Looking for meaning where there may be none.

A very pregnant cat came to our SPCA hospital from the shelter yesterday, and according to protocol she could be either euthanized or spayed. Nice and simple choice, kind of like choosing a plan for your wireless phone. The veterinarian doing surgeries was able to fit her in. Any vet I know, including myself, would find a way to get her spayed if the alternative was euthanasia. The logic behind this is seemingly clear-cut: the mother cat is already the subject of a life, but the kittens' lives have not yet begun. I know, many would argue that the kittens are in fact already alive, or at least viable, if the pregnancy is advanced enough. Never mind cats - the question of when a human life begins has still not been settled to everyone's satisfaction, so there's no need to repeat the debate here. In veterinary medicine in a shelter setting we of necessity simplify things: an animal that has already started its life and lived some of it, usually takes precedence over an animal whose life - growing, learning, playing, experiences - has not yet begun. I have no intention of pondering what's right and wrong here. There is no right and wrong, only consequences - and I can't even lay claim to this great saying. The consequences in question are the number of lives that require homes, and that are in danger if these homes aren't found. Fewer lives mean less potential for suffering in our cat-unfriendly world, and lives that have not yet started (in the simple, non-convoluted sense) should not be encouraged to start. Simple math, and no need for moral agonizing.

But consider the other official shelter choice - euthanizing both mother and unborn kittens. The mere fact that it exists is interesting. Even more interesting is the fact that some veterinarians avail themselves of this choice. Think about it: a cat who has not yet become pregnant is entitled to spay and subsequent life, but one who is pregnant has somehow lost these wonderful privileges conferred by humans. Why is that? I doubt it's because the non-pregnant cat is considered healthy whereas the expectant mother is somehow an anesthetic and surgical risk. Spaying a pregnant cat is more involved than spaying an immature one, but it's still a fairly simple surgery (compared to dog spays) with little or no health threat to the mother. So, why would a pregnancy even theoretically threaten a cat's right to be spayed and to continue living?

Brachial plexus injury, and a big spot of doubt.

Last Saturday I had the honour of meeting a young marmalade cat who'd been hit by a car and found his way home a couple of days later (judging by the dried blood on his chin and the degree of dehydration). He had a broken lower jaw, a broken upper canine tooth (fang), and an injury of the front leg that made it impossible for him to use it. A fracture would have been much better, medically speaking. But this cat had a brachial plexus avulsion (torn or badly stretched nerves that run through the armpit to the front leg) which happens when the arm is suddenly and violently thrown sideways. With this injury there is almost no hope of meaningful recovery. In the best case scenario, the animal 1. is a dog, 2. has a calm and patient temperament, and 3. has undamaged nerves running from the back to the muscles above the elbow. Then they may learn to throw their leg forward to unfold the wrist onto the ground. If they are not so fortunate, the wrist buckles under and is dragged along, making it necessary to amputate the leg. Either way, they are unable to actively move the wrist and position the foot. This cat had two major disadvantages going against him: his injury was bad, making amputation necessary, and he was an inveterate outdoor cat.

I explained the injuries to the owners and said that physically the cat would recover just fine after a leg amputation - he was a robust young cat with the will to live, and ate a whole plate of food after the painkillers had kicked in. (He would also have needed dental surgery to remove the root of the broken fang and to wire the lower jaw together.) I told them that he would have to be an indoor cat for the rest of his life, as it is not safe to let a three-legged cat outdoors - he can neither run fast enough nor climb to get out of harm's way. Then I asked the owner about this cat's day - what he does, what he likes to do. The answer I got told me he was a dedicated outdoorsman, and would probably be miserable if confined. Unless he was frightened off the outdoors by his experience. My broaching of the subject, and asking the owner about his lifestyle, may have sealed his fate. Because an hour later, after we'd given the owners a financial estimate of the surgeries and hospital stay, they called back to tell us they'd made the decision to euthanize.

The things I've learned since starting in this career are the tip of the iceberg of what I want to know and be able to do. Yet one thing that came naturally (and perhaps too easily, given other veterinarians' typical reaction to the issue) was reluctance - or inability - to judge most people for life-and-death decisions relating to their animals. Of the things we do, passing judgment has to be one of the most exhausting procedures. I know this from the times when I was unable to resist. I'm actually quite easily annoyed by people, but this is different from feeling morally indignant at their choices. In this case, I did not feel the cat was being done a gross injustice. I needed to know his lifestyle, and I needed to tell the owners that the only safe life for a three-legged cat would be an indoor one. The God complex that afflicts many veterinarians made me feel responsible for the owners' decision - even now I can't help thinking the cat might still be alive if I hadn't stressed indoor lifestyle or if I'd been more forceful with the possibility that he might not even want to go outside from now on. Alive and recovering from a major surgery to see if his new life was livable to him as a cat as opposed to feline patient. He spent his last hours free of pain, ate a hearty meal, and dozed off slowly as the barbiturate I injected into his belly took effect. Then the receptionist told us that she got a vibe from the owner when he first brought the cat in that morning - he would not go ahead with any involved procedures. She has enough experience with people for this to be believable. And enough kindness to say things that would make us feel better. I still think I may have swayed their decision, but it must have been ready to be swayed.

Free Lance (or would that be Free Scalpel?)

Since the beginning of January I am no longer gainfully employed by someone else. Business was slow and work a little too relaxed, and I'd started forgetting what it's like to be a doctor. By mutual agreement with my employer, we said our goodbyes. They tell you not to leave your current job until you have another one lined up (or is it - don't leave your current boyfriend unless you have a new one lined up? I get confused). I had nothing lined up expect for a few locum days at the SPCA hospital. Such perhaps unwise audacity was inspired by a trip to a First Nations reserve in November where a team of us volunteered at a spay-neuter clinic. Just like that, I was happy to be busy, to be run off my feet in a sustained adrenaline buzz. And no longer afraid of making a bad mistake, or of not being able to give people an answer as to what's the matter with their animal. Not that my skills and knowledge were significantly different from what they were a year back. It's just that I'd had time to take stock of what I knew, and cross some invisible barrier from rookie to doctor. Some people cross it sooner than that, and some start out as fully-fledged doctors on their first day of work. I envy them, but I'm old enough to know I'm not going to be someone else.

The few locum days at the SPCA hospital have been a blast. I've picked up more, and have made agreements with other hospitals in BC to work for short periods. There is no way I could have done this kind of work straight out of school. It takes the relatively sheltered cove of a permanent job with a mentor for reassurance if nothing else. Mine was very kind and easy-going but still buggered off on holiday two weeks after he hired me, and I remember being furious with him for having that kind of faith in me. I was particularly furious one night when I had to do a resection-anastomosis on a dog who'd impaled its abdomen on a sharp stick, with the stick tearing up a tuft of fur and driving it right through the jejeunum and out the other side. I felt dumped, abandoned, and somehow deeply wronged. I resented my boss for his failure to understand how hard it is for someone without his 20 years' experience. In hindsight I think he knew what he was doing: forcing me to do things I'd be too timid to undertake on my own initiative. I learned a heck of a lot. But I was scared a lot of the time. Most newbies tend to get scared in various new situations, and until that fear is overcome, it's probably not a good idea to take it with you to different work places where there are new people and new protocols to learn every time. Now that I finally have the same faith in myself as my boss had in me from the start, but no longer working there, I'm trying myself out as a locum. Or locust, as my sweetie likes to say. Hopping off on a new adventure each time.

The nerd knowledge I had on graduation is about 80% gone, by a generous estimate. I no longer remember what exactly happens at the proximal and the distal tubules of the nephron, what gets resorbed or dumped and by what mechanisms. I know where to look it up quickly when the need arises. The new things I learn are, and will remain, the tip of the iceberg of veterinary medical knowledge. I know how to go about the uncertainty without panicking, and how to talk to people without feeling personally responsible for their emotional state. And I also know how to select CE courses that will actually teach me something, now that I'm paying for them out of my own pocket ;-)

Stooping to their level.

Pets are family in today's world, at least in today's Western world. Good or bad, this tendency is here to stay. And as with anything that is here to stay for the foreseeable future, it is silly to launch into a discussion of whether it should be abolished or not. Like arguing over whether trees should maybe grow roots-up, because that would somehow be more right. It's harmless and very entertaining to have philosophical debates on what it means for a pet to be a family member, as long as philosophers don't delude themselves into thinking that their conclusions matter very much outside the ivory tower. And personal opinion, although we were taught that it matters greatly, matters only to the person who holds it. My own pets are not my family and I use a simple criterion to make that distinction: no family members of mine lick their private parts to wash themselves. But this changes nothing in the world at large.

So I work with what is, rather than with what should be in a perfect world. Sometimes I even have fun with what is. And sometimes in retrospect I can even slip a philosophical foundation under that fun - old habits die hard, if at all. But it always starts out very simply, usually as a fulfillment of prosaic needs. Like hunger.

On many occasions a veterinarian's day lasts well into the evening, and the food supplies we bring with us have run out. We get hungry. It becomes hard to stay focused on cases, medical records and anything else that can't wait till tomorrow. The solution to this predicament is so glaringly simple and yet so shocking in its simplicity that few have actually resorted to it. Which is strange really, because veterinarians are not a squeamish crowd. Somewhere in the hospital there is always enough food to feed patients and boarding animals, even if the hospital does not routinely sell food. Do we just not think of what's in those bags and cans as nourishment fit for ourselves? Food is food, says my Old World heritage, and my rumbling stomach responds with complete agreement. Add to this a little scientific curiosity and a sense of communion with living beings under my care.

I remember well the first food I tried, maybe like a girl remembers her first kiss (and despite what you see it movies, it's usually neither perfect nor even that good). It was m/d, a prescription diet prepared by Hills pet food company for diabetic dogs and cats. This particular one was the canned version we were feeding a diabetic cat boarding with us. My immediate impression was that it was very tasty because it was sweet. And it was sweet because it contained corn; I could see the bright yellow bits of kernel and taste their fragrant sweetness. Corn is not the evil it is often portrayed to be, and its function here was to contribute protein, which it generally does quite well. But it was delightfully sweet. And the cat was diabetic. I've used the word "sweet" too many times in one paragraph, so I'll stop. I'll just say that this corn was in the wrong place at the wrong time. Yes, Hills and other major pet food producers do solid research into the nutritional needs of animals, and they do it remarkably well. They just don't always implement it. But someone else usually does.

Since then I have tried all the prescription foods and many over-the-counter ones. Some taste awful and yet many animals don't mind them, and some taste quite good. A particular kibble designed for intestinal ailments gave me terrible heartburn; maybe it just wasn't very fresh. Some kinds of kibble, especially those made for pups and kittens, are almost devilishly tasty; I'd certainly eat them if I were a baby animal. But then I remind myself that animals' sense of taste is not the same as ours. And no matter what kind, kibble is pretty darn filling. So filling that I don't want any dinner once I finally get home. If a handful of kibble can do this to a 120-pound human, imagine what it can do to your dog or cat. Imagine it well next time your pet begs for more with eyes that seem to say it hasn't eaten in years. Better yet, don't even take my word for it. After all, if they are family, even kids or babies as many people insist, is it not normal to be curious about what the kids are eating?

Next step: a wine pairing.

Justly, a cat.

On Saturday I saw two cats in need of help and was able to help only one of them. The owner of the other cat was entirely unprepared for the financial reality of treating a sick cat in our day and age. I highly suspected the cat had pancreatitis with the attending host of problems that afflict its digestive tract, and she was not going to get better without aggressive measures. There was no guarantee that the cat would fully recover after a hospitalization on fluids and IV medications, which already was too much in financial terms. Cats are not cars and we are not mechanics, we don't "fix" living beings. Most definitely she would need some degree of followup treatment, at least monitoring, even if it was only pancreatitis (which it rarely is). As a veterinarian I would be careless to offer anything less. As a person who lives in the real world I cannot possibly criticize people for refusing to put a cat through these measures, whether for financial or emotional reasons. To my credit - or shame - I was not about to blame the owner for deciding on euthanasia, had no impulse to do so. Part of me agreed with her. And to the owner's credit, she did not suggest taking the cat home to see if it would get better by itself. She understood very well that it would not.
In my everyday work there is a lack of middle ground between two extremes: doing everything possible for an animal with a serious condition, and hearing "it's just a cat." We seem to have forgotten to say "it is a cat." Not a fur person, not a feline patient, but an animal, with all the dignity of being one. And their dignity may well preclude the involved, often invasive, and undoubtedly troubling (to the cat) measures we are trained to take. We do not know what is going through the animal's mind in the period of medical treatment and recovery - or deferring imminent death, - and tend to forget that they cannot possibly understand that "it's all for their own good." Certainly the animal is alarmed, anxious, and confused - unless it's so ill that indifference and withdrawal have set in.
The fact that we've forgotten to say "it's a cat" was brought home to me in a much lighter context on the same day. Our receptionist has several cats, and one is an avid hunter. Her daughter called to report that the cat had likely eaten a squirrel: she brought home the head and feet, with the rest of the squirrel missing and presumed ingested. The receptionist asked me with a good deal of alarm: what should they do? I said, nothing can or needs to be done now besides keeping a good eye on the cat's appetite and comportment. I thought, how did we arrive at this point? When a cat's normal behaviour is pounced on as a potential cause for medical intervention?

Leave your gonads at the door.

Last week I said to my employer that I miss doing surgery (business has been much slower than usual lately), and the next day they called the new branch of the SPCA - conveniently located almost across the highway - to bring in cats in desperate need of sterilization. The SPCA is inundated with cats. We are not the cheapest clinic in the area, probably the most expensive after the emergency hospital, but we have a discount policy for the SPCA as well as for our clients: the "public service discount," meaning that spay and neuter are for the public's benefit and not just the owner's and the animal's. I will give these cats a chance at longer lives in people's homes, as they have no future unless they are spayed and neutered. Spaying and neutering has become the standard of veterinary care in the New World, so much so that people and vets who fail to do it are looked down upon as morally lacking. Of course, an exception is made for breeders - those who breed more or less healthy animals in good conditions.

The standard of care is a curious concept. It is supposed to be determined by the patient's best interests in terms of health and welfare. Our society does not accept packs of feral dogs or colonies of feral cats sharing living space with people - this is considered barbaric, unsanitary, and unsafe. But another way to look at them is no-kill shelters under the open sky, and this is how it works in many countries and communities where these animals are trapped, sterilized and vaccinated, and released. Not all of them, of course. Many continue to multiply, so the arrangement is far from perfect. Moscow has many colonies of feral cats who live in basements of apartment buildings (the city has no private homes, these are all brand-new and on the outskirts). They access the basements through small ground-level ventilation holes and live in safety and warmth by the hot-water pipes, taking care of any incipient rodent problem in the building. Packs of dogs live in the city parks and take shelter in subway entrances. The animals are fed by self-appointed caretakers. They are much smaller and thinner than the animals we are used to seeing in North America - they do not eat as much food and do not grow as big. Aggression is not an issue if the animals are not deliberately bothered by stupid or cruel people. But Russia is not a culture where the stupid are protected from themselves. The animals have each other's companionship, something shelter animals do not have even if they are fortunate to spend only a short time there before finding a home. In a shelter they smell and hear each other, but cannot interact, which I imagine contributes to anxiety and stress. So there is no reason to think that these feral animals suffer any more, or nearly as much, as millions of shelter animals awaiting adoption - or death. It is another culture's acceptance of the fact that some animals will never live in homes with humans, that this is an acceptable albeit imperfect way to live, and is no reason to destroy the animals.

What about health as a criterion of standard of care? We are taught in veterinary school that spaying and neutering are beneficial for the animal's health. Spaying a dog before her first heat pretty much protects her from breast cancer; after the first heat her risk of this disease increases but is still not very high if she is spayed before the second heat. After that, a spay is protecting her from pyometra and ovarian cancer but no longer from breast cancer. Dogs who are not neutered are at risk of developing prostatic hyperplasia that is often bad enough to squeeze the urethra shut so the dog can't pee. And there are, of course, behavioural issues that hormones contribute to - but habit and training have as much to do with this as hormones. We are also taught that a neutered male dog is more likely to develop cancer of the prostate than an intact one, but this latter piece of information is rarely if ever shared with owners when we discuss reasons for neuter. Stories of testicular cancer, urethral obstruction from prostatic hyperplasia, perianal tumours, and dogs getting hit by cars while seeking a date, are the usual fare dished out to owners in preparation for neuter. Cats may be a slightly different story. Spaying a cat has roughly the same benefits as spaying a dog, and neutering a male averts spraying and roaming. Recently I had the satisfaction but also the challenge of spaying an 8 year-old cat who had never had a litter. Her uterus was warped and her ovaries fragile as butter, tearing with the slightest pull - all that hormonal influence over the years! A confined tomcat makes a very unhappy animal indeed (which is quite different from a male dog kept from mating), while letting him outside guarantees that he will sow his seed and populate the world with more kittens. I don't know of any increased health risks for neutered cats compared to intact ones. Urethral obstruction is a frequent condition in neutered males fed dry diets, but we don't know how this compares to tomcats and whether they are at risk too - they don't stick around to be observed, or to survive when afflicted. All spayed and neutered animals have a tendency to put on weight much easier than intact animals, but - look at our human population. Obesity has more to do with how much a body, animal or human, is eating than with presence or absence of gonads.

So what came first as the determinant of the standard of care - health, or demographics?

More suck-the-fun-out-of-it thoughts ;-)

Three cats I saw this past week have brought me closer to understanding why I have chosen to work with this animal exclusively. (I still feel obligated to justify my preferences rationally. Still feel an envious nostalgia for "Real doctors treat more than one species" T-shirt I never bought and never will now :-) One is a Persian who came in vomiting, not eating, overall miserable and sick. Nothing new about any of these circumstances. But this little Persian was an extreme example of what breeding can do to an animal. She has no face to speak of, and her tongue is forever sticking out of a mouth too short to close over it. The canals that drain tears from her eyes into her nose are twisted shut, so the tears trickle out and soak the fur under her eyes. And I have yet to meet a Persian cat that is not extremely alarmed by a physical exam or any kind of holding for treatment - they are hypersensitive animals, disturbed and upset by the smallest of changes in their surroundings. I can't help thinking that this has something to do with cramming the brain into a box much too short to house it. If you had never seen a Persian before, you'd think this cat survived some horrible accident that chopped off her face and flattened what was left of it. That's pretty much what happened, except it took a few decades of dedicated human effort instead of a head-on collision with a speeding car - which in the end would have been more merciful.
There is only one fortunate circumstance to this story: this little cat and her breed are an exception, in that cats as a species have been allowed to remain much closer to their wild ancestors than have dogs. In dogs, there is just too much variety of human-induced abominations and woes for a wimp like me to push to the back of my mind. Delivering a litter of Boston terriers by C-section did not fill me with joy and dreams for the future, only with sadness and concern. Nor I do not ever wish to excel at being a glorified janitor, at cleaning up a mess I have no power to prevent. (Vets have no official say in what animals can or should be bred.) I'd like to practice in a way that would make my profession obsolete and redundant. I'd like cats to be eating good canned food or well-balanced and carefully prepared raw food, I'd like to see cat kibble outlawed as something bordering on animal cruelty - with special penalties for the label "Natural", but of course I can only afford this attitude on Sundays after sleeping in :-) On working days I diagnose and treat cats with inflammatory bowel disease, cats with failing kidneys, cats who can't pee because they are plugged up by crystals or stones. I get good at doing this, and I take pride in my skills - as long as I remember not to look at the big picture.
The second encounter was with a little animal at a local PetSmart. My boyfriend fell in love with him and started joking about buying or kidnapping him, so of course we had to go see this cat. He was a young Cornish Rex lad, alone in his cage as his brothers and sisters had been sold. He alternated between staring into space and pouncing at his toys, playing with abandon. He had the wrinkled face of a newborn baby - or an old man. Ever so slightly disconcerting. We asked to meet him and an assistant opened the cage and picked up the kitten and gave him to us. He was very quiet and dignified in his affection. A covert ten-second physical exam told me he had all his little testicles well in place, and a umbilical hernia - not necessarily dangerous by itself, but a likely sign that something else might be amiss inside. We asked his price, and were told that it was $1198. I have only heard of such prices for breeding-quality animals, not for pet-quality, no matter how pure-bred. There is no moral to this story, only questions. Such as, will the people who eventually buy him, allow him to breed and pass on his possibly not harmless imperfections? Once again, I completely failed to go "aaaaaah, how cuuuuuuute!" at the sight of this wrinkled little creature. All I wanted was to hold and shelter him from his very uncertain future.
The third cat was a magnificent snow-white Oriental Shorthair - a breed that kind of looks like a Siamese, but is more extreme in the prominence of its long muzzle and cheekbones. He was quiet, shy, and probably all-forgiving. His owner, a very old gentleman who dotes on him but has less-than-perfect vision, had cut his nails to the quick, and apparently the cat had not protested once. The only loud thing about this cat was his heart. This cat had the loudest heart murmur I have heard on any animal thus far: it was difficult to hear the heartbeat behind the whooshing noise. And yet - at home he runs and jumps and flies like a kitten, and shows no signs of illness. I shall see him again this week for a heart ultrasound that will show his heart and the work of its valves from the inside. No moral to this story either. None needed.