Reality Bites

Sometimes, people just don't want to hear the facts.

This week, I am standing in the office, looking at some blood work, when I notice SS getting A Look on her face. I pause and listen for a moment; sometimes this indicates a question that a doctor has to answer. But it appears that SS is discussing travel regulations. She is (quite patiently) repeating herself over and over, in a loop that goes something like this:

"Yes, sir. The Canadians will require a current rabies in order for you to enter Canada. They usually will not require a health certificate, but if you are passing back into the United States, you may be asked for one at that border. No, sir, we don't insist that you get the health certificate OR the rabies vaccine, but if you don't, you may be stopped at the border. No, sir, that rabies certificate is expired. Yes, the Canadians will require a valid and current rabies certificate at the border. No, the CANADIANS aren't the ones who will require the health certificate. That may be required in order for you to re-enter the United States. No, sir, WE don't require you to get the health certificate or the rabies vaccine. That will be the people at the border. Yes, sir, you DO need a current rabies vaccine....."

While I am wondering what is so difficult about this, SS is clearly wondering the same thing. Finally (after several minutes of this) she appears to have settled the question, and hangs up.

"Man, I'm glad I'm not that guy," she says. "I could hear his wife in the background the whole time, screaming about the rabies vaccine and how it's just a conspiracy to get their money. I don't envy him the chance to drive 3,000 miles with her harping at him all the way."

"Well, he doesn't have to get a rabies vaccine; he can take his chances," I say.

"So I told him," SS agrees.

I think nothing of this until a few minutes later, when KD comes back.

"Can you talk to this woman?" she asks SS. "She has all these questions about health certificates and rabies vaccines."

"I just talked to them," SS says, exasperated.

"Well, can you talk to them again? This lady is getting pretty nasty with me and I don't know what else to tell her," KD says.

"I'll take that call," I say. "What line is she on?"

This is one of those situations in which sometimes the client has to talk to the doctor. Although, having listened to SS, I know that she has accurately (and civilly, and with considerable restraint and patience) dispensed the correct information, sometimes clients will not believe it until the doctor tells them the same exact thing. In addition, certain people feel perfectly comfortable rudely abusing the staff, but will rein themselves in when talking to the doctor, so sometimes it is best that one of us just steps in and takes the call. I admit I take a small amount of lurking pleasure from this; I figure that if a caller has already been abusing my staff - particularly when I am aware that said staff has been more than professional and forbearant about it - the caller is then due a firm reality check, delivered calmly and with professional detachment, but without equivocation or ambiguity. This is in part to defend my staff, who work damn hard for me; partly to stave off future assaults on them by repeat attacks by the same client; partly because I personally feel that anyone who believes that the rules shouldn't apply to them has another think coming; and partly because I am, by being a doctor, engaged in a lifelong battle against ignorance and misinformation, and I love to slay those monsters.

I pick up the line and say, in a pleasant tone of voice (because after all I am not averse to slaying this particular dragon), "This is Dr. H. Did you have a question about rabies vaccine?"

"Yes," says the client. "I just want to know why rabies vaccine is better up here than in New Mexico."

"Better....?" I ask.

"Yeah, why is it only good for a year in New Mexico and it's good for three years in Alaska?"

"For one thing, that depends on the age of the dog; the first rabies is good for only a year in Alaska, too. It's only the adult boosters that are a three-year vaccine here," I tell her. "In addition, each individual state sets its own laws for the required frequency of rabies vaccine. This is dependant on the risk of exposure and what the public health officers of the individual states have determined to be appropriate in that environment."

This checks her for a moment.

"But you're saying I have to get another rabies vaccine because it says it's only good for a year in New Mexico, even though Alaska says the shot is good for three years," she protests. "We got the shots two years ago."

"If the certificate is expired, then it can't be used as proof of current rabies vaccine, no matter when the vaccine was given," I tell her.

"So you're telling me you're going to MAKE me get another vaccine," she says, waspishly.

"No," I tell her, "I'm not telling you that, the state and national officials who require the paperwork are telling you that that. If the state of issue will only honor the vaccine for a year, then the certificate is expired, and can't be used as proof of current vaccine."

"This is all scam just so you can get our money!" she accuses me.

Ah, yes. She's caught me. I personally invented this scam just so I could force her to pay me seventeen dollars (of which only a small percentage will actually go into my pocket). Yep, and highly worth it, too, for that princely sum. I resist the temptation to bang my head against the filing cabinet beside which I am standing, and settle instead for gazing out the window at a lovely view of the mountains, serene and peaceful under a crisp white mantle of fresh snow.

"No, Ma,am, it's not a scam so we can get your money," I tell her patiently. "WE don't set any of these laws, but we do comply with them."

"My brother is a - a biochemical - a biochemical physicist," she says, stumbling over the term (and leading me to speculate that he is no such thing.) "HE says that if you get one vaccine then you're immune for life." (Ah, yes. The well-known medical authority of the biochemical physicist. Whatever that is.)

"Well, ma'am, that's not actually true. A great deal depends on the health of the animal in question, not to mention their age, the agent being vaccinated against, the type, condition and quality of the vaccine, and the immunological status of the animal - in addition to which, if you want to have aggressive immunity sufficient to prevent infection and not just enough to hopefully stave off death, you do need to do boosters. Some animals will have longer immunity than others and some might even have lifelong immunity, but some animals are non-responders and will have no immunity at all. The only way to tell the difference and know which one your animal is, is to run titers."

There is a momentary silence.

"So what you're saying is that I have to get vaccines for my pets whether I want them or not," she says acidly.

"No, ma'am. I'm not saying that at all. We personally have no stake in whether or not your pets are current on vaccine. What I'm saying is that if you want proof of current rabies vaccine then, yes, you are going to have to have your dog boosted."

"What a crock of shit!" she spits. "This is all just a big conspiracy to get our money, isn't it?" (this last delivered in a tone of demand, as if she is insisting that I agree with her.)

"Ma'am, the state of issue has determined, for whatever reason, that in that environment it is appropriate for companion animals to be vaccinated yearly for rabies. Since rabies is a fatal disease of humans, in the interest of public health, they have set a protocol which they feel to be appropriate to protect human life and the public well-being. If you wanted to prove that your pets did NOT need rabies vaccines, you'd have to do titers, which run around $200 per animal. The state has determined that if you adhere to their rabies vaccination policy, they won't require you to do the much more expensive titer and will instead accept a rabies vaccination certificate as adequate proof that your pet does not pose a risk to the public health."

Now there is a pause. Since she can no longer return to the "this is a scam to make money" theme - given that the state could make a LOT more money if they insisted on titers - she takes up a new position.

"Well, it's a stupid law. All the states should be the same."

"Ma'am, not all states have the same risk of exposure. Moreover, it appears that your biggest obstacle right now is actually the Canadian border, and we in the United States do not have the right to set policy for another nation. They have the right to protect their citizens and animal populations from fatal infectious diseases in whatever way they see fit."

"Well, someone should make sure all the states do it the same way," she repeats, truculently.

"Perhaps so, in which case I suggest that you contact your local legislators about that when you reach your destination," I say.

"What I want to know is why you can't do something about this."

Sigh. That filing cabinet is looking better and better.

"Ma'am, this is not a legislative body," I tell her. "This is a private practice clinic. If you want to change the law, I recommend that you contact your legislators in whatever community you settle in at the end of your move."

"Oh, like that's going to help," she retorts sarcastically. "If 80% of the people didn't want a bailout and it went through anyway, it won't matter what I say, they won't listen to me. I think you guys should do something about it."

"Ma'am, I am not a legislator, I'm a private practice veterinarian," I say, increasingly baffled as to what this client wants from me, and unsure how government bailouts have anything to do with rabies vaccines.

"Yeah, but you'd have more pull than I would," she says.

"Ma'am, I have no pull whatsoever in New Mexico, as I do not live there and am not licenced in that state, nor do I practice there," I tell her.

"Oh, I'm not going back to New Mexico," she says. "That's just where I got the rabies shots the last time."

"Be that as it may, I can't affect any state law outside the state in which I live, and your beef isn't with the state of Alaska, it's with the state of New Mexico," I say.

"I still don't see why I have to get another rabies shot."

ARGH.

"You don't have to get one," I tell her. "It's up to you if you comply with state and federal law. We don't set those laws, we just comply with them."

"I DO have to get one," she contradicts. "You're telling me that I can't leave the state without another shot and a certificate."

Ah, I knew we could be back to square one eventually. I narrowly resist the temptation to say, "So, did you just want someone to listen to you bitch about this?" and say instead, "Did you just want someone to listen to your concerns about this, ma'am, or can I help you in some way medically?"

"Well, I just think it's a stupid law," she says, running out of steam. "I guess I'll call back about the shots."

"Okay, then," I say.

Shaking my head a little, I turn away from my window mountain view to hang up the phone. Unbeknownst to me, I have gathered a little audience. SS, KD, and Drs. S and G are all standing behind me in a little ring. SS and KD (having both already had the pleasure of chatting with these clients) are grinning appreciatively. Drs. S and G are looking at me with eyebrows raised.

"What was that all about?" asks Dr. G.

"Some people didn't want to get rabies vaccines. Said it was a scam to get their money," I tell him, going to take the next appointment and leaving him shaking his head.

I thought no more about it until the next day when I look up from a chart to see my receptionist B ushering Dr. G into a room. She whispers that it's "those rabies people" from yesterday. Oh, goodie. I am cravenly glad it is not me taking the appointment, and return to making call-backs.

Thirty minutes later Dr. G comes back out of the room. He has an expression of incredulity on his face.

"What?" I say.

"They came in for rabies vaccines for their dog and cat, but he asked me while I was there if I could look at these bumps on the dog. So I felt under the jaw where he said the bumps were and the dog has these huge lymph nodes. So I checked the other lymph nodes and they're all huge. So then I feel the dog's abdomen and he has a giant cranial abdominal mass. So I tell him all that and that I can't be sure where the mass is coming from but I suspect spleen or liver and I think the dog might have lymphoma," he says. I suspect the same thing; it's not a certainty, but it would absolutely be a big enough suspicion to take up the top three slots on my rule-out list.

"So what'd he say about treatment?" I ask; having gone the rounds with the wife yesterday, I figure the dog's hope of treatment isn't good. At the best of times, lymphoma in dogs is regarded as an incurable cancer. But curable or not, it can certainly be treated, prolonging good-quality time for the dog. Depending on the type of therapy, treatment can be relatively inexpensive (although the remissions achieved with minimal therapies are short). Longer remissions require more complex regimens and are correspondingly more expensive, and more taxing in the short run for the dog (although this is paid back by the greater duration of good-quality time on the other side of chemo.)

"He declined anything, even pred," Dr. G says. Pred is an inexpensive treatment for lymphoma, and while it doesn't provide a long remission, it at least provides good quality time while it lasts. Still, given the previous day's conversation, I'm not surprised to learn the owners won't consider it, and I'm not even all that surprised when Dr. G adds, "He says his wife has a bunch of herbals which will cure the dog." Well, or not; I'm not averse to alternative therapies, but if there were herbals out there that would cure lymphoma, we'd all be investigating them pretty eagerly.

"He says the cancer is there because of the Chinese poisoning the dog food with bugs," Dr. G continues.

"Bugs?" I repeat, not sure I'm hearing him right.

"Yes. The Chinese put bugs in the food to poison it, and the white cells attach to the bugs, which mutates them. Normally the liver filters out the bugs, but due to the mutation, the liver doesn't recognize the bugs. The second line of defense is the spleen, which sends a registry to the rest of the body."

"A registry?" I ask.

"A registry," Dr. G nods. "Then, because the bugs have mutated, the spleen misses it too and the registry isn't sent to the rest of the body and so the kidneys get cancer, which is how the poisoned Chinese food causes kidney failure. [Here I will point out that Dr. G told the client the dog had lymphatic cancer, not kidney disease.] But evidently it's all okay, because the owner's wife has herbals and grapefruit extract and these will obviously cure it, so I shouldn't worry about it."

I goggle at him for a moment.

"What did you say to him?" I ask.

"I was trying not to laugh about the mutating Chinese bugs," Dr. G says, "so I was mostly just biting my tongue. But I figured it was a lost cause anyway. I told him what I think going on there, and I even showed him the other lymph nodes were enlarged and that I didn't think grapefruit extract was going to do it. He doesn't want to listen to me. I don't figure he's going to, no matter how many more times I say it."

Well, he has a point. Some clients are so attached to their belief systems that no amount of logic, proof, persuasion or sweet reason will shake them loose from their delusions.

Reality: It's not for wimps.

The Glamorous World Of Veterinary Medicine

[Author's note: Okay, you guys, I admit it: I've been cheating. Some of these stories are ones I wrote in previous years, to entertain my sister or my BF. I'm re-printing them here because most of you haven't had a chance to hear them, and some of them still make me laugh. Besides, I'm getting ready to travel; that means I have 2 zillion things to do in a very short period of time, so for a little while I won't have time to write new stories. So.... I hope you don't mind if I go to my archives to keep you entertained for a little while. If not, read on for one that happened in late February of 2003...]

It was one of those days today, lots of interesting events - too many for one story, though, so I'll start at the end and work backwards as I have the time.

The day ended with two just-before-closing emergencies. Since I'm on call, we told them both to come in. One is an Iditarod leader who just got bitten by another dog and has a one-inch laceration on its wrist. There are a select few clients from whom I will believe this assessment; it seems to be quite difficult for people to accurately report the size of lacerations on their animals. Unless it is a client who has proven their accuracy in this regard, I read "one-inch laceration" as "some kinda cut, which could be anything from a degloving injury to a puncture wound - on the owner".

Since Iditarod is starting this weekend, this dog needs to be seen ASAP. The dog is in Willow, though, and it's just started to sleet in earnest, so the owners estimate they might get in by 6:30 if the roads are passable. I elect not to try to make it home and back in 30 minutes (I can make the round trip in 23 minutes, traffic permitting, but it isn't worth it for the 7 minutes at home.)

As it happens, just a few minutes after this call someone rings in with a cat laying around and crying as if his stomach hurts. My receptionist quite rightly suspects an obstructed tomcat and tells them to bop on in lickety split. They arrive at six on the dot and I spend the approximately 22 seconds it takes to diagnose a blocked tomcat (this includes the time it takes to take the crate apart to get the cat out... it's isn't a tough diagnosis in general, and Zeke's bladder is approximately the size and hardness of a softball, in any case.)

Fortunately as I walk into the treatment area with my (eighteen pound) patient, I note that not only has JG not left yet, but M has stopped by for some reason and is chatting with her, so I have TWO nurses available. This turns out to be a fortunate event, as all three of us are ultimately necessary to pass Zeke's catheter, a procedure I can usually do alone. We clear away the surgery laundry that JG was folding on the treatment table and replace it with poor Zeke, who is purring madly despite his extreme discomfort - his owner says he purrs when he's nervous, which he has every reason to be about now; his life is on the line and I am all that stands between him and death. Fortunately we have a neat little toy to help unblock tomcats, an ultrasonic device which is supposed to break up the crystal plug so you can catheterise the cat, and I am keen to try it out. M gets out the dental machine, to which it attaches, and JG and I anesthetise the cat.

Now the fun begins.

Zeke, like the majority of my obstructed toms, is a bit (read: rather a lot, really) on the portly side. In addition, he isn't the "manliest man" I've ever encountered. I can find his prepuce amidst his chubby and luxuriantly furred thighs, but exteriorising his penis is another matter entirely. He is so fat (and admittedly he's remarkably under-endowed to boot) that I can't get more than the tip of his little Johnson to peer out of the sheath (although considering that I'm about to clip a hemostat onto it and run a catheter up it, this may indicate a certain degree of reasonable caution). It is impossible to catheterise a cat unless you exteriorise their little weenie first, and since Zeke's life quite literally depends on me catheterising him - and right now - I have to find a way. With JG holding Zeke's substantial thighs out of the way and M applying pressure to Zeke's peri-genital tissues I finally am able to get a bit more of him to extrude itself, like a snail emerging cautiously from its shell in fear of small boys with salt. I make a lucky grab with my hemostats (although about this time I bet Zeke's Johnson wasn't feeling especially lucky). It's not in the ideal position, but I am unlikely to get a better one; the minute you let go or try to hold it in place with your fingers while you move the hemostat, it slips through your grasp like a bar of wet soap and has to be laboriously fished out again (which, as you might suspect, I am reporting from personal experience with Zeke's very own penis, which is already a deep reddish purple from the strain of trying to pass his urethral obstruction, and would surely rather not be pinched any more with the hemostats than is absolutely necessary).

M has hooked up our ultrasonic toy and I manage to get the slender tip of it into the (tiny) urethral orifice. It is a SLICK little device and zips through the gritty crystal plug in Zeke's urethra like a hot knife through butter. Zeke's distended bladder, under considerable pressure until now, gratefully sends a high-velocity jet of cat urine geyserlike into the air, arcing gracefully above his prostrate form and onto my neck (liberally dousing of my nice long hair and my clinic coat). M and JG are frozen for a microsecond of dismay, but I start laughing, which leads them to conclude (correctly) that none of it went in my mouth, no matter what it looked like. The front of my shirt is generously sprinkled with Zeke pee, but while I will say I don't love the smell of cat urine in the evening (or any other time), I'm just as glad to be doused in it this time: it means I've just saved Zeke's life, which goes some way to making a shirtful of cat pee seem like a minor deal. All part of the glamorous world of Veterinary Medicine.

Meanwhile, my other emergency has arrived and the dog-handler is watching the circus with bright-eyed interest. I go to change my shirt - which, I notice, is dotted with tiny domes of sand, courtesy of the incredibly high crystal content of Zeke's urine - while we manage to express the rest of Zeke's bladder (primarily into the sink). The treatment area reeks of cat urine, and there is bloody urine and a visible sediment of sand on the treatment table, but I am feeling cheerful about this; Zeke is way better off than he was 10 minutes ago. The dog handler wants to know how it happened, what we're doing, how we'll prevent it recurring, whether the cat is anesthetized and so on. I answer absently, concentrating on getting Zeke emptied out and setting up to pass our catheter, but when I get to the part about prescription diets, she says sagely, "Just as long as you stay away from Science Diet," nodding firmly to underscore her point. This rather irritates me (in actuality, in my hands at least, it's the best on the market for this problem; I've had all other prescription and non-prescription crystal control diets fail at least once, but so far Hill's hasn't let me down.)

"Actually, in my opinion, that's the best diet on the market for this problem," I tell her, still working over Zeke's slumbering form; we've pretty well emptied him but we still have to place a urinary catheter that will stay in place until at least morning.

"It has soy in it," she argues. "That's really bad for them." I suddenly suspect she has Internet access. Sigh.

"Be that as it may, if this cat is going to recover, it'll be on that diet. Nothing else is as good for this problem," I reply, rather shortly, as I tease the catheter into the still-gritty opening of Zeke's urethra. After a little stutter, it passes into his bladder. Ahh. Success. Until it is pulled, the catheter will keep Zeke's bladder empty. This is important not only to prevent re-obstruction, but also because the bladder, having been stretched well beyond its normal limits, has lost its tone temporarily. In nearly all cases the bladder will regain its contractility, but it needs to stay small for a while to re-establish the tight connections between the smooth muscle cells that are responsible for contracting the bladder. Until this happens, the muscle cannot contract in synchrony to empty the bladder, and not only will bladder tone not re-establish, but re-obstruction is a risk. But I have hopes that Zeke will be peeing on his own in 24 to 36 hours.

Zeke having been stashed away in a cage, we get to Butch, who, it is revealed, actually has TWO lacerations, neither of them an inch long (sigh). By great good fortune, both have missed all the rather important tendons and ligaments and joint capsules and vessels in their vicinity. I will need to repair this without benefit of shaving (since this dog is intended to run the Iditarod in a few days and the dog can't have bare skin exposed in that kind of cold). Luckily it looks do-able. I spend a few minutes tracking down the record (the reception staff had pulled the handler's record, not the owner's). We anesthetize our lacerated leader and prep the wound without shaving it. I begin suturing, pleased to see that the wounds are coming together nicely. Meanwhile, the dog handler (who has ceased annoying me, mainly by dint of her genuine and sympathetic concern for poor Zeke), asks me, "Did you vaccinate Raymie's dogs for rabies?"

"Hmmm, I'm not sure," I say, wondering which "Raymie" she might mean. Ramie Reddington? Raymie Smyth? Some other Raymie I have never heard of? Apart from which, I have no idea how many Iditarod dogs I have vaccinated for rabies in the last 2 months, but it was somewhere between "a lot" and "REALLY a lot". I am only half listening as she burbles happily on, but suddenly JG recalls that I DID vaccinate Raymie Smyth's team, because she recalls M helping me, in a slick little tag-team. Now I recall it too... we counted out 17 vaccines (for the 17 dogs we were told he brought) but ended up one short. Raymie and his assistant, another musher, are counting and re-counting dogs and insisting there are only 17, but I am counting 18 - did they remember to count the one in the cab with them? Nope. That's it.

"Yeah, he [does she mean Raymie or his musher assistant?] said the shorter woman who was vaccinating was really good - very efficient. So I thought, I have to see who this woman is," says Raymie's handler now. Well, that would be me - the shorter woman: M and JG are rather taller than I am, as is nearly everyone else at the clinic. But now (apart from being rather abashed that I was short in correcting her on the diet issue, since she really is very well-meaning and clearly loves animals) I am wondering: just HOW does one vaccinate a dog for rabies in such a way as to impress someone enough to mention it? There's really not much to it: grab 'em and stab 'em, basically. Maybe they were just impressed that I was able to count to 18.... Just part of the outstanding service at the clinic, where amongst other things we are all smarter than we look.