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