A few weeks ago I asked your opinion on a potential change in format for the Vet Vault. The plan: I’d gather a panel of mentors to help me answer specific listener questions, instead of just me having conversations with one person at a time. Your response was overwhelmingly positive, so we’re making it happen. I put up my veterinary bat signal (or is it a cat signal?) for wise mentors and guides, and they have heeded the call. They are assembled - the Vet Vault Council of Elders (elders in insight, not years) and they’re eagerly awaiting your questions. So - hit us with your trickiest vet life conundrums - the stuff that keeps you up at night, the interpersonal issues that make work hard, the tricky client interactions, the career decisions, the personal well-being tips. No question too big, too weird, or too insignificant.
Submit your questions as a voice message at thevetvault.com (just hit the little microphone icon at the bottom of the screen) or send me an email at info@thevetvault.com. You can ask anonymously, or you can be loud and proud, but don’t be shy - if you are thinking it, odds are so is somebody else who would like to hear the answer.
From Episode 225 Medicine Feed With Dr Linda Fleeman
In our last newsletter I flagged a few ways our thinking around Cushing’s diagnosis is less than perfect. This week we follow-up with some of Dr Linda’s “under-the-radar” clinical alarm bells for HAC that you might be missing. (I definitely was!)
Coat colour changes. You know that middle-aged chocolate lab whose coat is now less “rich Belgian heaven” and more “cheap Cadbury’s left out in a hot car for a month”? Sure he’s a bit fat, a bit lazy, and always hungry, but, you know, he’s an old lab, so it’s normal, right? Maybe not - don’t ignore that colour change.
Specific Cushing’s colour-clues to look for:
Black or brown dogs: yellowing at the tips of the hair.
Apricot poodles and poodle crosses: a generalised fading of the coat.
Pro tip: Changes are usually most obvious over the limbs and tail.
And it’s not just colour. The textbook tells you to look for alopecia, but Dr Linda describes three different coat types with three different hair-growth patterns in response to Cushing’s:
Short-coated breeds (Dalmatians, Jack Russells) don’t get classic endocrine alopecia - they just start shedding less.
Double-coated breeds (Labs, Cattle Dogs) also don’t go bald - but clip them and the hair just won’t grow back.
Curly-coated breeds (Poodles, and the legion of poodle-crosses currently colonising our waiting rooms) are the ones who show classic alopecia. But before they go bald, they lose their curl first. No, they’re not using hair straighteners - they’ve got Cushing’s.
Once you see these things, you can’t un-see them - it’s just so obvious.
From Episode 227 Medicine Feed With Dr Bing Zhu
Your patient has been puking for three days. It’s dry as a prune. You run bloods and, no big surprise, it’s moderately azotaemic. Because, as we were all taught: Dehydration = decreased GFR = increased creatinine. Right? Case closed. Moving on.
But wait....
In this episode on those tricky little beans, nephrology guru Dr Bing Zhu challenged that neat little story:
Think of your last young, previously healthy, severe AHDS dog. The poster child for acute, severe dehydration. What was its creatinine? Dr Bing’s guess: often normal, or maybe mildly increased.
Contrast that with the crusty 10-year-old sick dog that is 7% dehydrated. Now we are 200, 300 +.
There is something in that discrepancy.
The emerging thinking in nephrology is that what we used to call ‘just pre-renal azotaemia’ may well be, at least in part, a reversible episode of acute kidney injury driven by the disease process that led to the dehydration. The official term is volume responsive AKI.
So back to our two patients: remember that for azotaemia to occur we need global nephron function to be less than around 25%. The young AHDS went into it’s crisis with a healthy reserve, so even if a significant percentage of it’s nephrons take a hit - you’re not seeing it in the creatinine, while crusty old pancreatitis dog was probably already low on nephrons.
So, does this change how we treat the sick dehydrated patient today?Probably not dramatically. (And if it does - it’s over my head - I’m still trying to find a comfortable spot for this shift in thinking somewhere in my brain!) But it does change the mental model.
As for my heading suggesting that pre-renal azotaemia is a myth - it’s a bit of a click-baity, and an over-statement. (You just read a big schpiel about renal physiology, so it worked!) The myth is not: “Dehydration can reduce GFR.” It can. The myth is: “It’s just pre-renal, therefore the kidneys are fine and fluids explain everything.” That is the trap. AI reckon listening to this epic episode is a very good way to start thinking your way out of it.
From Episode 221 Surgery Feed With Dr Rebekah Donaldson, recorded live at IVECCS25
What’s the riskiest part of cutting a foreign body out of a dog’s gut? It’s the -otomy bit - the bit when you cut into the intestinal tract. That’s your critical failure point, where if things go sideways, they go very sideways. Everything else about the surgery is basically no worse than a big spay. (Actually, less scary, with fewer repercussions.)
So, what if we could get rid of intestinal foreign bodies without that risky bit?
In this conversation about Dr. Rebecca’s in-depth review on what is new in the field of dogs eating dumb things, recorded live at IVECCS25, Rebekah shared a novel surgery technique that allows us to do just that:
One way of avoiding cutting is endoscopy: if the foreign body is within reach of your scope - well, there’s your non-invasive solution. But we all know the limitation: once that foreign body has moved past the stomach, there’s very little chance of you retrieving it without surgery.
But what if we could have our cake, AND eat it? A novel technique called laparotomy-assisted endoscopic removal does just this. Here’s how you do it:
Wheel that scope tower into theatre with you.
Do your X-lap as normal, but don’t cut into the stomach or intestines.
The surgeon milks the foreign material up into the stomach, and the scope operator grabs it, which will be easier than normal, because the surgeon can shepherd the offending foreign body right into the waiting jaws of the grabbers.
And if you fail, well, you’re already in there, ready to cut it out. Genius!
2 Other Things
“Wisdom tends to grow in proportion to one's awareness of one's ignorance.”
-Anthony De Mello
“The task we must set for ourselves is not to feel secure, but to be able to tolerate insecurity.”
-Erich Fromm
A fortuitous opportunity recently came my way. A friend approached me to ask if I could help with the design of a new vet hospital. The architect firm had a first draft, but none of them have ever worked in a vet hospital, so they needed somebody with insights around workflows and how spaces in a vet hospital are actually used to review the plans. My friend, also a vet who consults for this firm, thought that I had the right experience to be this person.
My knee-jerk reaction: “I’d love to, but I’m no architect, and I’ve never actually designed a practice, so I don’t know whether I could add any real value.”
“That’s classic imposter talk. Trust me - you don’t even know what you know. You’ll be just fine,” he reassured me.
“Well, it sounds like fun, but I’m really short on spare time.”
“Oh, I’m not asking as a favour, by the way. This would be a paid gig.” He told me the hourly rate that they were willing to pay for my insights - close to three times what I currently earn as a clinical vet!
Unfortunately this was a short-term gig, so I’m not laying down my stethoscope and buying a fancy new house near the beach just yet, but it did give me a few major perspective shifts that I think are worth sharing.
These shifts were brought into focus by a conversation I had shortly after my little stint as a practice designer. I was catching up with one of the people I’d met in the co-working space where I do a lot of my Vet Vault work. Chad has a background working for big tech companies, including stints as a workflow and productivity consultant for some major players in that space.
“How has your week been?”
“Really interesting!” I gave him a rundown of what I’d been doing. “And the best bit is that I was earning almost three times as much as I do as a clinical vet!” I bragged.
The conversation strayed into actual dollar numbers. Chad seemed slightly unimpressed and more than a little bit confused when I told him what the design job was paying. To give him some more perspective I told him what the average veterinary salary is. His confusion turned into surprised shock.
Once he regained his composure he said: “I’m happy for you, mate, but let me tell you that what they paid you is absolutely fuck all for a consultant in Australia. For a big company like that, it’s like loose change falling out of their pockets.”
“Well, I’m not really a consultant, am I?”
“It’s exactly what you were doing - you have unique expertise and experience across multiple domains, and it’s expertise that they need and are more than happy to pay for.”
Here’s the thing: I would have considered doing that work for free. It was interesting and fun, and I completely underestimated my own worth. Actually, not underestimated - I was completely blind to it.
Sound familiar? “Oh, it’s just a…” “It only took a minute.” “Let me just quickly…” “Maybe I won’t bill for that…”
Our ‘value blindness’ starts in our clinical work. Like Chad said: you have unique expertise and experience. I think we KNOW this at a cognitive level, but we don’t truly SEE it - don’t FEEL it.
By the time you leave vet school you’ve already forgotten what you didn’t know on the day you walked into that lecture hall on day one. Layer a decade of experience (and hopefully a bit of CPD) on top of that, and your expertise is a reflex - kicking into action when called upon without you having to think about it. (Trust me - you don’t even know what you know.) Which is exactly why we’re so bad at recognising it.
I thought I was going to write about money today - about our dollar value in the vet profession and the factors that limit that. But in writing this it dawned on me that before we get to any conversation about pay, pricing, or what your boss should be doing differently, there’s an uncomfortable bit of internal work to do: we need to actually see what we do. Not in the vague “vets are amazing” platitudes that we love to share on social media. I mean REALLY see it.
Here’s your one thing to think about this week: pick one moment from your clinical day where you did something that felt routine. (Maybe it’s so routine that you felt awkward billing for it?) Ask yourself - what it would have looked like to that day-one-of-vet-school version of you? Or better: what would it look like to Chad?
Because until we can see our own expertise clearly, we’ve got no hope of having a sensible conversation about what it’s worth.
Much love,
Hugh
P.S. I still want to unpack why I can get paid 3x my vet wage to give opinions on a building I’ve never designed, versus the work I’ve spent twenty-plus years getting good at. We’ll leave that for next time. (I can feel another multi-parter coming on.)
How to connect with us:
Comments
Nothing yet. Say the first thing.
Sign in to join the conversation.