In The Dark

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

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

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

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

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

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

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

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

Begins With The Letter "A"

This post carries a mature content warning. Seriously.

  

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

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

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

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

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

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

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

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

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

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

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

 *What a bizarre world we live in. The "For Dummies" series actually has a tutorial on this:
http://www.dummies.com/pets/dogs/how-to-empty-your-dogs-anal-sacs/

Elwood Regrets Nothing

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

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

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

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

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


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

The Accidental Veterinarian

I did not plan on becoming a veterinarian. In fact, when I was a child I was only dimly aware of what that was as we did not have any pets other than a gerbil, for whom professional medical care was honestly never a consideration. For many years I wanted to be a geographer or a historian at a university. Yes, I was a strange child. Then in high school my interest in animals and nature, which had always been there at some level, began to grow and I added research zoologist to the list. But veterinarian still wasn't on the radar.

My father was a practical man, and a man who had become cynical about academia. He was a physics professor at the University of Saskatchewan and he believed that academic jobs were becoming both increasingly scarce and increasingly unappealing due to university bureaucracy. Consequently he viewed my interest in pursuing an academic career in zoology, history or geography with growing apprehension. He was fond of the pithy German phrase, "Brotlose Kunst", which translates directly as "breadless art" - in other words a career or job that doesn't put bread on the table. He left the choice up to me, but made it clear that he recommended I pursue a profession instead.

I was a freakishly obedient teenager (mostly), so it came to pass that I spent a sunny Saturday afternoon in March of 1983, the year I graduated from high school, methodically going through the University of Saskatchewan's course calendar. The programs were listed alphabetically. I began eliminating them one by one - Agriculture (boring), Anthropology (Brotlose Kunst), Art (Brotlose Kunst)... and so on. As per the profered advice I paid particular attention to the professional colleges, but I steadily, inexorably, eliminated them all too - Dentistry (ha), Engineering (boring), Medicine (nope - sick people are gross) etc... I was comprehensively alarmed by the time I got to Theology (ha) as I had almost reached the end of alphabet without finding anything that made sense to me. There was only one program left. I turned the page and saw Veterinary Medicine written there.

Huh. Veterinary Medicine...

I couldn't think of a counter argument. In fact, the more I thought about it, the more appealing the idea became. This was essentially applied zoology! Moreover I reasoned that I had always liked dogs and cats, although I had never owned one...

In the impulsive way of 17 year olds I decided right then that, yes, this was Plan A. It also helped that the father of a girl I had a crush on was a professor at the vet college... But I knew absolutely nothing about the profession. I hadn't even read James Herriot. When I did find out more about it I began to waver (Herriot had the opposite effect on me than he did on most people) and completed a Biology degree first, but my faculty adviser echoed my father's advice - get a profession, go into veterinary medicine like you had planned. And so I did.

The great majority of my colleagues wanted to be veterinarians for as long as they could remember. In most cases they had to move a considerable distance to Saskatoon or Guelph to attend veterinary school. Their plan was clear and their commitment was strong. In contrast I still marvel at the accidental nature of my entry into the profession, a profession that has not only given me a wonderful career, but through which I met my wife and through which I moved to Winnipeg. What would have happened if the U of S hadn't offered Veterinary Medicine and the last entry in that course catalogue had been Theology...?

Some accidents are happy. This is one of them.

The Anatomy Of A Vet Bill

Mr. Malloy was the type of jovial older guy who wore a camouflage coloured cap and red suspenders over an expansive gut. And the type of guy who loved cracking lame jokes. You know the type. Kind of annoying, yet also kind of lovable.
One day he was at the counter paying his bill when he said, "Holy Dinah! A hundred bucks? You gotta be kidding me? I must own a wing of this hospital by now!"
At the other end of the counter Mrs Chu was paying her $1500 bill and quietly exchanging knowing smiles with the receptionist.

If we had a hospital wing for every client who felt they had paid for one, we would be the size of the Pentagon by now. (Besides, veterinary hospitals generally don't have "wings"...)

But I get it. For a lot of people veterinary medicine is expensive.

Some in my profession push back against that statement and say that we just need to look at dentists and plumbers bills to see that we are not that expensive. No, dentists and plumbers are also expensive, just like us. A lot of modern life is expensive. For many people living paycheque to paycheque (47% of Canadians in 2017) a surprise $500 veterinary bill (or dental, or plumbing, or whatever) is difficult to manage, and a surprise $2000 bill is a potential financial catastrophe.

So now that we have established that veterinary medicine "is expensive", why is it expensive? The number one reason is that we have rapidly evolved to a point where our standards of care compare favourably to those for humans. The arguments about the rightness or wrongness and the whys and wherefores of this evolution are best left for another post, but the fact remains that we now practice close to "human level" medicine and consequently have some "human level" expenses. There are no special veterinary grade sutures, catheters, pills, computers, rent or education for that matter. In fact, for many of our supplies we pay more as we don't have access to the volume discounts the human hospitals do. It is interesting  to note that Americans complain about veterinary bills less often than Canadians because they know what human health care costs.

There are many scary expressions in a practice owner's lexicon - "audit", "lawsuit", "burst pipe", "crashed server" - but one of the scariest is "overhead". The others are avoidable, but overhead is unavoidable and in some practices it can gobble up almost all of the revenue. In my clinic I have calculated that it costs us $400 an hour to keep the lights on, the doors open, the supplies stocked and the non-veterinary staff in place. This is before any veterinarian gets paid. During the busy season this is easy to cover, but in the doldrums of January when you can hear the proverbial crickets in the waiting room you may see me obsessively watching the bank balance and line of credit. I might even be chewing my fingernails...

So, where does your money go? In our practice on a very broad average, for every dollar you spend about 25 cents covers veterinary salaries and benefits, 21 cents to staff salaries and benefits, 27 cents for variable costs like drugs, supplies, lab charges etc., and 15 cents for fixed costs like rent, computers, utilities, accounting, maintenance etc.. This obviously varies enormously from service to service, and it also varies a bit from year to year. Our veterinarians are on salary, so the 25 cents doesn't go straight to them, but in some practices vets are paid a percentage of their billings.

The mathematically astute among you will notice 12 cents missing. That is the theoretical "profit" or, more accurately, "return on investment", that is divided among the owners (there are seven in our practice) when we have kept a good eye on our overhead. I discussed this in a previous post, but in brief, those of us who own practices have to take out substantial loans to buy them, or, in the case of a new clinic, build them, so this money helps slowly pay those loans off. I suppose a theoretical non-profit clinic would be able to lower it's prices by that 12% and would have to somehow fundraise to build, expand etc.. It still would be expensive. Veterinary medicine is expensive. But - and forgive the self-serving nature of this comment - it is so worth it. What price can you put on health and love? Especially in a world where people are apparently buying thousand dollar smartphones...

Mook

Mook was my first "real pet". This statement may prompt hate mail from the gerbil lobby as I did have a gerbil named Bobo (http://vetography.blogspot.ca/2015/12/bobo-christmas-gerbil.html) when I was twelve years old and I suppose I loved him, but to be honest, only in the way I loved my favorite toys. I really wanted a dog, but there was simply no way that was going to happen. My parents didn't have pets growing up (it was worn-torn Germany after all - there were many other priorities, like survival) and none of the people they knew once they emigrated to Saskatoon had pets. It simply wasn't part of their world. They didn't view it as a bad thing necessarily, but it was something "other people" did, like line-dancing or cross-dressing.

Then while I was starting second year biology at the University of Saskatchewan, we moved to an acreage about 20 km southwest of the city. It had always been my father's dream to own land and live in the country. Experimental plasma physicist by day, gentleman farmer by night (and weekends and holidays). He began to collect tractors and outbuildings to house these tractors.

One late autumn day a black-and-white kitten appeared in the tall grass around one of these outbuildings. It was good mousing terrain I suppose. It was a boy and it was probably about 10 weeks old. My parents had no idea what to do. I was preoccupied with school and with being a young adult with a car and a social life (such as it was...), so I didn't pay too much attention at first. The kitten was extremely friendly. It would run up to you and immediately begin rubbing on your pant leg, purring at an improbable volume for such a small creature. And in the way of cats who hone in on the least cat friendly person in any given crowd, he took a special liking to my father.

Winter can hit quickly in Saskatchewan and it can hit hard. After gentle badgering from the rest of us my father allowed the kitten to come into the detached garage and began to feed him there. He did this himself, saying he was in there all the time anyway. Sure, it was a nuisance, but not much of one. But the kitten was only to be allowed into the garage, nowhere else. Certainly not the house.

Somewhere around this time the kitten acquired a name. We called him "Mook" because my mother said that that was the chirping sound he made when he head-butted your hand, "mook, mook".

I imagine that many of you have already worked out for yourselves where this story is going. You are absolutely right. As winter set in the garage became quite cold as well. My father said, "Ok, the cat can come into the house, but only the basement. Nowhere else." Our basement stairs had a door at the top, so in theory it was relatively simple to keep him down there. Mook would however cry pitifully from behind the door. So soon my father said, "Well, during the day Mook can come up on the main floor, but at night he goes down. And he does not go into the bedrooms or my study."

A few weeks later I came home early from a Saturday running errands in town. My mother and brother were still out. When I came in the front door I heard an odd sound coming from upstairs. It was a shuffling and scraping noise and the sound of my father chuckling, although he was home alone. I went upstairs and saw that the door to my father's study was open. I peeked inside and saw him on his hands and knees, playing with Mook, both of them delighted.

I started veterinary school two years after Mook came into our lives and he was my constant study companion. He knew exactly where to lay on my desk where I wouldn't shoo him off. He made some of the abstractions that were being taught seem more real and he was a source of comfort when I was stressed.

In 1990 I graduated and moved to Winnipeg. Although I called him "my cat", Mook was really more my parents cat, so there was no question that he would stay. He continued to have adventures on the acreage including being quite seriously injured when he was either hit by a car or fell out of a tree, we're not sure which. My mother was visiting family in Germany when this happened, so my father nursed him back to health, giving pills, changing bandages and phoning me frequently for updates and advice. My father had never phoned me any other time for any other reason. Something shifted between us when he did this. Two adults talking together, needing each other. He passed away in 1994 from a brain tumour.

Then in 2002 my daughter Isabel was born. Mook was quite old by that point - I suppose 18 when I do the math. During one of the first visits with the baby to Saskatoon Mook padded into our room and clambered up onto the bed, where I was holding Isabel, trying to settle her to sleep. Mook curled up beside her, purring. I remember so very clearly how grateful I was to him and how strongly I felt the connection from Isabel to my father through this cat. A living link. I couldn't stop myself from crying.

A Duck Tale

    His name was Puddles. His photo still hangs on the wall above my desk. Our relationship began, like so many, with a phone call from a client.
    "Philipp, Mrs. Wickland is on the phone. She wants to know whether you'll see a duck."
    This immediately got my attention. To be honest I sometimes only half tune into what I'm being told as I attempt to catch up on my office work by ineptly multi-tasking. I put down my pen and turned to face the receptionist.
    "Did you say duck?"
    "Yup, a duck."
    I picked up the phone.
    "Hi there, Dr. Philipp Schott speaking. I understand you have a duck now?"
    "Yes! His name is Puddles! I got him from my daughter. The house was so empty after Al and Bandit died."
     Al was her husband and Bandit their dog. Al was an interesting guy and was one of my favorite clients. He was short and round and had a gravelly voice. He was probably in his sixties and you could tell he used to be quite muscular. He told me that he had once been a biker and that if I ever needed help dealing with a difficult client I should ask him because he "still knew some guys" who would straighten things out. I limited my response to a smile and a nod. He also wanted to know whether he could volunteer to walk dogs for us at Christmas. We didn't have any patients stay over that Christmas and then Al died of cancer the next year.

     It turned out that there was nothing wrong with Puddles and that Mrs. Wickland just wanted him to get a checkup. So I read up on ducks as best as I could in advance and then on the appointed day Puddles waddled in the front door, herded gently by Mrs. Wickland. Puddles was a standard white farm duck. Have you ever been up close to one? They are surprisingly large. He was easily ten pounds and when he stood tall he reached halfway up my thigh. Now imagine the scene in the waiting room. A half dozen clients, a couple dogs, a couple cats and in walks a duck. You could pretty much see the pupils of the cats eyes dilate from across the room. The one dog was indifferent while the other, a little Cairn terrier, began barking furiously until the owner settled him down. Puddles was as cool as a proverbial cucumber. He ignored everyone, let out a few soft quacks, strutted (a waddling kind of strut mind you) about the waiting room and generally assumed the air of having claimed the place.

    The examination went well, despite Puddles's clear indignation at aspects of it, and I was able to pronounce him healthy, although I was at pains to make it clear to Mrs. Wickland that I was far from being a duck expert. The years went by and Puddles came in regularly for his check ups and once or twice for relatively minor foot and skin issues. I always looked forward to his visits. I shouldn't play favorites among my patients, but he definitely was a favorite. He was treated like a rock star by the staff and the other clients and his arrival never failed to spark delighted gasps.

    Then one day Mrs. Wickland called to say that Puddles wasn't well. He had been eating less and less and his bowel movements were much wetter than normal. When I looked at him it was obvious that he had lost weight and he wasn't nearly as feisty as he usually was. Also, it became clear that it wasn't watery stool she had seen, but excessive urination mixing with the stool. We ran some tests and determined that his kidneys were failing. He was eight years old at that point, which is elderly for a duck. We struggled along with a few attempts at treatment as Mrs. Wickland wasn't ready to say goodbye yet, but nothing made any difference. With tremendous sadness one blustery March day we let Puddles go.

    Spring is a busy time, so despite his celebrity status I soon stopped thinking about Puddles until six months later when Mrs. Wickland phoned. I hadn't spoken to her since the day of the euthanasia. She had trouble keeping the emotion out of her voice, but she wanted reassurance that she had done everything she possibly could for him. She missed him terribly and she always would. Love is blind. It is blind to gender, colour, age, shape, religion, and it is absolutely blind to species.