A Routine Spay And A Need For Skin Art

The day started simply enough, with several surgeries scheduled: a few spays and some mass removals along with dental cleanings and tooth extractions. I was looking forward to a fairly light day where I had plenty of time to tend to my patients and could enjoy my tasks, as well as train a newly graduated veterinarian, Dr. Karen, who was visiting with us.

The morning proceeded without any disruptions, and we started our third procedure, an ovariohysterectomy (spay) on a darling Akita, “Destiny” Smith, who was new to the owners. Originally her owners planned to take her to a spay and neuter clinic, and I supported their decision as the owners do not have the funds for emergency care if pyometra should develop or if Destiny was impregnated and had trouble delivering. Destiny was their first pet and she came to them from a friend who did not believe in spaying dogs.

Mr. Smith wanted Destiny spayed prior to her next heat cycle; he had no desire to experience doggie diapers! Mrs. Smith was very concerned about Destiny’s surgery and called to ask several questions in the days prior to surgery. I answered her questions and assured her I would never put Destiny through a surgery that I did not believe benefited her or that she was not healthy enough to handle with minimal issues.

Destiny’s physical exam and blood work were ideal, I had no concerns about surgery. She was a sweetheart for her shot of premedications, the shaving of her belly, and induction of anesthesia was very smooth. As we scrubbed her belly to ensure a sterile entry for surgery, I checked one last time for a scar or small tattoo indicating she was previously spayed. She didn’t have any evidence of a previous surgery.

Many veterinarians shy away from spays on large dogs because their body has padded the ovaries and uterine horns in a thick bundle of fat, but I’m pretty comfortable with the procedure. The procedure is performed by entering the dog’s belly about an inch lower than the umbilical scar. Generally, I make an incision about an inch long through the skin, using a scalpel. Adult dogs have a decent amount of fat between the skin and the body wall, so I trimmed this fat away to make closing the belly easier. I then elevated the linea alba, a white center line in the body wall that is free of muscle tissue, and cut through it with the scalpel. The cut was clean and the structures beneath the incision looked healthy.

In a female dog, the reproductive tract starts at the vagina, which transitions into the uterine body past the cervix. These structures form the base of a “Y,” where the dog’s uterine horns form the arms of the Y by extending towards the dog’s ovaries (located just below each kidney). When we enter a dog’s belly, we have to access these organs, which are buried beneath all the intestines and the bladder.

I gently massaged her spleen out of the way, then introduced the spay hook to her belly. A spay hook is an 8 inch long device with a blunt curved tip used to catch or hook a uterine horn. I gently slid the spay hook down along the inner tissue of Destiny’s right body wall, angled towards her left knee, then brought it back up with a slight motion towards her intestines. With this technique, I can fish out the uterine horn (arm of the Y) and bring it out through the incision. I can trace the uterine horn to the ovary, then proceed to carefully remove those organs.

spay hook

A surgical spay hook

Now, hooking the uterine horn is a bit of a finesse move, and I don’t always manage it on the first try, which was true in Destiny’s case. Our new veterinarian has only performed a few spays and I was explaining to her that often I can ‘feel’ when I have the weight of the uterine horn on the hook rather than an intestinal loop. I repeated the motion with the hook, angling it slightly farther back but still didn’t feel any tissue catch on the hook, so next I adjusted it farther forward. When the hook came up empty, I sighed and said ‘good thing we have two sides!’ I reoriented the hook to direct it down the inner tissue of Destiny’s left body wall and repeated the same motions with the same results.

I frowned, but let Dr. Karen know that we had another option: we could increase the incision a bit in length and try to feel the uterine horn with our fingers. I used the scalpel to expand the incision down Destiny’s belly by about another inch, then slid several fingers into her abdomen, scooping them along her body wall. However, I couldn’t feel the uterine horn, which is nickel or quarter sized tube in a large healthy dog.

I slid my fingers along the other side of her body, but still came up empty. I muttered but repeated the action a few more times, coming to the dreaded realization that Destiny was possibly spayed already. With a sigh, I shared my concerns with Dr. Karen and she asked how we would know. Realistically, we don’t have a way to be certain. We would check for Destiny’s organs in the expected places, but it would require us to expand her incision large enough to perform an exploratory surgery so that we could visually and tactilely explore all of Destiny’s abdomen.

Dr. Karen scrubbed in to assist with the surgery, as additional hands help in moving the intestines, an organ that likes to expand to fill spaces. I expanded the incision so that I could see all of Destiny’s abdomen. A dog’s vagina is sandwiched between her colon and bladder, so that is where we started our search. By pushing the intestines forward, I could elevate the bladder away from the colon, which revealed only a small fibrous piece of flesh, possibly a ‘stump’ from a previous spay. We certainly couldn’t find any tubes between the colon and the bladder.

Next, we gently traced the entire intestinal system to ensure no uterine horns were somehow masquerading as intestines. We then moved the intestines out of the way to take a look for Destiny’s ovaries. A dog’s ovaries, typically the size of dried apricots nestled in nests of yellow fat, would rest just below her kidneys, but often are hard to distinguish from the fatty tissue that insulates the body. I ran my fingers across the fat, but did not feel any thicker nodules suggestive of ovaries.

Since we already had Destiny’s belly open, I checked her stomach, pancreas, spleen, and liver, all of which appeared healthy. We gently replaced her intestines and I sutured her abdomen closed. After we woke Destiny up from anesthesia, I left the operating room with a feeling close to despair

Today I performed an unnecessary surgery on a beautiful and charming Akita. I called Mr. and Mrs. Smith to explain that Destiny was already spayed. Mrs. Smith was very upset that Destiny would need to heal from a surgery she didn’t need.

I often hear reports of veterinarians performing unnecessary surgeries to have vacation homes and expensive cars, even though I don’t personally know of any veterinarians that have either (unless their spouse or family works in a well-compensated profession). The rumors exist likely because performing veterinary medicine is expensive: the cost for the staff, supplies, building, amenities, and equipment are 5-10 times what the veterinarian earns, but it is easy to blame the cost on the most prominent person.

Today I couldn’t claim that the costs were due to providing the best care for a pet. When a pet has an unnecessary surgery, like most veterinarians, I feel sorrow.

While we can perform surgery safely, and we have done all that we can to minimize risk, we cannot eliminate the risk. In Destiny’s case, a small simple tattoo on her abdomen would have prevented this unnecessary surgery.

Dr. Ev's tattoo on a kitten

Dr. Ev’s tattoo on a kitten

Please ask your veterinarian to tattoo your pet when she (or he) has a de-sexing surgery. This simple technique involves creating a light scratch in the dog’s skin with a scalpel blade near the incision, then touching the tiniest amount of green tattoo ink to the scratch. Should anything ever happen to you or your pet, all future veterinarians will know your pet was already spayed or neutered.

A Lively Liver Tango

Hero was a very handsome German Shepherd and at seven years of age, he visited our hospital every six months for routine preventive care. He was current on heartworm and flea prevention, was well trained, and had a surgery as a four year old for a ruptured ACL ligament in his right knee. His annual blood work was always unremarkable. He is a charming dog that behaves beautifully and handles life with grace. Today, though, Hero wasn’t feeling so great. His head was dropped down, he didn’t wag his tail when the nurses chattered at him, and he walked with an odd, hitching gait. Mr. and Mrs. Davis were worried about Hero. He was fine the evening before, playing with the neighbors dog, ate his normal evening meal, and went to bed. He seemed a bit restless overnight and this morning her refused his breakfast. Mrs. Davis was adamant that something was wrong with Hero, and Mr. Davis called off work to bring Hero to the hospital. I rubbed Hero’s ears and he gazed into my eyes with the most piteous look. His eyes were a bit sunken and his gums were sticky to the touch, indications of dehydration. His gums were darker than usual, a sign of decreased blood flow. Hero’s heart was beating a bit too fast. His joints had normal range of motion with no pain on palpation and a rectal exam was unremarkable. As I pressed my fingers into his abdomen I was surprised to feel a large mass, just before Hero cried out. He tolerated me pressing into his lower abdomen; his intestines and bladder felt normal.

I relayed my physical examination findings to Mr. and Mrs. Davis and stressed that we needed to do further diagnostics, but Hero might need emergency surgery. The Davises were visibly upset and Mr. Davis said “Doc, we don’t have much money.” I felt dread welling up in my stomach; finances and hearts often diverge in veterinary medicine. I took a deep breath and explained that we needed to start with blood work and IV fluids. I provided an estimate and asked them to approve the initial costs so that we could start helping Hero feel better. I promised that we would help them figure out finances as soon as we had Hero’s blood work and fluids started. While a nurse drew blood and placed an IV catheter, I considered the possibilities. The possibilities in an adult German Shepherd were numerous; gastric bloat with possible torsion, toxin ingestion, pancreatitis, foreign body, gall bladder disease, liver disease, and diaphragmatic hernia. After giving Hero an injection of pain medications and while we waited for the results of Hero’s blood work, I explained the possibilities and talked about funding. The Davises applied for Care Credit, a deferred interest rate credit card for medical care. I’m not a fan of deferred interest rate cards because of the high interest rate that takes effect if the balance isn’t paid in full by the end of the interest-free term, but often don’t have better options for owners. The Davis’s qualified for Care Credit but were very concerned about taking on such debt. We talked about Hero and how everyone in the neighborhood knows Hero. It’s hard, as a veterinarian, to talk to owners about money, and it is hard for folks like the Davises to ask for financial help. Sometimes, when the stakes are high, we do things that aren’t so comfortable. We encouraged the Davises to visit their neighbors, share their story, and see if anyone was able to help out. We also provided the Davises with a list of charitable organizations that might be able to provide some assistance.

Hero’s blood work revealed mild elevations in liver enzymes and increases in white blood cells. We also took radiographs (x-rays) of Hero’s abdomen, which showed mild gas distension in Hero’s stomach but no evidence of gastric dilation volvulus or bloat, where the stomach swells with air and twists upon itself damaging organs and cutting off blood flow. The lines of the tissues in the radiograph were blurred by excess fluid in Hero’s abdomen. The lines around Hero’s liver were blurred and his liver seemed enlarged. We discussed emergency surgery, the risks to Hero, and the possibility of not being able to solve his condition. The Davises agreed to surgery and headed home to make phone calls and try to raise funds. We prepped Hero for surgery by shaving his entire belly from sternum to pubic bone then scrubbed him for surgery. This type of surgery is called an exploratory; we don’t actually know what we will find when we enter the abdomen, but we hope for answers and wish for cures. Just before we opened Hero’s abdomen up, we ran antibiotics into his blood stream to help reduce the risk of infection.

Long incisions aren’t as simple as they appear; I braced my left hand against Hero’s sternum (covered by a sterile drape) and placed my finger and thumb on either side of the midline of his belly to draw the skin tight towards the sternum and away from the midline. I gripped the scalpel in my right hand and extended my index finger over the top to rest on the back of the blade, then placed it between my left finger and thumb and drew back with mild pressure, opening the skin from sternum to pelvic bone in a single long slice. The skin pulled slightly away from the incision and subcutaneous tissue, mostly fat, peeked from beneath. With the scalpel set aside, I used a pair of forceps that appear similar to large tweezers to draw the subcutaneous tissue up and cut it away from the body wall beneath the skin with a pair of surgical scissors.

The motion is similar to trimming fat from a turkey while skinning it for a holiday dinner. This leaves the linea alba, a fibrous connective tissue that runs between the sets of abdominal muscles, exposed. Cutting through the linea alba leaves those muscles intact and gives us access to the peritoneal, or abdominal, cavity. To cut into the peritoneal cavity, we pull up on the linea alba near the pubic bone with the forceps and, turning our scalpel blade upwards, stab into the linea alba while trying to avoid damaging any organs. Some doctors will use the blade then to cut the linea alba from pubic bone to sternum, but I prefer to replace the blade with surgical scissors called Metzenbaums. I can actually use the scissors to draw the linea alba up and free from the underlying organs then cut, similar to slicing through wrapping paper.

When I performed my first abdominal surgery, I expected the variations in color and the movements of organs, but I was surprised by the heat of the body. Hero’s internal organs appeared darkened, almost as if I were wearing sunglasses under the bright surgical lights. These organs contrasted with bright red blood that was oozing from the top of the liver. The blood pooled around Hero’s intestines, which were stiller than usual. Dogs have seven liver lobes resting above and draping around the stomach and gall bladder. Hero’s left most liver lobe, the left lateral lobe, was large, dark, and the surface was slowly oozing blood. As I felt around the top edge of the left lateral liver lobe where my fingers encountered something that felt like a twisted cord; Hero’s liver had twisted on its own vessel. I resisted the urge to untwist the liver lobe as doing so would release toxins from the dying tissue of his liver lobe back into his blood stream, which would send him into shock. Hero’s liver had danced a tango and twisted about in his abdomen.

My fingers tucked thick suture material around the vessels and tissues where the torsion originated, far into the abdominal cavity in a space I couldn’t see, where the surgery light wouldn’t reach. My fingers rotated the line of the suture, tucking the right line beneath the left, then the left beneath the right, repeating the pattern several more times and wrapping the line across my fingers and drawing as tight as I could between each tuck. This causes the suture to ratchet down and the layers of tucks lock the first knot in place to form a ligature around the tissues. After carefully placing another ligature above the first, I slid a hemostat, or clamp, closer to the damaged liver lobe. I then laid the closest ligature over my left index finger and the hemostat over my middle finger with my thumb resting in the space in between. This is the space I would cut to remove the twisted liver lobe. I took a deep breath and tucked the scalpel blade into my right palm with the blade placed between my index and middle finger tips to cover the sharp edge to prevent stabbing important, healthy liver tissue. When I had the tips of my middle fingers touching, I used my right index finger to gently slide the blade across the vessels. As the vessels separated between the fingers of my left hand, I gently grasped the damaged tissue and lifted the lobe from Hero’s body. I carefully dropped the liver into a sterile dish and set the scalpel aside. Gently grasping the sides of Hero’s abdominal cavity, I angled his torso to shed more light on the source of the problem. To my relief, the ligatures were holding.

Next I carefully searched for other signs of bleeding around Hero’s liver, then traced his gastrointestinal system; stomach healthy and in its proper place, pancreas and spleen looking lively, intestines laying in their proper place, and kidneys still resting in the back of Hero’s body. I reviewed Hero’s response to anesthesia; his heart was doing well, blood oxygenated, and blood pressure improving. I carefully tacked Hero’s stomach to the left side of his abdomen, in a procedure called a gastropexy, to help prevent it from twisting like his liver had. I then started the long process of closing Hero’s abdomen up, slowly pinning the sides together by using single sutures starting in the middle. When the edges were held relatively close together, I threaded the suture through each side of the linea alba in an easy simple pattern. Once the linea alba was secured, I closed the subcutaneous and subcuticular tissues in a similar manner, then placed staples along the entire length of the incision.

We brought Hero up from anesthesia and he nuzzled our faces before we could even remove the tube that delivered oxygen from his throat. After a quick call to his parents, we examined the liver, then made long even slices to help the preservative seep into the tissue. The liver was placed in a jar of preservative and sent to a lab for a careful analysis. While I was pretty sure the liver lobe had twisted on itself, we didn’t know why, and we couldn’t absolutely rule out a cancer in that lobe. The Davises were thrilled to see a happy Hero that evening and reported that their friends and community had come together to support him. While they had asked friends to lend them money, many gave them smaller gifts and spread the word. As neighbors and other associates found out that the gorgeous Hero was in need of his own heroes, contributions flowed in. The Davises found support for their charming dog, and Hero’s bills were paid more quickly than expected. Two weeks later the tissue came back as not cancerous and Hero’s staples came out. His parents visit our hospital regularly, and Hero continues to amaze all of us.

Hair of the Dog? to Cure the Kitty

A cat needs blood. Feline blood products aren’t readily available. You don’t have any cats that can supply the amount you need but there’s a dog who can donate. What do you do? Hope for the best, harvest some blood, and transfuse it into the cat. We’ll have to wait and see if there are any negative consequences to this trans-species donation of blood cells, but for now, it’s a great story from the hospital where I complete a senior preceptorship. Sometimes the greatest medicine comes from the leaps of desperation; hope this leap lands the kitty with a healthy body. I am a little concern about how this cat’s immune system, kidneys, and liver will process the alien DNA, but perhaps the cells can serve their good before the cat’s body eliminates the foreign cells.

http://abcnews.go.com/US/cat-lifesaving-blood-transfusion-dog/story?id=25993654

The Case of the Wide-Eyed Cat

Elwood, a 9 year old neutered and slightly overweight short haired cat, cowered in the back of his kennel, his lanky frame hunkered down and his head tucked beneath a blanket. “He is normally so outgoing! I’m really worried” Ms. Jackson’s voice wavered. Elwood was Ms. Jackson’s late mother’s cat and Ms. Jackson was afraid of losing this loved one as well. As I peered into Elwood’s kennel, Ms. Jackson continued “He hides all day now, and wants attention all night. I just don’t understand. He won’t even come out for his meals anymore.” I gently scratched around Elwood’s left ear and a rumbling purr arose from under the blanket and Elwood raised his head to look at me. I slid my hand beneath his chest and started to bring him out into the light, at which point Elwood desperately scrambled for the back of his kennel. “Ms. Jackson, when did Elwood start hiding?” “It started last week; I thought he just wasn’t feeling well, but that he would come back out in a day or so!” Elwood peered at me a again and gave a sad, plaintive ‘meow.’ I stared into his very wide eyes and wondered if he had really just turned into a night owl or if he was experiencing photophobia, a painful sensitivity to light. I reached out and flicked off the lights, then crooned to Elwood who emerged from his kennel and butted my chin with his head.

“I think Elwood’s eyes are hurting in the light.” I asked Ms. Jackson about any changes at home; no litter changes, no food changes, monthly Revolution to prevent fleas and heartworm disease, no access to the outdoors, no new pets or plants in the house, and Elwood didn’t have access to human medicines. Normally I start physical exams with the face by shining a light in the throat, eyes, and ears, but this time I worked my way from the rear end to the head. Elwood tolerated my fingers probing his abdomen and hands stretching his joints. He purred enthusiastically as my stethoscope delivered the notes of his heart and lungs. His temperature, pulse, and respiratory rate were all mildly elevated. I picked up my pen light and took a quick look in Elwood’s clean ears, then checked his teeth and throat. Finally, I shined my light in Elwood’s wide dilated eyes, a condition known as mydriasis. In a darkened room, I expect Elwood’s eyes to be wide, but when I shined a light into his eyes his pupils should contract. They did, slightly, before rebounding to their full widened gaze. Elwood tried to wrench his head away and I lowered the light for a moment. My nurse stepped in to cradle Elwood, gently gripping his jaw and skull. I reached into my pocket and withdrew a single lens, about the size of a small drink coaster, then rested my finger’s just below Elwood’s right eye, bracing the lens a few inches from his eye before raising the light to line up with my own eye and directing it through the lens.

This light shined through the lens in my hand, through the cornea and lens of Elwood’s eye, and onto the structures in the back of Elwood’s eye, letting me look at the vessels, nerve, and retina that enabled Elwood to see. Slightly off center was a creamy white egg shape known as the optic disc. Viewing the optic disc is similar to looking at a river flowing into the ocean; the disc is the visible end of the optic nerve that courses from the brain to spread into a thin sheet of nerve cells, called the retina, that collect visual information entering the eye. If the optic disc appears enlarged, much like a river overflowing after a storm, I worry about inflammation or high blood pressures. A small optic disc may indicate damage to the nerve or lack of use. The shape of the optic disc varies with some appearing almost triangular and others perfectly round. From the optic disc blood vessels project outwards like uneven spokes of a wagon wheel. I look to see if any of these vessels appear normal; larger vessels are at risk for putting pressure on surrounding tissues or even bleeding into the tissues while smaller vessels may not supply adequate blood to the tissues. Then I look at the retina stretched across the fundus, a fancy word for the back part of the inside of an organ, which can vary in color and texture. Some are stunningly beautiful like a bowl of sparkling blue, green, and yellow confetti while others are reddened and reminiscent of the eyes favored by horror film directors. Elwood’s fundus was a lovely glowing green that would match a firefly’s light on a dusky evening. I peered intensely, looking for cracks or bubbles, changes in color or texture that could represent damage to the retina. The inside of Elwood’s eye looked perfect and an examination of his left eye provided a perfect match.

Eyes really can be a window into the health of a creature by offering a platform to view nerves and vessels. Changes in other parts of the body, such as increased blood pressure from a straining heart, or an infection with certain viruses, are often visible in the eyes. Elwood’s wide-eyed gaze had alarmed Ms. Jackson and brought him to my examination table, but such an evident symptom wasn’t going to reveal a cause right away. We talked about what tests we could run to determine what was wrong with Elwood. We started out with blood work to check indicators of organ function, blood cell health, and response to infections. Elwood’s blood work was unremarkable; none of those values were outside of normal ranges. Next we took Elwood’s blood pressure using a smaller cuff, one that is used on newborn babies, but instead of wrapping it around a baby’s arm, we placed it around the base of Elwood’s tail. Elwood, being such a charming fellow, accepted this test with grace and his blood pressure was slightly above normal range. These could be signs of illness or stress from the visit to our hospital. Next we performed a test to see if Elwood’s irises had atrophied, or weakened and thinned, preventing Elwood from constricting his pupils. We test for iris atrophy by applying different concentrations of a drug called pilocarpine to one of his eyes. By responding to the pilocarpine, Elwood’s eyes showed us that the irises weren’t the issue; his issue was somewhere in his brain.

By this time, I noticed that Elwood was drooling a bit and seemed a bit twitchy. I was worried that Elwood had a disease that affected his brain or a cancerous tumor within his skull. We took a series of x-rays, which revealed nothing awry. With my mind whirling, I sat down with Ms. Jackson again. We discussed every visitor to her house, every cleaning product she had purchased, and every grocery item that came in the house. I asked Ms. Jackson to go through a detailed account of her day, and as I listened to her recount her morning coffee and afternoon walk I realized that she was giving Elwood treats every few hours, but that I had not noted treats on my previous history. My mind raced; could the treats be toxic? Was there a defect in the manufacturing process? A cruel hoaxer that found a way to add poison to the treats at the store in a manner reminiscent of the Tylenol tampering of 1982? I asked Ms. Jackson for the name of the treats, but she couldn’t remember, so I sent her home after the package. She returned with a package labeled ‘calming treats.’ Working with patients who have behavior problems, I recognized a key ingredient; L-tryptophan, which is a precursor to serotonin, a neurotransmitter. Ms. Jackson started using the treats because she was working longer hours and thought they would help keep Elwood calm while she was away. He was receiving 8-10x as many treats as the package indicated. I couldn’t be sure, but I feared Elwood was experiencing Serotonin Syndrome. I explained my concern to Ms. Jackson, noting that I didn’t have any way of testing my theory other than treating Elwood for Serotonin Syndrome and monitoring his response and that there were other diagnostics we could try to rule out other causes such as testing Elwood for toxoplasmosis and bartonella, performing a cerebral spinal fluid tap to look for infectious agents, or sending him to a veterinary university for a CT scan or MRI. Ms. Jackson explained that her savings were limited and she wanted to try treating for Serotonin Syndrome first.

We hospitalized Elwood, put him on fluids and monitored his vital signs, and gave him a drug called cyproheptadine, which competes with serotonin for spots on receptors in the brain, kind of like adding a whole bunch of extra people to a game a musical chairs. The chairs are the receptors, the original players are the molecules of serotonin, and new players are the molecule of cyproheptadine. We don’t know for certain, but we assume that fewer serotonin molecules can grab receptor seats if cyproheptadine is present. Meanwhile we monitored Elwood; if his condition worsened, the muscles supporting his lungs could stop functioning and we would need to provide him with respiratory support or he could have a series of seizures which we might need to treat with emergency drugs. I knew we should see improvements within 24 hours, but the total affects might last for 36 hours. Elwood continued to hide, the fluids helped bring his fever down, he never experienced trouble breathing or seizures. On his second day of treatment, his twitches stopped and his eyes returned to normal. Elwood returned home with Ms. Jackson, who promised not to use calming treats again! Now, I am not certain that Elwood had serotonin syndrome or that the treats caused it, but I am grateful Elwood returned to good health. Ms. Jackson is refraining from feeding calming treats to change behavior, instead she is sticking to Elwood’s flavorful favorites!

What’s your wide-eyed pet story?

Dear Dr. Yin, I understand and I will miss you.

Every once in a while I pause my hustle through life long enough to write a letter to someone who has touched me, often without realizing it.  I have sent letters to teachers who helped me develop as a writer and scientist, 4-H leaders who cajoled me into leadership roles, animal trainers who challenged my concepts, and strangers who caused me to examine my own beliefs, often without any awareness themselves.  These individuals never expect these letters, most feel they were fulfilling their purpose, and many don’t even remember me, and all of that is okay.  I am saddened, Dr. Yin, that you will not have the time to read my letter to you.  I doubt you remember me in the scores of individuals that you reached out to at seminars and conferences, and I am certain you knew how many of us admire the energy and skills you brought to the table in helping our pets.  I know that in those final moments, when you were making the only decision that made sense to you, this letter and thousands like it couldn’t have made a difference, but I want you to know that you made a difference, every day, for thousands of people and pets, and you will continue to make a difference for thousands more.

We met years ago at a seminar at a Wolf Park in Indiana in 1999; I was an undergraduate from Knox College attending a part of the seminar with a professor for credit in my Animal Behavior course.  We had a contemplative discussion about the merits of studying wolf behavior to understand domesticated dog behavior. You were a veterinarian with a passion for behavior, a great smile, and an engaging personality, I was a young adult who had trained dogs for a little over a decade and thought I might pursue a research career in behavior. I mentioned, in passing, that I had wanted to be a veterinarian as a child and you encouraged me to take additional courses in research methodology and statistics. A year passed, and I expanded my training skills into a new realm; I started an internship at Glen Oak Zoo (now Peoria Zoo) in Peoria, Illinois in the education department.  I was fascinated at how easily most animals could be trained if I first observed and schooled myself.  You, meanwhile, were working with giraffes and ostriches at the Sacramento Zoo; which would be valuable for me later on.  I followed my zoological passions into a T. J. Watson Fellowship where I interacted with zoological and conservation projects around the world, and I lost track of your activities.

It wasn’t long before you popped up on my radar again.  A year later I was working at a zoo in Louisiana as a curator and we bumped into each other at a Bud William’s livestock handling seminar.  I was trying to come up with ideas that would help corral our zebras and giraffes safely into their barns at night and you were, as usual, learning everything possible about behavior. You shared your knowledge about training giraffes in targeting and we brainstormed how to convince giraffes the less-than-ideal barn, which required ducking for them to enter, was acceptable while their permanent housing was built.  By that point you had started writing for dog magazines and I started seeking out your writings and I started training dogs again, this time with the added benefit of years of training zoo animals and a modernization of dog training.  After a few years of zoo work, I started working out-to-sea on the Eastern seaboard; I thought I had put the training bug behind me and my childhood dream of veterinary medicine seemed more like a distant memory. Then my company experienced layoffs; I was in the 50% of employees released from service.

Old habits die hard; I started training dogs again to make ends meet.  I even drove cross country from North Carolina with a friend to attend the Association of Pet Dog Trainer’s convention in Louisville, Kentucky.  When I saw your name on the program, I had to attend your seminar on “Are You Seeing What You Think you Are Seeing?” and afterwards I asked you about how to work more closely with veterinarians as a trainer.  As our conversation ended, I mentioned that I sometimes wished I had pursued veterinary medicine.  You pointed out that in another decade I could be a practicing veterinarian or I could be wondering if I should have become a veterinarian.  I had a lot of time to digest that piece of advice as I drove back home!  That started a whirlwind of finishing a few pre-requisite courses and applying to veterinary schools. I thought about the impact you were having in behavior training and veterinary medicine, how you were serving your own authentic purpose, and I wondered if I could do the same. Ultimately, I applied to veterinary school and was admitted.

Oh, Dr. Yin, veterinary school was nothing like I imagined!  We did have a behavior course, but it seems of little consequence in light of anatomy, pathology, and pharmacology. I didn’t thrive in veterinary school but discovered that I had a penchant for behavior and that the previous years of working with animals and people provided valuable information inside and outside of the clinics. I also had friends in a lot of sectors of pet care; groomers, trainers, veterinarians, and owners who helped keep me grounded and remind me of my ultimate mission.  My goal is to connect behavior across sectors by focusing on cooperation, communication, and citizenship. I shared this goal with you at your lecture I attended as a veterinary student entitled “Mini Miracles with Clickers workshop: Developing technical skills and learning tricks for quick results” at the American Veterinary Medical Association annual convention in 2010. You told me it was a worthy goal.

Dr. Yin, the last time I saw you was at the Veterinary Behavior Symposium in Chicago last summer; I shared my experience of using a Thundershirt on my cat, who was diagnosed with separation anxiety by a veterinary behaviorist at North Carolina State University.  I mentioned that I was having a hard time finding work that would pay the shocking amount of student debt that funded my veterinary education.  I was sad and anxious myself, worried about my future within the profession, and debating with the direction my path should take as a veterinarian.  You told me that clinical experience is valuable and that there was nothing wrong with practicing veterinary medicine, supporting patients and clients, and providing great care for the mental, physical, and emotional health of pets.  I listened to you, Dr. Yin, and am now completing my first year of veterinary medicine.  This journey has been heart-rending and joyous.  There are days I can’t wait to see my patients and days where getting out of bed seems like the most insane act of my day. Thank you, Dr. Yin, for always encouraging me, always responding to my questions and comments, and for providing guidance to an unknown person in the crowd, even when you struggled with your own place in this world.  I wish you had found a space to keep you in this world, but I understand, Dr. Yin, and I will miss you.

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