By Holly Sawyer, DVM
Those are pearls that were his eyes,
Nothing of him that doth fade,
But doth suffer a sea change,
into something rich and strange…
-Shakespeare, The Tempest
When I graduated veterinary school in 1999, I thought with startled satisfaction, “I’ve arrived. I have achieved THE dream. My calling, my career, and my identity are set.” I headed off into the wild blue sea of private practice, expecting a straight-line voyage toward a sunset forty years in the future, as yet unaware of the ceaseless currents that propel medicine forward and the rogue waves that submerge you long enough to change you forever.
Like every other grad who headed straight into general practice, I stepped out of the Ivory Tower and tripped headfirst into “the way things are really done.”
Cats were often boxed down with straight Iso for neuters. If pre-op injections were used at all, they consisted of atropine and [big: read 0.5 ml/cat] doses of acepromazine to ensure a docile induction. Add a squirt of butorphanol in there, given a solid 3-4 hours prior to surgery, and we felt pretty good about ourselves. At best, we used ketamine/valium like water; at worst, we used speed to flush stinging abscesses, clip painfully melting hot spots, and otherwise get ‘er done.
Analgesia, far from being considered essential, was instead frowned upon.
The prevailing wisdom in the real world was that pain inhibited overactivity, thus decreasing complications. With thinking like that, morality became a close friend to the status quo.
I practiced this way for a good seven years. Yes, I felt terrible when a dog stood hunched and trembling, unwilling to lie down after abdominal surgery. But that would pass, and this was safer than using drugs we didn’t trust or keeping controlled drug logs we didn’t understand. The patients just had to endure for a little while longer before they were back to their old selves.
I did not recognize my first paradigm shift in practice until it was well upon me. I’m not an early adopter by nature; neither were the owners of my practice. There were murmurings of a seismic shift in general veterinary practice at CE events. Anecdotal stories flourished from close veterinary friends in bigger cities. Veterinary Information Network, still in its relative infancy, saw an explosion of discussions on the topic.
The upheaval was all about analgesia. It wasn’t just gaining popularity. It was the new standard of care. The body of evidence in favor of proactive pain control soon towered over every general practitioner, blotting out the sun. Our next step was clear. If we wanted to call ourselves good veterinarians, we needed to order morphine for dogs and buprenorphine for cats. That was the beginning for us.
Our protocol soon expanded to include polypharmacy, nuanced timing of administration, and a growing focus on pre-op bloodwork and intra-op IV fluids due to the use of injectable NSAIDs. All of this happened because pain control was not only the best medicine physiologically, but it had unequivocally earned its place on the moral high ground as well.
I felt…released…as if I had been breathing through a mouth gag for seven years and could finally fill my lungs. This was wholly right and good. I didn’t realize how wrong the old way was until it was held up in contrast to the new way. And I didn’t just give pain meds to my patients. I became a veterinarian who was ardently proactive about pain control. In a flash, I progressed from doing a new thing to embracing a new identity. I was changed—and proud to have been made better.
When Fear Free came around, I was in fact a fiercely ardent early adopter.
I was recently asked why I believe in Fear Free. After some soul searching and mental sifting, the answer came to me in a flash. It was the giraffe. For those of you who have taken the Fear Free modules, do you remember that slide? It shows a giraffe munching lazily on a bucketful of lettuce and carrots as the zoo handler calmly trims a front hoof.
The next slide shows the quintessential WWE photo of three vet techs sprawled on the treatment room floor, pinning a 70-pound dog to the ground, as a fourth tries to clip the toenails. I saw those slides juxtaposed together, and I felt shame.
I had been on that treatment room floor, getting raked in the belly by a flailing back leg or pinning the dog’s head to the linoleum as foam bubbled through the blue nylon muzzle and anal gland juice spurted out the other end. Or worse, I had simply told the vet techs and assistants to get the nail trim done and then left the treatment area altogether, leaving them to obey or fail.
Seeing that giraffe (who was entirely too big to bully) allow a hoof trim in such peace felt like a slap. I could no longer accept the excuse, “This is just the way things are done.” I had seen a better way. I bought peanut butter and canned cheese, pretzels and paper plates. I sent home pre-visit sedatives. I did new things, not just to do new things, but because I had changed my identity.
I had become a different veterinarian. I had become better.
A move to a different state provided an opportunity to transition out of private practice and into a management position for an after-hours veterinary triage company. One second, I was wearing the white coat; the next, I was on the other side of the exam table. At every visit to my local clinic, I have done my best to support the veterinary team. I bring cookies and write thank you notes and accept delays with a friendly smile. I know what it’s like to wear their shoes.
But I am also getting an exquisite feel of the pet owner’s shoes. I live in a rural area. I chose this; I must own it. But it presented me with a singular crisis when my adult Golden Retriever sloughed his gut for no good reason one night at 2AM and dragged himself outside during a winter blizzard to die. I had to decide between hazarding a 90-minute drive through the storm to the nearest emergency vet or muddling through the night on our own. My boy looked bad. Bad bad. But I didn’t want to die in a ditch on a desolate, frozen highway either.
I called the emergency facility to give them a heads up that I might be heading in, but my fear of the blizzard won. Angus made it, thanks wholly to the 2L of SQ fluids I had in my home stash that bought us time until my local clinic opened six hours later. But it was scary, and I was a professional with resources. It is a hundred times worse for the regular pet owner.
Through the triage company, I’ve heard pet owners calling their clinic in a furious panic but leaving the call calm and grateful, with a plan and some semblance of control over their circumstances. It’s all because the veterinary technician walked them through life-saving first aid and then directed them to the on-call doctor or closest ER clinic. I know the power of these calls firsthand. They can be miraculous.
If I were still in private practice, I wonder if hearing one of those calls for the first time would be a sea change moment for me, a transition from the old way to the new.
Would it stand shoulder to shoulder with my boss’s announcement that we were ordering morphine for the first time?
Would it hit me like the giraffe eating her salad?
Is continuity of care—giving your clients after-hours access to advice and direction while you sleep—your next opportunity to embrace a new identity and become a better veterinarian? Only you can say.