Sunday, 29 September 2013

The hardest part of the job

Death. It's not something we like to talk about. It's not something that most of us like to think about, unless it's affected us recently.
            The first patient that I ever saw die was in my second week in practice: a big, young and beautiful black labrador with wide brown eyes, a face that was always smiling, and perpetually wagging tail. When she was admitted (she came in to see Corrie, my colleague at Beech House Veterinary Surgery), she was vomiting badly enough that she couldn't keep water down - never an encouraging clinical sign. It was my ops day - one of my first - and so it was my job to take the blood sample and place her on a drip. She licked my nose as took the blood. A few minutes later, as we were bandaging the catheter in, she was sick again. I got on with my day.
            Just before the start of evening surgery, I went to see how she was getting on - not well. She'd vomited several more times, and was now lying on her sternum, groaning. I lifted her lip, and was worried to see that the colour of her gums had turned a little pale. I went and grabbed Corrie, and asked her to look at her patient. Corrie checked her over, checked her temperature, and nodded.
            'You're right. Not going well. I think we're going to need to operate in the morning, find out what's going on in there. X-ray wasn't all that helpful, but something's clearly not right in there.'
            Corrie was right; the x-ray hadn't revealed any foreign bodies, obvious tumours, or gas build-up. I looked at the labrador. Her tail thumped against the inside of the kennel as my eyes caught hers, and I asked the question that so many owners have asked me since.
            'She's not going to die, though, is she?'
            Corrie shrugged. 'Not tonight, at any rate.' She left. I stayed with the dog for a little while, tickling its ears, still worried. I looked at her. I remember very clearly thinking that Corrie must be right. She couldn't die. She was too big, too vibrant an animal for that to happen to her overnight. Tickling her warm ears, with her grunting in pleasure, it was hard to imagine her dying at all.
            I didn't have to imagine it. By the end of evening surgery, her abdomen was so painful that if you touched it, she was sick. Her colour was now deathly pale, tinged with red around the edges, and Corrie knew she'd have to operate then and there. We never made it that far. As we were prepping for surgery, the beautiful big-eyed smiling labrador stopped breathing. She never started again, despite all our efforts. Half an hour later I was standing in theatre with her dazed owner - a dark haired young woman with a large silver cross around her neck. She had her hand on her pet, who was already growing cold. I was explaining to her about the pancreatic cancer.
            'I just... it can't believe it,' she was saying. 'It doesn't make any sense.'
            It didn't to me, either. Right up until that moment, I had made it through my veterinary training without ever really believing that death happened like that. Our brains have something of a blank spot to do with death; unless you absolutely and finally hammer it home, it never really sinks in. That evening, it sunk in for me. Death, final and irrevocable, happens. It happens all the time.
            Thinking back to that evening now, all these years later, it seems almost impossibly naive that I thought the labrador couldn't die, but I still clearly remember that thought, impertinent and against all logic, that she was too big to just... die.

*          *          *          *          *         

It seems that every few years a newspaper article is printed about vet suicide rates - solely for the purpose, in my opinion, of worrying my mother. We consistently come at or near the top of the charts - although occasionally we're beaten by doctors or paramedics. There's lots of suggested explanations - the stress of the job itself, the working hours - but for me the answer is obvious. Death isn't taboo for us, just as it isn't for doctors. It's something that happens, and it's not always something to be feared.
            Death happens, but for everyone else life, of course, goes on. As a new graduate, I swiftly learned that one of the first things people say to you when they learn that you're a vet is 'Oh, I couldn't do that, putting all those animals to sleep. It must be that hardest part of your job.'[1]
            When people said this to me, I'd nod, and look serious, because... well, you have to. Obviously it was the hardest part of the job. Except that honestly, it wasn't. In my time at Beech House, I was fixated upon getting the practical things right - talking things through with the owner, clipping the hair on the leg without causing distress, hitting the vein, easing the animal to the floor without letting them fall. A euthanasia consult meant a lot of things at the time - a longer consultation, a practical challenge, a professional challenge. It meant, and there's no denying it, a resolution; an end to worrying about difficult cases, and a full stop at the end of suffering. Owners were often grateful that you've made something they've been dreading for weeks go relatively smoothly. There is - and it's hard to write, but it's true - a great degree of satisfaction to be gained from performing a euthanasia professionally and competently.
            The shock of that evening surgery, where the fragility of life hit me in the way that it's hit so many others, soon wore off, and for a time, euthanasia was just one more thing I did. I was never happy about what I was doing, and it was never enjoyable, but it was, as I say, satisfying - in a way that isn't talked about outside of veterinary medicine. So when people used to ask if it was the hardest part of my job, I would nod, and agree, and think of the hundreds of other things about the job that I was finding more difficult.
            Over the years, however, a strange thing has happened to me. I find euthanasia harder and harder to perform. I suspect it's because, over time, my worries about 'getting it right' have faded into the background - it's almost second nature to me now. This gives me more time to dwell upon what it is I'm actually doing: bringing a life to an end. It's a selfish and irrelevant thought to have in the consultation room - it's far more important that it's done painlessly and quickly than that your veterinarian feels remorse about what he is doing - but nontheless the feeling grows. Now, when people say to me that it must be the hardest part of my job, I nod, and look serious. And I agree.

[1] Actually, it's usually the third thing people say; the second is 'Hey, you have to put your hand up a cow's bum!'; but always, always in at number one we have some variant of the time-honoured 'A vet eh? You do all right for yourself then.' This is usually followed by a wink, and the unspoken suggestion that for the rest of evening, drinks are on me. 


  1. Thanks. I always enjoy reading your writing.

  2. As a vet I don't really relate to this directly. The death is often a relief - relief from the suffering and obviously it is the least worst thing to do when the time comes, which is why we do it.

    From a personal point of view, what causes me most psychological harm is the exposure to the owners' grief and the emotions that go with the sense of empathy towards the grief. Known as secondary traumatic stress (STS, related to PTSD), it's a common problem in many care professions (rape counsellors or first responders, for example).

    I think STS creeps up on every vet but few of us take it seriously enough soon enough. Learning to recognising exactly what aspects of the job cause STS in myself has been of massive benefit to me.

  3. Well, that's true, I'm certainly affected by the owners. Personally, I wouldn't be so quick to write-off the death as a relief. It certainly is when there's no question that you're doing right thing... but how about such cases where you're not? I'm sure you've experienced such cases where the owner 'doesn't want to put him through too much' - when what you're suggesting is a course of tablets; or cases where you're putting a healthy animal to sleep because it's bitten someone, when you're pretty sure that's due to poor socialisation. What I'm saying is - I think I may find euthanasia easier to cope with if it was always clear-cut.

    Your point on STS is a good one, however. I still feel, for me, however, the more stressful part being responsible for the death - but I may be unusual in this respect.