Merck Veterinary Manual Online

December 28, 2011 at 11:29 pm

Did you know that the Merck Veterinary Manual is available in its entirety online? For more information that you could ever absorb, take a look: http://www.merckvetmanual.com/mvm/index.jsp. It’s the self-described “World’s Most Trusted Veterinary Reference,” now in its 19th printing, with detailed information on emergency care, nutrition, diseases, behavior, reproduction, etc. There’s a handy index, so you can search and sort by species (unless you really want to read about Pseudopregnancy in Goats).

Whether you want to learn more about canine cancer or brush up on the immune or circulatory system, this is a meaty volume written for professionals.  If you’re not a veterinarian, this is probably “inside baseball” stuff. But I thought it was so cool.

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Veterinary decisions: How much should we push?

My approach to helping pet owners make decisions about their pet’s care can be summed up in one word: options.

Depending on the situation at hand, I try to provide as many options as I can, and give owners the information (and time, if I can) to make an informed decision that they will feel comfortable about when all is said and done. In some cases, the options may realistically be limited to two, or perhaps three if we get creative and start bending the rules.  In others, I can sometimes come up with five or six pretty realistic paths we can toss around.

I try to come up with options that will meet with most budgets (from the near-destitute to the wealthy) and most views on pet ownership. Like it or not, we see people who don’t value their pets as much as I do, and I have to serve the owner’s as well as the pet’s interests.  There’s no point in my demanding an MRI for someone who either can’t pay for it or thinks it’s a crazy thing to do. I still discuss it, but I don’t hold their feet to the fire.

Along with the options, I will usually offer up a recommendation for what I see as the best course of action. Sometimes, all the options are equally good, or equally crappy, and sometimes the one I see as best also has the biggest price tag (but not always). I have found that this combo of delivering options with a recommendation thrown in the mix seems to hit the right note of satisfying my conscience that I am doing right by the pet and the owners.

Human and veterinary medicine used to ascribe to a more paternalistic way of doing things; the doctor was always right, the doctor told you what to do, and the doctor usually drove the bus, wore the bossypants and made the decisions. No so anymore.

For human and animal patients alike, the age of the empowered patient and owner is here. People are educated about their health and the health of their pets, and rightly want to be a part of the decision-making process. I celebrate this, and find that discussions with educated and smart people are one of the joys of practice. We develop a plan together, and we all take pride in it if it works and we all take the lumps if it doesn’t. I get to bask in a little bit of the glow when things come out well, and I have a partner in crime if they don’t.

My options/recommendation scenario doesn’t always work, though. In order for it to work, the people on the other side of the exam table have to be able to actually make a decision when the time comes.  There is a segment of the pet-owning public that gets stuck in an endless Möbius strip of uncertainty, obsession about blame or flat-out fear, and is unable to give me a go/no-go on any decision.  I am not sure if this is the same contingent that really does want the decision pre-formed and handed to them, a lá 1950s-era Marcus Welby-style medicine or not.

In these cases, we may spend time in the exam room coming up with our two or ten options, but be met with blank stares and silence when it comes down to picking one. When I gently try and get an opinion from them about which direction they feel is right, in some cases nothing comes of it.  Prodding or being insistent is not my style, and I think rarely bears fruit; the discussion usually just degenerates at that point and we don’t get anywhere.

I am sometimes met with angst (“I don’t know what to do!”), anger (“You’re the doctor; which is the best?”) or, more often than not, just crickets.  We just sit there staring at each other.

I will usually give the family some time alone to discuss things, and then come back to answer questions and see if we can pick a path forward. Sometimes a little gentle power-of-suggestion stuff will work wonders, as in “I’ll give you some time to talk this over, and then when I come back you can let me know which way to proceed.”

What’s your take on this? Are there times when you just wish the doctor would make the call for you? Are there times when none of the options are attractive to you, and all the options suck? Have there been times when you felt a doctor did not give you all the options and merely made the decisions for you?

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What makes a veterinary specialist so ‘special’?

Veterinary specialists may not be as “special” as we sometimes think we are, but there’s a lot that goes into the making of one.

When you see your family veterinarian for most of your small animal (meaning dog or cat) routine veterinary visits, you are probably seeing a general practitioner, or GP.

Most GPs have gone through four years of undergraduate college (usually resulting in a bachelor’s degree, which I always thought was odd for the married ones), followed by four years of veterinary school, after which most are granted the degree of Doctor of Veterinary Medicine, or DVM.

One school, just to be difficult, doles out their degree in the vibrant, living language of Latin and uses Veterhinoninarius Medium-rare-iciniuius Doctorfeelgoodius (I am pretty sure I got that right) or VMD. So, if you look on your veterinarian’s business card, you can tell right away if they went to one of the normal 27 schools that are not in Pennsylvania (DVM) or to the one school that has gone all batty and needs to be different, and also has piercings, tattoos and keeps its snake at the dojo just to show how unique it is (VMD).  Note: I have many, many special Penn Friends, and my gentle and loving ribbing about their weirdness, degeneracy and insanity should not be misconstrued as evidence that I think they are weird, degenerate, or insane.

So, your average vet goes through eight years of training to be where they are. Some schools allow the four year undergrad to be fast-tracked, but for most US veterinarians, eight years is the norm.

However, if you elect to specialize, after your internship you apply for and hopefully obtain a residency (so called because the doctors frickin’ live in the hospital, the duty hours are so long) in the area you want to specialize in. It could be surgery, oncology, cardiology or, as in my case, emergency medicine and critical care. Some people, insane people, elect to specialize in more than one area at a time and are known as “double-boarded,” which means that someone should have taken two very large boards and beat some sense into them.

The 2- or 3-year residency program immerses you in the discipline at hand and gives you the skills you need to, a) become a specialist and, b) pass a big-ass test known as a board exam. Most board exams are 2-3 day sadism sessions that leave the test-takers with little self-respect, stomach lining or bladder control.  Most folks take 2-3 months off from work to study for the board exam, usually living in a cave, not bathing and gnawing on a haunch of deer while surrounded by textbooks. (Vegetarians gnaw on a haunch of cauliflower).

During my board exam, among other things, I had to do a pretend surgery on a balloon. If the balloon popped, I failed. I was sorta hoping I would get extra credit for twisting the balloon into the shape of a kitten afterward, but no go.

Once you pass the test, as if by magic you are certified in your specialty and given magical powers, a cape, a tie pin and a swift kick in the ass.

As an example of what a specialist does, let’s look a little closer at surgeons. They are very special people.

Any veterinarian can do any surgery. Your family veterinarian, for example, could elect to do a kidney transplant if they felt competent and you agreed to the procedure (please sign here and write me a check for $15,000. Thank you for your patronage). But many surgeries (beyond spays and neuters and some abdominal procedures like foreign body removals) are done by specialized veterinarians who are board-certified in surgery.

There are lots of talented GP surgeons out there (and some GPs who are better than some boarded folks I have met), but, as a general guideline, the more complex and risky procedures are referred to boarded surgeons if the GP and pet owners think it best. Surgeons are amazing at what they do, and I have the deepest respect for them. I have seen a good surgeon put a busted and well-nigh unrecognizable pet back together, looking for all the world as if almost nothing ever happened.  They can be as close to an artist as a veterinarian is ever likely to get (except, of course, for my balloon animal art).

Just like any of us bipedal hominids shuffling about this rock, though, surgeons are mostly just normal people who have the world go in and out of their bodies through the same holes the rest of us do. Some of them tend to be a little on the vain side, though; I worked with a guy once who wore pointy orange shoes to work every damn day, convinced they were the apex of fashion.  Little elfy numbers they were, curled up at the tip in a let’s-see-what-Santa-is-making-in-his-shop-today way.

Some surgeons, though, run the risk of over-stating either their skillset or the benefits of surgery in general; not every condition known to man or beast can be fixed with a swipe of the scalpel in their well-manicured and bronzed hands.

The same principle also applies to internal medicine. This is the branch of medicine that deals with giblets; kidney, intestine, pancreas, liver – all of the variety meats. Internists are detail-oriented specialists who will gleefully listen to pet owners describe their pet’s bowel movements in excruciating detail. Repeatedly.

They have cases that play out over months or years, and are adept at long-term, complex case management. I could never be an internist, as my memory span is about the size of a baby newt (called an ‘eft’) – this is why I chose emergency medicine; hit by car – fixed up in 2 days – off to home, Bob’s your uncle. Emergency medicine doctors have flings with their patients, internists have marriages.

This is just a wee overview of what goes into making a specialist. So, the next time you see your veterinarian, or your veterinarian refers you to a specialist, tell them ‘thank you’ for all the schoolin’ and maybe ask for a balloon kitten.

Image credits: Both images from flickr creative commons. Top: cpeachok. Bottom: sean94110.

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Headstrong Dog Busts Out of Secured Veterinary Hospital

Clever Jack let nothing stand in his way when he made a break from his digs at the vet's (Photo: Mail Tribune, Julia Moore)

An Oregon German shepherd is being heralded as a “canine Houdini” after he busted out of his kennel at a veterinary clinic, tripped a dead bolt on the clinic door, pushed the lever, and escaped to freedom.

Was it the hospital food that drove Jack to such extremes? A too-chatty roommate? Homesickness? He’s not talking. But his owners say Jack is smart, stubborn, and tall — a recipe for success when it comes to mischievous endeavors.

“He knows where his treats are,” owner Marsha Billeci told the Medford Mail Tribune. “He self-serves. He hooks his claw on the handle and pulls. He yanks super hard.” She said the technique has helped him open cupboard doors and other locked places.

Three days before his escape, Billeci had brought a very lethargic Jack to the vet’s. He wasn’t eating, and had flu-like symptoms, and signs of pneumonia. The vet hooked him up to intravenous antibiotics. In a couple of days, six-year-old Jack was starting to come around. The next morning, when staff arrived at work, they were shocked to see Jack’s kennel open, but no Jack.

The only signs of the wayward shepherd were four bags of dog food that had been torn open and plundered, and claw marks at the clinic’s locked door.

His shocked veterinarian, Shannon Sierra, shut down the clinic to join the full-out search.

“…he was so sick he could barely walk. Then, 72 hours later, he’s on the lam,” he told the Mail Tribune.

The hospital’s security company said Jack set off three motion detector alarms: One at 10:30 p.m., one at 1:30 a.m. and the last at 4:45 a.m.. Police responded at least twice, but the crafty canine outwitted everyone, scoring freedom after tripping the last alarm.

He headed in the general direction of home, but about seven miles away from the clinic, he tried to get into a woman’s house. After she and her son tried repeatedly to shoo away the persistent dog, they called animal control. A report had already been made, so Jack and Billeci were reunited in no time.

Jack is now continuing his impressive recuperation on his living room couch, taking his meds in the comfort of his own home. Sierra says the wily dog caused an immediate change in hospital setup: Every kennel now comes with its own lock.

If Jack ever ends up at the hospital again, Sierra might want to think about posting a 24-hour sentinel as well.

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The price of experience in the veterinary ER

Christie and I recently had the start of a discussion about the fact that most veterinary ERs do not have specialists on staff after hours. They seem to be staffed with predominantly recent grads who are general practitioners (obviously there are exceptions; there are lots of seasoned and experienced ER docs out there). But when you need a specialist (for example, a surgeon) in the middle of the night, there are none to be found.

Many ER docs can perform surgery, and they do a very good job in the vast majority of cases. There are some cases, however, that would benefit from someone extensively trained in surgery through a residency program, and who only does surgery. Additionally, there are some owners who are more comfortable with (read: demand) a board-certified surgeon when their pet goes under the knife.

At 3 in the morning.

I think this is something that she and I can take further, but I wanted to poll the tiny and loyal readers of PetConnection to get their take on the issue.

Shift work, especially overnight work, is grueling and unhealthy. There is a reason that most jobs are 9-5, M-F: that is what our bodies have come to expect and can tolerate.

By contrast, a veterinary ER doc or technician can work 16 (in some cases, 24) hours straight with not so much as a pee break. Burnout is an ever-present threat, and the average lifespan of an ER doc is about 4-5 years.

At some point, we tire of the hours, the endless fights over money, the naked carelessness, neglect and outright cruelty that ER work can shove down your throat. Some can subsist on the adrenaline rush, or find a way to partition things so they can continue to function in the ER year after year, but for many, the toll becomes too much and they seek the so-called “cushy” shifts during the day.

One out is to become a specialist. This was the path I chose when the overnights and the  burnout became too much to bear — coupled with the desire to start a family and actually, y’know, be home.  N’stuff.

So, when the specialists have completed their training (which involves a crapton of overnight or on-call work) they typically think to themselves “I’ve paid my dues — hello day shift!”

On-call work also means a loss of freedom for the person doing it as well.  It’s no picnic. Imagine if you were on call tonight. That means no glass of wine with dinner, no relaxing and knowing that the night is yours and no one can bother you.  You are just one pager beep away from dropping everything in the middle and rushing in.

And, coming in in the middle of the night means that your day will almost certainly be craptacular the next day. Can you imagine leaving your family at home in the middle of the night to spend four hours doing surgery, knowing you are going to have a full docket of surgeries the next day, too? It only takes a few times for this to suck the soul and lead to the search for greener pastures.

Somehow, in human medicine, they manage to do it. They have surgeons on call all the time. (Not every specialty does this on-call rotation, though — you would be surprised what they let the green docs and residents do in some specialties). But for MDs there is usually a more spread-out on-call schedule (as there are more of them) and the financial rewards, sad to say, are significantly higher that for veterinarians.

So — what’s your take?

Do you begrudge the poor, tired ER doc’s wish for a simpler daytime existence, knowing that it may mean that there are fewer specialists around in the wee hours? Or are you of the camp that thinks a fully functional clinic should have a line-up of specialists in multiple disciplines a phone call away at all times?

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Team Sparkly Starfish at the 2011 Western Veterinary Conference

Veterinary continuing education (or CE) conferences happen all year around, all over the globe. Pet Connection sent a team of five of us to the Western Veterinary Conference in Las Vegas to give you all the low-down on what happens in Vegas (baby).  I am on the plane home right now, slightly lighter in the wallet, slightly smarter and minus a goodly portion of my liver.

This is the third time I have attended this CE conference – the first being when I was in veterinary school (at Washington State University – Dr. Marty’s alma mater) and the second being last year, when I delivered several lectures on emergency medicine topics and was lucky enough to be voted speaker of the year.  I was able to finagle a press pass for this trip – the first of my life.  Since my dad was a dyed-in-the-wool reporter (in the days when there were still newspapers around), this trip had special significance for me.

Dr. Marty, Gina, Arden Moore, Kim Campbell Thornton and I made up the team, which I have dubbed Becker Team Sparkly Starfish Optimus Awesome, or Away Team One (I can’t decide which – I am waiting on input from the other members). David stayed home to make sure everything hummed along smoothly at PetConnection.com, and also because he is banned from entering the state of Nevada until the year 2035. I am not sure on the specifics, but I believe it involved a showgirl, a missing slot machine, and either Roy, Siegfried or both.

Conferences are an opportunity for your vet to hone skills, network and have a little fun.  All states have a requirement that veterinarians must attend a certain number of continuing education classes every year to keep their skills sharp and stay abreast of changes and advances in our profession.  A vet who makes it a point to attend conferences and lectures (beyond the minimum requirement) is one who is demonstrating a commitment to personal and professional excellence. It would not be a bad idea to discuss what areas your vet seeks out for professional advancement and CE  the next time you are in their office.

On the ‘honing skills’ front, there are usually 8 to 10 lectures to choose from every hour on a variety of topics, for both small, exotic and large animal practitioners.  (As a side note, I learned that in Vegas the word ‘exotic’ does not have the same connotations that it does for most veterinarians; for example an ‘exotic’ animal veterinarian treats hedgehogs and iguanas, while an ‘exotic’ dancer in Vegas is a naked person, usually female).

Lectures this year were offered from Sunday through Thursday (I fled a day early). Lectures are offered from 8 a.m. until 6 or so p.m., so the day usually starts by scanning the schedule grid and looking for suitable talks to attend. I made it to several ER topics this time – from dealing with GDV (gastric dilation volvulus syndrome) to managing patients after cardiopulmonary resuscitation, and a smattering of others. Gina was going to be cruel and make me attend lectures on the dreaded topic of dermatology (I am assuming that she buys into that whole ‘suffering builds character’ mystique) but she relented when my big brown eyes filled up with tears and my lower lip quivered a bit.

If your vet has a particular area of interest or expertise, say pain management or reproduction, they can focus on these and just attend lectures in this arena; the talks tend to be grouped by similar themes and topics, so it is fairly easy to get in the groove and gain some in-depth knowledge on special areas of interest. Your vet could also choose to expand their horizons a bit and branch out into areas they may not be familiar with – attend a lecture on acupuncture or check out what’s new in nutrition. It can get a little frustrating when there are several topics running at the same time that you may have an interest in, so you have to pick and choose your talks carefully.  The talks can vary in degree of usability – from ones where you are scrambling madly to write down every little nugget of information, on down to snooze-fests where you are desperately trying to stay awake and hoping a fire breaks out so the hall is evacuated. I found the caliber of the talks to be slightly below par this year when compared to prior years and other CE conferences, but this may have had something to do with some of the extracurricular activities that we took part in, and not the actual talks themselves.

Most CE conferences offer additional learning opportunities beyond just lectures for picking up some new skills (or improving old ones). There are often labs that vets can take (usually for an extra fee), round-table discussions to participate in and lunches with experts. The labs offer hands-on experience with new surgeries or techniques and are usually very popular and well-attended.

Conferences are typically held in ‘destination cities’ and usually in rather large and glitzy venues. The WVC was held in the rather large and glitzy Mandalay Bay hotel, but veterinarians tend towards being a rather frumpy and non-glitzy crowd (my wife excluded – she is a pretty and sparkly princess; her rhinestone-studded flippy-floppies meshed perfectly with the Vegas milieu). I think conferences serve an important function in keeping vets on top of their game, but also allowing for a chance to get away and see cities they may not otherwise be able to (many vets can write off the trip for tax purposes, or are reimbursed by their employers, or perhaps both).

The other thing that these conferences are good for is networking – when you get a whole buncha people who are interested in the same thing gathered together under the same roof, connections inevitably form.  One place that this occurs is the exhibit hall; this is a giant room (we’re talking several football fields in size) that is filled to the brim with corporate sponsors.  I am fairly used to them by now, but when I was a student I remember being totally floored by the sheer number of crappy free things I could make off with (example: a free dog food company logo pen that lights up when you press a button! Free! It does not write – but it lights up!). You take armloads of the stuff and then get home and think “What the hell do I need all this junk for?” The sponsors are even thoughtful enough to give you crappy free logo bags to hold all the crappy free logo items as well – they have really thought of everything, and have only our best interests at heart.

The exhibit hall is a great place to meet other veterinarians and suppliers and hash out deals on equipment, surgical instruments, drugs or any of the myriad other things that keep a veterinary practice running.  I know of many jobs that were lined up through conference networking, and more than a few romantic entanglements.

I will highlight some of the PetConnection networking that took place at WVC in the next installment, as well as give you a censored and family-friendly version of the ‘have some fun’ part – turns out there is a lot more than just gambling to be had in Vegas! (Here’s a sneak peek)

Photo credits: Top, wildnatureimages. Bottom, Dr. Tony Johnson.

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Scrub a dub your dog, hot veterinary news and a manatee

January 20, 2011

Just a fast post from Orlando, where I’m heading home to San Francisco after a week at the massive North American Veterinary Conference.

I’ve got tons of news — a new treatment for feline asthma, 0ne of the most interesting shelter medicine presentations I’ve ever seen, updates on treating canine skin disease (and yes, I got the list of products that Dr. Fadok recommends that you were all asking me for!) — but it will have to wait for me to be home where I can sort through my notes. I’m literally writing this on my lap at the Orlando Airport.

In case you’re wondering what’s up with that photo, I spent hours looking for a stuffed manatee for my nephew Ronan, and I found one at the airport gift shop.

Oh, and my column on SFGate.com ran this morning — it’s a much longer exploration of using frequent bathing to treat canine skin disease. I think I answered some of the questions you all asked when I teased the topic in a recent blog post — check it out! And, you know, share it on Facebook and stuff — these geeky health topics never so as well as I think they should, and I honestly believe this information is going to help a lot of dogs!

The ‘killer app’ for canine itching and skin infections

“See” you all soon!

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