But Doc, My Pet is Too Old for Anesthesia!

Every week I hear this at least once, usually from someone with an older (but not elderly) pet which needs to have its teeth cleaned or ears flushed or some other sort of surgery. Most of them tell me this emphatically, stating that their last vet told them so.

"Oh, I know her teeth are bad, but my last vet said she was too old for anesthesia."

Or

"I want to have her teeth cleaned but my friend/relative/drycleaner/stockboy said that they did that and their dog died."

There is some truth to this, but it's not what you think. If a vet recommends against anesthesia because the pet is too old, then I counter that in many cases (not all, so don't come after me with sticks!) the vet's anesthesia protocols are outdated.

I'm not talking about dogs or cats with legitimate health risks: pets with heart and/or respiratory disease, pets with advanced liver or kidney ailments, or animals with precarious endocrine conditions. On the contrary. The only thing these wrong with these pets (besides the easily treatable problem at hand) is advanced age. Last I checked, age isn't a disease.

Anesthesia and monitoring has come a long way in the nearly two decades since I graduated from vet school. I no longer use many of the techniques I was taught, or the drugs used by my first employers. I regularly attend continuing education to find out what the newer protocols are, and start using those in my practice.

With a thorough pre-anesthetic workup, we can address most issues with older pets and tailor their anesthesia to them. One size does not fit all. No one drug does it all.

For instance, in a pet with kidney issues, we will avoid drugs that need to be excreted by the kidneys or are known to potentially cause problems with the kidneys. We will pay close attention to blood pressure and fluid therapy to make sure the kidneys stay happy during the procedure. In a pet with cardiac issues, we will avoid medications that cause the heart to work harder, or that changest the blood pressure. We will be prudent with fluid support so as not to overload the heart. In a pet with liver issues, we avoid drugs that need to be metabolized by the liver.

So what do we do? A big part of our anesthetic protocols is pain management. First we administer medications that do double duty -- pain control AND sedation. Using pre-anesthetic medications allows us to use LESS induction agent and lowered gas anesthesia rates, and thus fewer side effects. When pain is prevented before it is inflicted, we don't need to 'turn up the gas' to keep the animal asleep during the procedure.

Another big part is monitoring. Is there a licensed technician monitoring the pet during the procedure? Checking heart rate, pulse quality, respiratory rate, oxygen level, palpebral reflexes, blood pressure, and temperature?

Bottom line: it's not the anesthesia that is the culprit here, it's the anesthetist -- the vet administering it. It's all in the drug choice, dosage, and administering to effect, not giving a calculated volume based on weight. Or rather, there is no such thing as bad anesthesia, just bad anesthetists.

Now I'm not saying that there are no inherent risks with anesthesia, because I'm not. And I'd be a liar to say that no pet ever died under anesthesia on my watch. I will say that all of the anesthetic deaths in my bone pile were young, healthy pets in for spay or neuter, and their deaths were likely due to an underlying yet undiagnosed heart condition in addition to inappropriate though commonly used anesthetics popular at the time (late 80s, early 90s). But times change and so do anesthesia protocols.

In many cases, the risks of anesthesia for your geriatric pet are less than living with the disease process at hand (usually really rotten teeth). I can't guarantee that your pet won't die. But by doing the preanesthetic workup, paying attention to each pet's current health, tailoring the anesthesia to the specific pet, and administering multi-modal pain control as part of a balanced anesthetic protocol, administering drugs to effect, we can certainly minimize that risk.

The Cost of STAT Bloodwork

I recently had the pleasure of discussing bloodwork prices with a former client who is thinking about coming back to our clinic. Seems the last time she was in with an emergency two years ago, we ran a battery of tests and made a diagnosis all within 20 minutes of her dog's arrival. Subsequently, though, we needed to run a confirmatory test as well as additional tests to find out the why behind the diagnosis (which helps us target our treatment better).

Due to the nature of her dog's condition, the dog needed to be transferred to a referral facility for 24-hour care. That larger, better-equipped hospital was able to do a few more diagnostics there, in-house, that we were not able to do.

The client then lodged a complaint that we should have been able to get all of the results instantly, because the referral hospital could.

I find this ironic. Today our conversation covered the costs of blood tests for her geriatric cats. Seems they're all getting on in years, and it's time to have some baseline bloodwork drawn. But gee, doc, the last time I was in, the cost of those tests was just outrageous! Why do they cost so much? Why can't I get them cheaper? She wants results now but doesn't want to pay for the convenience.

Convenience stores are cheaper than the grocery store for a reason.

Time for the clue gun:

CBC Machine: $18,000 (This thing guzzles gallons of various fluids to the tune of $100-200/gallon, and each gallon lasts less than a month)
Chemistry Machine: $12,000
Centrifuge: $350
Microhematocrit Centrifuge: $900 (All this thing does is spin blood).
Refractometer: $350
Reagents for the CBC and Chemistry machine: $8000 approx. per year
Binocular Microscope: $1500
Miscellaneous Lab Supplies: $4000 approx. per year

Getting blood results instantly so that we may institute proper treatment immediately? Priceless.

Yes, we could send out all of our blood, urine, and feces. But then you'd have to wait 24-48 hours or more for results.

And if your dog's life is hanging in the balance, which would you prefer: Instant results? Or cheaper results? You decide.

I Need a Refill!

Have you ever called your vet wanting a refill of that last medication you got because whatever it was came back and the medication worked? But your pet hasn't been seen since 2001? Has your vet incurred your wrath by saying no?

Join the club. But don't be mad at your vet. Blame the Feds.

Federal law prohibits dispensing of medication without a valid client/patient/veterinarian relationship. Period.

It means we can't give you medication for a pet we haven't seen recently. That means physically examining the pet in the hospital. For a younger, healthy pet, that is usually within 12 months. For an older pet with issues, it could be as recent as six months. Sooner if the pet has a complicated illness.

So asking for a refill on phenobarbital for a 16-year-old dog that I haven't seen in over three years is likely to get you a big, fat NO. Sorry, dude. My license is on the line.

The Naked Truth about Spay/Neuter Surgery

A spay is a spay and a neuter is a neuter, right? So why does one vet charge $70 for a cat and another $300? Isn't the expensive guy a rip off?

If you're talking about the fact that the ovaries and uterus are removed in a female and both testicles in a male, then yes, they're the same. But that's where the similarity ends.

Chances are, the more expensive place is doing far more to insure your pet's comfort and safety than the cheaper place. Let me explain.

When I graduated 18 years ago, the standard for a cat spay was injectable anesthesia alone, with a single injection of butorphanol (torb). Dogs were given IV meds and put on gas. With some torb. And, some places today still adhere to these protocols, because, after all, we've done them this way for years, they're safe, and they work.

BUT: We've since learned that torb's duration of pain control is from 30-90 minutes tops. With the advent of doggy blood pressure machines, we now know our gas anesthetics cause lowered blood pressure during surgery. And we've learned a lot more about pain management, thanks to advances in human medicine.

So what does that mean for your pet? Many clinics now address these issues. At our practice, all pets undergoing surgery must have a physical exam and be up to date on core vaccines. Cats and dogs are given medications for pain and are sedated prior to anesthesia. An intravenous catheter is placed, and all pets receive intravenous fluids, not only to maintain blood pressure, but to administer a constant rate infusion of pain medications during surgery and throughout the recovery period. Pain medications administered block the pain pathways from a many angles to insure your pet is pain free. Our surgery table is heated, as are our recovery cages. During surgery, your pet is monitored by a licensed technician (similar in education to an RN).

Surgery is performed in a dedicated operating room where no other procedures are done. Each pet gets a sterile instrument pack. The doctor is wearing a surgeon's cap, mask, and sterile gown. A sterile, waterproof drape is used. A new package of suture is used for each pet.

All pets undergoing anesthesia are intubated, on oxygen, and inhalant anesthesia. This provides control of the airway in case of emergency. The IV catheter, in addition to allowing fluids, also provides venous access in case of emergency.

After surgery, your pet is monitored until the tube is pulled. They are kept on the infusion of pain medication until shortly before discharge. Your pet will also go home with several days worth of medication, usually all included in the fee.

Pretty much like what happens in a human hospital, right?

Contrast that to several other places I've worked over the years: no cap, mask, or gown. No IV catheter. No fluids. No designated surgery room. Many also had an x-ray machine in there, or were also used for treatments (think abscesses and dental cleanings -- both very dirty procedures!). No heating pad. Cats not intubated. Torb only for pain control. Monitoring only by the doctor performing the surgery. And the biggie: spaying or neutering more than one pet per pack! YUCK!

So, the next time your pet is facing one of these surgeries, ask yourself: if it were me, which would I choose? Also, this will give you some things to ask of your vet when you make the appointment. Not all vets cut corners. But you deserve to know exactly what you're getting before Fluffy gets to the table.

And remember the old adage: You get what you pay for.

Can you bill me?

Vets hear this every day: Can I pay you next week when I get paid/my inheritance will arrive/my settlement comes in/when I can cash a savings bond?

The answer is, unfortunately, no.

But I promise to pay/always pay my bills/I'm one of your best customers (let the record show that usually the person has been in once or twice in the last 5 years for 'just the rabies shot').

If a vet had a nickel for every time he heard this, he could retire and live in the lap of luxury in the South Pacific.

Blame the hundreds of people before you that have used that line and failed to follow through. Every vet has wanted to be the good guy and has gotten burned in the process. Yes, you may be the exception. But the vet can pull out the drawerful of empty promises that precedes yours.

Think about it. What if you went to your job, put in a full day's work, and at the end of the day, your boss said, hey, can I pay you next week? Would you say yes? Would you keep working week after week if your paychecks didn't materialize? I didn't think so.

Promises to pay don't put food on the table for my family. I work a long day and deserve my paycheck as much as you do. Every penny I don't collect comes directly out of my pocket. Think about it.

I Deserve a Discount!

All the time I hear comments whining about the cost of these spay/neuter surgeries. "But we can't afford it!" "I'm a good pet owner. I deserve a discount!" "But if the vets didn't charge so much more people could get it done." "If vets would do spays and neuters for free, we wouldn't have so many homeless pets!"

Lots of issues here.

First, no matter where you have your pet's surgery done, the vet is losing money. The true cost of the time, materials, instruments, staffing, anesthesia, monitors, etc. is staggering. Most vets use the surgery as a loss leader, and donate the difference as 'community service.'

A discount? According to Veterinary Economics, a well-managed practice will net 25% after expenses. Note the words well-managed. Since most vets are trained as DOCTORS and not BUSINESSMEN, your average veterinary hospital is not so well-managed, and therefore nets even less. In most single doctor practices, the vet's salary comes out of what is left over. Around here a lot of these rescue groups want at LEAST a 25%, if not 50% discount. So not only is the vet now working for free, he's actually paying out of his own pocket to cover these discounts. So, good pet owner, no discount for you. You took on the responsibility of pet ownership, you pay the price. As for rescue groups, many vets do give discounts. But keep in mind that they do it for community service, not because their regular prices are expensive.

Lastly, the pet overpopulation problem is a community issue, not the veterinarian's fault. Heck, even human beings have problems getting their medical needs met if they have no insurance. So if people fall through the cracks, so do animals. Yes, there are a lot of services for indigent people for medical and dental care DONATED by these professionals. And many veterinarians donate their time and expertise to rescue groups and humane organizations.

But it seems more and more lately that people want all vets to work on the cheap, on owned pets as well as strays. Pet ownership is a priviledge, not a right. Your vet deserves to make a living. Stop demanding freebies.

Here's your clue...

You bring your dog in for his annual visit including a heartworm test. We ask if you need to purchase more heartworm pills, as they must be given monthly. You assert that you give them regularly, but you'll pass on a refill, as you still have plenty left. Computer records show the last time you purchased heartworm medication was in 1999. If you can clone those pills that are reproducing in your kitchen cabinet, let us know. I'd like some, too.

You bring your cat in because she's off today. I look at the cat. The poor thing is emaciated, dehydrated, shriveled like a prune. She's covered in fleas, her eyes and nose are crusted over. The only way I can tell the cat is still alive (if you can even call it life) is that the cat makes a gasping sound every so often. I ask a few questions to determine how the poor kitty got into this state, and you reply emphatically, "But she was perfectly fine, yesterday!" Fine?! I think not. Maybe she was sort of sitting sternally yesterday. But she was NOT FINE. Or maybe yesterday was actually 3 weeks ago, and you can't admit you haven't laid eyes on your own cat in nearly a month. And I'm sorry, but I can't fix this for fifty bucks and a shot of antibiotics. And when you choose to put the little kitty out of her misery, you sob and claim how well you treated her, how you did everything you could for her. Can I buy a cup of that delusion, please?

But...do you want THIS dog?

So many times we get clients who listen to our examination findings and treatment options only to say, "Well, it's just a dog." Or, "It's not really my dog. It's my son's dog." (That the son is only 4 fails to register). Better yet, "It's just a stray." Me: "How long have you had him?" Them: "Oh, about 7 years."

I hate to be the bearer of bad news: It's YOUR DOG. Not the kid's, not a stray.

To some, the dog is disposable. In the same sentence that they ask to put the dog to sleep for a treatable problem (broken leg, swallowed toy, bladder stones), they ask if we know a breeder so they can go purchase a NEW dog.

Easier to buy a new one than care for the one you've already got? Apparently the family dog isn't always a member of the family.

Over the years I've learned that I can't care about the dog more than the owner does. It hurts too much, and I can't save them all. And no, I won't take your dog and treat it for free.

Take responsibility for the life that YOU have taken into YOUR home. It's not the vet's responsibility to take the pet off of your hands.

Who needs training?

Listen up, dog lovers.

Dogs are like children. They are born with an inherent temperament. They are individuals. The new dog you just got is NOT likely to be exactly the same as the dog you had previously. Like children, dogs are inquisitive. They like to hang with the pack (ie you and your family). They want to do good, but need some help. Like kids.

Dogs need training. Attention. Exercise. Love. Did I mention training?

Lately we've seen a run of unruly dogs. Listen up, folks. These are not bad dogs. They are young adults. Most have not yet been neutered. Some have. These guys have no manners. They don't know how to behave. They are fearful. They are looking to you, the pack leader, for guidance. A feeble "Sit!" from you is not going to cut it.

So when we recommend a dog trainer, obedience classes, or a behaviorist, it is not an attack on you, personally. But here's your clue = your dog is on track to becoming the black sheep of the family. And it's NOT THE DOG'S FAULT.

Train your dog. You don't need to want to show or compete. But you do need to learn how to speak dog. And your dog will thank you for it.

Tips for Vet Visits

Make an appointment and be on time. In case of emergency, please call ahead so we can plan for when you come in.

Have your dog on a leash and your cat in a carrier. We never know how many pets will be waiting. Keep your pets under your control, and safe.

In the exam room, answer the doctor's questions truthfully. Don't tell us Fluffy never goes outside, only to mention she's always coming in with ticks and burrs in the next breath. Either she goes out or she doesn't. And don't say she never leaves the deck, especially when it's obvious she's been hit by a car. Unless your deck has been ripped from the back of your house, I'm not going to believe that she never leaves the deck. So, 'fess up. I'm not the cat police.

If we ask if Fido eats people food, don't say no only to later mention how you adorn his dog food with leftovers and gravy. Leftovers and gravy is people food. Fido is a dog. If Fido is sick, we especially need to know this. Now is not the time to pretend you're Mr. Perfect Dog Owner. And when Fido pukes up the sausages and biscuits, I'll know you're lying anyway.

If Fido runs loose in the neighborhood, in violation of the leash law, we need to know this too. If Fido is sick, we need to know if it's possible he raided the neighbor's trash, ate the dead deer entrails in the woods, or could have lapped up some antifreeze.

If you are new to our clinic, bring your previous records. This requires a bit of advanced planning, but is essential. In this day and age of HIPPA laws and confidentiality, many places won't give US the records without YOUR authorization. So get them before you come.

If you have any money concerns, let us know. We will happily give you an estimate (at our clinic we give them ALWAYS). We won't work for free, but we can pick and choose what tests to run first. If your pet is very sick, there may be no way we can shave the bill.

If you decline tests and elect minimal treatment (often against our advice), don't call us every hour to demand to know what is wrong with your pet and when he/she will get better. If you don't authorize tests, we don't know the answers. They don't hand out crystal balls upon graduation from vet school, nor do they give them to us when we get our licenses. I doubt you'd want me to pull out my kid's magic 8 ball, but that's in effect what you are asking.

If you tie my hands behind my back, I really can't help you. Pet's can't talk, so unless their problem is very obvious, we usually need to do a few tests to find out what's really going on.

If you don't like what I have to say, you are welcome to try the specialty practice up the street. Heck, we consult with them regularly on complex cases and refer them when pets need 24-hour care.

Trust me when I say that we vets WANT TO HELP YOU and YOUR PET. Make our jobs a little bit easier by being helpful, cooperative, and informative.

And don't forget the checkbook. The landlord won't waive the rent because we love animals.

Introduction

Your chance to pick the brains of a veterinarian. Why we do what we do, what we love about practice, and what we wish our clients would know.

I'll also tell you how you can drive us nuts, tick us off, and basically what will make our splendid day turn miserable in a hurry.

Yes, we love animals. Yes, we wish we could save them all. But, veterinary medicine is a business, and businesses as such need to make money to pay a decent wage to those who work there, and to put food on the vet's table.

Yes, some vets make over $100K. I am not one of them.

Read on, dear pet lovers. If you dare.