Fun with “D” words.

Burn out. Substance abuse. Suicide. Mental illness. These things don’t sound like behind the scenes issues at your friendly family veterinarian’s office anymore than they seem like behind the scene issues at the dentist or pediatrician’s office. But they are. They might even be behind the scene issues at your place of work, or in your personal life.

I might have ideas about why as a society we are seeing more – or in my opinion have more time, money and changing social views to deal with – issues of mental health, substance abuse and the relationship our working environment plays in them. But I am not a sociologist, I am a veterinarian and this is a veterinary blog. Though I do sometimes dabble in other topics I consider to be; fun Hooch Heart of Bixi, important Philosophy Sacrifice Communication communication Optimism Parenting, or even sometimes a little existential I don’t HAVE a body. I AM a body I typically approach most things here as a veterinarian, which ties into what I want to write about today. It would be easy for me to state here that being a veterinarian is who I am but in reality, being a veterinarian is what I do. If somehow, I couldn’t be a veterinarian anymore, I would still be me but would have to do something else to pay my bills. And that would be alright. Not great. Alright.

 

In veterinary medicine – as in probably any other profession – stress levels can be high. The emotional toll it takes can be immense and the burnout rate is getting higher as more brilliant doctors are graduating unprepared for a high-paced, service oriented profession.

My own career path has danced dangerously close to the edge of burnout more than once. In full disclosure, I struggle with Major Depressive Disorder which was diagnosed and a successful treatment/management plan was instituted while I was in college. That does not mean I am immune to relapse. While this has not helped me deal with professional stress directly, learning how to deal with depression has helped me realize how much I was getting in my own way when it comes to dealing with professional stress.

 

I have broken down the steps I have taken into topics that I was able to use to limit the professional stress I experience at work and ultimately allow myself to enjoy what I do in spite of myself sometimes. Because it worked out this way and because it was fun, I used words starting with the letter “D” to describe these steps. Hence the title of this post.

 

Decision: Before I could make any changes to my professional life I had to decide that a change was necessary. That was the hard part: deciding what areas were the most important ones to change. This meant looking at myself and my situations in an objective and critical light and determining what changes were going to bring the most satisfying and positive changes. This is the hardest part, as it involved taking a serious life inventory and acknowledging that at the end of the day, I was the person most responsible for my own happiness and my own misery.

 

Detachment: This was the most important part. If I was going to avoid burning out and giving up, I was going to have to step back to see this from outside my own head. Detachment was probably the best thing I was able to do for myself as it allowed me to recognize how much I was taking personally and why. I realized I didn’t want to get better, I wasn’t looking to improve and I definitely didn’t want to actually avoid burning out. I wanted to focus on my strengths and act elitist about stuff that matters to maybe 0.1% of the population. I wanted people to recognize that veterinarians- and me, by association- had it really hard and this job was really stressful. I wanted other people to validate me and my greatness. I wanted people to recognize how compassionate I was, how much I understood about medicine and science. I wanted people to understand how much we had to deal with. Ultimately, I wanted this to be about me. It turns out, when I detached and looked at that, it looked as bad as it does in black and white above.

Holy ego Batman! What is wrong with this person? In reality, nothing. It was simply that I had so much of my personal identity tied up in my profession that it was impossible for me to separate the two. This unsurprisingly led to me taking every criticism and obstacle as a personal reflection of who I was and how good I was. This is a formula certain to stunt professional growth as well as personal development.

 

Once I was able to step back and look at the situation instead of my response to the situation, I was able to see how much my perspective was limiting my ability to get better. I also saw how destructive it was to continue to see what I do as who I was and how ultimately that could lead to some pretty dark and destructive behavior on my part.

 

Then I had to institute a plan that could be executed daily. The first thing I needed was to recognize that this wasn’t about me. How people choose to approach their pet’s health care, how they feed their pets, whether or not they choose to utilize the preventative measures I recommend had little if anything to do with me. They were coming to me for the service I provide, true enough. But it is about them and their pet and has nothing to do with me, at least personally. Taking this position allows me to focus on how to be better professionally without allowing it to reflect on me as a person. Putting my ego in the backseat allowed me to learn more from a greater variety of people. No longer was someone who knew more about something in my field “better” than me. Instead, they were more interesting to discuss things with and conversations stopped being about being right or the best and started being about learning everything I could from everyone around me.

 

Discipline: Any plan is only as good as your willingness to execute it daily. For that, I have developed other daily habits that seem unrelated to my goals but ultimately keep me focused and consistent.

 

Deadlifts: I considered skipping this one but it is important. A huge part of what keeps my head on straight and helps me keep the darkness from pouring in and taking over my day to day is that I routinely go to the same place and lift heavy things until I am dog tired. This stress, success, consistency and ability to monitor progress helps immensely and might be the most important thing I do for myself. Turns out I am not making this up:

 

https://www.unm.edu/~lkravitz/Article%20folder/RTandMentalHealth.html

 

Ultimately, the take away from this is: whatever you do in this life for work may be a big part of your life, but it’s not who you are. If somehow your profession was ripped away from you, you would not cease to be who you are. The sooner we decide to detach from our professions more and discipline ourselves to stay detached, the better protected we will be from burnout, compassion fatigue and the burdens that follow.

Thank you for reading.

 

Advertisements

Meditation

You’ve read the articles. Clicked on the click bait. You know there are way more than ten reasons meditating will help you. But it’s just so boring. I know. I feel the same way.

Rather than clearing my mind and focusing on my breathing for a specific number of minutes every day, I’ve recently decided that I was going to pick a few of my favorite philosophers, read a small piece of their work, digest it, and write a short note on my thoughts about it. I’m using this exercise to do two things. The first is to help move my thoughts and actions further in the direction I would like to see them moving. The second is to get my mind back into the habit of writing daily.

Then I remembered I have this blog website I’ve been fairly lazy with for the past eighteen months. So, my plan is this; starting January first, I am going to post a daily meditation every morning. Each one is going to take less than two minutes to read and will be a very simple thought about a specific point made by the philosopher I am reading at that time. By no means do I consider my thoughts valuable or informed. I will be writing these to myself, not as instructions but as thoughts about how I can use these ideas. Because I am publishing them, I will use the plural ‘we’ instead of I.

I am not certain how long I am going to keep this up for but I’d like to get through at least one philosopher!

I hope you’ll come along with me on this.

Thank you.

Kitty Colds

You just adopted a kitten from the local shelter. She had sneezed a few times at the shelter but you hadn’t given it a lot of thought. When you got her home and she stopped eating, started with mucus from both nostrils and eyes and sprayed the room with her sneezes every few minutes you started to wonder whether or not she was a good idea. You put your new kitty in the cardboard carrier you brought her home in and rush her into the vet’s office. They tell you that she has a complex of diseases she was most likely exposed to as a kitten and that this condition was exacerbated by the stress of being in the shelter. Before you start to think it was the shelter’s fault however, let’s quickly get into what your cat has going on and why.

The major contributor to Feline Upper Respiratory Complex are viruses that your new kitten was most likely exposed to long before she arrived at the shelter. Because many of the cats that are surrendered to shelters, or the cats that are dropped there by animal control, have a herpes infection that is not currently causing disease it is not necessarily something that even the best disease prevention program can address. The shelter situation, no matter how well done, is going to be stressful for the feline participants. There is a lot of shuffling between cages to clean and keep angry neighbors apart. There are also a lot of sexually intact cats that come through the front doors of any busy shelter and their attitudes do not help in lowering the stressful conditions. This stress causes a drop in the immune systems ability to respond to disease. When this happens, the viral infection that your kitty was keeping in check has a chance to rise to the surface. The most common offender is the feline herpes-virus. It will manifest itself first as runny, watery eyes, light sneezing and maybe a bit of conjunctivitis.

Ok so maybe that’s why your new kitty is sneezing but what can we do to help her? Here is where many vets are going to differ a bit. This is yet another one of those times I feel compelled to inform you that this blog contains my opinions (professional though they may be they are opinions) about best medicine and current therapies. The following is what I would consider to be the best course of treatement for an owned cat with an upper respiratory issue.

I start with hydration, keeping your new kitten well hydrated is an important part of treatment. It makes the mucus secretions less viscous and allows for better expectoration of particles. It also helps in keeping inflammation at a minimum. If your new kitty is eating well and only sneezing a bit I may give her a small amount of fluids under her skin and ask you to place her in a room with a humidifier running when you go to bed. Sometimes that is all it takes.

If the sneezing has been going on for awhile, is getting worse or if she is breathing with her mouth open or not eating I will get a bit more aggressive. Treatment for these cats will include the fluids and humidifier but we will now add in some decongestants. Oral and nasal decongestants are available. I tend to use a lot of diphenhydramine but there are many available. If there is conjunctivitis present I will also add in some eye drops. Many of the drugs I would reach for here are available over the counter and will not require a prescription nor will they be terribly expensive. Not eating for a young cat is a big deal however, and I have started adding in an antiviral drug at this point. This is not an over the counter and will require a prescription. It will also require you to get a pill into your kitty. Good luck.

If stage 2 treatment plans are not making in a dent in your kitty’s upper respiratory disease we will start to have a conversation about further diagnostics. I probably won’t be too pushy at this point but I will at least put it on your radar. A cat should really be getting better by now. Here I am going to start to actively address some of the other issues with your cat’s respiratory system. Anti-inflammatories may make an appearance in this case. A brand of drugs called leukotriene receptor antagonists are useful in controlling the inflammation involved in the disease process as well. It is typically here that people start to ask about antibiotics. I am not huge on just prescribing out antibiotics for, well anything really. I like to know that there is a bacterial component to the disease I am trying to treat and I really like to know what the bacteria is and what kills it before prescribing an antibiotic. If the discharge has changed in consistency or color or if there is a fever present I may be convinced to add in an antibiotic at this point. If I am going to add in an antibiotic I try to choose ones that will also mediate the immune system and help to control inflammation at the same time.

If we are still having a problem now it’s been well over a month and it is time to get a bit more serious. Here I may start recommending sending in a culture for bacteria and funguses. I will definitely recommend retesting for feline leukemia and feline immunodeficiency viruses. If we are talking about an older cat (not a kitten) I might even recommend biopsies of the nasal passage. With more information comes a much more tailored medical approach and discussion of what we might find would carry us well over the thousand word limit I typically set for myself each week.

In closing, don’t hate the shelters for adopting out a sneezing cat, it’s not their fault and they do a job many of us wouldn’t be strong enough to handle. Make sure you get your sneezing cat to the vet early on and be wary of vets that just reach for antibiotics in these cases. It won’t help and will end up costing you more than it has to.

This Generation’s Reckoning

Right now, it appears as though the United States is going through a reckoning about how people are expected to behave in the workplace. Society has turned around in what appears to be- it isn’t, but it appears to be- a short period of time, and individuals from all walks of life are paying the price for behavior that never should have been considered acceptable. Yet it was still accepted. In many ways it was the price a woman- or in some rare cases, a man- would have to pay in order to advance a career, to even have a career to advance in the first place. I am writing of course about sexual harassment in the workplace.

 

While we have not yet resurrected the tradition of tarring and feathering the perpetrators of workplace sexual harassment (nor should we seriously consider tarring and feathering, google that before running such an idea up the flagpole), we appear to be very comfortable bringing up instances that are years or even decades old. It appears that we are witnessing a watershed moment in American culture. This is good. But it is also a little bit scary.

 

It is scary for me mostly because I am guilty too. And admitting that and facing it in my own life and my own head is scary. Scary not because I am afraid that how I acted in the past will have reprisals. Even if my actions in the past came back and cost me my job, influence, or friends, that wouldn’t be the worst part. It is scary because I want to believe I am better than that. I want to believe I treat everyone as an equal and consider others’ feelings with my actions. But I don’t. At least I haven’t always. And sometimes, I still don’t live up to the standards I set for myself.  

 

In fact, I’ve been pretty terrible about not recognizing the line where it stops being funny and starts making people uncomfortable.

 

In fact, I’ve been terrible about using the little power I have in the world to get what I want. Maybe never sexually, but definitely in a lot of other ways.

 

In fact, if we want to talk about social situations outside of the work force there are some stories that would make me blush even a decade and a half later. 

 

In fact, up until I was 25 years old, this behavior seemed totally normal to me. Boys will boys and all.

 

I don’t know what changed at 25 but a lot of things in my life and the way I viewed life changed. Maybe my brain finally developed enough to have a more complete understanding of the way I interacted with my environment. Maybe it was entering a profession where I often find myself the only male in any group of individuals. Maybe it was having to interact with women who would not tolerate that type of behavior.

 

Whatever it was, it’s not like I got better overnight. It’s not like I am 100% better now. I still find myself glancing in the wrong directions, thinking in the wrong words, and sometimes speaking in ways that my wife and three daughters would be ashamed of if they knew. I’m not there yet. I might never be. But I am working at it. I will continue to work at it until I get it right.

 

Recently, when I come across questionable thoughts in my own mind or I find myself in situations where my actions or words could become questionable, I apply a thought exercise I have been working on for awhile now. I ask myself if I was someone else and the woman I was interacting with was my wife, would I be alright with the way I was acting? If the answer to that question is no, I need to explain that to myself and correct it. I’m not always there yet. I might never be. But I am working on it.

 

How often does it happen that I have to correct my thought pattern? More than I want it to. I’m not perfect, behavior is hard to fix, and like a lot of men I thought my behavior was normal until I grew up and started thinking differently about the people I interact with daily. So this behavior is ingrained. But also like a lot of men, I am working on changing and I won’t stop working on it until I get it right. Don’t give up on me (us) yet.

 

Thank you for reading.

No poop.

You didn’t realize that you haven’t noticed any stool in Fluffy’s litter box until the veterinarian asked. By the way the vet was holding Fluffy’s belly you’re suddenly putting it all together. Fluffy has been yowling in the litter box for a few days now. You knew that he could urinate and he was passing those small, wet, slimy stools and you figured he had some diarrhea. Then he stopped eating, started vomiting and you got really worried and forgot all about what you had thought was diarrhea. Then in this room with this strange person squeezing your cat’s abdomen it all comes back to you.

There are plenty of reasons a cat could become constipated. It happens to dogs as well but cats really seem to know how to do it right. In fact, cats are much more commonly represented in the small population of pets that suffer from megacolon as a result of chronic blockage and subsequent loss of function of the colonic muscles.

Straining to defecate is the most commonly seen symptom with constipated cats. This seems straight forward enough but straining to defecate can be confused with straining to urinate. Feline Urinary Obstruction Straining to defecate is also the most commonly noted sign in pets with large intestinal diarrhea so even if we know they are trying to poop but aren’t getting anything out we can’t really be sure it’s constipation. A physical exam will give me some clues about whether or not your pet is constipated but to rule out obstipation or the serious megacolon we need an x ray. X rays of obstipated cats are pretty easy to read, you look at the x ray and instantly your mind says, “That cat can not poop that out.”

Here is a small fact about veterinary medicine; cats do not enjoy enemas. How constipated a cat is determines how extensive the enema needs to be. Some cats only need a little bit of help and a simple warm water or lubrication enema will do the trick. I say simple because I don’t have to do a lot of math or monitoring. I do not mean simple as in, you should try this at home if you think your cat is constipated. For more advanced cases a lot of enema fluid is going to be introduced and this typically requires a bit of sedation as it is going to be very uncomfortable. These cases generally haven’t been eating for a few days and will require some hydration as well. We like to keep these guys overnight if we can to be sure they are going to eat and are done vomiting once the obstruction is removed. The most difficult cases require not only an enema but a good deal of manual evacuation as well. These guys go under general anesthesia and a good amount of effort is put into cleaning them out. The cat who receives an enema requiring general anesthesia is definitely going to be groggy and definitely going to leak. It may want to have a sleep over. These poor patients tend to not want to eat right away and may take several days even a week to start having bowel movements again.

That last point leads into a bit of a tangent. The colon’s main job is to store feces. It can store weeks of fecal material at a time, this is why we may not seem terribly excited when your dog or cat hasn’t had a bowel movement for a day or two.

After we have removed the offending fecal material we will want to think about ways we can avoid this in the future. If this was the first time your cat has been constipated and it was fixed with a simple enema we might tell you to add a little more canned food or pick up a fountain to try to increase water intake.

Even if it was the first time, if your cat was really constipated we will probably recommend you change his diet around a bit. There are two ways we can go with this. We can try a diet that is high in fiber and will make more bulky stools that are easier to pass because they contain more water. This can be achieved with a commercially prepared diet or by adding fiber to the diet your cat normally eats. The other direction we can take this is to feed what is called a low residue diet, this means that the diet is highly digestible and may actually produce less stool which in turn means less work for the colon.

If your cat is a chronic offender we may add in certain medications to help the colon work a little harder or to lubricate the stool and make it pass easier or both. These cats are also going to be on special diets as well.

In extreme cases we might recommend that a small section of the colon be removed so that there is not room to store large amounts of feces. These are called subtotal colectomy surgeries. In these cases you can expect your cat to always have slightly loose stool. While cats tend to do very well after surgery and the loose stool is not typically an issue we do like to save surgery as a last resort.

Thank you for reading.

Declawing

Also known as onychetomy, declawing is the removal of the distal phalanges (third knuckle) of a cat’s front paws. Typically just the front paws anyway. There are some cats out there that have been declawed in the front and back limbs but most cats have only the front removed. This is typically to prevent scratching furniture, clawing people with health concerns and I have seen cats declawed to match the situation of the other cat(s) in the house and therefore ensure a safe level playing field for all involved. No matter the reason, the procedure is the same, it is the amputation of the last bone on each digit being declawed.

Typically this is done with very good pain control including general and local anesthesia, preoperative and post operative pain control and usually the cats will be hospitalized until the incisions have at least begun to heal.  It is done by extending the claw , placing a blade in the grove between the second and third knuckles on the digit, cutting through the tendons of the extensor muscles and continuing the incision in a slightly curved fashion to get around the curved end of the flexor tubercle of the distal phalanx and disconnect the tendon of the deep digital flexor muscle. This removes the distal phalanx along with the unguicular crest and unguicular process and as a result, stops the cat from producing claws.

Cats are digitigrade animals meaning they walk on the tips of their toes, you might think that cutting the tips off the toes and then asking the cats to walk around might be asking for complications. For the most part they seem to adapt but there are some who have to live with chronic pain following the procedure. Sometimes this pain doesn’t show up for months or even years.

If you follow animal health at all you know that declawing cats is a big hot button topic here in the United States. It doesn’t tend to be as big a deal in other developed countries because by and large they just don’t do it. The big issue is we are performing a procedure on a cat who can not give consent, this procedure provides no medical benefit for the patient, provides no benefit for the population of cats as a whole, is a relatively invasive/painful procedure and carries the potential to create a chronically painful situation.

In the interest of full disclosure, I have declawed many cats. Well, more than 20 but less than 1000. While I have never had a patient experience an immediate post operative complication, I can not tell you whether or not any are going to experience chronic pain from the procedure as that can develop years later and the vast majority of cats I have declawed are still under 10 years of age.

Here’s my thoughts on declawing, I don’t like it, at all. I think in most cases it’s a harsh reaction to an otherwise minimal problem. Yes they’ll destroy furniture, wood work and other things, but that behavior can be modified through training and working with them consistently. Yes, you can make a case that immunocompromised people are at an increased risk of infection from cat scratches but I have had more clients undergoing chemotherapy or treatment for HIV who had cats with claws than I have had clients who had their cats declawed. Total.

Why would I do it then? I could give you a story about how we control pain better and if people are going to have their cat declawed they are going to have it done regardless of whether I did it or not and I would rather they have it done right. Or I could be honest and tell you that the answer is easier than that. If I explain to someone how a declaw procedure happens, show them in a text book how we do it and prepare them for the possibility of having to aggressively deal with chronic pain for the remainder of the cat’s life and the owner still wants the cat declawed; I do it. I do it because if that is the cost of a cat having an indoor home with shelter, food, love and medical care provided then to me, the risks are worth the rewards. I do it because I would rather take that risk than see a cat go back through the gauntlet of shelter living and hoping to get adopted. I do it because from where I sit it is the better of the two options. I take heart in knowing that I will have to do it less and less as my career advances.

Thank you for reading.