A day in the life of an emergency veterinary clinic

The Sunday afternoon sun streams through the windows of Iowa Veterinary Specialties’ reception area, which stretches lengthwise, enough to comfortably seat at least a dozen clients. But none are there. Instead, they sit in their cars in the parking lot, the engines humming in unison.

Inside the reception area, the only sound is the low din from phones ringing and receptionists talking on the phone with clients. Often the conversations go like this:

“Thank you for calling Iowa Veterinary Specialties. This is Courtney, how can I help you?”

A pet owner asks how long the wait would be for a walk-in appointment.

“We are pretty busy today. I’d say it’s a one- to two-hour wait before a doctor can see you. “

The owner says she’ll come back Monday.

About every 20 minutes, an overhead announcement breaks the relative quiet to summon a veterinary technician to the front for an emergency case.

In mid-June, the emergency and specialty veterinary clinic in Des Moines, Iowa, was days away from allowing clients back in the building. It was yet another transition to navigate for the staff members, something they had already done a lot of during the COVID-19 pandemic. They’ve gone from the early days of the pandemic, with figuring out what COVID-19 biosafety protocols to put in place and how to do curbside service, to not knowing when staff members would be able to get vaccinated or how to procure personal protective equipment in short supply to now figuring out how to stay fully staffed and meet the demand for services.

Pre-COVID, the veterinary profession had already been dealing with staff turnover, productivity and efficiency problems, and mental health and well-being issues. Now those matters have become exacerbated with delayed client visits and pent-up consumer demand. According to national data from analytics company VetSuccess, appointments in veterinary practices are up 4-6% overall, which is healthy albeit not skyrocketing growth. While some local experiences may differ from the national average, this healthy growth in visits, coupled with additional productivity declines related to COVID-19 and increased staff turnover, has impacted workloads and created an overall sense of busyness.

JAVMA News spoke with veterinarians and other staff members at Iowa Veterinary Specialties to get a feel for how one clinic is managing during this unprecedented time.

Iowa Veterinary Specialties has at least three veterinarians working on Sundays when just one veterinarian used to be sufficient. On a Sunday in mid-June, nonurgent walk-in clients waited two hours from checking in to being seen.

Everything made a little harder

A sign in Dr. Angie Gearhart’s office reads, “Everything is figureoutable.” As medical director at IVS, she’s had to figure out a lot in the past 18 months.

She joined IVS in March 2019, with hopes of improving biosecurity and surveillance in the clinic. Then COVID hit, and that became her focus, developing standard operating procedures on how to provide essential services during the pandemic while minimizing possible exposure of staff members and clients to SARS-CoV-2. The clinic quickly adopted mask-wearing and had to remove the shared silverware. For a while, “I felt like I was the most hated person in the clinic,” Dr. Gearhart said.

Before COVID, it already took an hour or so before an emergency patient was seen by a veterinarian. Pet owners would come in, and the receptionist would walk them to an examination room, then step out and page a veterinary technician. After conducting an evaluation and taking a history, the veterinary technician would get a veterinarian.

Receptionist Caitlin Dozark said that since the clinic implemented curbside service in March 2020, she triages more than she normally would just to be safe.

“If a dog comes in with respiratory distress, you can obviously see that,” Dozark said. But if pet owners are on the phone, “I’ve noticed some owners will overreact, like with a broken toenail. But some others underreact, and they don’t know the dog is in critical condition. So they don’t really convey that to you on the phone. And then you see the dog, and you’re like, ‘I had no idea. They didn’t make it seem like this is happening.’ That definitely makes the job a little harder.”

With curbside service, the veterinarian examined each patient, made a plan, and then called the client to go over the information, provide an estimate, and determine what the client wanted to do. The veterinarian would offer a spectrum of care and then proceed from there.

Dr. Lena Ribbey, one of the practice’s emergency veterinarians, had just started working her first few shifts at IVS when COVID hit. She said the pandemic changed the way the emergency veterinarians operated, with them not being able to show pet owners what’s wrong and having to explain radiographs and ultrasound images verbally. Once the owner consented to treatment, a staff member emailed the owner, who signed off and left a deposit before going home.

“At the beginning, it was really inefficient,” she said. Should the veterinarian call the owner after getting temperature, pulse, and respiration? “Then we started getting more efficient.”

She said the emergency veterinarians always start with a plan that includes an ideal diagnostic workup, but then will work with owners to determine what meets their needs, including their budget.

“I’ve seen a lot of higher compliance because of the pandemic,” Dr. Ribbey said. “People have lost a lot already, and their pet means a lot to them. And people are sitting at home and seeing their pets more.”

Caitlin Dozark (left), a receptionist at Iowa Veterinary Specialties in Des Moines, Iowa, talks to a client over the phone. The front desk is fully staffed, but a few of the staffers are new to the practice. Dozark had two trainees with her recently on a busy day. She said it was hard because she had to be on the phone most of the time.

Dealing with staff shortfalls

Not knowing early on how the clinic would be affected financially, Dr. Gearhart said, administrators were careful with money. Staff members wanted hazard pay and bonuses, but administrators weren’t sure how much costs for supplies were going to increase, and they didn’t want to have to let people go. By September 2020, they were able to give bonuses and raises.

IVS has still suffered gaps in staffing numbers, though, like many other clinics. Even though only six staff members have become ill with COVID-19, and the cases didn’t appear to be related, staff members who got tested had to stay home until their results came back negative. If the results were positive, staff members stayed home for two weeks, and the clinic had to notify people they worked with and tell those contacts to get tested if they had clinical signs.

“But early on, it was taking 10 days to get a COVID test back. And so you’d wait, and you’d have employees off for 10 days to find out they were negative, which was great, but then you’ve been 10 days without employees,” Dr. Gearhart said.

Also contributing to staffing challenges was figuring out child care. Of the 15 veterinarians on the staff, four have been pregnant or recently gave birth, increasing the number of staff members who need to find and coordinate child care amid the pandemic.

The clinic leaned more into flexible schedules, telling people to come in when they could so they could be there for their kids when needed. “The most important thing we do is raise kids,” Dr. Gearhart said.

Dr. Shelby Mangus, one of the emergency veterinarians, had just gotten back from short-term leave after having her baby in January. She said that on her first day back, she was surprised how the other veterinarians didn’t seem concerned about a backlog of patients.

Dr. Mangus usually works on Wednesdays and would see two to three cases in a day; now it’s more like eight cases.

“I can tell there’s a big difference and that it’s busier. I keep thinking it’s me, but it’s not,” she said.

Dr. GearhartDr. Angie Gearhart, IVS medical director, is overseeing the hospital’s transition to “inside curbside” service, which allows owners to come into examination rooms and then go back to their cars. The clinic will leave up the plexiglass at the front desk and keep masking for a while. Even little things, such as having to turn down the music or the veterinarians wearing white coats again, will be an adjustment.

Taking it as cases come

It used to be, for example, the clinic would have a dog with a suspected urinary tract infection on a Saturday night. The clinic would do diagnostics, prescribe antimicrobials as appropriate, and send the dog home, telling the owners to follow up with their primary care veterinarian. But suddenly, no one could get in for a 10-day checkup. Or one client’s veterinarian couldn’t do a cystotomy until four months out. “So we’d call their primary doctor to ask if we can do it, and they’d say yes because they don’t have the time,” Dr. Gearhart said.

More recently, what’s been contributing to the increase in cases has been another local emergency clinic diverting cases—at least three times a week. IVS was getting cases from as far as six hours away over the summer because other emergency clinics have been diverting patients, too. “Which is overwhelming,” Dr. Gearhart said, “because we also don’t know when they’re going to do it. So then clients just show up and think that there’s no wait, which is super frustrating.”

Criticalists and residents from Iowa State do fill-in work at IVS, such as Dr. April Blong, who is a clinical assistant professor at Iowa State University College of Veterinary Medicine. IVS has also been hiring, on average, seven or eight people a month, Dr. Gearhart said. Before COVID, the clinic had 54-58 employees; now it has 81. It has tripled its overnight support staff coverage.

Retention has been an issue. Dr. Gearhart concedes that emergency work is different and very high volume. She said the new hires that the clinic lost mostly didn’t understand what they were getting into, although the clinic has lost a few long-standing employees, too.

“If you do the right thing, it will all work out in the end,” she said.

On a hiring spree

IVS was started 30 years ago by shareholders as a nighttime emergency veterinary hospital. Eventually, the clinic ran out of space, so it moved to its current facility 20 years ago. The clinic became a specialty hospital as well, with surgery, internal medicine, and dermatology. Ten years ago, the shareholders sold it to Iowa State to be an extension hospital that is a privately run teaching facility. A BluePearl specialty and emergency clinic moved in nearby a few months later.

Recently, IVS has seen “tremendous growth and change,” Dr. Gearhart said. The clinic added three emergency veterinarians—Dr. Shannon McMurray, Dr. Ribbey, and Dr. Allison O’Grady—in four months and was hoping to add two more. The clinic now has two procedures rooms, thanks in part to the hiring of the husband-wife veterinary surgeon team of Drs. Andy Law and Allison Kenzig. And the clinic has expanded to add oncology as well as an exotics practice, with two veterinarians who dedicate eight hours a week to these types of animals.

The practice used to have employee meetings every two months. Those have been replaced with email messages letting staff members know about mental health or financial counseling resources or announcing new hires.

“We had to start putting pictures of people in the break room and their bios because everyone has a mask on, so you don’t know if this person is new or you haven’t worked with them in a while,” Dr. Gearhart said. One veterinary technician grew a beard, and people didn’t know until months later.

Client relations

Dr. Gearhart always tells the emergency veterinarians and herself, “With emergency practice, you have about 10 minutes to establish yourself to a client as trustworthy, knowledgeable, and compassionate.” And then they have to ask clients for sometimes a substantial amount of money, which is probably why sometimes clients get more prickly with them, she said.

Dozark, the receptionist, was hired in December and works overnights. She previously worked in food service and a bar, so she’s used to belligerent and angry clients. However, she said people get even more aggressive and confrontational when they can’t be with their pet.

“Sometimes they’ll drop their pet off and ask if their pet is just sitting in there. I say, ‘No, we’re busy, and everything takes a little bit longer than it normally does,’” she said. “A lot of owners, especially if they’re waiting in the parking lot, will call and say, ‘I’ve already been here this long.’ Some get mad and take their pet before they even get examined, but most people are understanding.”

On bad days, owners had to wait two to three hours before their animals were seen. Rarely, IVS even had four- to five-hour wait times.

Dr. Gearhart agrees that long wait times combined with clients not being able to come in the building along with financial constraints can lead to clients boiling over with anger. She and the front desk staff have had clients make physical threats, and they had to call the police when people were beating on the door.

“I’ve never had people talk to me like this,” Dr. Gearhart said of her 22 years in practice.

The clinic has taken a phased approach to operating like it did before the pandemic. Starting on June 15, the clinic began allowing clients in the building, at first for euthanasias only.

By July, the building was open to clients again through “inside curbside” service, with pet owners staying outside until an examination room is available and then going back to their car “so it’s not a free-for-all in the lobby,” Dr. Gearhart said.

Dr. Gearhart said in early August that the change has been well received, but the clinic continues to see a higher number of verbally and physically aggressive clients.

“Those clients are sent an email and letter saying that they can no longer seek care here in the future and that they should take this opportunity to develop a plan for where they will go if their pet has an emergency,” she said. There is another emergency practice within 20 minutes, and Iowa State University’s veterinary hospital is 45 minutes away.

Caring for loved ones

Reflecting on the past year and a half, Dr. Gearhart said the clinic’s workload has highlighted how important people’s pets are to them, and she takes that as validation of how important veterinary professionals’ jobs are and of how much what veterinary professionals do means to people.

“I think words matter. And I think how you say things in your mind matters, too, right? So I always love when the staff will be like, ‘There’s so many patients, and we’re so busy.’ And I always say, ‘It’s such an honor and blessing to be able to do this.’ I mean I do believe that, but I understand some days you’re just like, ‘Stop coming here. Stop calling.’ But I think we have to, as a profession, take this as the validation that we’ve always been looking for. You know, there are people who say we’re just a vet. But people are spending the money. They’re spending the time. They’re waiting hours to have their loved one taken care of. And I think that that is an honor. And we are lucky to be in this profession. So I think that’s what I’ve taken from COVID, you know, is that what we do does matter.”