Still Standing in the Doorway

I was admiring the roses when I read the news. They were beautiful, and a deep, almost salmon, pink, just opening, and completely unblemished. How is it possible that three dollars can buy twelve perfect long-stemmed roses?

I was lost in their beauty, and lost in loving the life I live when I broke away as I often do for the summons of my phone. I was stunned to read that a well-known, often-referenced veterinary behaviorist had committed suicide. She had hung herself, at age forty-eight. Two years younger than me. I didn’t know her, but I had read her papers and watched her videos. She was a gentle and kind soul, a veterinarian who had gone into small animal practice after school only to be struck with the realization that so, so many euthanasias happen because of behavioral issues. Cats that pee outside the box. Dogs that are fearful and aggressive. She went back to school to try to figure out how she could help, and she did, likely thousands of people and their pets. But for some reason it wasn’t enough, and a couple of days ago the pain of getting up and doing it again for one…more…day…seemed, at that point, too much. And at that moment, ending her life was for her, the best choice.

Please don’t mistake me. I don’t pretend to understand. I only tell you that I have looked down into the abyss. I have safely trodden the rim, and have never considered stepping in, but I do know what despair looks like.

Perhaps more than any other medical professionals, the veterinarians I know, myself included, take our failures hard. And I don’t just mean failing because we don’t know enough, or we aren’t good enough. I mean failing to help. And it doesn’t even seem to matter if help was even possible. I’ve seen vets despair when euthanasia is the only humane option, for a pet that they’ve extended the life of multiple times. I’ve seen vets despair when it’s the only option for a pet and an owner they’ve just met thirty minutes prior. For reasons I don’t understand, we hold ourselves to unrealistic ideals and expectations that we set ourselves, and that no one could possibly measure up to.

I write this not because I have the answer. I don’t. But I have felt the despair. It would be a lie for me to tell you that I have contemplated suicide, and thank God I haven’t. I am lucky to have people who love me, and need me, and cherish my presence here on Earth. I come home after terrible days, filled with death and sickness and people who just wish they had never gotten the pet that they have, and I am enveloped in love. I am listened to, and I am cared for. Afterwards, somehow it all gets filed in its place. Maybe Sofia Yin didn’t have that. I can’t imagine living without it.

A 36 year-old me, wearing some sweet overalls I bought in India and waiting in the Kathmandu airport on a plane that would take me high up in the Himalayas. The plane was late, and that was a problem, because if we didn’t take off before noon the plane would certainly crash in the mountains,given the high winds that kicked up everyday around that time. We landed safely, and I embarked on a life-altering journey.

I decided to become a vet while trekking through the Himalayas. My husband and I were a little more than mid-way through a year of travel, and I had left behind a successful and lucrative career in software sales. It was fine, and I liked it. There was no reason not to plan to return to it. Except that I kept thinking that perhaps I had “phoned it in”, as they say, and not really looked for what I wanted in a career, and that perhaps I had just taken the job that was offered. It’s funny how getting away for a time opens your mind to possibilities, and makes you think about the choices you’ve made in life.

So there I was, wandering through the Himalayas. Not truly wandering, because there was a guide, and an ill-defined path, but at this point in the ten day journey there were big, wide-open spaces, and it was hard to get lost. Scree fields, and swift rivers to cross over suspension bridges, and long, flat rock fields. And for some reason Wiley and I were hiking separately, with a distance of a quarter mile or more between us. I don’t know if he was lost in his thoughts, but I most assuredly was.

I was thinking more and more, obsessively if you will, about the idea of becoming a veterinarian. I hadn’t told anyone, not even Wiley, that it was on my mind. It seemed long past crazy. I had spent more than ten years in software, investing time in becoming who I thought I was. The thought of pursuing another career – wait, not just another career, but one in a completely separate field, and one requiring six more years of schooling – seemed ludicrous.

As I walked I started thinking about how six months or so prior we had been in the jungles of Peru. We had traveled the Amazon River to see wildlife and the people who lived there, but also to experience a ceremony involving a centuries-old hallucinogenic drink called ayahuasaca. There were six of us involved in the ceremony, a group that included me and Wiley, as well as a West Point army physician and his wife. It turned out to be a fairly horrific experience, and I was not only the only one in the group not to puke but also the only one to experience visions. I saw ancient Peruvians in the room, and they were handing me gifts, which I could not see, but somehow knew to be important. They were as real and three-dimensional to me as anyone else in the room.

Circa 2000, me and Sebastian the dog who lived at our lodge in the Amazon in Peru. He and I got along famously. Maybe he knew something I didn’t at the time.

The next morning I told the shaman who had facilitated our journey about my visions. She told me that people often see very ancient people during ayahusaca experiences, but beyond that didn’t offer any real insight other than that it meant that I was developing a connection with my past. And then she looked at me and told me, in a matter of fact manner, that I was a healer. Startled, I said no, I sold software. But she insisted that I was, and then corrected herself to say that I was meant to be. So on that day in the Himalayas I was thinking of her as well, and what she had said to me that morning.

You pass only a few people, and maybe a couple of yaks as you’re walking in the Himalayas. The day was startlingly brilliant, and the sky was completely void of anything other than the sun. We were trekking though an area that was somewhat boxed-in compared to some of the wide-open fields we had been through the previous days.

Let me interject and say that I’m one of the most grounded people you’ll meet. I don’t really believe in fate, or luck, and I often struggle with the existence of a higher power, although I’m not ready to write that one off quite yet. My supernatural experiences, a la séances and summonings, ended pretty much simultaneously with my slumber party days, packed with my Ouija board. I don’t believe in ghosts, or witches, or even visions, for that matter. My rational mind most definitely has the upper hand at any given time.

I remember glancing upwards and to my left, to see a sheer granite face rising one hundred yards from the valley floor. There I saw, as clearly as if it were real, written in a cursive style of hot pink and turquoise letters reminiscent of something adorning Barbie’s dream house the phrase:

Why the Hell Not???

I stopped, and I stared at the message for several seconds, then shut my eyes, shook my head, and opened my eyes back up. The message was gone, but it’s clear to me that it had been real, and that it was addressed to me. The intent seemed clear, and I interpreted that vision to mean that there was really nothing stopping me from going to vet school, and that somehow I was meant to be a vet, and it was high time I got on with things.

Once I got home and started figuring out just how one goes to vet school, I began to understand what I was up against. At the time there were only twenty-eight vet schools in the U.S. and Canada, and despite having class sizes that varied from 80 to 130, each of them got over 1000 applications per year. And having a business degree meant that I had to complete at least three semesters of required classes in subjects like organic chemistry, biochemistry, and microbiology, before even applying.

But somehow I got in, and here I am. And I’m desperately in love with my career, but I can also see why it might possibly drive someone to contemplate ending their life, as hard as that is for me to say. The emotions I feel on a daily if not hourly basis while doing my job – despair, joy, anger, fear – are not for the unstable, or those without a network of support. The rewards are many, but the price is great. They told us at graduation that to those whom much is given, much is expected, and they were right.

So I want to write a book. Because I think that maybe people like Sofia Yinn, while they had so much to give, got very little back, and that’s just wrong. And it breaks my heart to think that others like her, with such talents and such gifts, might succumb to the despair, without seeing the light, without recognizing that they do so much good everyday of their lives. Without giving themselves back some of the love and caring they so freely give out to others. Perhaps it will be therapy for me as well.

Prayer flags and a Himalayan peak. Peace lives here.

Dog Days Are Over, Parte Dos

Sweet girl waking up from surgery, successfully

(To read Parte Uno, click here).  San Miguel de Allende, GTO, MX, August 24, 2014:We had to give our patient, recently anesthetized to repair a tongue injury and undergo sterilization, to the technician to care for because we had a very sick three month old puppy with Parvo that had been dropped off by its owners.  This dog was fading fast, but we did get fluids started, having to place a catheter in the jugular vein because it was so dehydrated that all of its peripheral veins were impossible to find.  When you place a catheter in the jugular vein you use a specially-designed long catheter, since this is clearly a high-motion area, and the typical short catheter will always kink when the patient moves its neck, and stop working.  The rescue doesn’t have these long catheters, and this is exactly what happened with this puppy’s catheter.  The vet made a decision to give it a small dose of “anesthesia” to keep it quiet while fluids were running. Once again, I’m standing there, not saying anything, and watching this dehydrated, minimally responsive one and a half pound puppy get xylazine.  Into his kennel he goes, so that we can look at the next Parvo puppy.

Turns out that puppy had died, waiting to be seen.  We all felt terrible, but the vet had to keep moving because another puppy that has been brought in for vaccinations.

Every veterinary clinic has to have a system, or some type of structure.  This not only helps to ensure the safety and well-being of the patients but also the sanity of the staff.  At my hospital our system is that while one doctor is performing surgery another doctor is seeing appointments, in order to minimize anesthesia time and allow the surgeon to focus on surgery.  In addition, the number of people involved with animals suspected of having infectious diseases is limited to one technician and the doctor who is caring for the patient.  Gowns, gloves, and foot baths are utilized to lower the risk of transmission to other patients. I could write a book about how we do this, but suffice it to say when we follow procedures we have good outcomes, and that’s what we’re all striving for.

At this rescue there really isn’t a system.  People bring in their pets and wait out front until they can see the vet.  At the same time the vet has to work in surgeries for both shelter animals and paying clients as well as take care of sick patients.  This means that she’s often forced to take care of an animal with an infectious disease and then move right on to seeing an animal that’s never been vaccinated against the disease she’s treating.  This actually happened twice that morning, and I asked her if she was worried about transmitting Parvo to these healthy puppies.  She washed her hands and sprayed her clothes with disinfectant and shrugged, and told me that yes, she was.

At this point I was developing a severe case of anxiety, along with a deep longing for my beautiful, sparkling clean hospital back in Colorado with its isolation ward, its highly educated staff, and its seemingly endless reserve of top-of-the-line supplies and medications.  An ominous feeling started to wash over me, and I went back to the isolation room to check on the first dog, the one with the tongue injury.  I put my hand on its femoral pulse; nothing.  Hand on its chest, nothing.  Pulled it out of the kennel and shouted for a stethoscope.  Nothing, nothing, nothing.

There are no words to describe what that realization is like, not feeling that reassuring thump, thump, thump that was just there thirty minutes before.  Your first thought is that you’re crazy, the dog must be alive, it has to be.  Maybe you’ve just contracted a serious neurologic disease and your hands have lost feeling?  Maybe your stethoscope is broken, or turned around backwards?  Perhaps you’ve lost your hearing?  But no, none of those things have happened, and a life that was in your care is extinguished.

I’ve been lucky that in seven years as a vet I’ve not had this experience often, if ever.  But having seen two dead dogs in a thirty-minute span I walked over to the kennel holding the tiny puppy with Parvo in something of a dream-like state, only to find it dead as well.  I somehow knew before I got there that I would find it dead.

Chances are good that the two Parvo puppies would have died even if they had immediate and aggressive care, but it’s also likely that the sedation hastened the second puppy’s death.  Without the additional dose of sedation the dog with the tongue injury would probably have recovered from the anesthesia, but possibly died anyways, since it’s likely that there was something very seriously wrong with it that we didn’t know about.  I’ll never know for sure, but it’s hard to find a place to put these things.  You can’t neatly file something like this away under “Experiences Encountered While On the Job”.

As a veterinarian you’re expected to counsel families through the difficult and final act of euthanasia, perform the act with compassion and skill, then compose yourself in sixty seconds and walk beaming and blissful into the adjacent exam room to see an exhuberent family with brand new puppy.  But private practice veterinarians walk a flower-strewn path compared to our colleagues who care for homeless animals.  They see the abuse, the neglect, and the overpopulation every minute of every day.  This rescue is a wonder and a gift – a no-kill shelter in the middle of Mexico, a country where just a few minutes ago a woman knocked on our door and had her little girl ask for money for food.  They are doing what they can with what they have, but hopefully I can help them do better.

I walked out of the rescue that first day, bought myself a Coke, and walked the thirty minutes home, lost in my thoughts.  I began to imagine what I would tell them, such as “Hey, listen, I know I said I’d help you guys out, but I just don’t think my schedule will allow it”.  From somewhere else in my brain came a chorus of taunts, such as, “Liar. Coward. These people need you, so step up your game and figure out how you can help them.”.   So I went back the next week, and the next, and the next.  Every day has been exponentially better than the first.  I feel a bond developing with Roxanda, the vet there, and I am slowly starting to talk to her about better anesthesia techniques and infectious disease practices.  She still feels unsure of herself when performing spays, so I’ve been handling those, and we’ve done four or five together with great results.  I showed her how I remove dew claws and tie a Miller’s knot, and I’ve gotten her to start treating Parvo cases more aggressively.  There is a big veterinary conference in Leon (about an hour away) in September and the rescue is paying my way so that I can help her pick out some new equipment and supplies.  We joke about Cat Ladies and clients who lavish praise on the guy at the front desk for saving their dog’s life.  It seems that at least some part of the veterinary experience is universal, and for that I am grateful.

 

 

 

Dog Days Are Over

Being a veterinarian certainly isn’t all puppies and kittens, but times like these make the tough ones easier to bear. Me and Magnus the adorable bull terrier puppy.

San Miguel de Allende, GTO, MX, August 22, 2014 – For the past several weeks I’ve been spending some time at the local animal shelter.  I usually go on Thursday, and I see cases and do surgeries with the vet there.  She thinks I’m some kind of surgical genius because I can spay a dog that’s in heat with minimal bleeding; I’m not telling her otherwise.  On my first day I successfully suppressed an overwhelming urge to run into the street and away, never to return.  I’ve had my share of rough days in my seven years as a vet, but seeing three dogs die in the space of 30 minutes was almost more than I could take.

The vet on staff there is a very nice woman, who cares a lot for her patients and their owners and is doing an admirable job considering the facilities and supplies that she has.  I am fairly certain the x-ray machine was built by Marie Curie herself.

They taught me lots of things in vet school, many of which I promptly forgot right after national boards, including the twenty-three causes of diarrhea in neonatal pigs.  But I very well remember being told that there is no such thing as “safe” anesthesia.  You are giving dangerous drugs that depress the respiratory, cardiovascular, and nervous systems, and even in healthy patients things can go wrong.  Your training is focused on how to administer these substances at what we know to be the safest dosages in the safest combinations, and what to do if the animal’s body reacts aberrantly.

On my first day at the rescue I was putting my stuff away and I saw an injectable drug bottle on the top of the refrigerator.  The manufacturer’s label was somewhat obscured by the hand-lettered word “ANESTHESIA”, and this is how the clinic staff referred to it, as in “give me ½ ml of ‘anesthesia’”.  The bottle actually contained a combination of two drugs.  The one that truly provides anesthesia is xylazine, a drug that I have almost never used.  It’s very widely used to knock out horses and cows and other such creatures but we have drugs in this class, known as alpha-2 agonists, that were developed especially for small animals.  In this combination the xylazine was mixed with another drug similar to Valium, which provides some sedation and muscle relaxation.  The rescue typically gives the drug combination in a muscle, and is used for everything from mild sedation for an orthopedic exam on a painful patient to abdominal surgery and dental cleanings.

Not to get too geeked-out on the veterinary stuff, but the majority of American vets would never perform abdominal surgeries using injectable anesthesia only.  It’s unreliable, and frequently patients start to wake up during surgery and have to be re-dosed.  This means if the patient starts to wake up five minutes before you’re finished, once you re-dose them you can expect them to be anesthetized an hour or so longer.  Gas anesthesia is by far the preferred method, as it provides a rapid way to change the depth of anesthesia, i.e. how asleep the patient is, as well as gives you a way to deliver oxygen directly into the trachea via the tube that is placed there to deliver the gas.  This tube also occludes the airway, so that fluid cannot get into the lungs.  This can easily occur during dental cleanings, or if the animal regurgitates stomach fluid during recovery.

But machines that deliver gas anesthesia and the assorted accoutrement that goes along with them are expensive, and it is unlikely that most vets in Mexico have them, much less any rescue organizations.  In addition there is a definite shortage of skilled veterinary technical staff, so most staffers probably wouldn’t even know how to use these machines if they had them.  So, they’re using injectable drugs to anesthetize patients.

OK, xylazine.  I’ve known small animal vets who used it and were very comfortable back in the day with it.  It’s a good drug when used properly.  The main reason vets use alpha-2 agonists is because they provide deep, reversible sedation.  Reversible, meaning there is another drug that is given once the sedation is no longer desired, and the act of giving the second drug makes the animal wake up.  We use drugs like this in my clinic to do things like suture lacerations in otherwise healthy animals.  Give the first drug, dog goes to sleep.  Fix up the mess.  Give the second drug, dog stands up and goes home.  It’s a beautiful thing, and in a healthy animal with a good heart it’s a good choice.

But the rescue doesn’t have the reversal agent, for reasons I’m not yet clear on.  I don’t know if it’s not available in Mexico, or if Mexican vets just aren’t trained to use it.  This is especially surprising in a situation such as this, where there is limited staff of varying skill levels and less-than-ideal monitoring capabilities.  And by “less-than-ideal” I mean “none”.  No heart-rate monitors, no pulse oxygenation levels, certainly no EKG or blood pressure.  We can see that they are breathing, and look at their gums to see that they are pink.  If we’re not performing a sterile procedure we can certainly listen to their hearts and lungs, and feel their pulses.  So our patients wake up when the drugs wear off.  At least, we hope they do.

But the vet seems extremely comfortable with using this drug combination in many circumstances.  On my first day at the rescue we started to see patients shortly after I arrived.  One was a puppy with parvo (a highly contagious gastro-intestinal virus that causes vomiting, severe diarrhea, and decimation of white blood cells) that’s had been in the hospital all night.  He was supposed to be getting intravenous fluids but his catheter failed.  Overall he was doing pretty well, though.  He was being cared for in the shelter’s isolation ward, along with several very loud cats and kittens with ringworm, who clearly felt fine and wanted out.

Later in the morning a teenaged boy left a middle-aged poodle-ish dog with us.  I understood from the vet’s explanation that she saw the dog last week, and that at that point he had just returned home from being missing for three days.  At the time his tongue was black, his mouth full of ulcers and abrasions, and he wasn’t eating.  She had given antibiotic and anti-inflammatory injections, but the dog was back today, still not doing well, not eating, and clearly not feeling well.

We were able to examine the dog and see that the entire end of the tongue was black and dying.  This looked extremely painful and infected, and was very likely the primary reason why the dog wasn’t eating.  We speculated about the possibility of electrocution (dogs will bite onto electrical cords and get these types of lesions in their mouths) or chemical burns.  There didn’t seem to be any fractures to the jaw or any pain elsewhere.

The shelter vet  felt that we could anesthetize the dog, remove the dead tissue from the tongue, and this would help him to feel better and hopefully start eating.  I couldn’t disagree with this theory, since there were no other diagnostics to support any other troubles.  He went quietly down with his anesthesia  dose and we cleaned up the mouth.  Throughout this procedure his heart rate was stable and his breathing was normal.

Noting that he still had his testicles I wondered aloud if his owners realized that he would probably stop running away and getting into trouble like this if he were neutered, and the rescue vet agreed.  She laughed and said they probably wouldn’t even notice if we neutered him today, and I laughed too, until I realized that she was serious.  Before I knew it he was given more “anesthesia” and was shaved and scrubbed for surgery.

Now, this would likely never, ever happen in the U.S., or at least not at my practice.  At home, this is malpractice plain and simple; performing a surgical procedure without the owner’s knowledge or consent.  But clearly, I’m not at home anymore, and the vet in charge believed that this was reasonable.  The clinic doesn’t obtain informed consent for anything they do; they are providing free or very low cost care and basically the owner provides information about what is going on with the animal and leaves it, hoping to get call later that its better.  The clients seem to trust that the vet knows best, and it’s up to her to do what she thinks is necessary.

During the neuter, the dog’s vital signs again stayed in the normal range, although the heart rate came down a little more, and afterwards we placed an IV catheter and started fluids.  I gave him to the technician to continue his recovery in the isolation room.  Final check of his vitals: still good, but he was still completely anesthetized.

Are you outraged at me?  Because I’m fairly outraged at myself.  Why didn’t I speak up and say you can’t do this procedure on this dog, you don’t have informed consent?  Why didn’t I stop everything and go look up appropriate dosing guidelines for xylazine, like how soon after a first dose can you give a second dose?  Why didn’t I say that I didn’t think it was a good idea to give an obviously dehydrated animal more anesthesia than necessary, especially not xylazine, which is contraindicated in animals with cardiovascular compromise?

I don’t know why I didn’t say anything.  I suppose the vet seemed very confident in her actions, and I am certainly a stranger in a strange land is so many ways, that I just didn’t feel right saying anything, and I was really hoping everything would be alright.  And quite honestly I did think the dog would be OK; he was doing well the entire time we were working on him and based on the information I had to hand I had no reason to think it wouldn’t be alright.  But in the end it wasn’t.  It went completely and horribly wrong.

I’ve got lots more to say about my experience that first day, and on those that followed.  Since Google tells me the optimal blog post is 1900 words long, I’m going to end this post just over that, and continue tomorrow.