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.

eddie_300

“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.

 

logo
Vancouver Feline

 

 

 

 

 

Advertisements

Edward (18) amputee

Edward is now 18. On Friday afternoon in September 2001, Edward was hit by a car on a West Vancouver side street. He was brought to a veterinary clinic in West Vancouver by a good samaritan. I was the veterinarian on duty, and it was just after 5pm, into the last hour of my shift. Stunned, in shock, and just overly handsome. Radiographs showed a very bad complex fracture of his right front leg. His owners did come in, and wanted to try save his leg, so he was transferred to the emergency clinic for ongoing care until a board-certified surgeon could be found to comment. He spent the weekend on heavy duty pain drugs. Monday a surgeon deemed his fracture unfixable, and amputation was recommended. The thought of managing a three-legged cat was hard to his owners, and they signed Edward over to me. With help and guidance of another veterinarian, I amputated Edward’s leg, including his shoulder blade. The next day, he came home – a new home, filled with cats, and feeling vulnerable and painful. Our pain management learning curve on amputees and what happens to them over a lifetime began.
On day three he was intensely grumpy but trying to jump. His back muscles were stiff and sore for the next few weeks, as he adapted his posture and walking to the single front leg. As a young cat (6), he healed and adapted rapidly. But he always snapped if I inadvertently touched his surgery site, and his back was often stiff and sore. Although he could do leaps up high, getting down was a problem, so we provided downward routes he could manage from his favorite spots.
Into his teens, he started experiencing severe back spasm and pain. His entire back eventually fused into one stiff inflexible system, and although the bouts of severe pain ended, there are still days when he really seems to ache.
I think his sensitvity to touching his amp site has lessened, and I no longer appreciate phantom pain in him. As a geriatric cat, now with no teeth, deaf, and having gone through radioiodine therapy for hyperthyroidism, and now dealing with progressive kidney disease, his absolute favourite thing is the memory foam bed.
Cats are more secure at about the height of a bed. Edward has steps that allow him access to different heights. He also has a secure padded downfilled grass basket in the closet, and he loves to sleep in boxes, again very well padded. He has heating pads, raised food dishes and several water bowls with the water level at just the right height. His litterboxes are open, low and big.
Many cats are amputees. They achieve a great quality of life, adapt to their disability with grace and aplomb, and age as any other cat. The difference is in the phantom pain, the sense of vulnerability some cats have to deal with (after all, if you were a street-fighter before, you stay a street-fighter), and the painful severity of the joint changes these cats experience early on in their ageing process.
Proactive and ongoing pain management makes a huge difference, from day of injury (before surgery) right through the entire lifetime. Simple lifestyle changes can make the most difference, especially in an older cat. As for drugs, be prepared to use acute pain management drugs as well as chronic pain management drugs. Each cat is different, and so there is no one recipe that fits all cats – I had to get to know the character, and then close observation with paying attention to details helps me decide when he is painful, and where. Edward has some mild cognitive dysfunction now, and we found one of the drugs made this worse. Since withdrawing that, he has been much more stable. Edward’s demonstration of pain or hunger is to get grumpy. I actively feed him through the night, on his memory foam bed. If I find him howling or stalking another cat, I will distract him with food.
He is well beyond the stage of metacam, and throughout the time I have known him, metacam was absolutely inadequate in providing pain relief. Opioids on demand have been his mainstay. I saw little response to amantidine or gabapentin (conversely, some of my patients cannot live without these); and understandably, since cartilage problems are not the cause of his joint pain, glucosamine did not appear to have effect. He still likes his glucosamine treats, but then he loves pill-pockets, Temptations and Greenies. Not a great one for stinky fish oil supplements, he will lap on the fluid in a can of salmon.
The dose of the drug varies according to the pain level – and chronic pain is never the same day to day and within the day itself. Being aware of the neuropathic effect of pain, and what will intensify it, and what seems to level it out, helps. Cats have imagination (so can anticipate pain), memory (so can remember and associate pain with space, time, smell, sight, sound, taste, touch and person), and emotion. Paying attention to the details, removing pain triggers, and redirecting emotions make a big difference.
Giving oral medication by opening the mouth and popping a tablet can cause pain in older cats. Explore other delivery options, and always be willing to adapt your technique to the cat. Forcing Edward’s head back, and his body into an unbalanced insecure position is not an option. He gets his meds as transdermal formulations (and yes, they DO work, in cats and humans!), hidden in treats, or given with his daily subcutaneous fluids.
Medicating him is on a routine, predictable and takes under five minutes. There is no fight. If he objects, is unwilling, we do not battle him down. We think and find a gentle, easy way. Some days are very different from others, and with cats like Edward, who are old, with limited mobility, and dealing with many concurrent conditions, no currently acceptable published veterinary standard and approach applies.
Providing quality of life to our older and disabled cats is possible. Caring for cats like Edward makes us think about it.

Vancouver Feline Hospital