DrAndyRoark.com

Articles, Videos, & Training on Pets & Veterinary Medicine

Lauren Smith, DVM

These Are My Thoughts When I Lose a Patient

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Yesterday I lost a patient. I wasn’t even there.

It all started last week.  He came in for vomiting.  His x-rays were inconclusive. We decided to treat him symptomatically with IV fluids and repeat radiographs. They were still inconclusive, but the vomiting had stopped and he was eating and acting normally.  We sent him home.

The next day, he vomited again.  He came back in for an ultrasound. From ultrasound, he went to the OR.

He had adhesions from another surgery years ago—scar tissue—that had resulted in an obstruction. I couldn’t safely break them down, so I had to remove a section of intestine.  The two healthy ends of bowel came together nicely.  I checked the incision for leaks and finding none, I closed him up.

The next morning he was eating great and acting normally.  The day after that he was fine too.  On the third day, he wasn’t.

“We have to go back in,” I told his Dad.  “The incision could be leaking.”

I hoped I was wrong.  I wasn’t.

We removed more intestine and repaired the anastomoses.  We flushed his abdomen with sterile saline to try to clean out any bacteria or ingesta that had escaped the GI tract.  We loaded him up with antibiotics.  We crossed our fingers and prayed.

He made it through the night but the next morning he still couldn’t sit up and his protein levels had dropped dangerously low.  I wasn’t there, but I called my colleague to confer on the case.  He needed a plasma transfusion, we decided.

He never got it.  While the fresh frozen plasma was defrosting, he decompensated.  They did CPR, but he died anyway.

I’ve been through it a hundred different ways since that morning two days ago when it all went south.  What could I have done differently? Did I do something wrong?  Was it my fault?

14. That’s the percent of dogs undergoing this particular surgery that encounter this complication. Not the percent of my patients—just what the retrospective studies show.  And adhesions increase the risk.

This should make me feel better, but it doesn’t.  Because he’s still dead, and I’m still left wondering.  Was it fate, or was it me?

I know I did everything I could.  I know I’m a good surgeon.  I know this happens to the best surgeons.  But it doesn’t matter because I still can’t stop wondering.  Would he be alive if another doctor had done the surgery?  Was it my suturing technique?  Was it my choice of suture material?  Was it my tissue handling?  Was it me?

Clients often think euthanasia must be the hardest part of my job.  It’s not.  This is.  The ones we try to save.  The ones we give our all to.  The ones who have a chance but die anyway.  That’s the worst part of the job.  It makes us doubt ourselves.  It makes us feel helpless and useless.  It makes us feel like failures.  These are the cases that you never truly get over.

Sure, the wounds will heal, but they will leave scars.  Adhesions will form.  And you can never cut them out or break them down.  They will sit there for years, not really causing a problem, until one day something gets stuck in our tangled web of emotions and the old wounds feel fresh again.

We will heal for our patients who won’t, but we will never be whole.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Why Compartmentalization Should Be a Regular Habit

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“You’re always so happy, how do you do it?” the client asked me as I examined her dog.

“Good acting,” I half-quipped. This day in particular had me believing my happy face was nothing more than a ruse.

It had been a tough week and an even tougher day. Our four (looking for a fifth) doctor practice was down a doc again as we had been for six of the previous eight weeks, a cat I had seen for a UTI had died unexpectedly at home, my parents’ dog was in end-stage kidney failure, and I had spent 15 minutes on the phone with an irate client who believed I was personally responsible for her dog tearing her cruciate while she was boarding.

I was on the verge of a nervous breakdown. How could I go into an exam room with a smile on and pretend everything was alright?

Compartmentalization.

In that exam room, for those few minutes, I was happy. I was with a client who loved her pets and was always kind and appreciative of my efforts to care for them. She had recently lost one of her dogs, but here she was with a newly adopted senior dachshund she had opened her heart to. I was happy for her. So I left everything else at the door.

Compartmentalization is how we focus on explaining atopy to one client while worrying about the CHF dog in oxygen in the back. It’s how we kindly and genuinely greet one client right after getting reamed out about charges by another.

And it’s how we go home at the end of a 12-hour shift filled with emergencies and still manage to enjoy a good snuggle with our own pets. Compartmentalization is how we stay sane. So how do we do it in a healthy way?

Leave Work at Work

We all do it. We bring a chart home to write up. We research a case on VIN from our house. We stay up all night worrying about our splenectomy from that morning. We don’t give ourselves a break and that is a recipe for burnout.

Start the process of disconnecting from work before you leave the office. Make sure your calls are made, your charts are written up and your in-patients checked on. Then tell yourself you’re leaving. Make it a mantra. “Goodbye vet med.” “Lauren has left the building.” “Peace out, pets.” Saying the same thing every time tells your brain to start shutting down.

The mental shutdown may take a while. Allow yourself to process the day on the commute, but once you’re out of the car, work is over. When you start thinking about work again, remind yourself that it can wait until tomorrow. Your patients are safe with their families or the next doctor on shift. Your clients have the number for the local emergency clinic. It’s okay to stop thinking about work for a while. You are not a horrible person if you take time for yourself.

Focus on One Thing at a Time

Multi-tasking has become an integral part of life, but it’s not always good for you or your patients. It may feel ingenuine to go from a euthanasia to a new kitten exam and act all ooey-gooey, gushing over the cuteness. It’s not. That kitten and her family deserve your enthusiasm as much as the family euthanizing their dog deserves your empathy.

When it’s time to move from one room to another, step into a neutral place. Close your eyes, take a deep breath, and tap into the energy that you’re going to need for the next appointment. Once you’ve made the change, move on to the next room and focus all your energy on the new task at hand.

Don’t Ignore the Bad Stuff

It’s not healthy or helpful to spend all your time obsessing over a case that went bad, a client that blamed you for something that wasn’t your fault or a bad review. Learn to shut it off—but not forever. The really bad stuff needs to be processed. You need people you can talk to about it and a time and place to analyze it where it won’t interfere with the rest of your life.

Repressing the difficult stuff only internalizes the pain. Trying to push through and ignore it is one of the risk factors for developing compassion fatigue. So if you have a compartment that feels especially heavy make sure you make time to open it up and lighten the load.

Learn to Say “No”

We hate hearing it almost as much as we hate saying it. We feel like we have to do it all. But we can’t.

We only have room for so many compartments at once. That means we need to decide what the most important things are, carve out a place for each, and say “no” to the rest.

If one compartment is for going to the gym after work, then when someone calls at the last minute asking you to see their dog with an ear infection, the answer is “no” because you need to get out on time. When you’ve made a compartment for Saturday with the family and a colleague asks you to cover their shift, the answer is “no” because you already have plans. And for all that is good in this world—PLEASE don’t give your cell phone number to clients to call you at all hours. A decent night’s sleep is essential for processing all the events of a day and waking up ready to do it all again.

Compartmentalization generally has a negative connotation, but the truth is, sometimes it’s necessary. It’s a tool we need to survive, to create a balance in our lives, and to give ourselves permission to enjoy the good things in life.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Why This Introvert is Wiped After Each Shift

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I am an introvert. If you’re reading this post, you might be too. Introverts are abundant in veterinary medicine. Many of us chose this field because animals made us feel connected to the world without the constant “work” of being around people. As it turns out, people are as big a part of this job as animals are. Most days it’s one part cuddling, two parts medicine, three parts grief counseling and four parts customer service. Just look at my typical day:

I walk into the clinic at 8:45 and am immediately bombarded with questions. A boarder has diarrhea, should we start him on ID? Buffy’s Mom is here for a Proin refill but we’re out of stock, what should we do? Once I’ve addressed those, I round on hospitalized patients. I check the EMR and see that I have 14 items in my inbox. I go through them, marking the negative heartworm tests as reviewed and making sure there isn’t anything emergent. I’m left with eight calls to make.

The first appointment is a family with a lab puppy. I get down on the ground and “ooh” and “ahh” with enthusiasm. I ask questions about how long they’ve had the puppy, how the little girl is enjoying her new friend and how the housebreaking is going. I give the puppy an exam and begin explaining vaccine protocol and basic preventative care. I talk about feeding and training. Once I’ve answered all the family’s questions, I say goodbye and take a few minutes to write up my records.

The next appointment is a 12-year-old Yorkie who’s been coughing. I go over the history and ask a few more questions before starting my exam. He’s got a grade four heart murmur and a heart rate of 180. I tell the client my suspicions but explain the need for chest x-rays to confirm. He’s got a vertebral heart score of 12, an enlarged right atrium and a perihilar interstitial pattern. I put the patient in oxygen while I go back to the exam room to talk to the client. I explain the pathophysiology of congestive heart failure, the treatment and the prognosis. The client already knows most of this because his father passed away three months ago from CHF, he tells me. I give my genuine sympathies and spend a few minutes listening and offering some comforting words before I have to move on. A quick glance at the clock shows me what I already know—I’m falling behind. I put off writing my medical records and head into the next exam room.

I see seven more appointments that morning. I ask detailed histories, go over differential diagnoses, explain the importance of diagnostic tests, go over results, explain pathophysiology, and advise clients on treatment options. I also hear about vacation plans, kids’ graduations and sick family members. I gush over Callie’s unique markings and Jake’s blue eyes.

I finish morning appointments at 12:30, and have only written up four of my medical records. I check my inbox and see I’m back up to 11 calls. Nothing is urgent so I head to the break room and take 30 minutes for lunch.

At one, I head back down to the treatment room to get started on some callbacks. I get through five of them before it’s time to start my cat dental; a break from the abundance of social interactions that morning.

Afterwards, I call the client to let them know surgery went well and that Pineapple is awake. I write up the dental report, then look at my inbox—the six from before the dental are now nine. I alternate returning calls and catching up on my medical records.

My evening is a lot like my morning, except in addition to nine more appointments, I have to discharge the cat dental and the CHF dog who was luckily stable enough to go home. Appointments go smoothly and I managed to finish on time. I called back three clients I hadn’t been able to get ahold of earlier, along with four more that had called over the course of the evening. At 8:45, 12 hours after I arrived at work, I get to head home; physically and mentally beat.
I am not complaining about my job. I am truly interested in making sure my clients understand what’s going on with their pet’s health. I genuinely empathize with their family circumstances. My interest is real but it’s exhausting.

For those of you who aren’t clear what it means to be an introvert, it means that social interactions use up our mental energy. But just because interacting with others is “work” doesn’t mean I don’t enjoy it.

I can enjoy being around people, but for every hour I spend doing so, I need two hours of alone time to recharge. That means after a 12 hour work day like the one above, I need a full 24 hours of recuperation. And after three or four shifts in a row, I need all weekend to myself. I don’t want to go out to a bar with my friends; even texting them back feels exhausting. And forget dating—I can’t even muster up the energy to type a response to my newest connection on Bumble.

I give my all to my job because I love it. But at the end of a long week, it really does feel like I’ve given it my all. Like I’ve drained myself so thoroughly that I have nothing left to put towards social relationships.

To my friends and family, I hope you can understand and forgive me when I seem to disappear for a while, or take two days to respond to your text. I promise to keep trying to find the balance and do my best to be a better friend.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

How Do We Get Over Our Guilt About Money?

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Veterinary medicine falls right in the middle of the Venn diagram conversion of emotions and money. Pets are increasingly considered part of the family, and we the parents of our furbabies. But medicine costs money, and unlike with our human family members, most pets are not covered by insurance. This can make for a pretty bad situation when a pet gets sick and clients can’t afford their treatment.

As vets, we’ve all been called “money-grubbing”, or accused of only being in it for the money. We’ve been guilted and manipulated by people who tell us that “if we really loved animals we’d help” when they can’t afford treatment. And we do love animals, and we really do want to help, so we fall for it; or at the very least, we internalize it.

Taking It Personally

No one smart enough to get into vet school was stupid enough to go into this field for the money. We rack up insane amounts of debt to work long, stress-filled hours barely getting by. So when people accuse us of only caring about dollars and cents, we feel the attack at the core of who we are.

We immediately go on the defensive. We wave our 6 digit student loan debt, 10 year old cars, lack of retirement funds and barely existent savings accounts as badges of honor. “Look how much I don’t care about money,” we say. “I haven’t been on vacation since 2009.”

Family outdoors with a dog looking very happy

We feel guilty about charging for what we do, so we don’t. We don’t charge for an ear cleaning, or re-bandaging that paw even though it came off because Milo chewed it off and not because we didn’t put it on right. We only charge for extracting 4 teeth instead of 10 because some of them “practically just fell out of the mouth.” It seems harmless enough. We just want to help a pet out. And what does it cost us really? The bandage material is pennies, so it’s really just our time, right?

I have yet to meet a fellow vet who doesn’t experience this kind of money guilt, myself included. We feel like we’re taking something away from our clients instead of giving them something valuable. Our time and knowledge and services are valuable. WE are valuable. And we are under- appreciating ourselves every day. It’s not harmless. We are harming ourselves and our profession.

If we don’t value what we do, why should our clients? Why should they come and see us for their pet’s annual when they can go to a vaccine clinic down the road for half the price? Why should they call us when their pet is sick instead of just turning to Dr. Google?

We need to stop! But how?

How Much You Have, How Much You Give

We need to change the narrative we give to ourselves and to our clients.   Stop reinforcing the idea of how little we make. When a client, or even a friend or relative comments or complains about how much vets charge, don’t make it about how little you have, make it about how much you give. Talk about the value of the services you provide. It’s an affirmation. The more you talk about your worth, the more you will believe it.

Stop feeling guilty for charging money and for having money. Money pays our bills. It gives us the freedom to take care of ourselves and our futures.   We work hard and we deserve to have financial security. Educate yourself about personal finance. Take a good hard look at your student loan debt, your amortization schedule, your interest rates and how much it will cost you to continue to only make the minimum payments. Learn about Roth IRAs and 401ks and how to invest your money and start putting aside enough to make sure you can retire one day without winning the lottery. The more you learn about how to save, the more you will accept that you need to make a decent living.

Smiling Cat Sleep On The Bed

And lastly, take a look at just how much you give. Add up all those “little” charges you leave off clients bills every day. Record every free recheck, wound cleaning, fluorescein stain… I’m not saying you need to start nickel-and-diming every client, but just be aware. Seeing the numbers, if only for yourself, will help remind you of your generosity as well as showing you just how much that generosity is affecting your own bottom line, so that you can be in control.

It’s okay to be generous with your time and skills, but make sure you’re doing it for the right reasons, not because you feel guilty. And make sure you’re taking care of yourself first. You’ve earned it.

[tweetthis]And make sure you’re taking care of yourself first. You’ve earned it.[/tweetthis]

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

 

The Real Reason Your Wait at the Vet’s Office is So Long

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I recently read a Huff Post article entitled “The Real Reason Your Wait at the Doctor’s Office is So Long.” Veterinary Medicine and Human medicine vary in a lot of very meaningful ways, but we are also often the same. And in this we share a common weakness—we sometimes run behind schedule. In fact, I’d wager to say we frequently run behind schedule.

Mid section of veterinarian and assistant examining dog

So, when I saw this article, I expected to read a well-reasoned explanation of why this is the case by someone in the know. Instead, the article read more like one woman’s angry Yelp review. Many of the comments in the article espoused similar experiences with complaints that doctors don’t value their time, overbook to cram as many appointments in as possible just to make a few bucks, and are generally greedy, no-good, shysters with big egos.

As you can imagine, myself and many other health professionals took offense to this so I am here to tell you the REAL “real reason” your wait at the doctor’s office (be that physician, dentist, veterinarian, chiropractor, etc) is so long—we care!

[tweetthis]I am here to tell you the REAL “real reason” your wait at the doctor’s office is so long[/tweetthis]

We care about you and your pet and your health, and yes, even your time. We care, and we are people pleasers who try to make everyone happy. We do our best to schedule responsibly (although sometimes there are managers and administrators who have more of a say in this than we do) but as Robert Burns said, “even the best laid plans of mice and men, often go awry.” Nowhere is this more true than in medicine.

Things are always going awry. Sometimes it’s a true medical emergency—the dog that ran into the street and got hit by a car, the cat that can’t breathe because it’s having an asthma attack, the person who goes to their doctor for heartburn but is really having a heart attack. In these cases we have to stop everything we’re doing to care for this emergency and that takes a lot of time.

White Labradors

Sometimes the problem is our own inability to say no. We save that appointment slot for an emergency and then someone calls up because their dog has a painful ear infection. Sure, it’s not really an “emergency” but we can’t stand the thought of that dog suffering in pain until tomorrow, so we fill the slot.

Then the next thing you know, someone calls up because their cat has vomited 6 times in the last hour and really needs to be seen. Sure, we could say we’re booked and send them to the emergency clinic, but then the client will wind up spending twice as much and they have two kids in college and can’t really afford it. So we fit them in, even though there are no open spots and taking x-rays is going to put us even more behind.

nice cat

We also get behind when simple appointments turn out to be not so simple. A client schedules a wellness appointment for vaccines and then “mentions” their cat is urinating out of the litter box, and can you check this lump and his breath really smells, and oh yeah, don’t forget to cut his nails. Or the patient I saw the other day for what the client thought was an eye infection but really turned out to be lymphoma. I’m not going to rush an appointment like that just because I’m afraid of getting behind.

Yes, I feel bad that I’m making the next client wait, but I know that if something terrible ever happens to their pet, they would want me to give them as much time and attention as they need, even if there are ten people in the waiting room who are just going to have to wait a little bit longer.

And sometimes it’s not terrible news I’m delivering, but just someone who has a lot of questions. Sometimes I have to have a lengthy conversation on weight management or dental health, or the importance of heartworm prevention, that runs long.

Veterinary Assistants And Dog

I could easily skip over these issues especially when I’m running behind. It’s not a problem yet after all. But instead, I take the time to make sure my clients are fully educated about their pet’s health so that down the line I can hopefully avoid discussing diabetes management or the heartworm treatment protocol.

All of these things aren’t a once-in-a-while occurrence. They happen on an almost daily basis in medicine.

The truth is, maybe I could be on schedule more often. I really do value your time, but I value your pet’s health more and if being better at time management means I’m going to be worse as a doctor, then I’m not interested.

[tweetthis]I really do value your time, but I value your pet’s health more[/tweetthis]

Reprinted with permission from laurensmithdvm.com.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.