Being a House Call Veterinarian – 1

The privilege is all mine. A home is a special place, and to be invited in, to handle the home’s innocent and intensely loved inhabitant, is an immense expression of trust.

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“Thank you so much for coming!” Beaming relief, Sandi ushers us out the door, “I feel so privileged!”

I glance back – Pebbles the cat is under the dining room chair, relaxed but watching us leave.

“That was the best veterinary visit ever! I just cannot get her in the box, and the trip to the vet is always so awful! She just poos on herself every time, and last time she peed herself on the vet’s table. It was so horrible! I could hear her screaming in the back. I felt so sad. I never want to go through that again. Thank you so much!”

The privilege is all mine. A home is a special place, and to be invited in, to handle the home’s innocent and intensely loved inhabitant, is an immense expression of trust.

My patients are wary, often downright terrified, and most of them are geriatric. They have a plethora of aches and pains, poor vision, diminishing hearing, and can feel quite insecure out of routine. It is a challenge to avoid causing them pain whilst we take blood pressures and lab samples. They have picked up on their owner’s anxiety, and the sense of relief when the visit is over, with all the unknowns having been dealt with, and knowing that there is no shaking, yowling, vomiting car ride back home, has an euphoric effect. I share that euphoric joy time and time again, because I can easily appreciate the vast difference between a clinic visit and a home visit for my patients.

Vancouver Feline Hospital, being so peaceful without the dogs and the tensions of a normal veterinary clinic, was already a reasonably cat friendly place.  However, after 13 years, the décor and workflow design was starting to show wear and tear. A revamp was overdue, but I had not the heart for it. Working ten and twelve hour days was taking a toll on us, and often I would be working several weeks without a break. A tired doctor is not a good doctor. In the last couple of years, our veterinary assistants had worked some magic, easing some of my workload. No associate veterinarian that applied for the job could afford to move to Vancouver. I was frustrated and exhausted with trying to find feline friendly staff. Feline only practices don’t sell easily, and I didn’t really want to sell so much as ease off.

I bought myself a wetsuit on a Christmas sale, and started cold water ocean swimming. English Bay of Vancouver has choppiness, strong currents and great mountain views. The climate is mild enough that if you buy the technical gear, you can comfortably do watersports or sailing year round. So it was that on a sunny day, early April 2015, whilst swimming, I thought of a way to make a change.

It was a great opportunity, to sell the commercial real estate in a hot Vancouver market, clear all debts, and take a more relaxed approach to being a veterinarian. We made the transition to housecall practice in summer 2015.

 

We were instantly busy. The first month was quite experimental, just figuring out logistics. So many asked us if we were going to have a special van. Cats are simple creatures, and my bulkiest item was the ultrasound, which fits into a suitcase. The rest of the stuff we need is in 2 rolling toolbags, 1 smaller toolbag and a backpack. We only take into the home what we need, and my assistant will return to the vehicle if necessary. Thomas did regularly drop the babyscale, and I am looking for a more rugged model! We work in a city, and relished having a tiny car that is easy to park. Maybe Vancouver is exceptional, but we found parking to be easier than expected, and much cheaper. In a year, we picked up only one parking fine. The rain didn’t bother us either!

Traffic could be tedious, and we learnt to deliberately schedule appointments to avoid the heavy traffic times. We also found it was best to limit the number of appointments in the day – we might visit four homes, but I would see 8 or more cats.

We revelled in the unexpected pleasures of housecall practice. I am absolutely hooked on housecall practice as being the most feline friendly way to be a veterinarian. It is sheer pleasure seeing my patients, whom I know so well in clinic, being (almost) themselves at home. Any cat owner, including myself, can tell you how terrified the cat is in clinic and how differently their cat will behave on the home couch.

Pebbles is a new patient. I have not met her before today. She is gentle beautiful calico, a little tubby as an indoor middle aged cat can be, and explores our bags without much nervousness. It doesn’t take her long to find the catnip treat at the bottom of the bag, and she drags this out to play with it whilst Sandi fills out some forms for us.

Cats share space with us, without the same degree of brain function (mass) loss as other domesticated creatures. They experience significant stress and anxiety when out of their safe zones, and adverse events such as veterinary visit can easily contribute to post traumatic stress disorders. They recognise individual human faces. Pain and fear is easily triggered by a movement, a smell, or even the sight of a stethescope. The converse is true too – they do remember the gentle touch, and can come to trust another veterinarian over time. Cats whom we have visited often treat us as family friends. They know what to expect, and know that we wont hurt them.

“So let’s go look at the litter box.” Pebbles has just turned 14. She has been pooping on the rug the last few weeks, with increasing frequency. Yesterday, she peed on the rug. I have watched her wander around her home, sit and lie down, how she gets herself comfortable. I can see her food and water dishes in the kitchen. She has a number of cat beds around the home. The small apartment is arranged around her needs. It is clearly her home. We sat on the living room floor, and I did my exam, talking about every little bit, nose to tail tip. We have checked her blood pressure, and taken a blood sample. Pebbles is resting on one of her cat beds. Her part in the consultation is over. She relaxes and watches us stare at her litter box.

“We want to make this easy for her” I say, pulling out my phone to show pictures. Together, we wander around the home, looking at my example photos, and discussing practical ways to accommodate Pebble’s ageing and medical needs within the constraints of the apartment space. This is the magic of doing this consult at home – we don’t misunderstand each other and can discuss our patient’s needs within the context of the home environment and the individual cat and owner abilities. This is so different from the lecture given to a stressed out cat owner over a wide-eyed trembling cat on the exam table.

Whilst I having been talking, my assistant has gathered Pebbles lab samples, packed up the bags, and prepared the invoice. That is my signal to conclude our discussion, which will continue a day or two later when the lab results come back.

“Pebbles bit the other vet” Sandi confides as she completes the transaction, “The other vet told us to never come back!” Sure, Pebbles was pushed to her limit, then, and I am relieved her emotional scars from that encounter did not trigger fear during my visit. There are some cats that will not allow easy handling even at home.

 

For me, I never have to close those cage doors on a sick cat and watch the feeling of abandonment (mixed with guilt, fear and worry) in the cats and owners.  Actually, I had stopped doing that many years ago. There was a reason why cats were so desperate to get out of those cages, pressing themselves against the bars and diving out as the doors open. No matter how big (we had 4’ and 8’ kennels for our patients, much more than any other veterinary clinic), how comfortable and homey we made that space with hidey boxes, endless washloads of towels and baby blankets, toys and accoutrements from home and the cat only cat friendly environment, most of the hospitalised patients were still fearful or worried. Cats heal better at home, if you can do the nursing. Several years ago, I realised I had not hospitalised a patient for more than a year! With good nursing backup, my patients were doing well with homecare. In the housecall situation, I can do so much more in guiding acute and chronic homecare. The difference is palpable, just because I can evaluate my patient and their dedicated nursing staff at home.

I don’t miss the clinic environment, and have no emotional regrets whenever I walk past the Vancouver Feline Hospital location. All its precious memories – those photographs and mementoes of my patients that kept us inspired, covering the walls of my office and reception, are now in the home office. The wall has been replaced with scrapbooks, and I still love to get those photos.

It has been a fantastic year being a housecall veterinarian. Unfortunately, my lung disease has got worse, and after several very bad adverse reactions to perfumes and cigarette smoke, I had to make the decision to limit my exposure to uncontrolled triggers. It may take several more ocean swims, but I guess, thinking of Pebbles and cats like her, that I will find a new way to take care of my patients.

 

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Taking care of the aged and terminally ill cats – 1

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Kiko

I was woken before dawn this morning by that distinctive cat vomiting sound. It was Kiko. She is 24, with lymphoma, and that means seriously old and frail. She will fall into her vomit. I have to leap up and hold her; grab desperately for the nearest towel to absorb the mess and prevent it getting all over us. As I cleaned her up, tucked her back in, comforted, medicated and dealt with the mess, I remembered I had started this blog post.

In veterinary medicine we have a gift, if you wish to call it that, of terminating life to prevent suffering and distress. That judgement call can be difficult. We use the quality of life scale together with our personal belief systems and deep attachment to our cats to help us make that decision. But until that point, many of us are first time caregivers of the seriously old or terminally ill cat. Veterinary literature is almost non-existent on this subject. The most I will plumb out of the new field of geriatric cat care is medically invasive – for example, place a feeding tube – and only superficially taking into account any of the special needs and considerations of the senior cat. It helps to draw on human experience in hospice care, coping with ageing and dying relatives, and all the other aspects of dealing with the ill and the dying. Contrary to what we expect, not all doctors are able to deal with this stuff – experience seems to be a requisite. In veterinary medicine, experience in terminal care is lacking – veterinarians and pet owners habitually request euthanasia well before the final comatose stage, and the support network required to help deal with caring for such patients is not there in vet medicine.

Each life as it approaches the end takes an individual way along a common path. There are some generalisations we can make. One of these is the lack of sleep you the caretaker will experience. And no-one within your social group may understand. Pacing. Howling. Appetite changes. Bad days. The uncertainty – is today the day of death? Whilst life becomes difficult, but still enjoyable, we the caretakers experience the emotional roller-coaster – emotions generated by inability to effectively communicate with our patients, thus relying on our interpretations and experience – is there pain, is there nausea, where does it ache, did this help, what more can I do….guilt at not doing enough, falling asleep, getting irritable…precious moments of quiet joy that the little one is sleeping so peacefully, soft peaceful moments of comfort together. These all wrap up into stress and we each have our ways of coping.

There are so many similarities in cat and human hospice care, that when I first saw a hospice booklet for human caregivers, I wanted to copy it for myself for the cats. Mostly, it was the relief that I was not just making it all up. I just wish I had been trained – rather than the learn-as-you-go experiences.

There are stages in the care –ill, but mobile, eating, reasonably well; progressing through increasing immobility, pain, and needing more personal hygiene care; to very weak; to immobile and the dying. The most important thing we offer in all stages is love – soft predictable comfort, even if we cannot purr, they know when we generate that emotion – love is the best pain medicine yet, dole it out wholeheartedly whilst you can.

The smallest things become the most precious. Life crystalizes to what is truly important. For the cat, that is you, food, water, warmth and toileting. You first. I cannot over emphasise that – just how much everything revolves around companionship, comfort and love. As pleasurable as that sunbeam may be, life is not about stuff, and the heat from the sun is weak without you there.

We do everything to maintain comfort and prevent pain. This involves different grooming tactics, changes to litter boxes, bedding and accessibility options. Treating infections effectively. Not causing extra pain in handling or veterinary procedures. We avoid oral medication, finding subcutaneous or transdermal drugs less stressful, less painful to give. Pain management is multifactorial, and managing pain takes a persistent experimental approach – what is required can change, and we have to observe responses to drugs. Pain is variable, never the same during the day or day by day. Recently, I have come to appreciate the value in pacing as part of pain management and pain awareness. There is also variation in the howling that the cats do that can help us clue in as to whether it is a pain-coping strategy or not.

For those who take care of the cat till the end, to and through the dying, it is important that we know that we can do the same care that we would give to a dying human relative. We need to know how to do it, and it helps to have the regular weekly or more often support visits. For me, as the busy veterinarian, I need a cohort of nurses trained in such support to help me – I know those 5 minutes I spend gabbling the long list of things to do is not enough – it takes constant care and re-evaluation. For you, it is private care, and that costs money, each visit.

Making the decision for euthanasia is the most heartbreaking difficult decision of anybody’s life. I have been through this way too many times with my cats. It never gets easier. In a way, I think that guilt we feel, that we pushed them too far, stems from a feeling that we were unable to care for them effectively at that point, and so the little one suffered. But then, terminating a life too soon – how fair is that and where is that line drawn between convenience and care? That is why we need that quality of life scale. It has been often the only way I could make that judgement call. But even then, and I will throw this doubt in here, that scale cannot differentiate between the very ill cat that will recover and the terminal cat. That scale can change from day to day. It is still not an objective scale. There are some cats that would have died, but are being cared for right now, with chronic illness that will be terminal one day, but absolutely enjoying life.

Kiko is enjoying her morning nap now, apparently blissful. I glue my eyes open with another pot of coffee.

There is a number to the title of this blogpost – that means the theme will be continued.