and financially able to buy into the practice, so when my time comes I will be able to sell to them without any trouble. This is not the case in every practice. Sometimes willing buyers are just not that easy to find. Sometimes junior veterinarians prefer to not to take on the responsibilities of ownership and management. Corporate practice therefore fills a previously unmet need and some of my colleagues are grateful for that. And as much as I might personally wish it to be otherwise, veterinary medicine is ultimately not immune to the laws of economics.

Sneak Peak

The advance review copy arrived today! I'm told that the official public release will be April 23.

Surgery For Dummies

When I came up with the post title I thought it was cute and absurd. The 'For Dummies' series of  books may have a breathtaking range, from ASVAB For Dummies ('Armed Services Vocational Aptitude Battery' - yeah, I have no idea either) to Zoho For Dummies, which is apparently a suite of cloud computing applications, but surely there would be no Surgery For Dummies. Ha ha, right? Well... it turns out that there actually is a Weight Loss Surgery For Dummies book, as well as Cosmetic Surgery For Dummies. One hopes these are written for the patients, not the surgeons.

I decided to stick with Surgery For Dummies, even though it now seems slightly less cute and absurd. My point was to highlight that there is no great mystery to surgery. A lot of surgery is much simpler than you might have thought. For many lay people surgery may seem like the pinnacle of a veterinarian's (or medical doctor's) specialized skill and knowledge, but I'm here to tell you that I could easily teach any of you the basics of the majority of the surgeries we do, and that I could teach you that with lessons that would fit on an index card. A small index card.

Basically most surgery can be boiled down to one of two processes - either you are removing something, or you are repairing something. The latter can be far more complex, but it actually only accounts for less than 10% of surgeries in a general practice. Most of the time you are removing something and that is usually not terribly complex. You could be removing testicles (neuter), ovaries and uterus (spay), a lump, a foreign object, or a stone, to give the most common examples. Here are the steps:

(NB: We are assuming the patient is already appropriately anesthetized.)
1. Use a scalpel to cut a straight line in the best place to find the thing you want to remove. Avoid cutting through blood vessels, but if you have to, tie them off with suture so they don't bleed.
2. Find the thing you want to remove.
3. Identify the blood supply to this thing and tie it off.
4. Remove the thing.
5. Sew up the cut or cuts you made. Depending on how deep the cut was, you may need to sew a few separate layers.

That's it. If you cut-and-paste those five steps, they'll fit on an index card.
If you have to cut into an organ to find the thing, such as a foreign object in the stomach or a stone in the bladder, then step 3 will be slightly different:
3. Cut into the organ containing the thing in the same manner as Step 1.

And the sewing is really just that - sewing. The thread (suture) may be special and we usually tie the knots using instruments, but the knots themselves are often just square knots. It's not hard.

All that being said, there are however two very important additional factors to consider before you dive into this. Ok, three if you count the fact that you need a license. And you should count that.

The first factor is that in order to "find the thing" and "identify the blood supply", and all that stuff, you do need to know the anatomy. Surgery is basically applied anatomy. (And, by the way, medicine is basically applied physiology.) Anatomy may seem complicated, but it's really just a lot of memorization. It helps to have a good visual memory, but it's not essential. And honestly, to perform a spay for example, you don't need to know the anatomy of the brain or the elbow or the lungs - just the abdomen and even there you don't need to know the name and location of every blood vessel running into the liver, you mostly just need to know what's right around the ovaries and uterus. Also, as soon as you start doing it, remembering becomes easier and easier as anatomy is something concrete that you can hold in your hands and see (unlike, say, the names of Prime Ministers you might have been forced to memorize in history).

This leads me directly to the second aspect, which is that it takes practice to become good at this. Duh. But this applies to veterinarians too! Regardless of how thoroughly a vet student has memorized the anatomy and the five points on my index card (or whatever notes they have from their surgery lectures), it will take them a ridiculously long time to perform their first spay. And they will be terrified and they will have to ask questions and get help and they will not be confident. At least one hopes that they will not be confident, as they shouldn't be, not yet. One of my classmates even fainted during their first surgery. Whump - hit the floor. They went on to become a fine surgeon. Eventually. With practice.

So learn the anatomy, keep the index card handy and practice, practice, practice under the supervision of someone who can swoop in should things go sideways, or you pass out. (And get a veterinary license.) And then you too can be a surgeon.

Vets Gone Bad

I recently participated in a brief Facebook conversation with some of my colleagues about the highest rated program on National Geographic Wild. I have not seen it, but I have certainly heard and read a lot about it. I may have the name wrong, but it's something like "The Appalling Dr. Pol".

Off stage, Vetography lawyers: "You can't say that! You know it's not called that. We'll get sued!"
Me: "Come on, get real. Nobody reads this blog." 

People appear to love this guy despite the fact that he is manifestly a quack.

Lawyers: "OMG!!"

You would be hard pressed to find a veterinarian who feels otherwise. But I'm not going to talk about the show or the details of his practice. I only mention him because his story is a useful illustration of the weakness of the professional disciplinary process.

One the hats I wear is as Chair of the Peer Review Committee (PRC) of the Manitoba Veterinary Medical Association (MVMA). I've been Chair since 2011 and sat on the PRC as a committee member reviewing complaints for about ten years before then. Veterinary medicine is like most other professions in that it has been accorded the right to self govern and self regulate.The reason professions are permitted to do this is that the government recognizes that only those who actually do the work are in a position to determine what is appropriate and what is not, and which errors are avoidable and which are not. Lay people are also appointed to the PRC to make sure that the public interest is kept in mind and that it doesn't evolve into an "old boys and girls club".

It's an interesting job but it's also a stressful job. Standing in judgment of your peers can feel like an onerous responsibility at times. A more subtle stress though is the knowledge that the worst offenders are getting away with it and that we are only seeing a skewed sample. This is because the process is necessarily complaint driven. Clinics are inspected for equipment, record keeping, sanitation etc, but nobody swoops in and looks over your shoulder to see how you are handling a case. There aren't the resources to do so and it would be pointless as you would be on your best behaviour when observed. The legislation states that for the PRC to investigate a complaint it must receive the complaint in writing. That's it, that's all. So we sit and wait for letters to arrive, our hands otherwise tied.

Think for a moment about your GP. Is he or she "good"? If so, how are you assessing that? Do you know enough about medicine to understand what is proper medical practice and what is not? Honestly? No, more likely, when you say that your doctor is good, you are saying that he or she is nice, and listens to you, and seems to care, and doesn't keep you waiting too long etc.. You have no real idea if the right test has been run and even if it was run, whether it was interpreted correctly. Your doctor could easily be incompetent and it would be very difficult for you to tell. Consequently you probably would not complain about your doctor to the College of Physicians and Surgeons, even if you had a poor health outcome. However, if you encountered a rude doctor with terrible bedside manner and had that same poor outcome, chances are higher that you would complain, even if he or she did everything right and the bad outcome was due to bad luck.

And so it is with veterinary medicine too. In all the complaints I have seen, the great majority have been due to poor communication by the veterinarian rather than poor skills or knowledge. Those of my colleagues who are a little more awkward around people, or perhaps are short tempered, but are objectively quite competent attract far more complaints than those who are charming and charismatic, but are objectively less competent.

The good news though is that given enough time, eventually the charming quacks trip up badly enough or often enough that they are unmasked and professional discipline can take action. As Churchill said regarding democracy, it's the worst system, except for all the others. Dr. Pol has been disciplined, albeit lightly.*




* And another more recent successful disciplinary case against him was reversed by a higher court in a ruling that effectively questioned the scope of authority of regulatory bodies. It doesn't impact us here, but it is interesting/frightening nonetheless.

Bee Med

One of the most fascinating aspects of this profession is the range of creatures veterinarians treat. Personally I have cared for animals from as small as a hummingbird to as large as a bull moose, although I will confess that both were while I was still in vet school. In my own pet practice the range is somewhat more restricted, running from mice to mastiffs. But my colleagues out there will attend to the full spectrum, from bees to whales. Whales, ok, you can probably picture that. Sort of. But bees? Surely I must be exaggerating or joking. I am not.

I am aware of at least three conferences this year that featured sessions on honey bee medicine. The Honey Bee Veterinary Consortium now has 345 American veterinarians listed in its database and there is also a British Bee Veterinary Association with a cool website (britishbeevets.com), as well as a Veterinary Invertebrate Society. The latter appears to be more focused on spiders and lobsters, but it is certainly interested in anything which creepeth or crawleth or buzzeth.

Ok, you can get the obvious jokes out of the way now. You must have a very tiny xray machine! It must be hard to give it a pill without getting stung! How do you take its temperature?! Har har. Nope, nope and nope. Bee medicine is like the medicine of many other food producing animals and is directed towards diagnosis and treatment of large groups at once rather than individuals. Dead bees are tested and then, if appropriate, something is prescribed for the entire swarm.

What has changed recently and made this something more than an obscure reference buried deep in the veterinary literature is a change in the laws governing antibiotics. Since 2017 in the US, and as of the end of this year in Canada, the regulatory authorities will require a veterinary prescription for most antibiotic use in bees. And a veterinary prescription requires a valid "veterinary - client - patient" relationship. Yes, the vet will have to have a relationship with the bee (bees). He or she will have to see them and make a diagnosis before anything is prescribed. This is because in the past bee keepers were able to buy the antibiotics over the counter and misuse, largely due to lack of knowledge and training rather than actual negligence, has led to antibiotic resistance and residues appearing in the honey.

So now vets will have to learn about "varroa mites" and "acarine mites" and "nosema fungus" and "small hive beetles" and "Israeli acute paralysis virus" and "black queen cell virus" and the wonderfully medieval sounding "chalkbrood" and "foulbrood", among many other bee ailments. Foulbrood, a highly infectious bacterial disease killing bee larvae, now affects about 25% of hives in Canada and is the main reason for antibiotic use. With correct diagnosis and careful prescription of appropriate antibiotics at the appropriate doses and times this can be managed better than it has in the past. Veterinarians to the rescue! Other veterinarians though - I'll stick to my mice and my mastiffs, and most of what's in-between. 

The C Word

Yes, cats and dogs get cancer. And turtles, and goldfish, and budgies, and rats. Actually, especially rats. As a very general rule most diseases exist in some form in most animals. We are all really remarkably similar under the hood. Yet people are sometimes surprised to hear it. And of course they are upset to hear it. It is the most feared diagnosis after all.

But there are some things you should know about cancer. First of all, it is not one disease, but rather it is a large family of diseases. Really whenever cells begin to divide in an uncontrolled fashion it is technically cancer. Everything from that gross little warty thing on the top of Buffy's head, right through to the aggressive volleyball sized thing that caused Duke's liver to fail. When these dividing cells don't destroy important tissues or spread through the system we call it benign cancer. When they do, we call it malignant cancer. Fortunately most cancers are benign. To reduce confusion a lot of us try to avoid calling the benign ones cancer at all and will refer to them as tumours or growths, but you should always ask if you are unclear – is it benign or malignant?

The second thing you should know is that even malignant cancer is not a death sentence. In human medicine many cancers are increasingly viewed as chronic diseases that even if they cannot be cured, can be managed well enough to allow a good quality of life for a reasonable length of time. That is our goal in veterinary medicine too, with a strong overriding emphasis on the quality of life aspect. Ultimately it does not matter what label we put on the disease, what matters is what we can do to provide a good quality of life. The cancer label is not helpful – there are many non-cancer diseases that are worse than many cancers. To be sure, there are too many cancers where we have to move rapidly to a euthanasia conversation, but my point is to not view all cancers the same way as there are some that can be easily managed to provide that good quality of life for some time.

I am sometimes asked, “Aren't we just prolonging his life?” If I'm in the right mood and if I know the client well, my answer to that is, “Everytime you take a breath you are prolonging your life!” It's true. The name of the game for every organism is life prolongation, just so long as it is without suffering. An animal doesn't know how long it's supposed to live. It has no thought for tomorrow and no anxiety when I tell their human companion that we can probably only keep it comfortable for another six weeks. Each happy day for an animal during those six weeks is a happy day. It's that simple. We just want to string together as many of those happy days as we can.

The other stumbling block in treating cancer in pets is the word “chemotherapy”. Some people react quite strongly when I suggest that, as if I've now crossed a line into ridiculous territory. But chemotherapy just means drugs to treat cancer, and much like the cancers themselves, there is a huge amount of diversity in these drugs. The most common treatment for a malignant bladder cancer is the same drug we use for arthritis (a non-steroidal antiinflammatory). Used for cancer it is “chemotherapy” (oooh... aaah...). Used for arthritis it is not. Exact same drug, exact same dose. Even aggressive chemotherapy drugs that can have really unpleasant side effects in humans often have far fewer side effects in dogs (cats are a different story). And we have the huge advantage that if one of our patients does become sick on the chemo, we can just stop. At least we tried. The bottom line here is not to dismiss chemotherapy just because of the scary word. It's not for every pet with cancer, but it is for some.

And finally, I am often asked about cause. People will say, “But we feed her the best food.” Or they will ask about the lawn chemicals or the water or the neighbour's treats. The truth is that none of these have any bearing. Cancer in pets (and in people, a few uniquely human high risk beahviours excepted) is mostly due to three things: genetics, age and bad luck. The genetics is obvious as certain cancers are far more common in certain breeds. This doesn't mean that Fido's parents or siblings had to also have it for it to be genetic, it just means that the risk for an individual in that breed is higher, like playing with loaded dice. The age risk should also be obvious. As time goes on your DNA accumulates damage and errors, like an old car or old house, and some of that damage and some of those errors could lead to cancer. But the biggest factor is simply luck. The body of even the tiniest animal is inconceivably complex. When you begin to look at that complexity it is amazing that diseases and disorders such as cancer aren't actually even more common. Be thankful for what works and don't be afraid of what doesn't. Sometimes it's not as bad as you think. Be like your pet and ignore the labels and words and just work to make each day as good as possible and then enjoy that day.

It's A Hell New World

When Isabel was little she wrote a short book called "Cat School". The first chapter was entitled, "Kitten Chaos - It's A Hell New World". Yes, she spelled "chaos" correctly, but was hilariously off with her attempt at "whole". Yet, weirdly she was also unintentionally perceptive.

Up until a month ago we had one dog and two cats. The two cats got along with each other well, united in their hatred of the dog, and the dog generally stayed out of their way, so it was a reasonably balanced little domestic ecosystem. Then Lily arrived. It's a hell new world.

Lily is an incredibly beautiful little Siamese cross and she is also the living embodiment of Leo Tolstoy's wise maxim, "It is amazing how complete is the delusion that beauty is goodness." Lily is badness, pure badness. From the very first day these few small ounces of cuddly fluff launched a terror campaign of such energy and ferocity that everyone - the cats, the dog, the kids, Lorraine and me - were caught completely unprepared. She moves so quickly that she appears to teleport. One second I am eating my dinner peacefully, the next second Lily's face is in my plate. Toss her off the table and instantly she is back. Again. And again. And again. One second Gabi is grooming herself peacefully, the next second Lily is on top of her, biting her ears. One second Orbit is munching his breakfast, the next second Lily is in his bowl and he is looking up me, mournfully. One second a picture is on the wall, the next second it is on the floor. One second a vase is... well, you get the idea.

As the internet people say, O... M... G... So, Lorraine and I are both veterinarians and between us we have 56 years of experience. Yesiree. For those combined 56 years we have given all sorts of calm, reasoned, sage advice to pet owners in similar straits. I am here right now to confess that none of this advice works in my own home. At least not yet. Doors are being kept shut to provide refuges to the other cats, toys are being accumulated at a manic pace, kids are being coached to occupy her, but it's still a demented circus around here. Probably the smartest suggestion we got was to get a second kitten to occupy the first. Intellectually I know that this would likely help, but I tell you, psychologically, it feels like we would be pulling the pin on a second grenade after stupidly doing so once already. Not happening.

So to bring this full circle, why did we get a kitten at all? Some of you have heard me advise that two cats is ideal and that three or more is pretty dicey, so what gives? We got her for Isabel. Isabel went from being that happy little girl, singing to herself and writing wacky stories, to being a teenager laid low by crippling anxiety and depression. She has missed so much school that the year is a wash-out. It's the last thing I expected and it's the hardest thing to watch. The sense of helplessness is immense. And then Lily came into Lorraine's clinic from a rescue shelter. Any other time I would have said no. Any other time. But Isabel was at her very lowest and the only spark I had seen in her in weeks was when she saw Lily's picture. And despite all her kitteny badness, Isabel loves her, really really loves her.

This isn't a tidy heart-string pulling story where the kitten saves the girl. If only depression were so simple. Isabel still has many bad days, but you know, there are some good ones now too. Is Lily responsible for any of this possible progress? I have no idea. For the rest of us it's still a hell new world, but for Isabel, hopefully perhaps the first steps to a whole new one.

Dogs Getting High

Ralph was certainly not himself. It was hard to tell how he actually felt, but the old shepherd was barely able to walk, stumbling and swaying each time he tried to take a step. And his eyes had a glassy far-away look.

"His arthritis is so much worse today!" Mrs Sorensen said, clearly upset and worried.
Although he was obviously having trouble getting up and walking, this did not look at all like arthritis symptoms.

"Have you been giving him anything for the arthritis?" I asked, a suspicion beginning to form.

"He gets his glucosamine and fish oil and then recently I started to give him a little CBD oil. Just a little doctor."

Suspicion confirmed - Ralph was stoned.

In theory this shouldn't happen with CBD, also called cannabidiol, because, in theory, it should not contain any THC, the psychoactive component of cannabis. But that's just in theory.

In one year CBD has gone from a "what's that" obscurity to an every day conversation with pet owners. Quite literally every day. I have been in practice long enough to have seen this phenomenon before. Just in recent memory vitamin E, eichinacea, grain-free diets and coconut oil have all had their moment in the sun as potential panaceas. The internet age spreads the word so much faster while amplifying the most improbable stories. In each case these remedies did not end up curing cancer, reversing kidney disease or noticeably "boosting the immune system", but each did end up finding a place in the array of options for some specific conditions in some specific patients. It's just a much smaller place than the enthusiasts had hoped for. If medicine were only so simple!

And so it will be for CBD oil. The range of disorders that people want to try it on their pets for is breathtaking, but the best evidence we have is that it might be useful for three things: epilepsy, nausea and, yes, arthritic pain. There are some problems though.

The first problem is that the research is lacking. There is a lot of work being done right now though, so hopefully we'll have some more clarity soon, but for the time being everything we know is based on anecdote and extrapolation from humans. There are plenty of examples in other areas of medicine where anecdotes and extrapolations have misled us, so some caution is warranted.

The second problem, as illustrated by Ralph's experience, is that quality control and regulation are also lacking. Contamination with THC is not that rare. I haven't seen numbers on that, but I did see another stoned dog with the same story soon after Ralph. Also, some reports indicate that the majority of commercially available CBD oil is contaminated with pesticides and other troubling substances. Google "contaminated CBD" if you're in the mood to be alarmed. Also, when tested, some of the products contain either very little or even no CBD oil at all. Moreover, all of this can vary from batch to batch, so just because Aunt Marge's corgi is like a pup again after three drops of "Doctor Good Earth's All Natural Holistic Small-Batch Artisanal CBD Oil", doesn't mean that your dog will have the same experience.

Patience people. My own dog is epileptic and I'll probably try CBD, but only once the science is in and the quality is truly assured (i.e. not just by the dude at the health food store). If your dog suffers from epilepsy, chronic nausea or arthritic pain and you feel like you can't be patient because nothing else has worked, please check with your vet first before winging it with CBD. New information is coming out regularly.

Ralph was better after about a day. Mrs Sorensen is going to be patient now.

The Shoemaker's Children

A few months ago my wife, who is also a veterinarian, and I began noticing that Gabi, our 11 year old little black and white cat, was becoming even more aggressive about stealing food. I say "even more" because our three cats and one dog are an unruly, barely trained lot who climb on tables and surf counter-tops with impunity. Ok, impunity is an exaggeration because we do shout at them, but this is apparently just a bunch of monkey noise as far as they're concerned. It is, of course, entirely our fault and we have more or less made peace with the situation, but Gabi had become so much worse that it got our attention. She was also yelling more and beginning to look a bit skinny, despite her impressive appetite.

Now those of you with some knowledge of cat diseases are beginning to go, "hmm..." However, Lorraine and I, despite having considerably more than "some" knowledge of cat diseases did not go, "hmm..." We just shrugged and didn't make much of the changes. She seemed fine otherwise.

Fortunately Gabi was due to have some dental work done, so I took her into the clinic for that. I was ordering routine pre-anesthetic bloodwork for her when the penny finally dropped. Seeing her in a clinical setting caused a sudden shift in my perspective. I asked them to run a thyroid level as well. Yup. Our cat was hyperthyroid and had probably been hyperthyroid for several months, displaying textbook symptoms right under our noses.

Most of you have heard the proverb regarding the shoemaker's children. The shoemaker is so focused on making beautiful shoes for his customers that he doesn't notice that his own family is shoe-less. It's not anywhere that extreme for most veterinarians most of the time, but at times the shoemaker's children phenomenon is quite real and it is downright embarrassing.

This is an interesting subject (I hope...) because many clients when faced with a difficult decision will ask us what we would do for our own pets. This is a fair question. In fact, when I first started out in practice I didn't have any pets of my own, but in giving advice I had "if this was my mother's pet" as a mantra to guide me. I can obviously only speak for myself  and I may well be a freakish outlier, but despite that mantra I have to confess that I do sometimes treat my own pets differently than my clients' pets. Often worse, as in Gabi's story, but sometimes better too. Maybe it's instructive to see where I deviate, so I've made a list:

- I never stop vaccinating due to age, because immune function can decline, and I never worry about reactions because they are so very rare, but I am not good at keeping to an exact vaccine schedule. A three year vaccine might sometimes be done in four years when I finally remember. I'm not recommending this slack approach, but it does illustrate that there is some flexibility. Thorough annual exams are important though as pets age five to seven human-equivalent years for every calendar year. If the experience with Gabi has taught me anything it's that I need to do this religiously for my own pets and not rely on those casual assessments that occur because I happen to live with them.

- The moment I finally recognize that something is wrong with one of my animals, I run every test that might conceivably be helpful. With clients we're often concerned about the cost of running lots of tests, but we should give them the option of doing more than the minimum if they can afford it and want the peace of mind.

- When one of my pets is deathly ill I am tempted to try heroics, and have in at least one case done more than was in retrospect sensible to do. I think we do a better job counselling our clients on end of life decisions than we do for ourselves.

- My family feeds more treats and "people food" than I recommend, so I understand what those soft brown eyes and purring leg rubs can do to a person's willpower. This is not an excuse though - you can and should be stronger willed than me (or my family)!

- Ditto for brushing their teeth. We don't do it and I really do know we should and I really do believe in the benefits of it. But it's supposed to be my kids' job. That's my excuse and I'm sticking to it.

Gabi is on medication now for her hyperthyroidism and is doing well, so no harm done. But it was valuable lesson and one that I hope I will actually remember this time!

Mismatch

Among the more venerable internet memes are the photos of people who look like their pets. Or who allegedly look like their pets. Honestly, in most case it seems to come down to some similarity in hair/fur and being photographed when they happened to have (or, more probably, have been coached to have) comparable facial expressions. Put a little wig on a potato and you could just as easily come up with photos of people who look like their potatoes. That being said, there certainly are a few pudgy flat-faced people with pudgy flat-faced dogs, as there are a few tall elegant people with long noses who have tall elegant dogs with long noses. It is safe to say however that the overwhelming majority of people do not resemble their pets at all. And this, you'll agree, is a good thing.

What strikes me as far more interesting than owners who match their pets are owners who are wild mismatches for their pets, not only in appearance, but in temperament. It goes without saying that veterinarians see all kinds of combinations of animals and people, but the ones that get our attention are the ones that seem the most improbable. I'll share two short stories with you about such mismatches.

The first pair is Tim and Mindy. Tim is the owner and Mindy is the dog. I suppose that's obvious, but you'd be surprised. I can't count the number of times I have accidentally called the owner by their pet's name and vice versa. Consider yourself forewarned if you give your pet a conceivably human name. But I digress. Tim made a vivid first impression with his considerable size, his forceful handshake, his loud expletive laden style of talking and the impressive array of smudgy blue tattoos that looked suspiciously like they had been done in prison. But, as we all know, first impressions can be misleading. Two facts immediately emerged that ran counter to that impression. First of all, Tim turned out to be very friendly and very eager to learn everything he could about looking after his pet. And secondly, his pet was a small quiet female Shih Tzu named Mindy, who sported pink bows in her beautifully groomed fur. There were no pink bows anywhere on Tim. Nor was he especially beautifully groomed. They did not resemble each other in the slightest. In fact, they could be considered opposites.

Tim was a long distance truck driver and Mindy was his companion on the road. "Been with me to 43 states and 8 provinces!" It appeared that Mindy was his only family as well. To see Tim transform instantly from brash and boisterous with me to tender and calm with her was as astonishing as it was heart-warming. Utterly unselfconscious, he would gently and repeatedly kiss Mindy on the top her head while I explained something to him. Almost everybody loves their pets, but Tim's devotion to Mindy was in a category of its own. All of us adults know by now that love is a strange thing that cannot be predicted or judged. This was a prime example of that truth.

I typically saw Mindy once a year in the early spring for a check-up and to make sure that her shots and paperwork were in order for the frequent border crossings. Tim was also one of the few clients who insisted on regular bloodwork to follow baselines on her organ functions. He explained that he wanted the peace of mind and pressed me whether there was anything else we could do to ensure Mindy's health. He gave up smoking when he got Mindy because he was worried about second hand smoke, and he planned his rest stops around where it was best to walk her. I said he was devoted and I meant it.

You might be girding yourself for a heartbreaking ending to this story, but fortunately, to the best of my knowledge, Mindy remains healthy as I write this and I expect to see her again next year. One day there may be an anguished phone-call from Alabama or Arizona, but it hasn't happened yet and, I tell you, I don't even want to think about it.

The second mismatched pair is Mrs Abrams and Max. Max was a German Shepherd. Actually, "Max" is almost always a German Shepherd, unless he is a Boxer or a black cat. I picked this pair for the second story because it is in many ways the inverse of Tim and Mindy. Mrs Abrams was small, quiet, elderly and fragile looking. Max, on the other hand, was large and loud and  rambunctious. He weighed as much as Mrs Abrams, if not even a little more. Her son had given him to her for protection. I suppose this was effective as Max would lunge and bark furiously whenever someone other than Mrs Abrams moved towards him. Actually, he would lunge and bark furiously whenever the wind blew a scrap of plastic towards him as well. Fortunately he was a classic example the bark being worse than the bite and there was no need to be afraid of him, but unfortunately all that lunging made walking him dangerous for Mrs Abrams.

One day she came in sporting a cast on her wrist. Max had pulled her down again. Apparently he had seen a particularly irritating squirrel. Mrs Abrams always excused his behaviour with a chuckle and a 'dogs will be dogs' remark. After I addressed the rash that he had been brought in for I talked to her about safer options for walking him. I had talked to her about this before, about halter types of collars and training methods, but the answer was always the same. In her soft voice she would say, "Oh no, he wouldn't like that." And that was the end of the discussion. What Max liked and did not like was always the decisive factor.

Eventually it came out that Max was also pooping in the house. Here too excuses were made and any type of training that would inconvenience Max in any way was dismissed out of hand. She would smile at Max like all the light in the world emanated from him. Like with Tim and Mindy, this was clearly also love and love that should not be judged, but my God, it was hard not to judge. Max was so manifestly the wrong pet for her. Wrong size, wrong temperament, wrong breed, wrong everything. But she felt safe with him and she loved him with all her heart and these two things obviously made broken wrists and poopy carpets seem like trifling inconveniences to her.

When Max eventually passed away I didn't think I'd see Mrs Abrams again. She seemed incalculably ancient and there sadly comes a time in many people's lives when looking after an animal is just too difficult. I was surprised then to hear that she had booked an appointment with a new pet. Perhaps a cat, I thought, or a little Yorkie? Nope. Another German Shepherd. Also named Max.