The Vet School Journey

Internal medicine = busy (again)

2012-02-16T06:20:00.002-07:00

Internal medicine is picking up speed as the week progresses. I had a relativly easy start to the week, with 2 hepatitis patient rechecks on Monday and my rock-eating buddy Emmie on Tuesday.

Yesterday, I had a dog with a 10 month (yes *10 month*) history of straining to defecate and fresh blood in his stool. After much rectal examination and poking with many needles, we diagnosed him with a perianal gland tumor, which, in his case, probably has few treatment options. His owners elected to try a diet change, antibiotics, steroids, and stool softeners to see if they can keep him more comfortable for a little while.

My second patient yesterday was a transfer from Urgent Care -- a DKA (diabetic ketoacidosis, "diabetic crisis") dog also with severe pancreatitis and a gallbladder mucocele. The mucocele was a "bonus" find on the ultrasound. Mucoceles generally head to emergency surgery, but this poor kiddo is so sick that we're taking a chance with managing her medically for awhile, and hoping her gallbladder doesn't burst in the meantime. It's a really interesting case, and I hope to have time to blog about it soon! However, as these things go, the more interesting and busy the caseload is, the less time for blogging...

Lesson #895: Don't eat rocks

2012-02-15T07:51:00.002-07:00

Yesterday's internal medicine patient was a 9 month old Lab named Emmie.

Emmie presented with the complaint of rocks in her stomach. Upon further discussion with Emmie's mom, I learned that this is Emmie's third offense of rock-eating in the last 4 months, with the first 2 offenses requiring abdominal surgery to remove (count 'em) 7 rocks the first time and 15 the second time.

After Emmie's second offense, her mom completely re-landscaped the yard and thought there were no rocks left for Emmie to access. However, Emmie discovered a hidden cache of rocks and gleefully chowed down.

Two days earlier, Emmie vomited up 5 rocks at home. Her mom brought her to an ER clinic, where vomiting was induced and Emmie produced another 5 rocks. However, abdominal rads showed that Emmie still had 4 rocks in her system.

Emmie spent a day at her rDVM on fluids, hoping the rocks would pass one way or the other. However, repeat radiographs yesterday morning showed 3 rocks in Emmie's stomach and 1 in her colon.

Since Emmie's mom (understandably) didn't want Emmie to have a third abdominal surgery at the tender age of 9 months, she hoped we could get the rocks out endoscopically.

Endoscopy requires general anesthesia, but once a scope is passed through the mouth and esophagus into the stomach, it is often possible to retrieve foreign objects like rocks, coins, hair bands, and tampons using graspers or a wire basket to pull the objects out through the mouth. In most cases, surgery can then be avoided, though in a few disappointing cases, the objects cannot be removed endoscopically and the animal ends up in surgery anyway.

Emmie's first two rocks came out with moderate difficulty. The rocks were very smooth, so kept sliding out of the wire basket. However, within about 30 minutes of starting the procedure, we were 2 down with 1 to go.

The third rock was the smoothest, and was also very long and thin, so it was difficult to get the basket seated around the rock without the rock just slipping out. But after about 2 hours of trying for this rock, with the combined efforts of 3 boarded internists with massive combined experience using the endoscope, the last rock was finally retrieved! In comparison, this type of foreign body removal is usually accomplished in about 45 minutes.

Emmie's mom was thrilled to have her leaving the hospital the same day, with nary an incision, suture, or cone of shame. Now the hard part begins again -- keeping Emmie away from rocks for the rest of her life! It's possible that Emmie may have an underlying disease process like a liver shunt or exocrine pancreatic insufficiency, that may be causing a nutritional deficiency that makes her feel like eating rocks (which is called pica -- a desire to eat non-food objects). But given that Emmie has seemed perfectly healthy her entire life except for eating rocks, it's probable that her rock-eating is simply an annoying habit that will have to be managed. Say hello to the basket muzzle!

Humphrey's tracheostomy, or Why brachycephalic dogs are so sad

2012-01-22T19:37:00.003-07:00

Humphrey is a Pug who consumed most of my Thursday-Sunday this past week on Soft Tissue Surgery.

Pugs are one of several breeds of dogs that are considered brachycephalic. "Brachy-" means "short" and "cephalic" refers to the head. Hence, brachycephalic dogs are "short-headed" or "short-faced" dogs, also referred to colloquially as smush-faced dogs.

One of the biggest problems that we've created by breeding dogs with such a smushed-in face is that brachycephalic dogs often have serious respiratory difficulties. They are often born with two anatomical problems:

1. Stenotic nares, or overly narrowed nostrils, which allow for only very limited airflow through the nose.

2. An elongated soft palate, which interferes with the flow of air at the back of the throat.

Both the stenotic nares and elongated soft palate create extra resistance to what should be the normal passage of air through the upper airways. Think of it like trying to drink a thick milkshake through a straw -- you have to suck really hard, but you can probably do it. Now think about trying to drink that same milkshake through a coffee straw, which has a much smaller diameter and thus creates much more resistance and makes you work a lot harder.

So these brachycephalic breeds generally start out at a disadvantage when they have these congenital abnormalities. But the most serious trouble comes when the stenotic nares and elongated soft palate are not corrected early on.

After months or years of trying to breathe through such narrowed airways, the constant resistance to air flow and the excessive negative pressure that is created each time the dog breathes can lead to something called laryngeal collapse.

The larynx ("voice box," in humans) is a structure formed of several different cartilages that sits at the back of the throat and connects the oral cavity to the trachea (windpipe). Air passes through the nose and/or mouth, through the larynx, down the trachea, and into the lungs.

But with enough extra resistance in the airways for a long enough period of time, the cartilages that comprise the larynx begin to weaken and break down. Think of it like how you can suck your cheeks way into your face if your mouth is closed.

And like bending a paperclip back and forth enough times, eventually the laryngeal cartilages collapse. When this happens, they fall into what used to be the open space in the larynx where air passed, and create an obstruction to air flow.

Now, brachycephalic dogs are not born with laryngeal collapse. It is a sequela to years of increased resistance to air flow, resulting from their stenotic nares and elongated soft palate. So if the nares and palate are surgically corrected early enough in life, the increased resistance to air flow disappears, and the larynx does not undergo the stress that might have caused it to collapse.

However, often by the time an owner or veterinarian realizes that a brachycephalic dog might benefit from surgery to correct the nares and palate, it has already been a long-standing problem such that there is already some degree of laryngeal collapse. For this reason, more and more vets are now recommending that brachycephalic breeds have their nares and palate corrected at the time of spay or neuter, or as soon after that age as possible.

Here enters Humphrey, our dear 3 year old Pug. Humphrey was born with stenotic nares and an elongated soft palate, but nobody saw a need to do anything about it. Humphrey was a happy, healthy little Pug until he was about 2 1/2 years old, at which time he began to have difficulty breathing.

Humphrey's mom took him to her regular vet, and eventually to a specialist, who performed the surgery to correct the nares and palate (which, by the way, is a fairly minor surgery to do). Unfortunately, at the time of surgery, the surgeon noted that Humphrey already had a moderate to severe degree of laryngeal collapse.

Many dogs, even those that already have some degree of laryngeal collapse, will benefit from surgery to correct their nares and palate. Humphrey wasn't one of them. He had progressively more and more respiratory difficulty over the next several months, until eventually he ended up at my vet school's teaching hospital, after his regular veterinarian felt there was nothing more to offer than euthanasia.

At presentation, Humphrey was able to breathe adequately in the exam room, but was depressed and underweight. His owner reported that Humphrey's breathing was the worst when he was relaxed or trying to sleep, presumably because then he lost some of his conscious control over the accessory muscles that were helping to keep his airway open. As a result, Humphrey couldn't sleep well because whenever he relaxed, he'd be unable to breathe, which gave him no energy to do anything during the day.

We performed a laryngeal exam on Humphrey, which involved lightly anesthetizing him just to the point where he would let us open his mouth and look at his larynx. The exam confirmed severe (almost total) laryngeal collapse.

The only known solution is to perform a permanent tracheostomy. This surgery involves making an incision through the skin on the throat, then removing a rectangular piece of the cartilage that makes up the trachea, and finally suturing the inner lining of the trachea directly to the skin. The tracheostomy allows air to flow directly into and out of the trachea, bypassing all of the upper airways, including Humphrey's problematic larynx.

It's not a minor surgery to undertake, and obviously it requires somewhat of a lifestyle adaptation -- the most important aspect of which is no swimming for the remainder of the patient's life!

Humphrey's surgery went well, and he recovered okay. His owner will have 4-6 weeks of hard work ahead of her, while she learns how to clean the mucus from around the tracheostomy site multiple times a day, and while Humphrey learns how to position his body so that he can breathe well through the tracheostomy. But eventually, he should be able to enjoy most activities he liked to do before surgery, and he should have a fairly normal lifespan.

I intended this to be more of an amusing post, detailing some of the more hilarious aspects of Humphrey's surgery and our instructional sessions with his owner in how to care for him after surgery -- and maybe I'll have a chance to write about some of that later -- but although there are some amusing aspects to this tale, it's at heart a tragic story of how we humans have manipulated some breeds of dogs to such extremes of anatomy that they suffer so that we can remark how "cute" or "unique" they are. Some examples:

- Most English bulldogs cannot give birth naturally and automatically need a C-section
- Shar Peis have such excessive skin folds that many of them suffer from lifelong skin infections
- Cocker Spaniels' long, fluffy ears are a perfect environment for trapping yeast and bacteria, leading in some cases to ear infections so severe that surgery is required
- Great Danes and St Bernards have been bred to such enormous proportions that their average lifespan is only 6-8 years
- Italian greyhounds, with their petite, delicate skeletons, can fracture a leg at the drop of a hat
- Chihuahuas with their adorable apple-shaped heads often suffer from open fontanelles (failure of the skull to close completely, leading to an opening where the brain is not protected) and hydrocephalus (water on the brain)
- Dachshunds have elongated backs and stubby legs, resulting in frequent back injuries and neurologic disease
- Brachycephalic breeds, including Pugs, English bulldogs, French bulldogs, Shar Peis, Boston terriers, Shih Tzus, Boxers, and even Persian cats often suffer from anatomical abnormalities such as those discussed above that can cause such severe respiratory trouble that quality of life is drastically reduced

It is a cause for serious thought when we humans, who have such affection for the animals in our lives, and consider them members of our families, at the same promote breeding practices that aim to further exaggerate the smush-face-edness of Pugs, the enormity of Danes, the long backs of Dachshunds, and the wrinkles of Shar Peis that leave these poor dogs with diseases that could cause years of suffering or shorten their lifespans.

(Aaaaaaaand.... off my soapbox!)

Since we last spoke

2012-01-22T19:27:00.002-07:00

Here are a few of the things that have happened in the last several weeks:

1. Stopped by 7 small animal vet practices in southeastern Minnesota and southwestern Wisconsin to drop off my resume and cover letter.

2. Had a phone interview with one of the aforementioned practices (alas, though I followed up by email, I've had no additional communication about the possibility of a job at that practice).

3. Found out I passed NAVLE. Huzzah!

4. Got my score report for NAVLE, which told me I scored a 598 on a scale of 200 to 800 with 425 being the minimum to pass, and an 86 on a scale of 0 to 99 with 75 being the minimum to pass. Nice scoring system, eh?

5. Visited the career counselor-type-person associated with the vet school who will edit resumes and cover letters; got plenty of suggestions I've not yet had time to implement.

6. Started my Soft Tissue Surgery rotation, which is one of those busy-busy-busy rotations that I've had the fortune of not experiencing for quite awhile (probably since I was on CCU in October, and Oncology in September).

After 4 weeks of "radiation vacation" followed by 3 weeks of actual vacation, it was a bit jarring to hit the ground running with a full caseload, long hours, on-call shifts, and weekend duties in Soft Tissue. I remain not the hugest fan of having to be at school from 7 am till 7 pm most weekdays. And on-call still stresses me out -- although I had my first on-call shift this past Friday night, and did not get called in (which for me is almost unheard-of!).

Anyway, the upside of being on a busy, interesting service with lots of neat patients, clients, and cases is that I have lots of things I'd like to blog about. The downside of said busy, interesting service is that I lack the time to write. But stay tuned -- I promise some good stories are on their way!

Uncomfortable

2012-01-02T20:29:00.002-07:00

I've been on actual vacation for the last 10 days, and Radiation Vacation for 4 weeks before that. So, in lieu of having anything truly exciting that's happened recently in school that I can blog about, I thought I'd share this somewhat awkward anecdote from one of my final days on ultrasound.

We were really bored, so when an unexpected anesthetized ultrasound patient rolled past our door, we leapt up to investigate. And soon regretted it.

The patient was a young adult male hound mix, a research dog enrolled in a study of erectile dysfunction. The goal of the study was to investigate why radiation treatment of prostatic cancer in adult men invariably causes erectile dysfunction.

This was the first part of the study for this particular dog, so he had not yet had any radiation treatments and was just having a baseline prostatic, testicular, and penile ultrasound.

Which we completed.

Then injected a chemical into his penis to give him an erection.

Awkward.

Then ultrasounded him again. And called it quits.

Fortunately, it was only women in the room. Still felt like we had violated the poor anesthetized male dog, though!

Welcome to Radiation Vacation

2011-12-03T15:39:00.003-07:00

I've had my first week of "radiation vacation," more officially known as Diagnostic Imaging rotation. It's another 3 week rotation, for which I'll get a "bonus" partial week before Christmas.

And, yeah. There's not that much to say about it. Basically we sit around the radiology department, waiting for requests for radiographs to come in. Sometimes we walk over to the patient wards to retrieve a dog or cat; sometimes the animal is brought to us. Sometimes the pet is sedated or anesthetized for radiographs; sometimes they don't need to be; sometimes they aren't sedated but should be. Sometimes we take abdominal rads or extremities (quite a few stifles), but mostly we take "met checks" (3-view thoracic radiographs).

Sometimes we take radiographs pretty much non-stop for a period of several hours. And then there are days like yesterday, when we took 3 sets of rads in 5 hours. Blechh.

On the one hand, it's nice to have a chill rotation requiring arrival at 8 am and from which we usually get to leave at 4, but always by 5. However, I'm already anticipating an extreme worsening of my current level of boredom by the time another 2.5 weeks have passed. Oh, well -- should give me some time to polish up my resume and start job-hunting!

NAVLE, shmAVLE

2011-12-03T15:24:00.002-07:00

I took the North American Veterinary Licensing Exam, aka NAVLE, aka "boards" 2 days ago. And it went pretty well. I've spent about 3 months doing practice questions and practice exams regularly on VetPrep, and I felt like I was pretty well prepared.

NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.

My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.

However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.

I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!

NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.

I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.

I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.

Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.

The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.

It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!

Groundbreaking news

2011-11-27T18:11:00.003-07:00

I did NOT get called in yesterday.

What?

You heard me.

A full 12 hours on call with no calls.

Which is common for most of my classmates, but virtually unheard-of for me.

Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!

Anesthesia: Almost done!

2011-11-26T09:57:00.003-07:00

It's been a long, long month of Anesthesia.

Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.

What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:

Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.

Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.

Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!

Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!

Along the way, some of my more interesting patients included:

1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?

2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")

3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.

4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!

5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!

Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!

Anesthesia on-call

2011-11-08T21:08:00.003-07:00

Last night was my second on-call shift for Anesthesia. Here's my schedule for the last 2 days:

Monday:

6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep

Tuesday:

1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!

As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!

Anesthesia, Week 1

2011-11-05T13:02:00.003-06:00

I've just finished my first of several weeks of Anesthesia. It's typically a 3 week rotation, but since mine falls over Thanksgiving, I get an extra 3 regular days plus a "bonus" fourth on-call shift.

Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.

It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.

So, to review my first case:

1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.

Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.

That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.

On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.

Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.

My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.

The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.

Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.

Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.

Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.

However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.

Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.

However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!

Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.

Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!

"Fleas make everything worse," or "Why I hate bureaucracy"

2011-10-27T20:24:00.003-06:00

Today I had another cardiology patient whose main problem wasn't really cardiac-related. (See: The case of Mr. Beagle.)

My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.

When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.

However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.

Sigh.

I hate fleas.

To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).

In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.

And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.

Oh my Lord. I was so wrong.

Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.

Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).

I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.

So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.

The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.

All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.

The moral(s) of this story:

1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.

2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.

3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.

4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?

5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)

6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.

7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.

8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.

Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.

I killed a little old lady's only companion

2011-10-23T17:45:00.002-06:00

By "killed," I mean "humanely euthanized." By "little old lady," I mean the cutest 90-year-old woman you've ever met, who loves to tell hilarious stories. And by "only companion," I hope I'm wrong.

Ever-talented and CCU-loving student that I am, I managed a feat that few cardiology students ever achieve: I had a CCU inpatient while on cardiology rotation. (Yeah, I'm that good.)

My patient, a 13-year-old Beagle, arrived as a referral from a local clinic for what the rDVM felt was a cardiac arrhythmia (3rd degree AV block), with the intent of having the dog evaluated by the vet school's cardiology department for the feasibility of placing a pacemaker.

However, upon arrival Mr. Beagle was laterally recumbent, breathing quickly and shallowly, and had bluish purple gums and tongue. So, good student that I am, I immediately brought Mr. Beagle back to the cardiology department for some wonderful oxygen, then headed up to take a history from his owner.

Mr. Beagle's mom was the aforementioned elderly woman, accompanied (and driven, thankfully) by her son (who doesn't live with her). Mr. Beagle had started coughing several months ago, was diagnosed with an enlarged heart a month prior by his rDVM, and was placed on a diuretic that hadn't improved the cough at all. The night before presenting to the vet school, Mr. Beagle had experienced an acute onset of respiratory distress, which improved slightly overnight but not much, so Mr. Beagle headed to his rDVM that next morning.

Long story short, Mr. Beagle ended up in CCU in an oxygen cage overnight, along with several other treatments, none of which did anything to help his breathing. It turns out that his cardiac disease, while present, was rather minor. His arrhythmia was actually atrial standstill, not AV block, and was most likely incidental. His real problem was very severe respiratory disease, and we couldn't figure out the cause. Mr. Beagle's chest x-rays looked horrendous; a variety of diagnostics failed to show why. The next step would have been general anesthesia with airway endoscopy and possibly a bronchoalveolar lavage, but Mr. Beagle was just too unstable and probably would have died under anesthesia.

So Mr. Beagle's owner elected to do the unselfish thing and euthanize him. Tears were shed by all involved, but Mr. Beagle went peacefully with his owner telling us stories about the time he brought a live rabbit into the house and chased it around, how he once scared off a raccoon in the backyard, how he sleeps by his owner's feet in the living room every night before bed. When Mr. Beagle had passed, the cardiology resident and client counselor escorted Mr. Beagle's owner and her son out of CCU while I stayed behind to escort Mr. Beagle's remains down to necropsy. It broke my heart.

Ai, Chihuahua!

2011-10-23T17:30:00.002-06:00

I got to have my very own high-maintenance CCU inpatient during the second half of my week of CCU day shifts. (A little clarification: most of the patients in CCU are under the "primary care" of another service -- like surgery, medicine, or oncology -- meaning that the doctor in charge of that patient's care comes from one of those services, and the patient's "primary student" also comes from that specialty service. The primary student is responsible for all of the communication with the clients [or making sure the DVM is giving the client updates], doing a physical exam on the patient every morning, writing new CCU orders, obtaining all drugs needed for that patient while in CCU, and, most fun of all, writing a daily "SOAP" which is an assessment of the patient's current status and a discussion of all of the patient's medical problems. Occasionally, however, a patient in CCU is under the primary care of one of the CCU clinicians, so one of the CCU day students "gets" to be the primary student on the case, meaning you "get" to take over all of the above responsibilities in addition to your already "action-packed" and "fun-filled" day of menial CCU tasks. So no, I was not overly excited to have my own CCU patient.)

Aside from the bureaucratic nonsense and busywork, though, I really liked my sad little patient, a middle-aged Chihuahua who presented in acute oliguric renal failure.

"Renal failure" means your kidneys have stopped working, or are close to it. "Acute" means it happened all of a sudden, versus being a drawn out process over months or years. "Oliguric" means "small urine," in that the kidneys have lost their ability to produce a normal amount of urine, so it's extraordinarily difficult for the body to remove excess fluid and waste/byproducts that are normally peed out. (However, "oliguric" is better than "anuric," which means no urine production.)

After many diagnostics, we determined the most likely cause for Mr. Chihuahua's acute renal failure to be leptospirosis, a nasty bacterial infection usually spread through contact with urine or contaminated standing water.

In addition to his renal failure, Mr. Chihuahua also had ongoing liver disease (also possibly caused by leptospirosis), unhappy muscles, complete loss of appetite, nausea and occasional vomiting, intermittent seizures, and diarrhea.

Since leptospirosis can be spread to people Mr. Chihuahua got his very own "isolation" area requiring people handling him and his urine/stools to wear a plastic gown, latex gloves, a cloth face mask, and plastic goggles. He also got 2 IV catheters (since he was on so many IV medications that many of them could not be combined into the same IV line because they didn't mix well), a urinary catheter, and a nasoesophageal feeding tube (which we fed down his throat through one of his nostrils, then stapled to his face. With a staple gun. While he was awake.).

Anyhow, Mr. Chihuahua was a pathetic mess for the longest time (okay, only about 4 days, but it felt like forever). Finally, he started producing massive amounts of urine (thus transitioning from oliguric ["small urine"] to polyuric ["many urine"] renal failure). Seriously, normal urine production is about 1-2 milliliters of urine per kilogram of body weight per hour, and Mr. Chihuahua got up to 25 ml/kg/hr. Yeesh.

Finally, after 9 days in the hospital, Mr. Chihuahua went home with a tiny appetite, no recent seizures, only a handful of medications, daily subcutaneous fluids to be given at home, and normal kidney values on his bloodwork! It's a testament to what we all need to be reminded of periodically: though the odds may be small, some animals can pull through even the most severe disease conditions if given a chance (and 9 days in CCU, and about $7000).

I survived the marathon!

2011-10-23T17:10:00.003-06:00

I'm greatly enjoying my first weekend after successfully completing my fantastical 19-days-in-a-row school/work marathon.

My second week of this most recent CCU rotation was the CCU "days" shift, requiring me to arrive at 6 am every day (Monday through Sunday) and stay till, on average, 6 pm. Yes, I kept track of my hours, and yes, it was a total of 85 hours in 7 days.

That week was definitely my most physically and emotionally challenging week of senior year (at least so far). For one thing, though I usually do quite well with being awake in the morning, I don't actually enjoy the act of getting up in the morning (at least not at an early time), and hearing the alarm go off at 5:15 am was, not unsurprisingly, even worse than getting up at 6 or 6:30.

There was the fact that I had multiple days in a row where it was pitch black when I left the house (my, how many stars you can see at 5:45 am!) and dusk when I got home. There was the way my days started with an hour of frantically running around CCU trying to catch up on all the 7 am treatments that the overnight students hadn't gotten done. There was the unpleasant habit of other students of walking hospitalized dogs on the nearest patch of grass outside the building and not taking the extra 1.5 seconds to grab a poop bag on their way out the door, or taking the extra 30 seconds to run back into the building and grab a poop sack. Which led to me stepping in a giant pile of dog crap and getting it all over my sneakers and scrub pants a mere 15 minutes into my 7th day shift. (Fortunately, it was a slow morning, so the night nurse sent me home to change into other pants, but it was oh-so-tempting just not to come back after that. Ask me how the rest of that day went. About the same as the first 15 minutes.)

The "fun" part about CCU is that they let you do a lot of procedures. As long as the patient isn't actively trying to die, you get to put in IV catheters, urinary catheters, arterial lines, jugular catheters, etc. However, that's not the case if you're working with an intern who also wants to practice those procedures.

The other "fun" part about the CCU day shift is teaching rounds in the afternoon. You work your butt off all day until 3 pm, then you have case rounds till about 3:30, then take a half hour or so to check on your patients and make sure all the 3 pm treatments were done, then you reconvene with the after-hours students and one of the residents for discussion on whatever topic you want to talk about from 4-5 pm.

Well, at least that's the idea. On Monday, our first day of the day shift, we finished case rounds at 3:30 pm then headed out to check on patients. By "we," I mean the students. The doctors and nurses all made a beeline for the brand new ultrasound machine so they could play with it and figure out how it worked. Which they did for an hour and a half. Until it was 5 o'clock and it was too late for teaching rounds and we students had wasted 90 minutes waiting for someone to teach us something. I confess, I had a little bit of a breakdown. Remember, I worked from 3-11 pm on Sunday night and had to be back at 6 am the next morning to start the day shift. For myriad other reasons, it was such a crummy Monday that the thought of having teaching rounds (which I honestly enjoy) was really all that had gotten me through the day. All I wanted to do was learn something then go home and sleep, and instead I worked my butt off then waited around doing nothing for 90 minutes then went home. There may have been some under-my-breath ranting about not getting my money's worth from the ~$1000/week in tuition I'm paying for senior year. It was not only the wasted time and the lack of teaching rounds, but the fact that 90% of a senior student's time in CCU is spent walking dogs, cleaning cages, feeding animals, giving pills, reconnecting tangled EKG leads, and trying to get the %&#*!@ IV catheters to draw so you don't have to stick the animal for the blood sample. I don't learn anything any time I do one of those things.

Anyhow, though it's only been a week since my last day in CCU, it feels like it was months ago -- which is great. And on the positive side, I've now completed all 3 of my weeks in CCU, so I never have a rotation there again!

I've moved on to cardiology, and thankfully I'm halfway through that. Well, kind of thankfully. On the one hand, the schedule is wonderful. We have morning rounds at 8:30, followed by one appointment every hour for 2-6 hours depending on the day (Tuesdays are "procedure days" so no appointments). There are no afternoon rounds; if it's slow, we talk about a cardiology topic like radiograph or EKG interpretation. We have time to eat lunch (at actual lunch time -- novel idea!) and as long as nothing's happening, we get to head home between 4 and 5.

However, cardiology is one of my least favorite subjects. I do feel like I've learned it better by working with some actual cardiology patients than by listening to lectures, but it's still a huge challenge for me. And one of the cardiology residents is not the nicest person in the world. Additionally, my single rotation-mate is probably my least favorite person in the entire senior class.

Oh well. You can do anything for 2 weeks, right? Only one more week to go for me, and then it's on to a fun-filled month of anesthesia. Yahoo!

The marathon continues

2011-10-13T05:34:00.003-06:00

I'm halfway through my epic 19-full-work/school-days-in-a-row-with-no-breaks marathon.

It started with 7 days of the CCU swing shift (roughly 2:45-10:45 pm).

I'm now 3 days into my 7 days of the CCU day shift, and I've worked 38 hours in the last 3 days, with 4 more days to go at this pace. Ask me how that's going. (There have been tears.) PS: this shift starts at 6 am every day.

The last 5 days of the marathon will be my first week of cardiology, which I'm hoping (praying, begging, pleading) will be as laidback as I've heard. I could really use some days of showing up at 8:30 and leaving by 5 or 6. Plus, the odds of an inpatient are fairly low, so if all goes as planned, I'll actually have the weekend off once my 19-day marathon is done.

Would love to blog about what I've been doing on CCU (good and bad) but too tired. Stay tuned...

Necropsy: meh

2011-10-01T15:40:00.003-06:00

That pretty much sums up my second week on necropsy. I've become somewhat accustomed to the gore, though I don't think I'd ever get to the point of enjoying hacking up people's pets and companions. However, it was easier to head to the necropsy floor during this second week knowing that I was nearing the end.

This week we necropsied lots of dogs, some cats, a few adult horses, several sheep, a couple chickens, a chameleon, a hedgehog, and a hamster. I stayed as far away as possible from anything but dogs and cats, though I did end up with one of the chickens. (Turns out chickens look all weird on the inside.)

My coolest case of the rotation was a 6 month old kitten who presented for an acute onset of respiratory difficulty. His owners didn't have any money so their rDVM took thoracic radiographs for free and diagnosed a diaphragmatic hernia. That's a hole in the diaphragm, which normally provides a complete separation between the chest cavity and abdominal cavity. With a hernia present, abdominal organs can sometimes migrate up into the thoracic cavity where, obviously, they can cause some difficulty breathing.

And it was no surprise that this kitten had been in so much respiratory distress. His entire intestinal tract, including all of his duodenum, jejunum, ileum, and most of his colon, were up in his chest, along with 2 of the 6 lobes of his liver, and his right kidney.

Most of the "ooooh!" moments came when we first opened up his abdomen and noticed how empty it was, then opened up his chest and observed that it looked like a second abdomen, then kept pulling organs back through the hernia and discovering more and more things that had displaced up there.

After taking "courtesy" (i.e. free) radiographs, the rDVM referred the kitten to the vet school for possible surgery. Why, I don't know, because if they couldn't even afford the $$ for radiographs, there's no way they could afford surgery. Had the kitten been a little more stable, and had finances allowed, surgery would probably have been curative. However, he was so distressed by the time he arrived that even putting him in an oxygen cage didn't really help. He might have died during surgery, even being on 100% oxygen and a ventilator. On necropsy his lungs were totally collapsed, so I can see why he couldn't breathe.

Other than that, my personal cases (we all help on most of the cases but one person has primary responsibility for each case and writing the necropsy report) were an old golden retriever with some kind of weird disseminated abdominal cancer, an old golden retriever with probable GI lymphoma, and an adult chicken with respiratory disease and conjunctivitis. (Here's a tip: turns out that deciding on your own to medicate the sick birds in your backyard flock with random antibiotics you have "left over" from your own illnesses generally does not do the birds any good, as evidenced by their presentation to necropsy.)

Anyhoo, I only had to go in for a couple hours this morning, which was nice, and I'm going to be optimistic and just head to church tomorrow morning in hopes that I won't get called in for a fun and exciting horse or cow necropsy. Fingers crossed I'm done with this unpleasant rotation!

Next week I start my second CCU rotation. The first week is the "after hours" shift, requiring me to arrive every day (Monday through Sunday) at 3 pm and hopefully finish between 10-11 pm, though it's possible I'll have to stay later sometimes. The second week is the "days" shift, where I'm scheduled for 7 days in a row (Monday through Sunday) from 6 am to 5:30 pm. Yes, that's right, 11.5 hours x 7 days = an 80.5 hour workweek (and note that those are the hours I'm scheduled for -- it doesn't include any time I have to stay late to do paperwork or finish up patient care, or any time I spend at home reviewing topics or studying for rounds -- hooray?). Suffice it to say, blogging may be intermittent or nonexistent for the next few weeks. Oh well, weekends, sleep, and sanity are overrated, right?

Dead kittens and koi and bulls -- oh my!

2011-09-24T20:19:00.002-06:00

I'm halfway through my necropsy rotation. I've not blogged about it yet not because I'm terribly busy (I'm not) but mostly because it's just depressing.

A necropsy is an autopsy or "post-mortem examination" on a deceased animal. Why they call it a necropsy, I have no idea.

And what we do during a necropsy is basically what they do during human autopsies: namely, cut out and examine all of the organs.

Over the last 5 days, I've necropsied dogs (young and old), cats (kittens and adults), cattle (beef and dairy, bulls/cows/aborted fetuses), horses (adults), and a koi (16 years old).

------------------

Warning: the following information is not for the faint of heart. You've been duly advised.

Here's a sample of how we do a necropsy.

1. External examination of the animal, noting any bruising, swelling, masses, etc.

2. Lay the animal on its back (or on its side, in the case of large animals). Use a giant knife to make an incision through the skin on the underside of the animal, extending from the point of the chin down across the chest, across the abdomen, and down to the anus. Use the knife to cut the skin away from the subcutaneous tissues along either side. Cut through the muscles that bind the scapula to the thorax, so the forelimbs can be splayed flat out to the sides. Cut through the hip joints so the hindlimbs can be splayed out as well.

3. Poke a hole into the abdominal cavity. Cut the musculature along either side of the abdomen to expose the cavity. Look for any free abdominal fluid.

4. Pull back the liver so you can see the diaphragm and look for any holes. Poke a hole in the diaphragm and make sure air rushes into the chest cavity.

5. Use a knife to cut through the muscles along the ribs on either side of the chest. Then use giant garden shears to cut through each of the ribs so you can eventually pull off the underside of the rib cage to expose the thoracic cavity.

6. Use a scalpel to cut along the inside of the mandibles on either side under the jaw, so you can cut out the tongue. Disarticulate the hyoid apparatus (the tiny bones that suspend the tongue muscle). Peel the tongue back, down the neck, cutting connective tissue to free the trachea and esophagus as you go. Cut the esophagus, vena cava, and aorta where they enter the diaphragm. Remove the "pluck" in its entirety (includes the tongue, tonsils, thyroid, trachea, esophagus, thymus, heart, and lungs).

7. Flop the liver up into the now-empty thoracic cavity to get it out of your way. Cut out the omentum with the spleen attached.

8. Push the feces out of the rectum. Cut through the rectum, then cut through the connective tissue that suspends the intestines within the abdominal cavity until the intestines can be entirely removed, along with the pancreas and stomach.

9. Cut out the liver, gallbladder, and diaphragm as one unit.

10. Cut out the adrenal glands.

11. Cut out the kidneys (with ureters attached).

12. Cut into and examine the lining of the urinary bladder.

13. Examine each organ (tongue, tonsils, thyroid, trachea, esophagus, heart, lungs, lower airways, pulmonary vessels, thymus, spleen, omentum, mesentery, rectum, cecum, ileum, jejunum, duodenum, pancreas, liver, gallbaldder, diaphragm, adrenals, kidneys, urinary bladder) in detail. Take samples of most of those organs to submit for histopathology.

14. Cut out a femur or humerus and have it sliced in half so you can look at the marrow.

15. Cut open some or all of the joints (hocks, stifles, hips, elbows, carpi) to look for arthritis.

16. Cut off the head. Hack open the skull with a meat cleaver so you can remove and examine the brain.

17. Clean up.

------------------

See why I'm not having very good dreams this week? The 'highlight' of Friday morning was cutting off a 3 week old kitten's head. The 'highlight' of Thursday morning was watching a live cow being shot then exsanguinated in the parking lot so we could necropsy it. Who knew, but it turns out that not all animals that arrive at necropsy are dead yet. Well, we fixed that.

It's heartbreaking when you let yourself realize that all of the animals (at least the small animals) were someone's pet with a name and a history and relationships. It's easy (and often helpful) to forget about that and just hack out the organs in a routine fashion, but sometimes it strikes you that this dog was only 2 years old, or look how cute this kitten was, or you think about how much pain one of the animals must have been in before it died, based on what you find on necropsy.

So, yeah, I'm ready to be done. If I'm to look on the positive side, at least I've gotten a good review of basic gross anatomy. And I'll undoubtedly need to do at least a few necropsies during my career. And I've learned an efficient way to decapitate a pet for the times when I need to submit a specimen to the public health department for rabies testing.

But that's about as positive as I can be after 5 days of eviscerating, dismembering, and decapitating dead animals, with another 5-7 days (depending on how many cases arrive next weekend) to go.

Grand Rounds: no fun, but done

2011-09-24T20:06:00.003-06:00

Last Friday was my day to present for Grand Rounds, and my case was, as planned, the "comedy of errors" case I wrote about previously.

As you might guess, my presentation did not include mention of any of the errors made during this case. Hope none of you were worrying about that (Dad).

The "exciting" part of that week leading up to Friday was completing my 40-slide PowerPoint presentation on Tuesday evening, and my laptop (containing my sole copy of said PowerPoint presentation) experiencing hard drive issues on Wednesday afternoon that left my laptop unable to start up completely.

No, I have not gotten it fixed yet. Yes, that did mean that I got to re-write my entire Grand Rounds presentation. Sigh.

After several hours of struggle on Wednesday evening, trying to get the laptop to work, I resigned myself to the fact that I lacked the technological savvy to fix the computer, as well as the fact that I was slated to give my presentation in less than 36 hours. Thus, I started a re-write about 9 pm on Wednesday.

Which was continued and concluded between 5:30 and 7:30 am on Thursday morning.

The re-writing of the presentation went (thankfully) much faster than the initial research and formatting. And, since I used the older desktop computer's elderly version of PowerPoint (which I actually prefer to the 2007 version), I found a format I liked better.

But I'm not going to lie -- it was no fun and made for a rough end of the week.

By the time Friday morning rolled around, though, I wasn't all that nervous. I ran through my slides once with my advisor (the surgeon for my case) on Thursday night, then made CLH listen to me talk through the presentation when I got home. I did get up a little earlier than usual on Friday morning so I could run through it about 3 times under my breath.

I was scheduled to go last out of the three presenters that morning. The first two cases were about horses (a case of nephrosplenic entrapment and a case of Neorickettsia risticii infection). When it was finally my turn, everything went very well. There were no computer or microphone malfunctions. I really didn't feel nervous and was even able to make a few jokes as I went along. It was over in about 12 minutes (we are allotted 15 minutes and are supposed to leave a little time for questions from the audience), and nobody among the roughly 100 clinicians and students in attendence asked me any questions (the part I most feared -- it's really uncomfortable to watch classmates standing in front of their peers and instructors and being asked questions they don't know how to answer).

The rest of Friday breezed by after that. One of my oncology rotation-mates brought a chocolate cake with "Congrats" written on the top to celebrate (which was really sweet of him). I ended up with just 3 radiation patients (who all left by the end of the day) and an outpatient mammary mass removal. The mammary mass was an interesting case. The mass was subcutaneous and only about an inch in diameter. The surgeon (who I'd not worked with prior to that week) basically told me what to do and then left the surgery suite. Which was admittedly terrifying, but also pretty cool.

Overall it feels great to have Grand Rounds over with. I attended Grand Rounds yesterday morning, and felt much more relaxed and at ease, and more able to enjoy the presentations than before I'd done my own. And I never have to do it again!

Bring on the juniors!

2011-09-11T16:44:00.003-06:00

The new juniors (I call them "new" juniors because it still seems a little weird to me that we are no longer the juniors) started their morning clinical rotations 3 weeks ago.

However, since I was on CCU overnights and Urgent Care days for the first 2 weeks of the semester (and there are no juniors on those rotations), I did not get a chance to work with any of the juniors until this past week on Oncology.

And they're so cute! It almost makes me a little nostalgic for the terror of starting junior year, the wild-eyed barely-restrained panic you can see in their faces when you ask them to do something, the mostly inaudible mumbling when they give (usually correct) answers to questions during morning rounds, the silent apology in their eyes when they know something that all of us seniors have failed to remember.

The 2 juniors we had on Oncology with us this week were very enthusiastic and willing to conquer their fears and tackle appointments -- which was quite fortunate, because they didn't really have a choice. Oncology schedules a certain number of new cases every morning based on how many seniors are on the rotation that week, so that each senior has one new appointment every morning. Somehow, the schedulers got word that there were 6 seniors last week and next week, so they scheduled 6 appointments every morning. However, there are really only 3 seniors from my vet school, plus 2 students from other vet schools who are basically the equivalent of us (so we are making them take cases) -- which leaves 1 appointment every morning for the juniors to handle!

I'm having a really good time helping them out, teaching them how to fill out forms, where to drop off prescriptions, how to navigate the medical records department. It's early enough in their semester that they really don't know much about hospital procedures, and are very grateful for assistance. And it's not like they don't know enough medicine at this point in their curriculum to be able to do a physical exam and take a history from a client (though they probably doubt their abilities) -- it's more the annoying logistical stuff they need help figuring out.

And I remember being a junior myself, when so many of the seniors would rush off to their appointments without pausing to ask if you wanted to tag along. They'd hurry through online forms and completing medical records without talking you through them, or look at you like you were an idiot if you politely informed them that you didn't know how to enter a radiology request yet. It was often frustrating to feel like you were getting in their way, or interrupting them while they were busy doing important things and you had some lowly question with an easy answer (albeit one you couldn't figure out without asking).

So I'm trying not to be one of "those" seniors. I figure that investing a little extra effort in the juniors this early in the year will help them be more confident and competent as the year progresses. It'll allow them to get more out of their own junior year since they will be able to do more things for themselves, and they will be able to help us out more and more as the year progresses. And I hope that, come this time next year, they'll remember some of the nicer seniors who didn't mind showing them around and answering questions, and they'll be prepared to pass that positive attitude along to the next class. Lord knows you need all the help you can get sometimes in this fast-paced, whirlwind adventure we call vet school.

My case for Grand Rounds: a comedy of errors

2011-09-10T21:27:00.005-06:00

I've been on Oncology this week, which has been an exhausted but informative and often fun rotation.

One storm cloud looming over my head, however, is the fact that I have my requisite Grand Rounds presentation this coming Friday.

Grand Rounds is a cruel vet school tradition wherein every senior student selects a case they've seen on clinics to present on a Friday morning sometime during the year. We are assigned a general topic for our presentation, typically the rotation that we have been on 2-4 weeks prior to our Grand Rounds date. This means that my topic is Oncology.

For Grand Rounds, you put together a 15-minute PowerPoint presentation discussing a case of interest to you. Then you get up in front of the junior lecture hall in the VTH, which is filled with other senior and junior vet students, nurses, and (most terrifyingly) clinicians.

Yes, that means that you have to give a presentation to basically the entire rest of the hospital, including the doctors who have been teaching you for the last 3+ years and working with you on clinics all year.

Okay, now that I'm done throwing up, I can finish typing.

The case I've selected for next week's Grand Rounds is a 13-year-old female Lab/Chow mix named Vega.

Vega has very dedicated, well-informed, responsible, and caring owners (no, I didn't say "obsessed," but maybe you get my drift...) who refer to her as their daughter. They have no human children or other pets, so Vega really is their only child.

On routine pre-anesthetic bloodwork prior to a dental cleaning 5 years ago, Vega's rDVM noted elevated liver enzymes. Vega had a battery of tests, including bile acids and liver biopsies, to try to discover the underlying cause of her elevated liver values, but everything came back normal. Vega's rDVM has managed her liver enzymes in the intervening period with a regimen of liver support drugs (ursodiol, SAMe, vitamin E) and a liver diet (Hill's l/d).

And Vega's done fine. She's had bloodwork monitored twice yearly, and her rDVM has noted elevations in a couple of Vega's liver values that sometimes fluctuate but have never gone back down to the normal range. Vega has never acted sick or shown any clinical signs of liver disease.

About 6 weeks ago, though, Vega went in for her 6-month geriatric wellness exam, and Vega's rDVM palpated a mass in the front part of Vega's abdomen. She repeated Vega's usual bloodwork, which was unchanged from her previous values, and recommended an abdominal ultrasound.

The ultrasound confirmed the abdominal mass and determined it to be about the size of a large orange, arising from a lobe of Vega's liver, and appearing to be solitary. Vega was referred to the vet school for an Oncology consultation and possible surgery.

Now, a lot of owners would hesitate at the thought of dropping $2-3K on anesthesia and abdominal surgery to remove a liver mass that might very well be an incidental finding in a 13 year old dog. However, Vega doesn't act her age -- if I hadn't known her age prior to meeting her, I'd have thought she was maybe 8 instead of 13. She's very fit and active, and otherwise totally healthy except for some arthritis which is under control. And though it's possible that Vega's liver tumor could be something benign that would never cause her a problem, there's also a possibility that it could be a vascular malignancy that could rupture suddenly and cause internal hemorrhaging, or some other type of malignancy that could spread elsewhere and make her sick if not excised. So, given the fact that Vega's owners didn't have much in the way of financial concerns, I can absolutely see their rationale for wanting to go to surgery.

Vega stayed in the hospital for a few hours with us on Thursday so we could repeat bloodwork and urinalysis (unchanged from her rDVM's labs a month earlier), run coagulation times (normal), check her blood type in case a transfusion was needed during or after surgery, and take chest x-rays (normal).

Vega went home on Thursday night and came back bright and early on Friday morning for surgery. She was anesthetized around 11:30 am and I was called to come shave her around noon. Given the fact that she has about 25 variably sized SQ and skin masses all over her body, and particularly on her abdomen, it was a remarkable challenge to have to try and clip her hair over and around the masses adequately to make her abdomen ready for surgery. She rolled into the OR around 12:15 pm.

Upon making our abdominal incision (difficult to find her midline due to her lumpiness!) we removed her falciform. The falciform is a very thick, fatty, gelatinous ligament that sits on the belly of the abdominal cavity and is often excised during abdominal surgery, simply because it isn't necessary to leave it in the dog and it gets in the way during surgery.

Immediately under Vega's falciform was her enormous tumor, popping right out at us. It was more grapefruit than orange-sized, and very ugly and vascular. Fortunately, it appeared to be growing on a stalk out of one of the 6 liver lobes, and the remaining liver did not appear to be involved.

Here comes Error #1: The surgeon elected to use a surgical stapler to cut off the tumor from its stalk. The way it works is that the stalk of the tumor is placed in the mouth of the stapler, the stapler is clamped down, and a double row of staggered small staples is automatically fired into the intervening tissue, effectively ligating the blood supply.

It works great.

Usually.

Unfortunately, it wasn't apparent that the stapler had misfired until the surgeon cut the tumor off of the stalk, released the stapler from the remaining stalk, and hemorrhage ensued.

In retrospect, the bleeding wasn't that bad. It certainly wasn't as bad as it would have been had none of the staples been placed as intended. But there was a heck of a lot of bleeding nonetheless, and significantly more than we'd have expected had the stapler functioned correctly.

Luckily, the surgeon remained very calm, and directed me to retract the abdominal wall and apply pressure to the hemorrhage while she obtained some additional materials to help start clotting and clamp off the bleeding vessels. There were about 10 minutes of panic, though, when multiple surgery nurses rushed in to assist us, and a flood of about 6 anesthesia personnel ran in to help the student anesthetist monitor blood pressure and heart rate, administer additional fluids, and get ready to send someone to the pharmacy to pick up some blood for a transfusion.

In the end, no transfusion was needed, and Vega'a anesthesia actually remained quite uneventful. The thing is, the liver is a very vascular organ, since its job is to filter toxins out of the blood. Tumors anywhere in the body tend to be very vascular, since they can produce factors that stimulate the growth of extra blood vessels to feed themselves; liver tumors are exceptionally vascular. Though this complication ended well, it could have been much worse and might even have led to Vega bleeding out.

Okay. Bleeding under control. Surgeons' and my heart rates were dropping back down to some semblance of normal.

Here comes Error #2: An important part of an abdominal surgery (other than something elective, like a spay) is to perform an explore of all of the abdominal organs, whether you expect them to be abnormal or not. As part of Vega's abdominal explore, we noted that one of her remaining liver lobes had a slightly abnormal appearance. The surgeon collected a biopsy sample, and placed it on a small piece of sterile paper on the instrument table. Unfortunately, she did not immediately hand the biopsy sample off to a surgery nurse to place in a formalin container, as is usually done with tissue samples, and we all forgot about the sample. It was presumably thrown away with all of the wrappers and packaging from everything needed for Vega's surgery -- but when I "got" to go hunting for it in the trash about an hour later, it was nowhere to be found. Oops.

Anyway, the rest of Vega's abdominal explore was fine. We closed her up, then transported her to CCU where she woke up slowly but normally, and proceeded to return to her usual neurotic behavior -- panting, pacing, barking, and generally trying to destroy everything in her kennel. The poor CCU staff were apparently rather irritated by this (and understandably so), since she received 5 doses of IV sedatives during the night (which reportedly did nothing to alter her behavior), and she was eventually shut up in an oxygen cage on room air, which did nothing to stop her barking but did at least dull the sound so it was almost inaudible in the room.

Vega's owners received a surgery and hospitalization estimate that included a second night's stay in the hospital if needed, since arrhythmias and pain are not uncommon complications of a surgery like this and are best dealt with in a hospitalized setting. However, Vega experienced no arrhythmias, seemed nonpainful, and clearly expressed to us that she was ready to be discharged, so we arranged a dismissal time for 9 am on Saturday.

I met with Vega's owners at 9 am and went through her dismissal instructions -- her pain medications and their side effects, how to care for and monitor her surgical incision, activity restrictions, etc. It all went well, and I advised them it would be a few minutes while I went to CCU to unplug Vega from all of her lines and monitoring, remove her IV catheters, and remove the bandage that had been placed over her incision so it would stay clean in the hospital.

Well, it turns out that the surgery nurses have gotten some new brand of extra-mega-super adhesive to get the bandages to stick onto the skin around the incisions, because Vega threw a tantrum when we tried to remove her bandage. It was really an all-out drama-queen hissy-fit, complete with howling, moaning, and thrashing, even when we were just gently restraining her and not even touching her bandage.

I should explain what the bandage looks like. It's a long, thin, flat strip of what looks like cotton padding, about 2 inches wide, laid down along the length of her abdominal incision (which goes from her sternum to her pelvis). A piece of clear plastic (which looks like plastic wrap) is placed over the cotton layer, and extends about an inch and a half onto the skin on either side of the bandage. An adhesive is sprayed onto the skin around the incision as well as onto the outside of the cotton bandage, to affix the clear plastic to the skin around the incision as well as to the outside of the bandage.

Since we couldn't easily peel or pull the plastic layer off Vega's skin (even with the help of adhesive remover wipes), the surgeon decided to very carefully cut into the cotton layer in the center of the bandage, overlying the incision. Her goal was to cut out the cotton layer (which was not affixed to the skin) and just leave the plastic layer around the edges to fall off on its own.

Error #3: Unfortunately, while cutting into the middle of the cotton layer, the surgeon accidentally cut some of the skin sutures from Vega's abdominal incision.

Luckily, not many of the sutures were lost, and we only had to replace 2 or 3 stitches in order to re-secure the suture line. But, it still meant a lot more drama from Vega, as well as more time that her poor anxious owners spent up front waiting for us to bring her out, and there's the pesky little fact that the skin likes to bleed a lot when poked with a needle, so there was still a little blood that appeared to be coming from Vega's incision (though it wasn't) by the time her owners saw her.

All in all, none of the "oops"es were major or complicated Vega's recovery. Her liver mass shows every sign of being consistent with a hepatocellular carcinoma, a tumor type for which complete surgical excision is essentially curative. We won't have biopsy results until Monday or Tuesday, but we're hopeful that it won't be something worse than that.

Now what's left for me is to put together my Grand Rounds presentation. I have some really cool pictures that were taken of Vega's abdomen and tumor during surgery. Once we have the histopath back and have confirmed that it's hepatocellular carcinoma, I'll do a little more research, but until then I'm ready to sleep for awhile!

Helpful advice for CPR

2011-09-03T16:01:00.001-06:00

I wanted to add to my last post -- during CPR rounds, the critical care clinician told us something that I think was extremely helpful in allowing me to stay calm and not panic during last night's CPR:

"When a patient presents for CPR, they are already dead. Whatever you do, you can't make it any worse. So don't worry!"

Good point!

Euthanasia #2, CPR #1

2011-09-03T15:19:00.003-06:00

My daytime Urgent Care rotation ended with a bang. We were far busier on Friday than any other day last week. We saw probably 15 patients in the first 4 hours of the day -- which is probably more patients than we saw total during any 10 hour shift on any of the other days. It was crazy -- about every 10-15 minutes we'd get a page that a new patient was here, along with pages about phone calls from clients or rDVMs every 5-10 minutes. It was kind of a lot of fun, in a strange way -- it's more exciting and invigorating to be busy like that than to be sitting around all day waiting for patients to show up, and it gave us students a real chance to learn how to triage patients. We also got practice explaining to owners that they are here to see an Urgent Care service, which means that some of the stable patients will be sitting around and waiting for awhile while we stabilize the more critical patients.

I primarily ended up with 2 patients, after most of my other ones were transferred to different services (neurology and internal medicine). My saddest patient was Joey, a middle-aged Labrador retriever who presented as a transfer from his rDVM with a complete urinary obstruction.

Joey was neutered only 1 month ago, when his owners noticed he was intermittently straining to urinate and his rDVM diagnosed an enlarged prostate (very common in intact adult male dogs). Testosterone causes the prostate to grow in size, consequently compressing the urethra and sometimes the rectum, resulting in difficulty urinating and/or defecating. The treatment is generally castration, and although the body's testosterone levels subside fairly quickly after the testicles are removed, it can take several weeks or months for the prostate to shrink back down to a more manageable size.

Since his castration, Joey had been able to urinate and defecate, but had still had some intermittent straining, which Joey's owners were told to expect. However, two days ago Joey became completely unable to urinate. His owners brought him to their rDVM, who felt that Joey's prostate was still somewhat enlarged but not enough to be causing his inability to urinate. Joey's rDVM took radiographs, which showed small stones in Joey's bladder, and a stone lodged in his urethra. The rDVM tried several times to place a urinary catheter (we are unsure if this was successful or not, or if the rDVM drained Joey's bladder by placing a needle through his abdominal wall), and eventually recommended that Joey head to the teaching hospital for treatment.

Upon arrival, Joey was happy and wagging his tail, but was clearly experiencing quite a bit of discomfort from his by-now distended bladder. Joey's owners were quite conflicted about how to proceed with his treatment. Our initial stabilization (about $500) would include the Urgent Care exam fee, pain meds, ensuring the rDVM's IV catheter was patent, starting IV fluids, running some bloodwork and a urinalysis, and attempting to place an indwelling urinary catheter. Long-term, Joey's owners would be looking at anesthesia and surgery for stone removal from Joey's bladder, as well as possible surgery to remove the stone from Joey's urethra if it could not be moved, and maybe even a perineal urethrostomy (crudely, a surgery that would make Joey pee like a girl) if Joey's urethra had been too badly damaged from the stone sitting in it and the repeated attempts to pass a urinary catheter.

As you can imagine, the financial estimate for these surgeries was pretty staggering, especially given the fact that, not knowing why Joey's urinary stones had formed in the first place, we could give no 100% guarantee that we would be able to prevent them from ever returning in the future. Sure, depending on the type of stones, there are medical things that could be done to decrease the likelihood of recurrence, but we couldn't say that they would never return. And Joey's owners knew that although they might be able to scrape together the funds for his initial surgery, it really wasn't in their budget, much less a second surgery.

In the end, Joey's owners permitted his initial stabilization to allow themselves time to make a decision about how to proceed with Joey's care. With sedation and multiple attempts, we managed to place a small-bore urinary catheter to drain Joey's bladder and keep him comfortable. However, the fact that his penis was dripping frank blood on presentation and throughout the day was a sign that his urinary tract was very unhappy.

Toward the end of the day, Joey's owners made the decision to euthanize him. They wanted to spend a few minutes with him outside the hospital in the garden area, then to put him to sleep out there. The intern on duty and I brought Joey to his mom and dad, and they said tearful goodbyes. Once we had Joey settled on some nice cushy blankets in the grass, his owners decided they couldn't stay until the very end, so the intern and I talked to Joey and rubbed his belly as he watched his owners walk away for the last time. Then we anesthetized and euthanized him. He went peacefully, with lots of petting and us telling him how much his owners loved him, the sun shining down through the tree above and a breeze in the air, but it broke my heart a little bit.

We made a clay paw print for Joey's owners to have, and clipped some of his fur for them to keep along with his collar and tags. His owners consented to a necropsy, so we'll be able to find out how severely damaged his urinary tract really was. (His owners didn't want to know the results of his necropsy, and I wouldn't have either.)

It was about 6 pm by the time I had prepared those mementos for Joey's owners, delivered his body to necropsy, and started a sympathy card to send to his mom and dad. After 7 nights in a row last week of 10-12 hour overnight shifts, followed by 4 days this week of 12-14 hour Urgent Care daytime shifts, and almost 12 hours into my 5th day on Urgent Care, I was emotionally and physically exhausted.

However, about 10 minutes after sitting down to complete the day's paperwork, I got quite the adrenaline boost when another student rushed down the hall toward the Urgent Care room yelling, "Get ready, we need CPR!"

The patient was a small elderly mixed breed dog, whose owners had rushed him in after he had developed acute respiratory distress as they were driving out of town for a Labor Day weekend camping trip. The dog appeared not to be breathing on presentation at the VTH, so he was immediately rushed back for CPR.

Other than walking into a patient undergoing CPR during one of my last overnight shifts (the CPR in that case was well underway by the time I arrived, and all I did was write down the drugs that were given as the rest of the team did compressions, etc.), yesterday's CPR situation was the first in which I've really been involved.

Fortunately, we had "CPR rounds" two days prior, in which a critical care clinician reviewed with us in detail the steps to perform CPR. I'm so very glad we had those rounds, because it allowed me to stay somewhat calmer in this situation.

One of the nurses immediately started chest compressions on the little dog (which is the most important thing to do), and another nurse and doctor got to work intubating the dog. A student and another doctor started placing an IV catheter, while another nurse placed an intraosseous catheter (directly into the cavity within one of the dog's bones) then hooked up an EKG. A second student went to get more help; a third student started recording what we were doing; and I headed to the crash cart to start pulling up doses of atropine and epinephrine.

We performed chest compressions, mechanical ventilation, monitored EKG, and gave 3 rounds of drugs within about 10 minutes, but with no change in the dog's condition, he was pronounced dead shortly thereafter. It was a sad situation for the family, who'd been told previously the little guy had a heart murmur but that there was nothing they could do about it (which may not have been true). Given the vast amount of fluid coming up from his lungs, it's possible he had acutely gone into heart failure. The family was shocked at his sudden death.

However, it was oddly rewarding to see how well everyone worked as a team. The goal of CPR rounds and "practice" CPR situations is to remind everybody how things are done so that nobody panics and everyone can play a useful role when a CPR situation arises. As you might expect, studies have shown that medical and veterinary teams that practice CPR regularly are more likely to have a successful outcome (although the reality is that, in CPR situations overall, there's only about a 5% chance of getting an animal 'back').

As the clinicians ever-so-helpfully remind us, in a matter of months we students will be the ones to whom the rest of the veterinary care teams look to as leaders in a time of crisis, and we'll need to be able to stay calm, give directions, and make decisions about things like CPR. That's a really scary thought, but CPR rounds and CPR practice make me feel the tiniest bit like I might actually be ready someday.

Urgently Caring, one day at a time

2011-09-01T18:52:00.002-06:00

My current CCU rotation is comprised of 2 pretty different weeks. Last week was the overnight shifts, and this week is a daytime Urgent Care shift.

Urgent Care (UC) sees patients from 7 am till 10 pm on weekdays, and more limited hours on weekends. (Emergencies during other hours go straight to CCU.)

On UC we see any patient who enters the building as a walk-in appointment, any patient who requires a same-day appointment but can't get in through the specialty service they hope to see, and any daytime emergencies like snakebites or hit-by-car cases.

It's kind of neat not to know what to expect when you get there for the day -- about 60% of the clients we see call ahead by a few minutes or hours to let us know when and why they are coming, and the other 40% just show up out of the blue. It definitely requires you to think on your feet.

I've ended up with an odd mix of patients this week. They are as follows:

1. A 6-month-old Lab puppy, presented on Monday morning for acute-onset (12-24 hour duration) vomiting and diarrhea. We hospitalized her overnight for IV fluids and supportive care. She was negative for parvo but did have coccidia and Campylobacter in her feces, which we are treating.

2. A middle-aged hound mix, presented on Monday afternoon for skin problems. He'd had an acute onset of severe generalized itching, lethargy, and inappetance 10 days prior, with some degree of improvement since then. We suspected an autoimmune dermatologic disease, so he came back on Tuesday for a dermatology consultation.

3. An older Australian shepherd, presented on Tuesday morning for a worsening head tilt and improving falling/abnormal gait of 2-3 weeks duration. She also had a 2 month history of recurrent vaginitis, and several skin masses. We worked up her vaginitis and she came back for an MRI and neurology consultation on Wednesday, which showed an inner ear inflammation.

4. A young Chihuahua, presented on Wednesday morning for neck and back pain, as well as a palmigrade stance (walking down on her wrists). Her rDVM suspected neurologic disease. We agreed but thought there may be an orthopedic component. The orthopods examined her and recommended a neuro consult. The neurologists examined her and recommended an internal medicine consult for immune-mediated polyarthritis. She had a fever, so stayed in CCU on fluids overnight and transferred to internal medicine on Thursday morning for joint taps.

5. My first euthanasia patient, presented on Thursday for euthanasia due to abject misery.

6. An elderly Doberman, presented on Thursday morning for an acute onset of steadily worsening neck pain and abnormal gait, suspected by his rDVM to be due to cervical disc disease. After seeing his bloodwork showing a lymphocyte count of 75K (normal is 1-4K) and collecting lymph node aspirates with severely abnormal cells, we diagnosed him with Stage Vb lymphoma.

The Doberman was definitely my saddest case of the week so far. He is such a nice dog with an equally nice owner, very willing to spend the money needed for an MRI and vertebral surgery (which is what his rDVM had prepared him for).

Lymphoma is a cancer of the lymphatic system, including the lymph nodes, which help drain infection and inflammation from the surrounding tissues. It's "staged" based on clinical presentation, from Stage I through Stage V. Stage I means the cancer is limited to a single lymph node or organ. Stage II means that nearby lymph nodes are involved. Stage III means that all of the lymph nodes around the body are involved. Stage IV means it has spread to the liver and/or spleen. And Stage V means that it has spread to the blood, the bone marrow, or other sites such as the brain or spinal cord.

Lymphoma is also given a "substage" of 'a' or 'b.' These are based somewhat crudely on how well the dog is doing: a substage 'a' dog is one who feels pretty good; a substage 'b' dog is one who feels poorly.

Negative prognostic factors (things that are associated with a bad outcome) for lymphoma are:

1. Stages III/IV/V are worse than Stages I/II
2. Substage 'b' is worse than 'a'
3. T-cell is worse than B-cell (Mr. Doberman is suspected to have T-cell)
4. Leukemia (cancerous cells in the blood) and spread to "protected sites" such as the spinal cord and brain are worse than lack of these factors

So poor Mr. Doberman has all of these things against him.

He became more and more painful throughout the day, eventually whining and moaning in pain even when lying in the most comfortable position he could find, and even after a whopping dose of oral pain meds. We started him on heavy doses of IV pain meds, which seemed to help somewhat, but pain meds alone would not be enough to control his discomfort, so he was anesthetized for a dose of palliative radiation in the area where his spinal cord is being disturbed, and he started on chemo.

It's so odd, because without doing bloodwork on this dog and seeing his enormously elevated lymphocyte count (which really can only be caused by leukemia or lymphoma), he probably would have headed for an MRI to see what was going on. He had otherwise been feeling well (normal appetite, energy level, etc.) and did not have any of the characteristic lymph node enlargement that is typically seen in lymphoma cases. That goes to show you why doing a step-wise work-up in these neurologic-type cases is always a good idea, starting with bloodwork/urinalysis and progressing to more advanced diagnostics one at a time.

I'm hoping for the best possible outcome for Mr. Doberman, but even that won't be all that great. If he responds well to palliative radiation, he may have 2-3 months of quality time left. However, it's possible that we will not be able to get his extreme pain under control, in which case he'll most likely end up in Doggie Heaven. The one consolation is that at least he hasn't spent a long, chronic period of time feeling miserable up to this diagnosis -- just a few days. I know his dad would love to see him get home for a few more weeks of loving.

My first euthanasia

2011-09-01T18:31:00.003-06:00

I had my first euthanasia case on Urgent Care today.

Oliver was an elderly long-haired terrier who had never been to the VTH before. His presenting complaint was "mass in mouth/possible euthanasia."

On presentation, he looked to be a definite euthanasia. His long tan-and-silver hair was badly matted over his entire body. His eyes were cloudy with sticky green discharge. He smelled like a sewer. He was recumbent and unwilling to move.

And, most notably, he did indeed have a mass in his mouth -- a mass that had spread from his mouth to engulf and deform his entire palate, nose, and muzzle. He was bleeding from his mouth, kept coughing and gagging, and seemed to be having a lot of trouble breathing.

Oh, and maggots were crawling in and out of his nostrils.

Oliver's owner conveyed to me that they had noticed a small oral mass about 6 months ago, and it had just kept growing since then. Over the last 3-4 days, Oliver had stopped eating, seemed to be in respiratory distress, and started to smell really bad. Her husband wasn't sure it was "time" yet, but she was pretty convinced.

Oliver's owner said, "Do you think it might be cancer?" which gave me some idea that poor Oliver had never seen a vet since developing this tumor. My reply was, "Yes, these types of things are usually cancer." I was stupefied enough not to know what else to say.

After some brief discussion, Oliver's owner elected not to be present for his euthanasia, and requested that we bring him to the back for the procedure. We obliged after she signed the consent forms to permit the euthanasia, as well as an "educational post-mortem examination" (aka necropsy). She did not want his body or ashes back, but thought a clay paw print would be nice.

We carried little Oliver to the Urgent Care treatment room, where I struggled for about 5 minutes to get the clippers through the thickly matted hair on his front leg, then placed an IV cathether (on my first try!). Oliver immediately received a heavy sedative injection IV, followed by euthanasia solution. All in all, it went quickly and peacefully. After his death, we discovered that Oliver had many other large masses over his entire body, and toenails about 2 inches long (on a 15 pound dog).

I had been quite nervous about my first euthanasia, since I know what a difficult thing it can be for owners (and for the veterinary team). I guess it turned out well that (a) Oliver's need for euthanasia was not at all ambiguous, and (b) Oliver's owner did not wish to be present when he was euthanized. That meant that I got to skip the whole part about "When Oliver's body relaxes as his heart stops, you may see some muscle twitching. He may vocalize. His eyes may not close. He may leak stool or urine," etc.

But I can't bring myself to even begin to think about what Oliver went through for the last few months, and especially the last few days. I mean, who among us can say what it feels like to have maggots crawling around inside your nose, eating bits and pieces of you? How about a huge tumor in your mouth so large that you can't even close your jaws? Spending several days gagging on the blood that is constantly running down your throat?

In the end, I feel that you can't be too hard on anyone who eventually seeks veterinary care for their pet. I don't think Oliver's owners had any idea how badly he must have been suffering. Their ignorance probably led to a lot of pain on Oliver's part, but at least they brought him to us for a peaceful ending instead of letting him die a miserable death from dehydration, suffocation, and sepsis at home. Did they wait too long? Yes. Should they have sought veterinary care long ago? Of course. But will it do Oliver or his owners any good for us to scold and shame them? Probably not. I think once they hear the results of Oliver's necropsy (which they requested we tell them), they will have a better understanding of what he went through at the end.

The power of euthanasia is one of the greatest gifts we have as veterinarians, which is lacking in human medicine. It's hard to describe the feeling I get when participating in a euthanasia that is well done and appropriately timed -- emotionally satisfying, gratifying, relieving, comforting... (I still haven't found the right words). It's a good feeling to help a well-loved pet die peacefully and painlessly when you know you've done all you can and that ending the pet's suffering is the best thing to do. My feelings are a little more mixed than that in Oliver's case. All in all, it made for an introspective, pensive sort of day.

My poor circadian rhythms

2011-08-29T05:17:00.004-06:00

I'm officially back to a daytime schedule now, following Saturday night's final overnight shift.

I arrived at 9:50 pm for my 10 pm shift start, and walked into CPR. One of the patients who'd had GI surgery several days prior had suddenly arrested. I assisted for about 10 minutes, at which time they called it off and pronounced the poor guy deceased. It was a surprising turn, since this particular patient had seemed to be improving quite steadily since his surgery. Everyone was, understandably, upset. Losing a patient really sets a gloomy tone for the rest of the night.

Other than the CPR, my shift was an uneventful one, with a mere 3 inpatients and no outpatients for which I was responsible. My 3 were familiar ones:

1. Mr. Presa Canario post-op Wobbler's surgery, here since Tuesday (Wobbler's patients typically stay 5-7 days in the hospital because they have a hugely extensive surgery on the vertebrae in their neck, and must be kept totally quiet for at least that period of time, which means we dope them up pretty heavily with IV pain meds and don't let them leave their cage for anything until at least 3-4 days post-op). Mr. Presa Canario is in need of an attitude adjustment (or maybe a breed adjustment) -- since he's started feeling better, he's become much grumpier and consequently more terrifying -- so his urinary catheter and IV lines were removed so we don't have to deal with those, and we pretty much do nothing with him other than feed him. He will have gone home yesterday or today.

2. Mr. Dachshund post-op hemilaminectomy, here since Tuesday. Poor Mr. Dachshund. Hemilaminectomy patients typically stay in the hospital about 2-3 nights after surgery -- 2 nights if they do exceptionally well after surgery, and 3+ nights if they are a little slower to recover. Most of them are still partially paralyzed when they are discharged (it can take up to 6 months to make a full recovery), but that's manageable for owners at home as long as the dog can urinate and defecate on its own. The problem with Mr. Dachshund is that he's had ongoing bladder issues since his surgery. Immediately post-op with all of these patients, we place a urinary catheter because we don't want to have to take them outside and we don't want them peeing all over themselves. Then a day or two post-op, we remove the u-cath and see if they can urinate on their own. If they can't, we see if their bladder can be easily expressed manually by placing pressure on their abdomen. If the dog is peeing on his own or can be easily expressed, he can go home. Unfortunately, neither is the case for Mr. Dachshund, requiring us to place a temporary urinary catheter several times a day to help him empty his bladder. I'm really hoping he improves in this area soon because he's going nuts in the hospital from boredom, and consequently driving everybody else insane with his whining and barking!

3. The older German Shepherd post-op hemoabdomen and splenectomy (patient #4 from Friday night). He's been doing somewhat poorly. His lidocaine infusion, meant to help control his cardiac arrhythmias, was making him terribly nauseated so we had to stop it. That meant that for the first 6 hours of my shift, his heart was all over the place -- his heart rate would rapidly jump from a resting rate of 55 beats per minute up to 150-200, all while he was sleeping -- and he had almost entirely ventricular-origin beats, meaning the electrical current controlling his heart was originating from the ventricles (bottom chambers) instead of near the atria (top chambers). At about 4 am, we started him on magnesium chloride, which seemed to help somewhat to increase the number of normal beats he had. Unfortunately, his arterial blood gas analysis in the morning showed that he was oxygenating more poorly in the morning than he had the night before, suggesting incipient pneumonia or something else happening in his lungs. He's such a sweet guy; I hope he improves soon.

We had a couple outpatients come in, but my rotation-mate happened to deal with both of them: a rat with a probable brain tumor that we ended up euthanizing, and a cat post-declaw whose owner felt she was very painful.

It appears that the weekend is the time for a lot of phone calls, which makes sense if you think about it -- on a Thursday night, people are probably more likely to decide on their own that something can wait till their regular vet opens at 7 or 8 am the next day, whereas an ill pet on Saturday night may not be able to see its regular vet until Monday morning.

My favorite call was a hoarse woman who sounded like a 60-year-old lady who'd smoked for 50 years. She called around 5 am to say that her toy breed dog had seemed fine on Saturday, then had bloody diarrhea late on Saturday evening, tried to drink some water afterward and vomited it right back up, and seemed lethargic when she went to bed. When she awoke on Sunday morning, she observed him having a seizure-type episode, and at the time she called, the dog couldn't really walk, was "breathin' pretty hard," and had blood coming out of his mouth.

My response was, "It sounds like your dog may be very sick and we'd recommend that you bring him in right away." (Note: for anything that may not be emergent, I get the caller's name and number, check with the intern on duty, and give them a call back with advice [which is pretty much always "Bring your pet in"]. This was one case where I felt pretty darn sure what the intern's advice would be!)

The caller's response was, "Well, I got some things ta do this mornin' but I'll try an' bringim in in a coupla hours." I reiterated that it sounded like it shouldn't wait, and she said she'd be in when she had time. (The little dog arrived just as I was walking out at the end of my shift, and fortunately looked to be in decent shape, just based on my cursory glance.)

My challenge yesterday was to figure out how to get from a daytime sleeping schedule to a nighttime sleeping schedule in the course of 24 hours. What I ended up doing was heading to church in the morning, then coming home and napping from about noon till 4 (though I'd set my alarms for 2 pm, but don't remember hearing them or turning them off, which I apparently did). Several hours of wakeful grogginess ensued, then I headed to bed for the night around 9:15 pm -- only to awake at 4:30 am feeling quite well-rested and ready to start my day, so here I am!

I can imagine getting used to a regular schedule of working overnight hours, as long as you didn't have to do much switching back to daytime shifts. By the end of the week, when I had gotten into a routine (you all know I love my routine!), I felt pretty human for most of the day. I'm fortunate that I can sleep easily during the day, so that helped me adjust more quickly at the beginning of the week. However, I have a feeling that today is going to be a long day, and that it'll take me a couple more days to fully switch back to regular hours. Luckily, I may get all of Labor Day weekend off, so I anticipate some serious sleeping in and napping to fill up the Sleep Bank before I head into what may be an exhausting 2-week oncology rotation.

Urgent Care (7 am-6 pmish?) starts today. Hope I like it!

One more overnight

2011-08-27T19:47:00.002-06:00

I'm down to my final overnight shift, which will start in ~2 hours.

The last couple nights have been manageable. We've not had any emergencies come in either evening, but there have been quite a few inpatients, some requiring a good deal of care.

Thursday night:

1. The young Presa Canario post-op Wobbler's surgery, still here since Tuesday (he's Tuesday's patient #1 here)
2. The middle-aged Dachshund post-op hemilaminectomy, still here since Tuesday (he's Tuesday's patient #3 here)
3. A youngish Yorkie, post-op tibia-fibula fracture repair after acting like a little nutcase when her owners took her out for a brief leash walk 3 weeks after bilateral patella repairs
4. A youngish Great Dane, post-op forelimb amputation after a presumed hit-by-car and severely damaged hock joint (tibiotarsal luxation with complete collateral ligament rupture)
5. An elderly Beagle, 1 month post-op from a partial maxillectomy for a fibrosarcoma, with waxing and waning lethargy/anorexia since his surgery, and an acute onset of hypotension, respiratory distress, and vomiting; suspected Addison's disease
6. An 8 week old kitten from the humane society, post-op from a PDA ligation (congenital heart defect requiring open-heart surgery); was so hyper and active after surgery that he removed his own chest tubes and IV line, and wanted nothing more than to make biscuits and suckle on your shirt all night; SO CUTE

Wednesday night's patients #2, 4, and 5 were discharged on Thursday. Unfortunately, Wednesday night's patient #6 (the very sick border collie mix) continued to decline and was euthanized during the day on Thursday.

I've not heard anything on how Boxer Puppy (suspected parvo) from Wednesday night is doing, but Golden Puppy from the same shift was hospitalized for about 12 hours on fluids, did very well, and was eventually diagnosed with a load of GI parasites (cryptosporidium, giardia, and roundworms) likely responsible for her GI upset.

Last night (Friday night), my 7 inpatients were:

1. Our friend the Presa Canario, post-op Wobbler's surgery on 8/23
2. Our friend the middle-aged Dachshund, post-op hemilaminectomy on 8/23
3. The elderly beagle with probable Addison's, patient #5 above (doing much better last night -- feeling well enough to be annoying)
4. An older German shepherd with acute hemoabdomen (belly full of blood) and a very low PCV of 18, who went for exploratory surgery where they removed his abnormal looking spleen, and biopsied lymph nodes, GI tract, and liver as well; he had several transfusions during surgery and did okay in recovery except for a common post-op splenectomy cardiac arrhythmia called VPCs/v-tach, which was managed fairly adequately with a lidocaine infusion
5. An 8 week old Pit mix puppy from the humane society, whose foster parents suspected he had eaten a sock or a piece of a soft toy when he started vomiting; he was taken to surgery last night and had an entire sock removed from his small intestine; did well post-op after getting out of surgery around midnight
6. An elderly Shiba Inu mix, post-op forelimb amputation for a soft tissue sarcoma; was doing pretty well with pain management and actually ambulated quite well for his first 12 hours post-op
7. A 1 year old mix dog who got loose from her owners, ran into a street, and was hit by a car, sustaining multiple pelvic fractures, the most severe of which were repaired surgically yesterday

The only patient who gave me any trouble was, unfortunately, patient #1, our dear darling Presa Canario. Though he entered CCU with a reputation for aggressive behavior and about a zillion caution signs on his cage and chart, he'd been nothing but a big sweetheart until my shift started last night. Yes, he was fearful and easily startled, and yes, we went slowly when approaching or handling him, but he had previously let me do all of his treatments (including unpleasant things like rectal temperatures and inspecting his urinary catheter) by myself.

Last night, though, he started growling at one of the CCU nurses (who has been caring for him all week) any time she would stand outside his cage and look at him. He was fine for his 11 pm and 1 am treatments (in fact, I did all of his 1 am treatments by myself) but started growling and curling his lips at me when I attempted to do his 7 am treatments.

Sigh.

With a smaller dog of a different breed, I'd push the issue a little more or not hesitate to muzzle the dog for whatever I needed to do. However, although this guy is still somewhat dopey on drugs, and is restricted in how quickly and in what direction he can move because of the surgery on his neck, he can sure whip his head around quickly if you're up within biting range, so I'm not going to push my luck. I did what I could do, and left the rest for the neuro department when they came in late morning to assess and walk him.

Hoping he'll have gone home today, but I'm guessing I'll see the bad guy again tonight!

The parvo puppies who weren't

2011-08-25T18:55:00.003-06:00

CCU overnight shift #4 was a busy one. I started with 6 inpatients:

1. The Presa Canario post-op Wobbler's surgery from yesterday (doing well, hasn't bitten anybody yet)
2. The adolescent shepherd mix from yesterday who ate a bunch of Rimadyl (doing fantastically well, no bad changes on bloodwork, still a 7 month old nutcase puppy going insane from being caged for 2 days)
3. The middle-aged Dachshund post-op hemilaminectomy from yesterday (also doing well, has motor function and deep pain sensation in his hindlimbs, was going to have his urinary catheter pulled today)
4. The senior coonhound post-op partial mandibulectomy and post-op second surgery for hemorrhage from yesterday (doing much better today, with no more bleeding from her incision, and less painful today)
5. The young Lab post-op enterotomy for rock foreign body from yesterday (still doing quite well today, transitioned from IV to oral pain meds and slated to go home today)

And my new inpatient:

6. A middle-aged border collie mix (who, incidentally, I saw last month on Derm for chronic management of a severe autoimmune disease, but who was doing quite well at that point) who presented with an acute onset of regurgitation, vomiting, diarrhea, anorexia, nosebleeds, prostatitis and fever, and who was subsequently diagnosed with DKA (diabetic ketoacidosis, or a "diabetic crisis"). His blood glucose was between 400 and 600 all night (normal for dogs is up to about 130-140). He was febrile with a rectal temperature that peaked around 105.5 and was finally down to 103-something by morning (normal 99.5-102.5). He kept regurgitating brownish bloody fluid intermittently. He was dribbling bloody urine, so we placed a urinary catheter (the second one I've gotten to do! fun!). Not sure what the plan for him was today since I didn't get to chat with his medicine clinician, but I'm guessing I'll be seeing him again tonight (as long as he's still alive).

(Sadly, patient #6 in yesterday's post was euthanized intra-operatively yesterday when they found that his bladder and urethra were very necrotic (dead tissue), probably from chronic distention of his bladder over the last few days as well as stones lodged in his urethra next to his u-cath. My understanding is that he had been blocked for a really long time by the time he got to his rDVM several days ago, so that probably didn't help either. Poor guy; he was such a sweetheart, even with what had to have been an ouchy bladder that we kept feeling, but at least I know that he was kept comfortable and happy with tons of petting during his last night with us.)

Last night we had 3 patients present on "emergency" (though none were truly critical patients). One was an adult dog with acute onset bloody diarrhea, who was handled by my rotation-mate.

My first emergency patient was an 8 week old Boxer puppy who presented for suspected parvovirus. Another dog in the household was treated at the VTH for parvo last week and just released 3 days ago; this puppy saw her rDVM 3 days ago for her first distemper-parvo vaccine but was in contact with the other dog and broke with diarrhea later that day. She started vomiting yesterday morning, and was lethargic and inappetant for about 24 hours before presentation as well.

Boxer Puppy's owners drove her to the VTH from about 2 hours away, passing multiple other daytime and ER vets, because they hoped to enter her in a parvo clinical trial that is being done at the VTH. The only problem was that her bedside parvo test last night was negative, which excludes her from the study. Most likely, she truly does have parvo and is just in an early stage of infection and not yet shedding the virus where it can be detected in the feces.

Unfortunately, Boxer Puppy's owners drove all that way because, if she had parvo, they really couldn't afford to treat it without financial assistance from a clinical trial. With her history and clinical signs, even with the negative test, we had to still assume she had parvo, recommended treating her as such, with hospitalization and IV fluids. However, due to financial restrictions we ended up sending her home on an oral antibiotic, an oral antiemetic, and instructing the owners on how to administer twice-daily subQ fluids. I'm hoping she does well; she wasn't clinically dehydrated yet on presentation, but being so young, it will be very easy for her hydration to fall behind.

About 15 minutes after Boxer Puppy left, I headed up to meet a second puppy and owner, this time a 4 month old golden retriever who was SO ADORABLE. This puppy had a similar-ish but more acute history -- she arrived at 2:45 am, having been completely fine until 6:30 pm the prior evening, when she began having softened stool that quickly progressed to watery diarrhea. Her attitude and appetite were a little off, and she started vomiting around 2 am. She had vomited pretty much nonstop since her vomiting began, and continued retching, vomiting, and passing liquid stool during our physical exam.

Despite her GI ailments, Golden Puppy was a happy little girl who just wanted to wag her tail and convince us to pet her belly. She was indeed somewhat sedate on exam, but did not yet appear dehydrated or otherwise ill. Her abdomen was soft and nonpainful, suggesting that a GI foreign body was slightly lower on our list of differentials, but still entirely possible.

Golden Puppy's mom works at the VTH as a receptionist and used to work elsewhere as a vet tech; she is super-nice, knowledgeable, and understanding of everything we wanted to do for hrer baby. Though Golden Puppy had had a normal series of puppy vaccines, and had already had her final distemper-parvo vaccine, we still had to consider parvovirus infection. Her bedside test was fortunately negative. A fecal cytology showed a massive overgrowth of cocci (which is bizarre, because bacterial overgrowth is almost always of rods). A venous blood gas showed low normal electrolytes.

Mom consented to hospitalize Golden Puppy on IV fluids for the rest of the morning (it was 4:30 am or so by the time she left) so we placed an IV catheter and started fluids. (Incidentally, I have failed miserably at the 2 IV catheters I've tried to place so far this week [Sunday night's Rottie with terrible veins from chemo, and Tuesday night's blocked tomcat who was really not interested in me shoving an 18g catheter into his leg] so it was quite a relief for me to finally have an IV placement that actually went well!)

Not knowing for sure if Golden Puppy might have an infectious/contagious disease, and preferring to be safe rather than sorry, we elected to place her in the isolation room in the back of CCU, with special nursing precautions including wearing a gown and gloves at all times when handling her.

Golden Puppy got a SQ injection of an antiemetic, an IV injection of Pepcid, and was started on oral antibiotics and an oral dewormer. By the time I left, she had not vomited or had diarrhea since her IV catheter was placed. Being a 4 month old puppy, she was not given the benefit of the doubt and had an e-collar placed immediately so that we didn't end up with a blood-covered puppy who had chewed out her IV catheter -- but she looked SO forlorn and mopey with the cone of shame! We submitted a fecal sample to the D-Lab for full screen, as well as bloodwork for CBC/chemistry. I'm hoping she continued to do well throughout the day -- guess we'll see tonight!

After rounds finished at 7:30 am, I ended up sticking around for a couple more hours to do paperwork on my emergency patients -- history and physical exam forms and RTG for Boxer Puppy, and history/physical exam/start an RTG for Golden Puppy. Not my preferred way to spend my morning, but I still got home by 9:45 or so and was asleep about an hour later. 4 nights down, 3 to go!

Overnights: 3 down, 4 to go

2011-08-24T19:19:00.002-06:00

I'm almost halfway through my week of CCU overnights, and it's been going well.

Sunday night was about the right amount of busy -- not too many patients, which was good because I was still learning how to do everything, and no emergencies came in.

Monday night was slower than Sunday, with only 4 patients for me and 5 for my rotation-mate. Mine were:

1. The middle-aged Shih Tzu from Sunday night, who for some reason ended up scheduled for his surgery on Tuesday instead of Monday so spent another night with us
2. An adult Lab who ate grapes
3. An elderly Lab post-op following a partial mandibulectomy for a recurrent aggressive melanoma
4. An elderly shepherd cross presented with anorexia, vomiting, and lethargy, and just diagnosed with GI lymphoma and slated to start chemo the next day

No emergencies again on Monday night.

Last night (Tuesday night) was a bit more hectic. I started out with 5 patients, then gained a sixth early on in the overnight shift:

1. A young Presa Canario (the dogs that kill people) post-op following a 12-hour-long surgery for Wobbler's (a vertebral malformation in the neck); thanks to ongoing infusions of happy drugs, he neither bit me nor made any attempt to do so
2. An adolescent shepherd cross who ate a bunch of Rimadyl (an NSAID) and a loaf of bread
3. A middle-aged Dachshund post-op following a hemilaminectomy for an acute disc herniation
4. A senior coonhound post-op following a partial mandibulectomy for a squamous cell carcinoma
5. A young Lab post-op following an enterotomy for a rock foreign body
6. A middle-aged cat who was seen by his rDVM 2 days prior for urinary obstruction; the rDVM placed a u-cath but sent him to us last night after being unable to remove the u-cath (he was headed for surgery today to remove his bladder stones, urethral stones, u-cath, and for a perineal urethrostomy to avoid re-blocking in the future)

We had no new emergency patients come in, but patient #4 above (the coonhound with the mandibulectomy) gave us an adrenaline rush. She was housed in ICW (intermediate care ward, a room across the hall from CCU that is usually used for stable post-op patients who just need IV fluids and IV pain meds overnight, then go home the next day -- ICW is staffed by a CCU nurse who is in there pretty much constantly supervising the patients, but does sometimes leave for a couple minutes at a time if everyone is doing well).

The CCU nurse left ICW for less than 60 seconds, and when she came back, the coonhound was covered in blood and there was blood gushing (like, literally gushing) from her mouth. This is a dog who, while not a total nutjob, did get removed from her baby-gated area in the corner of the room after trying to jump the gate, was wearing an e-collar after trying to chew out her IV catheter, and had been banging said e-collar around on the walls and doors of her cage.

The nurse rushed the dog across the hall to CCU where we immediately applied pressure and ice to the bleeding incision. However, the dog kept bleeding, and rapidly transitioned from her previously very alert state to basically passed out on the table in front of us. We bolused IV fluids and checked a blood pressure -- her systolic bp, previously normal, had dropped to between 50 and 60 -- low normal is 90-100. Her heart rate was dropping and her pulses were weak. We put her on an EKG and flow-by oxygen. Another nurse placed a second IV catheter. They called the doctor who had performed her surgery earlier that day, and the doctor rushed right in. Only 5-10 minutes after the dog's bleeding initially started, it was apparent that she had lost a massive amount of blood, so we started a transfusion. As soon as the surgeon arrived, back to surgery she went.

All in all, it was a definite spot of excitement in what was otherwise a pretty routine evening. It was crazy how much and how quickly the dog bled -- if she had been unsupervised for, say, 5 or 10 minutes, she could easily have bled to death. It was lucky that her bleeding was noticed immediately, which is why these patients are kept so closely supervised after surgery. I passed her rolling out of surgery this morning as I was leaving, and she seemed to be doing well (at least she was no longer bleeding, and they had washed her off -- she was a mostly white dog, of course).

Schedule-wise, I feel like I've adapted pretty well to overnight shifts. The first 2 nights and days were a little rough, but last night I really felt awake and almost normal throughout the entire overnight shift. Yesterday I slept for about 3 hours in the morning, then got up and had some lunch (dinner? breakfast? Chinese food, at any rate) and went back to sleep from noon till 5. Today I slept pretty much from 10 am-5 pm with minimal interruptions. It's nice to be able to sleep during the day -- I've heard horror stories from classmates who have had 5 or 6 of their overnight shifts before they can finally get on a sleeping schedule and sleep for more than just a couple hours in any 24 hour period.

Last night during some downtime, I was chatting with the intern and she asked me if I like emergency medicine. I replied that while the idea of seeing truly emergent patients makes me very nervous and a little panicky, I haven't been on CCU rotations long enough to know how well I actually handle it. Sure, it's fine to help care for and monitor the sick and post-op patients that are in CCU all night, but other than the coonhound episode last night, we haven't really had emergencies yet. The hours are not as bad as I expected -- I'm hopeful that I'll be able to keep up this eating and sleeping schedule for the rest of the week -- and it's certainly nice to do shift-style work, where whatever isn't done by the time the next shift arrives at 7 am, I can pass off to them and just leave when rounds are done between 7:30-8 am. The CCU nurses are really great -- they are fantastic at teaching technical procedures like placing IV lines, urinary catheters, blood draws, injections, etc. -- and they stay extraordinarily calm when things go wrong or it gets hectic. I guess I might like CCU/emergency work more than I thought I would, but at this point I can't really picture myself going for employment at an emergency clinic or anything like that after graduation. Maybe that will change; who knows.

Goodbye vacation, hello CCU overnights

2011-08-22T17:14:00.004-06:00

My first 2 weeks of vacation ended yesterday, and I had a heck of a good time. We spent most of the first week in Minnesota visiting family, including a trip up to the lake where we went fishing 4 times in 24 hours and I caught an awesome 14-inch largemouth bass. This is not my fish, but it looked just like this:

Week 2 of vacation involved sleeping in (a lot), a full day of doctor's appointments (all annual check ups), camping in Estes Park, and a trip to the water park (where it did not rain and nothing of ours was stolen -- there had to be a first time for that!).

I am so glad that we are given 2 weeks of vacation at a time. Although I was quite refreshed after the first week, the 27 hours of driving over the span of 2 days kind of sucked up 29% of my vacation that week, and it was really nice to have a second week to just chill out and get stuff done. It's hard to have doctor appointments, etc. during rotations when I'm at school from 6:30-7:30 am until late in the evening.

I'm also glad that we get 8 weeks of vacation built into our senior year rotation schedule, and Lord knows we need it. On orthopedics, we had a visiting senior student from NC State who informed us that they get 2 weeks -- TOTAL -- of vacation time during their senior year. Of course, they also have special time set aside in their schedules for externships, whereas we small animal trackers pretty much have to do any desired externships during our vacation time, but still. Two weeks? All year? I am already dreading how drained I'm going to be by the time my next vacation rolls around in January. By then I'll have completed 4 weeks on CCU, 2 weeks each on oncology, necropsy, cardiology, and 3 weeks each on anesthesia and radiology -- plus my grand rounds will be over (September 16, how I dread you).

But anyway, this round of vacation officially ended at 9:45 pm yesterday when I reported to CCU for orientation. Step 1 of CCU orientation was a visit to the night receptionist (who is around till 10 pm every day) to learn how to have emergency clients complete new client paperwork and how to take deposits and payments. Little did I know that I was going to get to play receptionist while on CCU overnights -- "lucky" me.

Then we had case transfer rounds, where the after-hours students passed on their hospitalized cases to us. That was followed by an orientation to the CCU room itself. Fortunately, the night nurse didn't seem bothered by the fact that I didn't know where anything was or how to do anything CCU-style, since my single rotation-mate had already had her first 2 weeks of CCU earlier this summer.

My 5 cases were as follows:

1. Middle-aged Chow with megaesophagus and a newly placed feeding tube
2. Middle-aged Shih Tzu with kidney and bladder stones
3. Middle-aged cat with possibly lily ingestion the day before
4. Middle-aged Rottweiler with previously diagnosed osteosarcoma treated with a hindlimb amputation, and acute inability to ambulate (suspected spinal cord lesion)
5. Middle-aged Lab that ate 30 Adderall pills (amphetamine used to treat ADHD in people)

As you can see, it was a night for the middle-aged, with all of my patients between 6 and 8 years of age. The Shih Tzu, kitty, and Lab were all super-sweet and happy with whatever I had to do to them. The Chow was a bit cranky, but couldn't do much to get around his e-collar at me. The Rottweiler bit another student badly before I arrived, but the consensus was that he had been painful and was startled -- nonetheless, I muzzled him any time I had to touch him in any way (especially when I tried [and failed] to place an IV catheter [his veins were totally shot from months of chemo], and when I placed a urinary catheter [much more successfully than the IV!]).

CCU overnights, as I understand them, mainly involve caring for the hospitalized patients, as well as dealing with any emergencies that come in between 11 pm and 7 am. Fortunately, we didn't have any emergencies last night, which was just fine with me since I was plenty busy harassing the poor lone night nurse to show me how to do things and where things were kept.

Treatment times in CCU are on a q24h (once daily), BID (twice daily), TID (three times daily), and QID (four times daily) schedule.

q24h treatments are done at 7 am.

BID treatments are at 7 am and 7 pm.

TID treatments are at 7 am, 3 pm, and 11 pm.

QID treatments are at 7 am, 1 pm, 7 pm, and 1 am.

As overnight students on from 10 pm-8 am, we were responsible for helping finish the 11 pms, doing the 1 ams, and doing the 7 ams. The 7 ams are the hardest because all treatments occur at 7 am.

I made it home around 8:30 am and went to bed at 10. I woke up every couple hours but did manage to sleep until almost 5 pm, so I'm hopeful that that will tide me over until tomorrow's daytime sleepfest. I made it through last night with just a 90 minute nap yesterday afternoon and was still functional by the time I got home this morning, so I hope I'll be able to get enough sleep during the days to be cogent and collected overnight.

Either way, it's going to be interesting. One down, six more to go.

My weekend

2011-08-07T17:51:00.004-06:00

Friday:

3 am -- called in for emergency surgery
4 am -- started hemilaminectomy
6:30 am -- hemi done; ran to grocery store for breakfast
7 am -- check on inpatients
7:45 am -- rounds
8:30 am -- appointments, rechecks, regularly scheduled surgeries, paperwork
5 pm -- home
6 pm -- nap on couch
7:30 pm -- wake up; eat dinner
10:30 pm -- bed

Saturday:

6:45 am -- wake up
7:15 am -- check on inpatients; paperwork
9 am -- visit with inpatient's owner
10:15 am -- home
10:30 am -- run errands; lunch
1 pm -- nap
2:45 pm -- wake up
3:10 pm -- movie at dollar theater
5:10 pm -- called in for emergency surgery
6:30 pm -- start abdominal explore/gastrotomy to remove foreign body
8:45 pm -- abd explore done
9:15 pm -- home; shower; dinner
11:15 pm -- bed
11:30 pm -- called in for emergency surgery

Sunday:

12:30 am -- start pyometra surgery
2 am -- pyo surgery done; grab a snack; paperwork
3 am -- start abdominal explore for foreign body
5 am -- abd explore done; paperwork; snack
5:30 am -- nap in VTH locker room
7 am -- wake up; check on inpatients; paperwork
9:30 am -- visit with inpatient's owner
10:30 am -- home; shower; meal (lunch? breakfast?)
12 pm -- bed
4:15 pm -- called in for discharge of pyo patient
4:40 pm -- back at VTH; paperwork
5 pm -- discharge pyo patient
5:45 pm -- home

Not sure how I am still awake and coherent, but there you go. Anticipating lots of sleep on the 13 hour drive to MN tomorrow. At least my pyo patient went home tonight so I don't have to go check on her before we leave tomorrow. Huzzah!

3 am hemilaminectomy? Yes, please

2011-08-05T17:24:00.003-06:00

My day started when I was startled from a deep sleep at 3 am by a phone call from the on-call surgeon, informing me my presence was required at the VTH to assist with an emergency back surgery.

This being my first opportunity to test my ability to get to the VTH within the requisite 20-minute time limit for on-call shifts, I was pleased to find myself somehow stumbling in the door a mere 17 minutes after being called.

The patient was, predictably, a middle-aged Dachshund with a sudden onset of hindlimb paralysis. Myelogram (injection of contrast material into the spinal canal, followed by x-rays of the spinal column) showed what was almost certainly a disc herniation in the caudal thoracic spine.

We started cutting on the little guy at 4 am, along with the on-call surgeon and the neurologist who offered to come help. Both of them were (not unreasonably) just a tad crabby. Everything went well (pulled out a huge bulging disc) and they let us loose at 6:30 am.

Which left just enough time to run to the nearby grocery store to pick up The Breakfast of Champions: a banana, a Snickers bar, a bag of Monterey Jack & Cheddar cheese cubes, and some harvest cheddar Sun Chips. That combination'll wake you right up.

I was back at the VTH by 7 am, to take a look at my poor hospitalized Westie (who took a turn for the worse yesterday but seems to have improved today). After doing a physical exam, helping with her treatments, running her blood down to the lab, and calling her mom with an update, it was time for 7:45 am case rounds.

I had a brief break from 8:45-9:30 to catch up on some paperwork, then headed up to the lobby to meet my drop-off appointment, an older lab mix who we'd seen the previous day for a workup of right hindlimb lameness. On physical and orthopedic exam yesterday, it was readily apparent that this guy's lameness had a neurologic basis, since he was pretty orthopedically sound. He had a neuro consult and the neurologists concurred, suspecting a lesion affecting his lumbosacral spinal cord.

We discussed the findings with the dog's owners, as well as the neurologists' recommendation of bloodwork, urinalysis, chest xrays, abdominal ultrasound, MRI, +/- CSF tap and surgery if indicated (e.g. for a chronic disc protrusion). We gave them costs as well as pros and cons of the neuro workup versus conservative/palliative management. They didn't seem entirely game for the full neuro workup (which, with surgery, would put them at a cost of $5-6K for their 10-year-old dog) but agreed to bloodwork, chest rads, and abdominal ultrasound as an initial step while they thought more about it. Bloodwork and chest rads yesterday were clean, and abdominal ultrasound was scheduled for today.

When I went up to get the dog from his dad in the lobby, I confirmed the plan as I understood it (drop off for ultrasound). Dad replied, "Yes, and if his ultrasound is okay, then we'd like to do the MRI and surgery if he needs it." I was mildly surprised since the orthopedic doctor who saw the dog yesterday felt the owners were probably not interested in workup (though I got a vibe that they could go either way).

This led to a frantic race around the hospital, discussing the case with neurology, MRI, anesthesia, and ultrasound to see if everything could be coordinated to take place yet today (since it was already after 9:30 am at this point). Fortunately, I'd had the foresight to ask the owners to fast the dog (yay, me!) so he was on an empty tummy and set for anesthesia.

His ultrasound came back pretty normal (some nodules in the spleen and liver which could very possibly be just old-dog aging changes, though cancer couldn't be ruled out), and he was officially transferred to neuro. I touched base with them later in the day, and they'd found a large tumor compressing his sciatic nerve on one side, and had plans to biopsy it to see if it could be safely resected or if he might need a limb amputation.

By the time that was all straightened out, it was time to watch one of the ortho surgeries -- a young dog with infraspinatus contracture, in for an infraspinatus tenotomy (a pretty easy and cool surgery). I had originally planned to scrub in, but it was a tiny surgical field and there were already 3 doctors and 1 other student scrubbed in, so I was glad to just sit it out.

After that surgery, I assisted with a consult on a lame dog that presented through Urgent Care. We didn't really find anything orthopedically abnormal with him, other than some serious edema around one of his tarsi, which didn't even really seem to be affecting the tarsus itself, just the tissue around it. Oddly, this dog had a lot of facial asymmetry, one bulging eye, a nose that deviated to one side, and strange mentation -- he just didn't seem very "with it," would periodically stare off into space and be pretty nonresponsive, and had these bizarre episodes of a repetitive chewing/licking motion that we suspected might be focal seizures.

Then it was time for afternoon rounds (doctors bought us pizza!) around 4 pm, then tidying up some loose ends, finishing paperwork, calling my Westie's owners for an evening update, and heading home.

I guess if I had to get called in during my 5 pm-8 am on call shift last night, 3 am wasn't a bad time for it to happen. It still allowed me 4+ hours of sleep, and was perfectly timed so that I didn't have much time to kill between the end of the surgery at 6:30 and the time I'd planned to come in (7 am). The oddest thing was just that my day felt shifted around by 4 hours all day -- by the time we had morning rounds at 8 am, I was ready for lunch. By the time actual lunchtime rolled around, it felt like time to have afternoon rounds and wrap things up for the day. Once I got through that, it was just like having a second entire afternoon. But I sure was beat by the end of it -- not falling asleep, but just having trouble paying attention during rounds discussions that weren't all that interesting to me (and wouldn't have been even if I'd had a full night's sleep). I'll also point out that I continued to exercise good judgment even at 4:30 pm by abstaining from the alcoholic beverages being passed around ("It's a Friday afternoon tradition!") at the end of rounds -- that is, until the hospital director came by and expressed his absolute disapproval (no disagreement from me). It was definitely an awkward end to the day!

I pride myself on good judgment

2011-08-03T18:55:00.002-06:00

Following Lilly's amputation today, I was tasked with bringing her amputated leg down to the necropsy department for disposal.

I'd hate for you not to have an accurate visual, so let me explain that this involves carrying a bloody severed limb in a translucent plastic bag through most of the hallways of the VTH, down to the necropsy cooler.

As I turned a corner to head down the final hallway toward the lab, I caught glimpse of the hospital director walking my way, followed by a gaggle of well-dressed people who were evidently getting a hospital tour.

In what I consider a moment of good judgment, I pivoted and headed back the other direction, opting to take the long way 'round rather than ambling through a group of hospital donors, gaily swinging a severed limb to and fro.

Yes, vet school beats a lot of the common sense out of you, but evidently not all of it.

Pit bull attack!

2011-08-03T18:35:00.002-06:00

There! Are you all frenzied up? Ready to frantically call the local news and demand a ban on those vicious, evil dogs?

Just kidding. Kind of.

My orthopedics patient today was Lilly, a middle-aged Westie who had the misfortune to be attacked by a larger dog while out for a bedtime walk last night.

Lilly's mom fended off the attacker, sustaining some bites to her own hands and arms in the process, then rushed Lilly to her regular vet. Lilly's rDVM briefly anesthetized her, just long enough to clip and clean the deep puncture wounds on her left hind leg, diagnose a dislocated hip, and place a bandage to keep the areas as clean as possible.

Immediately following the visit to the rDVM, Lilly's mom drove the 1 hour to the VTH, arriving with Lilly at 2:30 am. Lilly stayed in CCU on IV fluids and pain meds until she was transferred to Orthopedics when we arrived for rounds at 8:30.

Long story short, radiographs and palpation showed some serious subluxation of Lilly's left hip, with deep puncture wounds all around her left thigh. After briefly discussing the possibility of attempting a (not-very-likely-to-be-successful) salvage of Lilly's hip, everyone agreed amputation was the best option for little Lilly. So amputate we did.

My frustration with this case lies in the fact that, from the time I first heard about Lilly during rounds this morning, the phrase "pit bull attack" has been repeated about a thousand and one times.

Now, don't get me wrong, if Lilly was truly attacked by a pit bull, I have no problem saying so. If she had been attacked by a lab or a golden retriever or a Husky, I'd also have no problem saying so. No, I don't think the breed of dog that attacked Lilly is medically relevant (only the fact that she was bitten by a larger dog), but if you're sure of the breed, then go ahead and say it.

However, Lilly's presenting complaint (what the receptionists put on the appointment schedule as the reason a dog is coming for a visit) was listed as "pit bull attack." If there had been knowledge that any breed other than a pit bull had attacked Lilly, I can in no way imagine her presenting complaint being listed as "lab mix attack" or "German shepherd attack" or "Chow attack." It would just be listed as "dog attack," "dog bites," or "bite wounds."

I think the vilification of pit bulls implicit in the specification of breed in Lilly's case is unnecessary and damaging. Sure, I've met a good many pits who would indeed not hesitate to attack a cute little white dog walking down the street. But I've met a far greater number of pitties who would just as soon play bow or ignore another dog.

As Lilly's primary student, I traveled around the hospital with her to various departments today and ended up explaining her history to multiple people. My explanation went like this: "At 10 o'clock last night, Lilly was out walking with her owner when she was attacked by a larger dog. She went to her rDVM (etc.)...." Invariably, someone would ask me what kind of dog attacked Lilly, as if it would make any difference in how we would treat her or what her prognosis would be. I don't care if Lilly was attacked by a Boxer, a standard poodle, a Samoyed, a Chihuahua, or a potbellied pig, and I don't understand some people's need to hear that it was a pit bull so they can nod knowingly and look at Lilly with a greater degree of pity than if she had been attacked by another "less dangerous" breed. Even if I had personally witnessed the attack myself, and had 100% confidence that the attacker was indeed a pit bull, I still don't see the relevance to including the breed in every description of Lilly's injury. And we, as veterinary medical professionals, should know better.

And.... off the soapbox. The "good" news for Lilly is that, based on how severe her injuries were at surgery (her quadriceps were completed shredded and ripped from their bony attachments, with her patella hanging in the breeze and punctures through her skin that went all the way into her hip joint), there was zero question that amputation was the right move. And based on seeing Lilly before and after surgery, she already seemed more comfortable a couple hours post-op -- less painful and able to comfortably lie down and sleep. I've no doubt she'll be up and walking well on her 3 good legs tomorrow or the next day. Fortunately her injuries were basically limited to her left hindlimb (and her left groin region), so she's got a good prognosis as long as we can avoid infection.

"Let's play the sharing game"

2011-07-31T16:36:00.002-06:00

One of my most "interesting" clients on Orthopedics last week was a middle-aged woman who brought in her 9-week-old Australian shepherd puppy, Howie, for an exam.

Howie's presenting complaint was "Check legs, littermate had problems." Always ready for a cute puppy with possible deformities, I signed up for Howie's appointment right away.

After the requisite small talk with Howie's mom, we were ready to get down to business -- or so I thought.

"So, tell me about Howie and his littermate," I began.

"Well," said Howie's mom, "there's something wrong with Howie's littermate, but... I don't want to tell you what it is. I want to see if you can figure it out."

"Um, okay?" I offered.

"Because, you know," she continued, "I'm sure that you won't look at the rest of him as thoroughly and do a good orthopedic exam if I just tell you what was wrong with his littermate and what I think is wrong with Howie. And I'm sure you like to have a challenge, so I'd rather just see what you come up with."

(Let me just set the record straight here: A thorough orthopedic exam is performed on every patient that visits the ortho department, even if the abnormality is glaringly obvious. This means that we look at the neck, spine, digits, wrists, elbows, shoulders, hocks, stifles, hips, and tail of each and every patient, whether or not we expect to find anything wrong. Additionally, there are subtle variations in certain joints such that the only way you know whether a finding on orthopedic exam is significant is by placing it in the context of the dog's history and other problems. That is, a slight amount of laxity in a forelimb joint may be significant if the dog has been limping on that forelimb, but insignificant if the limp is in the hind end. Thus, having all the information that owners can offer us actually helps us do a better orthopedic exam with more reliable results.)

Having never encountered a client unwilling to provide information like this, I didn't know what to say, so we discussed Howie's general puppyness (has he had vaccines, when, how many? What are you feeding him?) and I completed my physical exam.

Physical exam showed an apparently normal, healthy, happy (though somewhat bratty) Aussie puppy.

I excused myself to take Howie to the surgery pit to meet with the new first-year surgical resident for Howie's orthopedic exam.

Gait observation (which by the way is rather difficult in a 9-week-old puppy who isn't really leash-trained and nips at your pants the entire time trying to "herd" you) was unremarkable.

Standing exam revealed normal puppy joints, bones, muscles, ligaments, and tendons, as far as we could tell. Nothing significant was found on recumbent exam, either.

By this point, after I had relayed the minimal amount of history that Howie's mom had shared with me, the surgical resident was fairly irritated.

One of the most important factors to a successful veterinarian-client-patient relationship (or physician-patient relationship) is mutual trust. That means that the veterinarian trusts the client to provide truthful information about the pet, lying neither directly or by omission. In return, the client trusts the veterinarian to answer questions honestly and act in the best interest of the client and patient.

Within the first 2 minutes of meeting me, Howie's mom had shown definitively that she did not trust me, the resident who would be Howie's doctor, the orthopedics service, or by extension the VTH. That did not set a great stage for a healthy vet-client-patient relationship, so I could see why the resident was frustrated and even insulted.

On our way up to discuss our findings with Howie's mom, the resident informed me that he was uninterested in telling Howie's mom what he had found on orthopedic exam until she shared with him the very relevant information about what she felt was abnormal with Howie and what his littermate's diagnosis was.

The resident introduced himself to Howie's mom, then said, "Let's play the sharing game. You have information I need and I have information you want. Tell me what was wrong with Howie's littermate."

At this point, Howie's mom fortunately got the drift that the resident wasn't interested in playing games, and readily offered everything she knew about the littermate, and everything she'd noticed in Howie.

In the end, Howie is probably perfectly normal. In any case, it's very difficult to know the accuracy of findings on an ortho exam in a young puppy. Puppies have a normal amount of looseness or "laxity" in their joints, so that you can find things in a normal healthy 9-week-old puppy that, if present in a 5-month-old dog, would be suggestive of orthopedic disease. Conversely, the absence of abnormalities at this age in Howie's case doesn't mean he won't develop orthopedic disease as he matures.

Though Howie appeared normal at 9 weeks and may stay orthopedically normal as he matures (though he'll probably always be a neurotic Aussie), we offered to see Howie back at 6 and 12 months of age to reevaluate him and see if any abnormalities had developed.

And if Howie's mom knows what's good for her and Howie, she'll learn to trust his doctors so they can trust her.

Fat Sam and his terrible joints

2011-07-30T17:27:00.003-06:00

My orthopedic surgery patient yesterday was a middle-aged golden retriever mix named Sam. Typical of most goldens (and golden mixes), Sam is about the sweetest, gentlest, most angelic dog you'll ever meet. If you stop petting him too soon, he'll ever-so-delicately offer you a raised forepaw and gently brush it on your leg to remind you he's still there.

Sam's mom adopted him from a rescue a year and a half ago. At that time she was told that he had recently been treated for heartworm infection, but was otherwise healthy. Sam's mom got him on regular heartworm prevention, made sure all of his subsequent heartworm tests were negative, and settled into a happy life, just her and Sam with occasional visits from her grown kids.

Sam's mom says that he was in rough shape when she adopted him -- his hair coat was in poor condition, he was "skin and bones," a number of his teeth were broken (possibly from chewing on rocks), and he just seemed neglected.

Several months after his adoption, Sam started limping in his hind end. His mom didn't think much of it until about two months ago, when Sam's limping became severe.

By the time Sam visited his regular vet 3 weeks ago, he was bearing almost no weight on his left hindlimb, with his right hindlimb also obviously painful on his rDVM's exam. Sam's rDVM took radiographs of Sam's hips and knees, and diagnosed him with hip dysplasia, cranial cruciate ligament (CCL, the equivalent of the ACL in people) disease, and luxating patellas. Sam left that visit with prescriptions for 3 different pain meds to help make him more comfortable.

Fast forward to two days ago, when Sam arrived at the VTH for an orthopedics consult. Sam hadn't improved much with the last few weeks of pain meds. He would bear some amount of weight on his left hindlimb but had an obviously limp, was reluctant to bend his left leg, and was more comfortable lying on his right side.

Sam's mom brought his radiographs from his rDVM for us to review. They revealed severe dysplasia of both of his hips, with moderate to severe arthritis. He also had evidence of CCL ruptures in both stifles, already with mild arthritis. Orthopedic exam showed a grade 1/4 medial luxating patella on the right side (insignificant relative to his other issues).

What Sam ideally needed to be ambulatory with minimal pain for the remaining 8-10 years of his life was a CCL repair on his left side, followed by treatment of his hips on both sides (total hip replacements or FHOs), and then probably treatment of his right CCL.

After Sam's orthopedic exam and reviewing his radiographs, we sat down with Sam's mom to discuss his joint diseases and his options. She was shocked to hear our diagnosis of "severe" hip dysplasia after reviewing his radiographs, having been told by her rDVM that he had "some" hip dysplasia but that fixing his knee should basically take care of his pain.

What Sam's mom could afford was a single surgery. So we planned to fix the most obvious source of Sam's current pain, his left knee.

I should mention at this point the other confounding factor: Sam weighs 72 pounds and should weigh 50-55. He is what we call a "body condition score" of 9 out of 9, with 4 to 5 out of 9 being ideal, 1/9 being completely emaciated, and 9/9 being, as the surgery resident put it in Sam's case, "shaped like a coffee table, with buttcheeks on his shoulders."

We proceeded to surgery with Sam yesterday, performing a TTA (tibial tuberosity advancement) which should eliminate Sam's need for a CCL (which was doing nothing it was supposed to in his left knee anyway) and will slow the progression of arthritis in this knee such that it will be almost unnoticeable.

And though Sam went home this morning with adequate pain control, a happy owner, and a bill that was less than her estimate, I can't help but feel that Sam has been failed in many ways in his 5 years of life:

(1) In this case, since Sam is a mutt, at least I can't blame a greedy, conscience-free, bad bad breeder for his joint disease.

(2) With the severity of Sam's joint disease at 1.5 years post-adoption, there is no way that a thorough physical exam performed by a competent veterinarian through the rescue group prior to Sam's adoption would not have identified at least some of Sam's joint issues (most notably his hip dysplasia). This would have allowed the rescue group to do something about it, or at least to better educate Sam's adopter about his likely need for costly medical and surgical care down the road, and the importance of keeping him at a healthy weight and on joint supplements. Whether the rescue group did not consult a vet, did not consult a competent vet, or had the information and chose not to relay it to Sam's mom is unclear.

(3) Sam's rDVM, who took his radiographs earlier this month, either mis-diagnosed the severity of his hip dysplasia, or was not upfront with his owner about how bad it was. Sam's poor mom was taken completely aback when we told her that Sam would ideally have surgery on both of his hips as well. Though there's not much that Sam's rDVM and his mom could have done differently in the last 3 weeks with a honest diagnosis of severe dysplasia, at least she would not have come to the VTH thinking that one surgery would make Sam all better.

(4) Sam's mom, though she loves him dearly, has allowed him to gain weight nearly to the point of literally loving him to death. Sam has pretty long hair, which makes him look like some amount of his bulk is due to fluff and not to fat, but it was a struggle to identify any of his bones underneath his deep fat pads during our orthopedic exams. If I hadn't seen Sam's hip joints on his radiographs, I truly couldn't have told you if he actually had bones there or not, based on palpation. Similarly, his ribs are nowhere to be found, no matter how deeply you dig your fingers into his chest. When we shaved Sam's left hindlimb for surgery, he had wads of fat sagging off his thighs.

It's the obesity that really gets to me in Sam's case.

Yes, there was probably no breeder at fault for Sam's joint disease (other than the owners of his parents who obviously didn't alter their dogs despite probable joint disease in those dogs). So no, Sam's probable inherent genetic tendency toward joint disease is not his current owner's fault.

Yes, the rescue group and Sam's rDVM could have been more thorough or more upfront about Sam's severity of disease.

But despite his "skin and bones" condition at adoption, Sam's mom did not have to allow him to become grotesquely obese, thus putting an enormous amount of unnecessary strain on his already painful hips and knees. This is the one thing that was truly preventible in Sam's case. Would Sam still be painful today and need surgery even if he weighed 50 pounds? I can't say with certainty that he wouldn't, but I'm quite sure he'd be more comfortable, more active, and could have made it longer before requiring the surgical treatment(s) he now needs.

You can give me all the excuses you want about living for months in a rainy climate, Sam not getting enough exercise from the rain, Sam getting "depressed" because he didn't get walked much and you "having to" feed him to make him "happy," and you being depressed from the weather and not caring about Sam's health.

Those excuses mean nothing to me after seeing how much Sam struggles to be a happy dog while combating an extreme amount of pain even while he's on three different pain meds.

Think about a person: Sam is the equivalent of a person having torn ACLs in both knees, and hip arthritis that makes it excruciating to take even a single step. Now take that poor person and make him wear a backpack, 24 hours a day, everywhere he goes (sleeping, getting up from the couch, walking to his car, sitting in a chair, trying to do any kind of exercise or mobile activity), with about 65 pounds of extra weight shoved into the backpack. Think they'd be as cheerful and loving as Sam is?

I find almost no excuses acceptable for an obese dog. You are the human. You can choose the type of dog food. You can choose the exercise plan. You can choose to feed measured amounts as meals rather than filling up the bowl once a day. In 95% of cases, you can make a decision not to have an obese dog.

Anyway, we had a heart-to-heart with Sam's mom about his obesity. I think (and hope) that she has a better understanding now of how important it is for Sam to lose weight. At his consult on Thursday, we recommended putting him on a hard-core weight loss diet (Science Diet prescription r/d), which Sam's mom picked up from her rDVM that same day and switched Sam to on Thursday night. She realizes that treats are now forbidden, and that she'll have to find Sam a new favorite treat from among her options of green beans, carrots, celery, unflavored rice cakes, and ice cubes.

If everything goes as planned at home, Sam won't be back for another 10-14 days, when he'll have his stitches out. At that point I'll be on vacation(!) and another group of ortho students will see Sam for his recheck. I sure hope he's doing well and has lost about 5 pounds!

Money, money, money

2011-07-25T21:19:00.002-06:00

I'm one day into my two week orthopedic surgery rotation.

My single appointment today reminded me just how much veterinary care can cost sometimes.

In a vet school/teaching hospital environment, it's often easy to forget that our clientele is not necessarily representative of the pet-owning population as a whole.

Our clients, as I'm sure I've mentioned in a previous post, come self-selected as a group of dedicated owners, most of whom have the time, energy, and especially money to "do whatever it takes" for their beloved pets.

On a rotation such as orthopedics, the vast majority of patients presenting to the service will head to surgery, for everything from limb amputations to fracture repairs to CCL repairs to corrections of congenital abnormalities to total hip replacements. The least inexpensive of the surgeries is, at the very minimum, over a thousand dollars.

So when you see these types of cases day in and day out (and it's not just orthopedics -- it's also the dermatology clients willing to commit $500 for skin testing for allergies, and $600/year for the rest of the animal's life for allergy shots -- and the neurology clients happy to drop $5000 to remove a ruptured disk from their Dachshund's back -- and the medicine clients who don't bat an eye at the $3000 bill for endoscopy and biopsies), it's easy to forget sometimes that in the eyes of a good percentage of the normal human population, spending thousands of dollars on a dog or cat's medical care just isn't something they can afford (or even want) to do.

Nonetheless, even seeing these clients every week who are unfazed by their enormous bills, I still run into the odd patient who makes me step back and re-amazes me with the staggering cost of vet care.

Case in point: Today's patient was a one-year-old exotic breed dog (one of those that you only ever see in the dog shows on TV, and have to struggle to pronounce) named Maggie. Maggie's owners bought her from a breeder as a young puppy.

Not too long after that, it became apparent that Maggie had some musculoskeletal issues. So when Maggie's rDVM spayed her at 5 months of age, he also took hip xrays while she was under anesthesia -- which revealed severe hip dysplasia on one side, already with evidence of arthritis, and moderate hip dysplasia on the other side.

Maggie and her owners made the 4 hour trip to the vet school about a month ago for an orthopedic consult. Given the severity of Maggie's disease (at merely a year old, she can barely walk because her hips are so painful, and has been on pain medication for most of her young life), the recommendation was to perform total hip replacements (THRs) on both of Maggie's hips, 8 weeks apart.

Maggie's owners said go for it.

Let's pause and consider that a single THR, without any significant complications, costs roughly $5500-6500.

Hope you didn't fall out of your chair. I almost did.

Now consider the fact that, in order to undergo a THR, a dog must be proven free of infection anywhere in its body that we can look -- so no fever, no elevated white blood cell count, negative urine culture, etc.

Maggie happens to have a not uncommon conformational abnormality of her vulva (external genitalia), wherein she has extra folds of skin leading to a "hooded" appearance to her vulva, and making her prone to skin infections in that region, which can (and have, in Maggie's case) ascend the urinary tract to cause bladder infections.

So before Maggie can have her first THR, she has to have her urinary tract infection resolved.

In order to keep her UTI from returning, she has to have her perivulvar dermatitis treated.

And her chronic, recurrent perivulvar dermatitis is almost certainly secondary to the abnormal shape of her vulva.

Which means that the news we delivered to Maggie's owners today was that, before we could even think about performing her THR, she'd have to have a vulvoplasty (classily described to the owners as a "facelift for the vulva" by the surgeon).

So we sent Maggie home today, following $400 of diagnostics for her recurrent UTIs, with a 2-week course of antibiotics (at a cost of $100 just for that single drug, due to Maggie's large size), with plans for her to return in a couple weeks for vulvoplasty. Then it'll be a couple weeks of recovery following that procedure, then we'll repeat many of the diagnostics we did today to ensure her infections have resolved, and then she'll be reconsidered for THRs.

As much as I love my pets, and as much as I admire the close relationships between Maggie and her owners, it still just kind of blows my mind that some people don't even bat an eye at the thought of spending what will probably be $12,000-14,000 by the end of it to get their dog in decent shape -- and all this before she's even a year and a half old.

The saving grace? Maggie's already spayed, so there's no chance she'll pass her crappy health genes (though wonderful temperament genes) on to another generation. :-)

Guess I should blog someday, eh?

2011-07-18T18:46:00.002-06:00

I'm glad to be done with neuro. Although the second week with a different clinician was much, MUCH better than the first, it was still a draining, depressing rotation. It's not much fun to spend 10-12 hours a day seeing dogs that can't walk, dogs with brain tumors, dogs with fatal nerve diseases, dogs with spinal cord cancer, dogs with severe congenital birth defects and owners in denial.

But it's over now! And on to dermatology, which is.... unexciting.

Don't get me wrong, it's nice to have a change of pace for a couple weeks. Knowing that I really won't ever have to be here early in the morning, late at night, or on weekends to care for "dermatology inpatients" (haha, oxymoron) is pretty awesome. Spending last weekend at the Renaissance Festival 2 hours away, a friend's house for dinner, and watching the Harry Potter movie made for some pretty nice relaxation. And you won't hear me complaining about the fact that I've left at or before 5 pm on 4 out of the last 6 weekdays. No, I can see why some people are really drawn to dermatology. (Would I commit another 3-6 years of my life to an internship and residency to become a dermatologist? Um, no.)

However, any enthusiasm I had for seeing dermatology patients in the very first days of my rotation has long since worn off.

The dermatology schedule works like this:

Monday, Tuesday, and Thursday -- 8:30 am topic rounds, then a "never been here" appointment (new patient) at 9:30 am; rechecks every 30-60 minutes from 10:30 am until 2:30 pm.

Wednesday -- reserved for general anesthetic procedures (e.g. biopsies, ear cleanings) and any "emergency" patients that need to be seen sooner than they can be worked into the regular schedule (note: there are not really any true derm "emergencies," but there are dogs and cats that are very itchy, painful, or uncomfortable because their rDVMs have exhausted their resources on how to treat or manage said dogs and cats, so they need to see a specialist). During the rest of the day when we are not helping with appointments or procedures, we work on "unknown" cases that are supposed to make us think about differentials, diagnostics, and treatments when presented with a fictitious patient, history, physical exam, and pictures of lesions

Friday -- grand rounds at 8:30, then rechecks every 45-60 minutes from 9:30 am to 2:30 pm

As you can see, with only 3 new patients in most weeks, that adds up to a LOT of rechecks. And frankly, after going through "How's Maddie been doing since her last appointment? Fine? You feel like her allergies are pretty well under control? She's been doing fine on antihistamines, shampoos, and weekly allergy shots? No new lesions? No new concerns today? OK, let me get the doctor" about 10 times, you're just sort of over it. I feel like, among our recheck appointments last week, a good 75% of them had to be dogs that were undergoing therapy for allergies and pretty much doing just fine.

The dermatology department is having somewhat of a freak-out this week because last week was their last week with multiple dermatologists. Over the last several months, they have made a transition from a four-doctor team to a single dermatologist on staff (albeit with brand new residents due to start sometime later this summer, but likely to need lots of hand-holding and mentorship at first, understandably so). This means they are packing in as many appointments as possible, so that instead of seeing perhaps 4 appointments in one day (the previous "usual" schedule for a single doctor), we're now seeing 7 or 8 appointments. Add to that the fact that there are normally 4-5 senior students on dermatology, and last week and this week it is just me and one other student, and you've got some hectic, paperwork-filled days.

Part of what is also discouraging about dermatology is that so many of the cases require so much time to reach a resolution. Many of the rechecks we see have been coming to see the dermatologists for months or years. Even among the new patients we see, the ones that should have a skin test for allergies, or biopsies of lesions, or anesthetized ear cleanings, can't be fit into the schedule until several weeks down the road, or need to have their medications withdrawn so the tests will be accurate -- which allows for very little continuity with the patients we get to know.

My lone rotation-mate is a poor large animal tracker who is not required to take dermatology. Large animal trackers take 1 small animal "core" rotation of their choosing, selecting from dermatology, ophthalmology, cardiology, or oncology. My rotation-mate got placed in dermatology by accident (it was her last choice of the four), and tried desperately to switch out of derm into another rotation, but since there were only the 2 of us scheduled for derm (and the minimum number of students for derm is usually 4), she couldn't get out of it. The poor thing; she has zero interest in small animals, and we haven't seen a single patient or discussed a single case that wasn't a dog or a cat. Even worse, she greatly dislikes cats and has ended up stuck with both of the cats that we've seen in the last week. I personally think she's doing a remarkable job, given that half of the dermatology lectures I've had took place in a small animal course that she didn't even take. I can't imagine being thrown out into the barn as a small animal tracker thoroughly uninterested in large animals, and being expected to stay cheerful and engaged and do a decent job.

Anyhoo, my first patient tomorrow morning is an itchy (and hopefully cooperative) 6 year old kitty. Here's hoping I don't bring anything contagious home with me!

Neuro cases

2011-07-05T18:49:00.002-06:00

In response to a comment on a previous post, here are some of the cases we have seen on neurology over the last week and a half:

* Dachshund with a herniated disk
* Beagle with a herniated disk
* Basset hound with a herniated disk (seeing a theme?)
* Cat with probably peripheral nerve or muscle disease, likely due to a congenital enzyme deficiency resulting in a storage disease
* Border collie with left-sided paralysis caused by a huge brain tumor
* Mixed breed dog with diskospondylitis (infection of the intervertebral disk and surrounding vertebrae, in this case caused by Brucella)
* Shih tzu with only the mildest neurologic dysfunction, probably due to a clot to the spinal cord
* Chesapeake Bay retriever with a left-sided weakness and inability to walk, probably due to a lesion in the cranial cervical spinal cord
* Min Pin/Chihuahua mix puppy with seizures, hypertonicity in all 4 limbs, a severely extended neck, inability to walk, and neck pain -- probably one or more congenital defects
* Maltese with a right-sided weakness and concurrent knee injury
* Australian shepherd with hindlimb paralysis (probably a clot to the spinal cord)
* Shepherd mix with constant tremors in the hindlimbs when standing still
* Bulldog puppy with spinal cord empyema (pus-filled spinal cord)

Pretty exciting, eh?

Is neuro over yet?

2011-07-05T18:29:00.002-06:00

3 more weekdays of neuro rotation (not that I'm counting), +/- 2 weekend days if I'm unlucky and manage to snare an inpatient for the 4th weekend in a row.

Sigh.

I did get to visit the VTH on each of the 3 mornings of this past holiday weekend (self-pity much?). My inpatient was a 12 year old Beagle who had an acute onset of inability to walk on her hindlimbs on Thursday, which is when she came to the VTH. MRI on Friday showed spinal cord compression, probably due to an acute disk herniation, so off to surgery we went on Friday afternoon. What with 12 year old dogs not healing quite as fast as 3 year old dogs, and all that, the dear Beagle got to spend a "bonus night" in CCU, beyond the usual 2 nights post-op. She went home with her owners yesterday, just in time for me to start my second (and final!!!) week of neuro.

Last week was okay in some ways and annoying/frustrating/irritating in others. The "okay" part was that we got done pretty early in the day (and by "early" I mean that I usually left between 5:30 and 6:30). My weekly hours from Monday through Sunday totaled a mere 54 -- positively relaxing!

I guess that's all I can think of for the "okay" part. On to the irritating parts: The doctors (1 faculty neurologist and 1 neuro resident in her last week of residency) had very little interest in teaching us. They showed up late almost every morning, whether that was late to rounds or late to a morning meeting time we'd agreed upon over the weekend. They would blithely rush through procedures and exams with nary a word of explanation to us students, and often with a great sigh or eye roll if we dared to ask a question about what the heck they were doing.

The faculty neurologist in particular had a horrendous attitude toward just about everybody else in the VTH -- clients, interns, lab personnel, receptionists, other departments, etc. I'm not sure I ever heard him speak to or about somebody else without a tone of arrogance, condescension, and derision. As an example, one of the patients we saw had been referred to the teaching hospital by another board-certified neurologist about an hour's drive away. Upon hearing her name, instead of saying, "She's not one of my favorite people" or "I prefer not to work with her," our faculty neurologist stated, "God, I hate that f***ing woman." Professionalism, where are you??

This attitude continued: About a prospective client trying unsuccessfully to send digital video of her dog's neurologic signs, he commented "Are they stupid or idiots or just trying to make my day even worse?" There was a huge fiasco when the doctors were only able to obtain a small amount of spinal fluid during a spinal tap, and thus had to submit several slides of the fluid to the lab rather than vials of fluid, as is usually preferred. On the lab report, there was a comment about the results being limited because the submitted sample came in the form of slides, not actual fluid to work with. Our faculty neurologist flipped out, raging about how condescending the clinical pathologists were, how it was so out of line for them to imply that he was stupid or incompetent, and how he was sick of people trying to tell him how to do his job. When he received a page from someone saying "If you're not busy or you have a moment, could you please call code #11," he derided the caller, muttering "Oh, like I'm not busy? Like I'm just sitting here twiddling my thumbs just waiting for someone to page me?" One of my favorite occurrences was when the faculty neurologist and the resident walked into the (approximately 10' square) neuro rounds room, loudly discussing how the senior students that come onto neuro rotation are never prepared and can't remember even basic information and how frustrating it is to deal with all of us, when us 3 seniors were already sitting in the rounds room, and the doctors continued their conversation about our incompetence as though we weren't even there. (Never mind that they are the ones that have been teaching us neurology for the last 3 years; never mind that theirs is one of the only specialty departments in the VTH that doesn't provide an orientation handout or list of topics to review before starting the rotation; never mind that, although we are still student doctors with a great deal to learn, we are nonetheless human and don't enjoy being mocked.)

Teaching moments last week were very sporadic; we never had afternoon rounds and only had limited morning rounds due to the doctors' tardiness and disinterest in going through learning topics. After the first couple days, we gave up trying to ask questions and get explanations for things.

Well, fortunately both of those doctors are off clinics this week and we have the other faculty neurologist on with us. He certainly has his own quirks and isn't perfect by any means, but in relative terms, it's a complete 180 from last week. We spent probably 4 hours during the course of today just sitting as a group and discussing cases and topics. He asked us to start a list on the board of things we'd like to discuss in morning rounds. We actually had case rounds this afternoon. We were invited to come along to help with neuro consultations for other departments, rather than being left in the rounds room to wonder where the doctors had disappeared to. Best of all, there was no mocking or deriding anybody all day!

Neuro is still not my favorite rotation, and I'm greatly looking forward to its conclusion. But it's nice to see how a simple change in faculty can make all the difference in a rotation.

Adios, Internal Medicine: On to Neurology

2011-06-27T20:17:00.003-06:00

My first two weeks of Internal Medicine ended on a happy note, when my very sick little patient of colonoscopy fame who spent a full 12 days in CCU was finally discharged.

Unfortunately, that kiddo's discharge to his loving family didn't happen until I'd spent a personal record of 73 hours at the VTH in a 7 day time period, including 9 hours this weekend.

It's okay, sleep is overrated. At least that's what I'm telling myself to keep from sobbing in the corner. Thank goodness for the 5 hours of naps I logged this weekend.

Internal Medicine started as a pretty stressful rotation for me. The cases are multifaceted and complicated. Internists have to have a vast knowledge base that encompasses clinical pathology, surgery, radiology, pharmacology, neurology, and many other subjects. Plus it was my first specialty rotation, having only been on community practice previously.

However, I really settled into Internal Medicine well after the first couple days, if I do say so myself. I put in long hours at school (averaged 12-13 hours on weekdays), and often spent an additional 1-2 hours studying up at home in the evening on the things from that day that I needed a refresher on.

So it was gratifying when the head internal medicine clinician from last week pulled me aside on Friday to tell me how much I had impressed him, that my medical knowledge at this stage in my career is "amazing," and that I was "leaps and bounds" ahead of my classmates on this rotation. I'll also admit to a little extra pride when one of my rotation-mates said to me at the end of the weeks "So this is what you're going to do after vet school, right?" and I said no, I want to do general practice, and they said "But you're so awesome at this!"

OK, let's move on to neurology and bring on the humility.

It's always a little challenging to start a new rotation (haha, as though I really know what I'm talking about, this being only my 3rd rotation -- maybe it gets easier as the year progresses?).

Each rotation is staffed by completely different doctors, nurses, and support staff. They have different procedures, different forms, different paperwork to complete. Appointment schedules are different; procedures for new patients versus rechecks versus inpatients vary widely. I've heard the senior year of vet school compared to starting a brand new job every 2 weeks, and that's really what it feels like sometimes. Just when you've had a good 10-14 days to settle into knowing how to deal with the clinicians and nurses, which forms go where, who calls the owners every day, and where all of the supplies live, it's time to up and move on to something totally different. It's frustrating.

Neurology started this morning with both of the doctors arriving late, then doing a very brief orientation, then shuffling us off to handle transfers, inpatients, and new appointments.

While I have to admit that I've not been looking forward to my neuro rotation since neuro has historically not been one of my favorite subjects, I nonetheless feel that that attitude toward neurology has not colored the following opinion I developed after my first day of neuro today: The neuro doctors are some of the pissiest, whiniest clinicians I've ever met.

I'm serious. The day started off with a round of bitching about clients that want to come visit at "inopportune" times for the doctors (i.e. any time on weekends other than 8-9 am), how the other services always want neuro to help with their cases that have neurologic dysfunctions, how the CCU nurses call them at night (when one of the CCU patients meets the "call the clinician if" criteria written down by the clinicians themselves, I might add) to ask about how to handle an exceedingly painful inpatient, etc. There was no end to the things that these people found to complain about (and not very nicely).

It was pretty funny to hear the contrast between the neuro doctors, who seem to have an attitude of "I am the almighty doctor and I will say what hours you can visit your dog and if you show up at a different time then God be with your soul," versus the internal medicine doctors, who, in my opinion, were much better at caring for clients in addition to caring for pets, and were willing to stay an extra hour or two on a Saturday morning so an owner could come visit, or discharge a hospitalized patient at 6:30 pm after the owners got off of work instead of insisting on a 4:30 discharge appointment.

I'm trying (and I think succeeding) not to take the bitchy attitudes personally. I feel that certainly on the first day of any rotation, it's reasonable to give the new students a little leeway and help them along and overlook (or point out politely) minor errors that have been made in procedures. And yes, we'll all become more efficient within a couple days of being neuro students -- hey, we were a lot faster by the end of the first day already.

So take a chill pill, docs! Otherwise it's gonna be one heck of a rotation...

Artificial sphincter to the rescue!

2011-06-17T19:57:00.003-06:00

Yesterday I participated in my first canine colonoscopy (okay, my first colonoscopy with any species) and debuted in the role of "artificial sphincter."

To explain: a colonoscopy is a small camera on an approximately 1/2-inch diameter cable placed into the rectum and advanced through the colon, and into the small intestine if possible.

Normally, the colon and intestines are pretty collapsed down on themselves, not just sitting wide open. So in order to be able to look around and visualize the inner surfaces of the bowel, it's necessary to blow a substantial quantity of air into the colon using the endoscope, to inflate everything.

The patient receives multiple enemas before the procedure to help clean things out, since it's a lot harder to see what the intestine looks like if there's poop all over it, but there is invariably a small amount of fecal material left, which is remedied by rinsing with water or saline through the endoscope.

Under the influence of general anesthesia, sphincters relax. It's possible to have spontaneous release of bladder and bowels. This makes it easier to pass the endoscope through the anus, but it also means that the water and air that are being infused into the colon through the endoscope have an easy means of escape through the loosened sphincter.

This is where I come in: artificial sphincter to the rescue!

No, it's not as exciting as it sounds.

Yes, it is absolutely as disgusting as it sounds.

Step #1: Wear your clinic smock over your nice clothes. Remove watch. Don latex gloves.

Step #2: Use your fingers to pinch the anus closed around the endoscope cable.

Step #3: Ignore the vibrations and farting sounds as small amounts of air leak out from the anus. Ignore the liquid fecal matter dripping out onto your (gloved) fingers.

Step #4: Smile idiotically as your rotation-mate, who is going to do her grand rounds presentation on this patient, snaps photos.

Step #5: Blog about it. (Oops, forgot Step #4a: remove gloves, wash hands.)

Yes, it was a once-in-a-lifetime experience, which is just fine, because it's not an experience that I ever need to have again. That was just a little more intimate with a dog's anal sphincter than I usually prefer to be.

(As an aside: this dog has been my patient since his arrival in hospital on Wednesday, and I'm hoping he can go home tomorrow. He is my favorite patient so far in senior year, and by far my most interesting and involved case. I'm hoping to have some time this weekend to blog about the cute little fellow!)

Goodbye Community Practice, hello Internal Medicine

2011-06-14T20:12:00.003-06:00

Community Practice is done, which is somewhat bittersweet. Sure, there were a lot of things about CP that I didn't like or that got old after a whole month, but overall it was an enjoyable rotation (which is good, since I think that my career goal after vet school is basically CP-type employment).

My first two days on Small Animal Internal Medicine (SAIM) have provided an interesting compare-and-contrast to Community Practice (CP). Here are a few of the variations:

CP clients are, overall, pretty nice but usually come with a financial limit. There's plenty of haggling over which heartworm medication to prescribe ($35 for 6 months versus $45 for 6 months), whether diagnostics like cytology of a skin mass (~$35) fit into the budget today, that sort of thing. CP clients are to always be advised of the cost of everything before we do any procedures or diagnostics -- even things as simple as vaccines or a nail trim.

SAIM clients arrive at the VTH having already been informed of the ~$90 exam fee. That means that they are aware that, just by walking in the door to see a specialist, they will be spending roughly a hundred dollars before we get to any bloodwork, urinalysis, xrays, ultrasounds, CT, MRI, anesthesia, surgery, endoscopy, cytology, biopsies, or myriad treatments. Most SAIM clients have already had their pet's problem(s) worked up by their referring DVM (rDVM), meaning they've likely already shelled out quite a bit of money before arriving at the VTH.

CP clients tend to be intelligent people who are not overly familiar with veterinary medicine, wellness care such as vaccine schedules, and the benefits of screening tests such as annual bloodwork and fecal exams. Their level of compliance with such recommendations is quite variable.

SAIM clients have typically done a lot of research into their pet's suspected illness, whether through the Internet, their rDVM, or multiple other consults before they came to us. They tend to be familiar with causes, complications, and treatments for their pet's disease, and are often quite comfortable with medical terminology.

CP sets a time limit for appointments: a goal of getting the client from the front desk checking to the client service desk checking out in under an hour. This goal is not always met, if CP is very busy or if the pet has complicated medical problems requiring diagnostics, but it is a goal just the same. CP clients tend to keep one eye on the clock throughout the entire visit and will readily inform you if you took 25 minutes instead of the 20 minutes you told them they would have to wait.

SAIM clients often spend an entire morning or afternoon in the waiting area or exam room while their pet is seen by one or more students and one or more doctors, in addition to diagnostics such as bloodwork and imaging. They tend not to bat an eye when they've already been at the VTH for 2 hours and you tell them you'll need to borrow their pet for yet another 30 minutes so you can take radiographs.

CP students can see quite a few patients in one day. On our very busiest CP days, we probably saw 35-40 appointments with 7-9 students sharing the case load.

SAIM students see generally 1 or 2 new cases per day, plus maybe some rechecks in the afternoon for ongoing cases. They may also have 1 or 2 hospitalized animals that are housed at the VTH overnight and on weekends to manage an illness or for owners' convenience the night before a procedure.

CP students have "topic rounds" in the morning, lasting about an hour and covering such themes as "new puppy visit," "new kitten visit," "heartworm disease," and "feline upper respiratory infections." CP students have "case rounds" in the afternoon, lasting 20-60 minutes and briefly discussing all of the appointments from the day.

SAIM students have topic/case rounds in the morning, lasting 60-90 minutes and including updates on all of the inpatients from the previous night, as well as often discussing one or two internal medicine topics (like diabetes or renal failure). SAIM students have afternoon/evening case rounds, lasting 1-2 hours and discussing most of the day's cases, especially any patients staying in the hospital overnight.

Two of the most stressful things about SAIM are (1) presenting cases to clinicians and (2) discussing cases in rounds.

Presenting a case to a clinician goes something like this: The SAIM student retrieves the paperwork, client, and pet from the waiting area, escorts them to an exam room, and spends 20-30 minutes (less if a recheck) getting a history and physical exam completed. The student then leaves the client and pet in the room, pages the clinician to the rounds room, then tells them about the case. You start with the signalment (pet's name, species/breed, sex, reproductive status, and age), then the presenting complaint, then the history, and finally your physical exam findings. Next the clinician asks for your problem list -- the list of each thing that is wrong with the animal (e.g. vomiting, coughing, lethargy, elevated liver enzymes on bloodwork from rDVM, etc.). Then you go through each problem one at a time and tell the clinician your "differential diagnoses" (what possible diseases could be causing the problem), rank your differential diagnoses from most to least likely based on the other findings, and discuss what further diagnostic steps you would need to take to prove or disprove each differential diagnosis.

Presenting cases to clinicians is somewhat harrowing because, for some reason, your brain tends to completely shut off when you are sitting down one-on-one with somebody with much more education and experience than you. It's something that I'm sure gets easier with practice, but at this point in our senior year we find that it's altogether too easy to misspeak, second guess ourselves, and overthink even simple problems.

Discussing cases in rounds is probably even more stressful. This means you're sitting in the cramped rounds room with 8 other senior students, the head faculty clinician, and 4 other doctors (interns and residents). The head clinician basically grills you, in front of everyone else, on the nitty gritty details of your case, the pathophysiology of the pet's disease, the pharmacological actions of the drugs you've chosen, the possible causes for all the abnormalities on the labwork, and anything else they can think of. There is lots of awkward silence while everyone avoids eye contact to minimize the chance of being asked about someone else's case -- and lots of empathy toward the poor individual stuck in the spotlight until their case has been thoroughly dissected.

Overall SAIM is a lot less physically exhausting than CP, because, for one thing, the rounds room and treatment area are right next to the lobby rather than at the farthest end of the hospital where CP is located. Second, seeing only 1-2 new patients a day means a lot less animal handling. Third, there is a group of 4-5 technicians who are dedicated to SAIM and extremely capable of obtaining blood and urine samples or restraining for procedures while you go off to research your case or discuss it with the clinician. So it's nice not to be on my feet quite as much, not to be racing around the hospital all the time, and not to be wrestling large dogs everywhere I turn.

However, SAIM is undoubtedly a much greater mental challenge than CP. It's a struggle sometimes to recall all of the important yet very detailed information I've learned about anatomy and physiology and disease processes over 3 intense years of classroom teaching, and to put it into practice when much of our previous style of exams has been more about regurgitation of facts than about decision making with real life case examples. And I just want to point out that many of the cases that we've seen in the last 2 days are referrals from rDVMs who had already tried and failed to diagnose the pet's illness. So it's not like they're just run-of-the-mill cases.

In any case, it's definitely going to be a fantastic learning experience and a challenge to my brain -- and I think I'll feel like it's been a rewarding experience at the end of my 2 weeks when (hopefully) I've become a little better at planning my case work-ups and thinking of logical differentials and diagnostics to pursue.

I can only tell you so many times

2011-06-11T13:52:00.004-06:00

I saw a sweet little lab mix last Tuesday named Copper, after she was seen by our emergency department last weekend for an exam after one of the small children in the family accidentally closed Copper's tail in a door. Much of the skin on the end of Copper's tail had been pulled off in the injury, and she had soft tissue and bone sticking out the end of her tail with not enough skin left to do a surgical closure over the exposed bone and tissue.

CCU bandaged Copper's tail and sent her home with an e-collar, antibiotics, and pain meds, with instructions to have the bandage changed on Tuesday at the owner's regular vet or at Community Practice. They also advised the owner that it was entirely possible that the tail injury would not heal on its own and may require surgical amputation, but the family had financial constraints that limited them to a bandage and supportive care at this point.

Copper arrived at Community Practice on Tuesday, tail cautiously wagging and e-collar banging into everything in the waiting room, surrounded by a gaggle of children under 5 (four kids, to be exact) and a rather exhausted looking mom.

It was a good thing Copper had a bandage change already scheduled, because her bandage had fallen off that morning anyway.

On physical exam, Copper's tail was very clearly painful and didn't appear to be healing, although it was still a little early to tell, being only 3-4 days out from her injury. We placed a sterile nonstick pad over the exposed end of the tail and wrapped the tail in a sticky, stretchy bandaging material called elasticon.

I sent Copper home with mom & children, with an agreement to see her back for a bandage change and recheck on Friday (3 days later). The hospital has a system for readmitting patients during a Monday-through-Friday time frame called "orange sheeting." Normally, when a patient's visit is concluded, the student turns in the fee sheet to the business office (oops, we are supposed to call it "client services" now), and the billing staff put the charges into the computer then have the client pay for the day's fees and close out the invoice. Every time an animal has a new appointment, there must be an associated charge (unless we do something special to write it off) -- the exception being orange sheeting, where you fill out an orange sheet for your patient and turn it in to the receptionist with a time written on it that the patient will be coming back for a "readmit" appointment later that same week -- then you just keep the fee sheet until all of that patient's appointments for that week are concluded, and turn it in at the end of the week when they have their final checkout -- thus saving the client recheck fees or exam fees or whatever else would have been charged for opening a new set of paperwork every day.

So Copper's mom & I agreed to see her at noon on Friday, meaning I kept Copper's fee sheet and other paperwork and put in an appointment for her at the reception desk.

On Wednesday, I made a quick follow-up phone call to Copper's mom to see if the bandage had stayed on and to ask how Copper was doing overall. There was no answer, so I left a voicemail, concluding with "Please call if you have any questions or concerns, otherwise we will see Copper at noon on Friday."

On Thursday, one of the Community Practice technicians went through the schedule for Friday appointments and called each of the clients to confirm their appointment time on Friday (i.e. "I'm calling to confirm Copper's appointment for a bandage change at noon on Friday, please call back if you need to change this.").

On Friday, noon rolled around and I waited for Copper's appointment to turn green (we have a flat screen TV in each of the rounds rooms that displays that service's appointment calendar; appointments are initially purple or yellow or some other color that denotes what kind of appointment it is, then the front desk makes the appointment color change to green whenever the client checks in at the front desk).

By 12:10 pm, the Copper's appointment wasn't green, so I went up to the waiting area to check and see if Copper had arrived, just in case the receptionists had forgotten to turn her appointment green, or if there was a computer glitch, which is not unheard of. No Copper, no Copper's mom.

I got caught up helping a classmate with their patient for a few minutes, and at 12:30 I finally had a chance to call Copper's mom.

"Hello, I'm calling from the veterinary teaching hospital. We had Copper down for a 12 pm appointment?"

"Oh!" said Copper's mom, clearly surprised. "I was sure her appointment was at 3."

"Hmmm... Can you bring her in any earlier?" I asked, knowing that our last Friday appointment is typically at 1:30 pm, and all the students and clinicians skedaddle as fast as humanly possible once the last appointment and afternoon rounds are over.

"I don't know -- my husband has Copper right now -- let me call his cell phone and I'll get right back to you," replied Copper's mom. I made sure she had the correct phone number for the direct line to Community Practice, and hung up.

By 1 pm, Copper's mom still had not called back, so I tried her number again (the only phone number in her record). No answer, so I left a voicemail asking her to please call back as soon as possible.

By 1:30 pm, my next patient (and the last scheduled appointment of the day) had arrived, so I left one last voicemail for Copper's mom, advising her that we were at the end of our appointment schedule, and I had tried repeatedly to get a hold of her, and unfortunately, she would just have to reschedule Copper's bandage change for Monday and call CCU or Urgent Care over the weekend if Copper needed treatment before that.

I was bummed, first of all because I was interested to see how the bandage I had applied had held up and if Copper's tail had started to show any inclination to heal on its own.

But I was also sorry that Copper's mom will almost assuredly end up paying far more in fees for Copper's care because of missing her Friday appointment. We would have saved her at least $25-35 just from orange sheeting Copper this week, plus we had bought a whole roll of elasticon on Copper's account, and kept it at the hospital, planning to use more of it to rebandage Copper's tail on Friday and teach mom how to do it at home. If Copper needs a bandage change over the weekend, she'll not only have to pay the $89 exam fee but also a bandage change fee and the cost of new bandaging material.

It's really too bad that we apparently had some kind of miscommunication about Copper's appointment time, but I can't for the life of me figure out how that happened. It was Copper's mom who, on Tuesday, selected what time would work for her best to come back on Friday. In addition to us agreeing on noon when she left on Tuesday, she had 2 voicemails after that that both told her the appointment was at noon -- which is one more than most owners get, and most clients still manage to remember the correct appointment time.

Just hope Copper is feeling okay this weekend, and that she hasn't run out of the pain meds that we planned to refill for her yesterday...

I forgot Zeke!

2011-06-07T21:18:00.002-06:00

I meant to post a picture of last Thursday's doggie castration: Zeke, another humane society kiddo!

Yep, it's gonna be one of those weeks

2011-06-07T20:32:00.004-06:00

2 days into this week and I'm already completely ready for another weekend.

Yesterday was my second Monday spent surgerizing at the county humane society. Actually, before we even got down there, we spent much of the morning at the VTH taking care of the patients who had dropped off from a different humane society for surgery on Tuesday. That meant walking, feeding, watering, setting up cages, weighing, doing physicals, taking temperatures, checking testicles, shaving for spay scars, and drawing blood on 6 friendly but exuberant doggies.

After getting those guys set up, we headed down to the shelter. Three of us went. We had 4 dogs on the schedule -- 2 black lab/pointer cross puppies, a tiny terrier cross puppy, and a large terrier cross puppy -- all spays. The lab/pointers were around 20 lb each, and nice and passive in their complete fear of everything (makes for cooperative patients!). The tiny terrier was, well, tiny (only 5 lb!) and wanted nothing more than to just be held. The large terrier was a complete nutjob (in a crazy happy sort of way), requiring just a "touch" of additional sedative pre-surgery.

Of us 3 students, I was the only one who had been to the humane society from Community Practice before, so I'll admit it was kind of fun to actually have a semblance of an idea what was going on and be able to answer the other guys' questions.

We started with anesthesia on my classmate's lab/pointer spay ("Annie Oakley"), which was relatively uneventful, then induced my lab/pointer spay ("Ariat"). This was my first time since junior year to be the one to do all of the induction stuff -- meaning premedication, IV catheter placement, induction with injectable anesthetic drugs, intubation, connecting monitoring equipment, shaving, etc. Since I've generally been a stress case about anesthesia stuff, and have had some struggles with technical skills like intubation and IV catheters, it was rewarding to do it all myself without any mistakes.

Ariat's spay went pretty well -- about an hour and a half in length -- and she recovered nicely (unlike her brother, neutered by the shelter's staff vet, who woke up screaming bloody murder).

Toward the end of my spay, the surgery instructor came by to ask if I was interested in doing the last spay (since there were 4 dogs and 3 students). I kind of didn't want to, but the answer to such a question is always "Sure!" -- I offered repeatedly to let my classmate (a general tracker with only 2 weeks on Community Practice instead of 4) to take the last spay, but the instructor insisted we flip a coin to make it "fair." Flip we did, and I was soon informed that I "won."

Sigh. Though I'm getting faster and more efficient in surgery, and gaining comfort with the procedures, I'm still at the point where a single spay (especially a dog spay) leaves me fairly well exhausted. It's partly physical -- standing over a surgery table, body tense with general worry about slicing into something that will hemorrhage everywhere, and holding arms and hands in a strange position to keep everything sterile -- and partly mental (that same sort of thing with the not wanting to cut a giant artery and watch the dog bleed to death).

But sometimes you've just gotta push on -- hunger, thirst, headache, and full bladder be darned.

So I finished up Ariat's spay, got her to the recovery area, and stepped out of the surgery suite -- only to find my classmate waiting expectantly with Shiloh, the tiny terrier, already premed-ed and out in the prep room, IV catheter and induction supplies at the ready. I did excuse myself for a big drink of water, but there wasn't time for much more than that.

It's been a long post so far -- so here's a cute puppy picture of Shiloh to keep you entertained:

So Shiloh was smoothly induced (again, a nice catheter placement and intubation) and I scrubbed in, again. Shiloh's teensy weensy ovaries and uterus were out and she was closed up and in recovery with a skin-to-skin surgery time of 1 hour on the dot -- my fastest dog spay yet! I started Shiloh's surgery well after one of my other classmates had started his spay, and I finished about 45 minutes before he was done. I don't mean to gloat or anything (keeping in mind that my first spay was at least 2.5 hours), but it was just a nice reminder of how far I've come surgery-wise with 2 more weeks' experience.

We got back to the VTH around 5:15, at which point I grabbed a quick bite of dinner, made some follow up phone calls from last week, helped out with a couple appointments (just restraint and that sort of thing), and did a proper PE on my surgery dog for Tuesday and got his paperwork going. I got home around 6:30 pm.

Today turned out to be a loooooonger day that Monday (even though I was thoroughly exhausted after Monday). I rolled into the VTH shortly after 7 am to get another good look at today's surgery patient and make sure everything was set up for his surgery before 8 am rounds. Today's doggie was a 6 month old red miniature Dachshund -- just about the sweetest and silliest hound dog you've ever met. His name is Mickey and if you sit on the ground he loves to race toward you and try to launch himself into your lap, but he just can't make it most of the time on account of his stubby little legs. He also loves to roll over and wait for belly rubs.

Anyway, Mickey's surgery and anesthesia were extraordinarily efficient today. I checked on him at 10:05 am, when the tech students had just brought him into the anesthesia prep room but hadn't started working on him yet, and when I came back 10 minutes later, he was catheterized, induced, and ready to be shaved for surgery. (And 10 minutes may seem like a plenty long time, but in the world of brand-new anesthetists, that's almost a world record.)

Mickey was in the surgery suite by 10:25 am and I started cutting at 10:35 and finished my last intradermal suture at 10:55 am -- a 20 minutes neuter, skin to skin, which totally beats my 40-60 minute neuters I've done previously. The nice thing about neutering young dogs is you can almost just rip those testicles right of them without having to mess with the scrotal ligament that attaches the testicle to the inside surface of the scrotum very strongly in older dog.

Mickey recovered well (though he was pretty chilly -- he got down to 94 degrees in surgery, with 100-102 being normal body temp). Since I had no appointments until 4:30 pm, I tackled about 8 phone messages that had been left over the course of the morning.

After all the lovely phone calls, it was a quick bite to eat and then a surprise 1 pm appointment. One of my rotation-mates has a dog of his own who has been battling lymphoma for a few months and recently going downhill -- the poor thing is only 4 years old -- and my classmate got some really bad news about his beloved doggie today, so he headed home around noon.

Which left me with his 1 pm surgery intake -- a client-owned animal dropping off for surgery on Wednesday. The patient is a pretty little yellow lab, about 6 months old, who's in for a laparoscopic spay and gastropexy. She's a bit shy, especially around men, but overall a good girl and very cute. And she finally went potty for me outside at her last walk of the evening!

Aside from the surgery puppy for tomorrow, I helped out with some blood draws, vaccine administration, nail trims, anal gland expression... basically a full afternoon of assisting with other people's patients when they were in the treatment room.

My 4:30 appointment was an 8 year old Chesapeake Bay retriever due for some vaccines, needing a nail trim and anal gland expression, and also with a long complicated history of urinary incontinence, right forelimb lameness, multiple skin and subcutaneous masses, etc. etc. etc. They also arrived at 3:55 pm for their 4:30 schedule appointment and seemed a bit put off when it was 4:05 pm before I came up to get them (my bad, I guess I should have been more than 25 minutes early to come see you).

My 6:00 was a sweet, happy 1.5 year old shepherd cross due for her annual boosters on her puppy vaccines. Her owner was super nice and signed her up on the VTH's wellness plan, started her on a lepto vaccine in addition to her DA2PP and rabies, consented to a heartworm test and sending home preventive, and allowed deworming and promised to bring back a fresh poop sample for a parasite screen.

When they left at 6:45, I was left with a couple records to write up, then feeding, walking, and medicating (ear meds) my lab spay for tomorrow, and feeding and walking my Dachshund neuter for today. With an arrival at home at 8 pm, it was nearly one of my longest days on Community Practice -- and there's no sign that the rest of the week will be any slower!

Weekends: so much better as a senior

2011-05-30T11:21:00.002-06:00

The transition from junior vet student to senior vet student has been abrupt and very interesting.

Though we're only 2.5 weeks into senior clinics, junior year seems so long ago. Was it really just a month earlier that I was sitting in class for half the day, taking at least 1 exam every weekend, and stressing out about capstone?

And was it only a month ago that the hospital was filled with confident, knowledgeable, soon-to-be-DVM former seniors? Now it seems like it's always been the norm to see my own classmates sitting in the rounds rooms, running the anesthesia cases, dealing with all the clients in the lobby, and striding around purposefully discussing cases with the clinicians.

I do miss having a few hours every day to sit back in class and engage in passive learning, taking notes on whatever topic the lecturer throws at us. It was nice to know that if I really had too much stuff going on outside of school, if I got sick, or if I was just running late, missing a few minutes of afternoon classes would go unnoticed.

However, despite the massive increase in hours spent at school (from 20 hr/wk of junior rotation + 10 hr/wk of classes, to 50-55 hr/wk of senior clinics), I am enjoying senior year so much more than junior year.

One thing I particularly love is the fact that, for the most part, when I come home from school, my time is my own. At this point, NAVLE studying hasn't started yet and Community Practice as a senior rotation doesn't require much studying other than the several hours I spent reviewing the surgery handbook. It's awesome to be able to relax and watch a little TV or hang out on Facebook or (gasp!) sit on the couch and read a book without the nagging feeling that I'm wasting what should be precious study time.

Weekends are fantastic too. The same sort of thing goes -- I don't feel bad sleeping in, hanging out with CLH, running errands. Spending Sunday morning at church doesn't give me the sense that I'll have to cram my study time into just a few afternoon hours. And no exams! No exams!

As a senior it's also more interesting to have primary case responsibility. As a junior, there were a few times when I was the one leading the appointment, but more often it was following along with senior and then finally learning enough about a given case to really be interested in it, only to have to leave at noon to grab a bite of lunch and make it to class on time -- then come back the following day and try to catch up on everything that happened the previous afternoon and overnight.

I love the opportunities to interact with clients. It's been pointed out to us students that the clientele at a veterinary teaching hospital is generally fairly self-selected to be the more dedicated clients who have intense bonds with their pets and are willing to educate themselves about the things we tell them. It's really fun to talk to these clients and learn about their dogs and cats and leave almost every appointment feeling like we had a successful visit and everyone left satisfied.

I really like that we still have another 3 months to "practice" being seniors before the new juniors will join us in late August and early September. Though we're gaining confidence every day, there is still a lot to be learned before we take the overly eager juniors under our wings and try to answer all of their questions fresh from 2+ years of book-learning that we will have pushed somewhat to a back corner of our minds by then.

Though Community Practice has been full of very long and very busy weekdays, with 12+ hour days on Tues/Wed/Thurs being basically the norm, I'm glad this is where I started my senior year experience. And I'm glad I have another 2 weeks to go before I get thrown into internal med with its caseload of hugely complicated medical diseases, hours spent writing detailed SOAPs for patients with 15-20 different problems, and increased likelihood of having hospitalized patients to care for in the evenings and weekends. For now, I'll keep my free time to myself, thanks very much.

Client drama

2011-05-27T17:59:00.004-06:00

I have a feeling that 11.5 months from now I will have had about a hundred blog posts that could have had this title. Sigh.

Today's dramatic client was actually a pretty sad situation. Mrs. A is an elderly, disabled client with extremely limited income. She has a 14 year old dog named Timber that she loves very much.

Timber has very severe arthritis in his hips and stifles (knees). He's been on carprofen, a non-steroidal anti-inflammatory drug [NSAID] kind of like a doggie version of Advil, for many years. He also has ulcerative bullous keratopathy, an eye condition that causes him some pain unless he is medicated daily, and has caused him to go basically blind.

Mrs. A started bringing Timber to the VTH this past January to see Ophthalmology for his eye problems. Given Mrs. A's severe financial constraints, Ophtho basically wrote off everything in the $150 visit except about $20 worth of fees.

Since then, Timber had several more rechecks with Ophtho (again, all but $10-20 of the bill written off) and a couple appointments with Community Practice (and again, tons of write offs).

Timber's most recent visit at Community Practice was to check bloodwork to see if his organs were doing okay with his chronic NSAIDs, since carprofen can sometimes cause liver problems in particular. Timber's liver values looked pretty okay for a 14 year old dog, so he was sent on his way with 3 more months of carprofen, instructions to come back in 3 months to repeat bloodwork, and a bill that had Mrs. A paying only the cost of the medication and not the $39 exam fee or the $45 of bloodwork.

Fast forward to this afternoon. Being a kindly, congenial student who likes to work as a team with my classmates, I jumped up from my chair to answer the Community Practice phone when it rang. I found myself conversing with Mrs. A, who started crying almost immediately, and told me all about her life, her financial problems, her health issues, Timber's health issues, and how she had made an appointment in 10 days to recheck bloodwork but would have to know in advance exactly how much she would be expected to pay.

Ugh. This is my favorite kind of random phone call-slash-complicated situation to wander into.

I went on my way to do some investigating. I first discussed the case with the head doctor in Community Practice, who said we really couldn't write off any more services for Mrs. A, but that it would really be an ethical concern to continue prescribing carprofen for Timber without checking his bloodwork to see if the drugs we were giving him were hurting his body ("first do no harm," and all that).

My next stop was Ophthalmology to consult with the specialist that Timber saw in January to learn at least a little something about ulcerative bullous keratopathy and whether it would be necessary for Timber to keep having his eyes medicated twice daily, at a cost of $30 per tube of ointment. The answer was "Um... I guess not? As long as he doesn't seem painful?" Ooookay, then.

Stop #3 was back to Community Practice to pull up the Walmart $4 drug list on my laptop to see if we could get either Timber's eye meds or his NSAIDs at a lower cost than through the VTH pharmacy. Unfortunately, his eye meds weren't on the list and carprofen is not a drug that's used in humans. It might have been possible to switch Timber from carprofen to meloxicam (another NSAID), but the dose of meloxicam he would need was about 1/7 of the smallest size tablet carried in human pharmacies, so he'd have to have it compounded into a special liquid formulation which would end up being more expensive than the carprofen anyway.

My last stop was to our fantastic client support institute, staffed by wonderful people who are highly skilled in talking to all manner of angry, sad, bereaved, frustrated, or confused client, in addition to giving us students advice on how to handle difficult situations. I mostly knew what I needed to tell Mrs. A, but it was just nice to let somebody know about the situation I was dealing with and get their opinion.

Finally I called Mrs. A back (by this time, all my classmates had left for the weekend and most of the hospital was shutting down). We talked for about 20 minutes (well, mostly she talked) and she told me about her beloved cat that she had for 20 years that died a couple years ago and she has never gotten over it, how she has had problems with severe depression and has a lot of health problems and takes many medications, how she has stopped taking her own meds at times so that she can afford care for Timber, how she cannot take him to the low-cost vet clinic in the large metro area an hour away because she doesn't have money for gas, etc. etc. etc.

She was very sincere and I got the feeling that this is a client in a truly difficult situation, not somebody who's just out to manipulate us into giving them free services. The complicating factor is that the medical records from Timber's most recent visits seem to indicate that he is not in very good shape despite the medications he's on, and that the students and doctors that have seen him in the past have been concerned about his quality of life.

Long story short, we eventually got to the point where Mrs. A said she has spent the last 3 months saving up the $94 that will cover Timber's $45 blood test, his $18 carprofen prescription, and his $31 eye ointment. So she can bring him in for a check up as long as we can waive the office visit fee. I guess it's my job next week to figure out how to convince somebody to do that before she comes in.

I did get into a bit of a discussion with Mrs. A about quality of life issues, although she would get very teary whenever we mentioned Timber's age or his serious health issues. I offered to have one of our client support people call her next week to chat about some of these things, which, fortunately, she readily agreed to.

All in all, it was a pretty emotionally draining afternoon. Mrs. A's situation raised two of my own fears -- at some point not being able to afford the care I'd like to provide for my pets, and getting to the point where it's time to let them go and not being able to recognize it. It's so unfortunate in veterinary medicine that we have to deal with this kind of financial situation all the time (fortunately not often to quite this degree of severity). Life would be a lot easier if care could be cheaper and pets were insured.

In other news, 4 of the 9 members of our Community Practice student team are leaving us after today. Next week we'll gain 2 new students who will join me on my "Team B" to make a 3 person team, versus 4-person "Team A." I'm sure it'll be fine, except for maybe Tuesday, when Team A will be down at the local shelter gettin' their surgery on, and my 2 new Team A-mates (who have no experience with how Community Practice does things) and I will be left at the VTH to handle a full schedule of 9am-6pm appointments, plus a double-booked afternoon from 1-3pm with surgery intake appointments every half hour in addition to the regularly scheduled 1, 1:15, 1:30, 1:45, etc. visits! Should be an interesting (and long) day. Hooray for the 3 day weekend!

Surgery & me

2011-05-26T19:14:00.005-06:00

We're approaching the end of our second full week of Community Practice, and let me tell you, as much as I've enjoyed it, I am SO glad we'll have a 3 day weekend!

My surgery confidence has been improving. I have thus far met my goal of not vomiting before, during, or after any one of my surgeries. My nerves have decreased quite a bit, although I still have to occasionally quell some panic when I'm actually in surgery.

Last week I had a dog neuter (4 mo Chi from the humane society) and a dog spay (5 mo client-owned hound x). This week I did an 8 week old kitten spay on Monday, a 1 yo cat spay on Tuesday, and a 5-10 year old Chi X spay named Cheeto today (all from various humane societies). Here's my Monday kitten, Celine, who has already found a home:

Cheeto's spay today was by far my most harrowing surgery. I was pretty stressed out for my very first dog spay last week, but that stress was due more to never having done a spay before and general concerns about cutting open an abdomen and yanking out parts. Today's spay was stressful because things started going wrong.

First of all, the anesthesia left something to be desired. Our anesthetists are technician students from one of the local community colleges, and although they have all been through several semesters of classroom learning and are all very nice people, they have a wide range of technical abilities, experience with animals, and experience with anesthesia. Still, I don't fault them for any error or oversight because I know they are still learning and I can't help but think back just a few weeks to my own introduction to anesthesia as a junior.

So Cheeto was pre-medicated, had an IV catheter placed, and was induced into general anesthesia. At this point the tech student intubated her and we connected all of her monitoring devices and I clipped her and we moved her to surgery.

Fast forward to about 20 minutes after arrival in the surgical suite. I've just started cutting, and Cheeto just isn't doing well under anesthesia. Her CO2 level is high, her oxygen level is low, she seems lighter than she should be given the relatively high % of gas anesthetic she's on, and.... wait... do I smell isoflurane?

The supervising anesthesia tech came over to help the student with Cheeto's anesthesia, and quickly ascertained that the endotracheal tube placed in Cheeto's trachea was too small -- meaning that it was not big enough to create a complete seal in Cheeto's trachea, so she was breathing a mixture of anesthetic through the tube and room air around the tube.

Really the only solution for this problem is to place a bigger ET tube. So, with her guts poking out, lying on her back, Cheeto was successfully reintubated and the remainder of her anesthesia was relatively uneventful (except for some hypotension and bradycardia -- oh, and when she kept trying to wake up every time I pulled on her ovaries).

On my end of the surgery table, I found myself dealing with a large, flabby uterus surrounded by an incredible amount of slippery fat that would not stay out of my way. Once I finally had the first ovary dealt with, I had to go fishing for the second horn of the uterus. Having found Side #2, I started to gently break down the suspensory ligament connecting the ovary to the kidney (which is a tough structure that usually takes quite a bit of effort to tear) -- and the thing snapped almost immediately. Uh oh.

Okay, then, guess it's time to start tying off blood vessels! I placed my clamp below Cheeto's left ovary, and was halfway through my first ligature around her ovarian vessels when the tissue between my ligature and the clamp just tore -- with no warning at all. Commence msasive amounts of bleeding. (Okay, in retrospect, it probably wasn't that much bleeding. I'm sure the surgery instructor laughs to herself when we freak out about these things. But hey, I don't like seeing blood everywhere!)

Fortunately, the bleeding was coming from a vessel in Cheeto's uterus which I was about to remove anyway, so I was able to clamp it off. When I'd at last removed both ovaries and most of both uterine horns, there was still more blood in the abdomen than I liked to see, so I worried that something was still oozing. However, I took the advice of the surgery instructor ("Doesn't look like that much blood to me!") and just closed the abdomen.

We close the abdomen in dogs in 3 layers. The first and most important layer is through the body wall -- the muscles and connective tissue that sit on the bottom of the abdomen and are the strongest thing we can suture. The second layer is the subcutaneous tissues, which we suture together mainly to eliminate dead space where fluid can accumulate. Finally, we place a third line of suture within the skin, the idea being to be able to bring the skin edges together over the incision without any suture sticking out.

I've been working hard on my intradermal suturing (the third and final layer). On my first dog, I didn't start or end the suture line well but it closed okay in the middle, so I had to place skin sutures at both ends of my incision. On my second spay, the middle and last end of the incision closed great but I needed a skin suture at the first end. On my third spay, both ends closed great but I had some gapping in the middle. This time, everything closed well but my knot at the end of the intradermal suture line, which is supposed to end up buried under the skin, would not bury itself no matter what I tried. So, I avoided any skin sutures, but did have to use some tissue glue on top.

In my 4 spays, the thing I've found to be most difficult each time is actually cutting into the abdomen and finding the parts I want. The incision through the skin is easy -- but then underneath there can be a hugely variable quantity of fat and subcutaneous tissues before you get to the linea alba -- the connective tissue structure we want to cut through to get into the abdomen. It's just very difficult to know how deep you're going with your gradual incisions in the same general region, although I'd imagine it gets a lot easier with time.

Once you're in the abdomen and have access to the guts, the next thing you have to do is actually locate the uterus. (Well, first you should make sure the spleen is out of the way. The spleen likes to sit right beneath the linea alba that you cut through to get into the abdomen, and the spleen is easily angered if you cut or poke it.)

The body of the uterus (the part connected to the cervix) sits between the bladder and the colon in dogs and cats. So with a dog lying on her back in surgery, the organ closest to the surface we're cutting into is the bladder, with the uterine body beneath the bladder, and the colon even further down. The two horns of the uterus are semi-mobile, so there isn't one exact place you can go to find them. So we use an instrument called a spay hook to fish around till we find what we want.

And even when you "catch" something on your spay hook, it isn't all that easy to identify it. There's a whole lot of intestines in every animal's abdomen, and in some cases they look very similar to the uterus (at least to us beginning surgeons -- again, something else that probably gets much easier with experience). So I had one spay where I kept pulling up intestine after intestine after intestine, and since I didn't know for sure that it was intestine and not uterus, I had to try to follow it one way or the other to find the uterine body or the ovary. Conversely, I had a cat spay this week when I kept pulling up uterus over and over and pushing it back, thinking it was intestine, until finally my surgery instructor came over and said "...Why do you keep letting go of the uterus?"

I've found that once the uterus is located, everything is pretty straightforward from there, because it's all a matter of ligating and transecting the things you need to ligate and transect, then sewing everything back up and waking up the pooch or kitty. It just seems funny that it takes so much time and effort to (a) get into the abdomen and (b) find the organs we're actually looking for.

I do think I've gotten over the feeling that I'm not ready to do these kinds of surgeries. It's true that I'm not yet ready to do them on my own with no supervision or assistance, but as long as I can keep from panicking, I do feel comfortable handling most of the complications I might encounter. All of our surgery patients stay in the hospital overnight after surgery, so it's gratifying to see how great they look the next morning and to reassure yourself that no, they didn't bleed to death overnight.

With 2 weeks of surgery left (which will probably be 4-5 more surgeries), I'm hoping to get in a couple more neuters as well as however many more spays I can do. The scary thing is, after this rotation is over, I'm pretty much done with primary surgery experience except for my externship rotation in the spring at a high-volume, low-cost hospital. Yes, I'll be scrubbing into plenty of surgeries between now and then, but mostly to handle the suction tip, pass instruments to the clinician, or maintain traction on the leg they're trying to fix.

Ah well, I guess that's why they call it veterinary "practice"!

Busy and tired

2011-05-18T22:14:00.003-06:00

Time to get to bed soon, so just a brief update:

As expected, activity at school has really picked up this week.

Monday was a full day of medicine appointments. I arrived at school around 8:45 am and left once all the paperwork and visits were complete -- around 7:45 pm. Nothing too exciting -- mostly well pet check ups.

Tuesday was my first surgery day -- my patient was a 4 mo Chihuahua mix from the humane society, whom I castrated quite successfully (I was totally freaked out about my first solo surgery but it went much better than I'd expected). Got to the hospital at 6:45 am after waking up at 5 am after tossing and turning all night. Left at 7 pm and drove straight to Windsor for handbell rehearsal. Medicine appointments and surgery intakes in the afternoon once my neuter was done.

Today was Day 2 of surgery -- I got to the VTH around 6:40 this morning to care for my neuter from yesterday and my spay doggie (client-owned -- nerve-wracking!) for today. Spay got going around 10:20 am and I finished closing just before 1 pm. Not the world's longest spay by any means, but I'm certainly going to be faster on my next one when I don't have to wait around for the supervising surgery doctor to assist the other 5 students before it's my turn to ask her questions again. Overall surgery was uneventful, other than being really long. Doggie goes home tomorrow. She's a 5 mo hound mix.

Lots of ups and downs -- it's fun to apply the knowledge we've spent 3+ years acquiring, but the random details bog us down -- like what forms to fill out and where to turn them in, which boxes to check on the fee sheets, which vaccines require a prescription to be turned into the pharmacy -- that sort of boring stuff. Tons and tons of paperwork, especially with the surgery dogs.

Tomorrow I'm the "relief" person meaning I don't sign up for surgeries, I just stick around the surgery recovery area, the treatment room, and the rounds room, and assist where needed. I'll probably take a couple morning appointments, and maybe some in the afternoon if the schedule fills up.

Having fun but looking forward to the weekend!

Here we go

2011-05-13T14:48:00.001-06:00

(Blogger was down all day yesterday, so here's my post from yesterday evening.)

Day 1 of senior year started out pretty gently. They eased us into what will soon become a demanding schedule with a laidback 3 hour orientation starting at 9 am. From there we hung around, chatted, ate lunch, etc. until our appointments began at 1 pm. With 9 appointments and 8 seniors, the work was evenly distributed and I ended up with just a single appointment at 2:20 pm.

First I got over the initial shock of introducing myself as, "Hi, I'm ____, I'm a senior vet student"(!!!) and noticed with great relief that my client seemed to have no idea that, had he made an appointment for yesterday rather than today, his dog would have been cared for by a student with 364 days more experience than me.

On my way up to meet the client in the lobby, I developed this paranoia that this client would be exactly like my first actor-client in communications rotation this spring -- i.e. antsy, impatient, and eager to get in and out with a minimum of talking and money spent. Fortunately my real client was completely the opposite -- he had a sense of humor, gave the impression of having all the time in the world to sit and wait for me to get things done, readily accepted all of my vaccination and preventive health recommendations, and was an all-around nice guy.

My patient was a huge fluffy black-and-white teddy bear of a dog (possibly a Newfie/border collie cross, or at least that was the best guess from the rescue that adopted him out as a puppy). Not quite two years old, he was in need of some vaccines and some serious weight loss. We enrolled him on the VTH's adult dog wellness program; vaccinated him for rabies, distemper/parvo, lepto, and bordetella; ran a heartworm test (negative); sent home 6 months of heartworm prevention; and threw in a lovely fecal sample cup to bring back a fresh "deposit" for parasite testing, given that this sweet doggie has a revolting habit of ingesting raccoon feces (and probably any other feces he can find -- I doubt he discriminates). He'll be back for a lepto booster and deworming in 3-4 weeks.

Each of us new seniors set several goals today for our time on Community Practice. One of mine was to improve my proficiency and confidence with jugular vein blood draws -- something I've always found difficult and that I'll use any excuse to avoid, even though it's something I really need to get good at. Unfortunately, a terribly obese and long-haired dog who didn't feel like sitting still turned out not to be the greatest candidate for a needle poke in the neck. But at least I gave it a shot!

Following the appointment (which took me 75 minutes from door-to-door -- which I consider respectable in light of the goal of 60 minute appointments, given that it was my first day and we got a ton of stuff done), it was time to sit down with the paperwork. Throughout his appointment, my teddy bear dog accumulated: a treatment consent form signed by the owner; a medical discharge summary; a heartworm test form; a vaccination reaction information sheet; 3 carbon copies of his rabies certificate; a history/physical exam form; a prescription for his heartworm meds; 2 pages of patient ID stickers; 2 patient ID cards; 2 fee sheets; and all of the electronic records forms I had to fill out in the computer system. I know it'll get a lot easier and faster the more appointments I do, but yeesh. No wonder last year's seniors griped constantly about paperwork.

Speaking of last year's seniors, the hospital feels empty without them. I saw one of the graduating-tomorrow seniors walking through the hall showing his family around, and he just seemed out of place. As I traipsed back and forth from the lobby to Community Practice (which is the farthest department from the reception area and exam rooms), it was so strange to see my classmates sitting in all of the rounds rooms. Yes, I'm used to seeing them in there during junior rotations, but we juniors are usually relegated to a chair in the corner or perching on a desk along the wall, rather than sitting at the rounds tables. Now it's just us.

I'm terribly thankful that we new seniors get three entire months to learn the ways of the hospital before we have new juniors tagging along with us. I remember thinking last fall, "I wonder how it is that we inexperienced juniors will magically become these total rockstar seniors" -- I now know that at least part of the answer is that we'll have 90+ days to mess up, get lost, fill out forms incorrectly, and fail 4 times in a row to dial a long-distance number (true story -- laugh all you want) before we have eager juniors sticking to us like glue.

I'm also grateful that the Community Practice clinicians and technical staff seem truly excited to have us there. After hearing many comments over the last few weeks from clinicians and interns about how much they're going to miss the old seniors, along with the occasional only-semi-joking exclamation of "Look out! The juniors are coming!", I really feel like we former juniors can offer, if not extraordinary technical competence and thorough knowledge of the inner workings of the VTH, then at least a bright-eyed and bushy-tailed enthusiasm for being out of the classroom and working full-time with real animals and clients -- an eagerness to participate in twice-daily rounds -- a positive attitude toward teamwork and stepping in to lend a hand to a classmate whenever needed. It can't be entirely fun to start basically from scratch with a group of students, but the clinicians seem to recognize that our ineptitude isn't entirely our fault, and that our ability to learn has not been totally damaged by the past 3 years of classroom teaching.

Now, I'll admit that I'm pretty tired after today, which was only an 8 hour day with plenty of downtime and merely a single appointment of my own. So I certainly can't blame the former seniors for the apathy and sullenness that reared its head starting a couple months ago. I hope, though, that we new seniors can maintain our energy and good spirit for awhile. (I say that now, when I don't have to come in until 10(!) am tomorrow -- but check back at the end of next week when I've been at the hospital 12 hours a day caring for my surgery patients and seeing appointments.)

Speaking of which: surgery. My first "goal" I mentioned during orientation today went something like this: "I'd like to be able to just think about doing surgery without wanting to throw up." And that's pretty much how I feel. I was a little panicked last week as I started to realize that senior year was so close, and it occurred to me that Community Practice isn't just medicine appointments (which I love), but also that pesky little thing called surgery. Fortunately, I've been spared from too much anxiety by knowing that I won't have a surgery of my own until at least Tuesday.

Surgery, surgery, surgery. Yes, I'm going to do it. Yes, I'll probably even do a good job. Yes, there will be plenty of people around to help me if I freeze or get confused or make a mistake. And yes, I'm sure my patients will survive and go home to their happy owners (or to happy adopters at one of the shelters). But I'm still not at the point where I can psychologically handle the idea that I will soon be cutting open the abdomen of a living, breathing creature (which I would like to stay that way), removing organs, and sewing everything back up as good as new. It just seems like a lot of power that I don't feel ready for (but I'd better be soon!).

Last thing to mention -- I got to file my first incident report today! Incident reports are the hospital's way of keeping track of any mistakes, errors, complaints, or malfunctions that occur in any way or shape in the hospital. You file incident reports for everything from a client complaining about having to wait too long, to the fluoroscope settings not working correctly, to the wrong dose of medication being sent home with a patient, etc.

Each of us new seniors got "callbacks" to do today (every case seen in Community Practice gets a follow-up call the next day, so we got all the cases seen by the old seniors yesterday). Mine was a puppy who came in on Monday for vaccines and follow-up from a rectal prolapse a few weeks earlier, likely caused by its heavy parasite load that was diagnosed and treated at the prior visit. The owners were instructed to bring in a stool sample, which they did on Tuesday, and the results from the lab on Wedneday showed a persistent Giardia infection. The senior student wrote a prescription for fenbendazole, which was picked up by the owner on Wednesday afternoon.

My follow-up call found the puppy feeling great after vaccines and deworming, but the owner was a little confused about the deworming instructions. Her prescription label for her 5 doses of dewormer indicated to give one dose every 5 days. After speaking with her, I investigated a little, having not much personal experience with fenbendazole, and learned that it is usually given 5 days in a row, one dose a day. I then called the Pharmacy, who looked up the handwritten prescription that was turned in yesterday and found out that the pharmacy technician had written the wrong instructions in the computer, which were then printed incorrectly on the Rx label. This was an innocuous mistake to have happen -- but had the owner not asked me to clarify the instructions for administering the fenbendazole, and had I not followed up on it, the puppy would have gotten possibly an ineffective course of dewormer. I'm glad it wasn't something more serious -- it's scary to think about how tiny things like that can potentially have a huge effect on a patient's health.

So close

2011-05-09T17:26:00.002-06:00

All that stands between me and senior year is a pesky behavior final tomorrow afternoon, and what I'm sure will be an exciting and informative eight hours of senior orientation on Wednesday.

The voice of reason inside my head tells me I should study for tomorrow's behavior exam, but I really, really don't want to. Sigh. I'll probably end up studying a little anyway, which is a good idea since I skipped about 6 of the latest behavior lectures.

Wednesday's orientation contains such thrilling topics as "Wildlife Regulations," "Biosecurity," and "SCAVMA Announcements." I'm just positive that they will manage to sneak some actually helpful information in there somewhere, like what time to show up to clinics on Thursday and how to use our pagers. Just kidding.

In the meantime, it's been a nice 3.5 day weekend with not much to do other than a dermatology exam and putting off studying for behavior. It certainly feels like the proverbial calm before the storm, since I'll be heading into 3 nonstop months of 50-60 hour weeks on Thursday.

Hope I'll have some time for blogging!

Capstone: 2/3 over

2011-05-04T10:49:00.002-06:00

This morning's oh-so-wonderful Capstone exam is over.

When I think back to how important my grades were to me as an undergrad -- how I really despised that one B+ I got in O-chem, how I so valued my stellar gpa -- and compare that attitude to how I feel now, I can't help but think to myself, "Nice job, vet school."

It's amazing how I am now capable of going through a 180-question exam and honestly feeling perfectly satisfied with providing a wrong answer for every single question relating to equine and bovine reproduction.

Really, why am I supposed to care how long a cow's estrus cycle is or how big a mare's ovarian follicle should be before you induce ovulation? Seriously.

C = DVM? Heck yes it does. "Just get a 70%" has become a mantra that sustains not only me but also my 137 counterparts.

Will I ever need to recall the most common circumstance under which a mare develops severe endometritis? How about the typical rule-outs for foot disease in feedlot cattle? Characteristic appearance of OCD lesions in the equine stifle? When to use or not use intramammary antibiotics to treat dairy cow mastitis?

Yep, didn't think so.

All I can say for this morning's exam is: Thank the good lord for an unusually high proportion of behavior and practice management questions in relation to the number of actual medicine questions. Gotta love something like:

"The factors that affect my happiness and feeling of self-worth include:

(a) Personal success
(b) Financial success
(c) Career success
(d) All of the above"

They forgot option E: "Only an excellent score on my junior-year Capstone exam will make me happy and increase my self-worth."

Now off to partake in some of my newest and most favorite Capstone study aid: Bubble Spinner.

Done with classes!

2011-05-04T10:38:00.002-06:00

Okay, technically we still have 3 more afternoons of lecture.

But psychologically? We are so, so through.

Yesterday afternoon marked the final set of lectures that all of us third year students, whether large, small, or general trackers, would ever have together as a class.

And yes, I'm talking about everybody's favorite course: Applied Animal Behavior!

Yesterday also coincided with the start of roof construction on the VTH, which, cleverly enough, they decided to begin directly over the lecture hall.

So, after two hours of small animal dermatology lecture, during which the entire lecture hall shook violently for about 5 seconds every 5-10 minutes, our hilarious exotics professor arrived to lecture on behavioral problems of birds, small mammals, and zoo animals.

Two minutes into his lecture, we encountered yet another simulated earthquake. The professor made a lame joke about "I didn't realize we had moved to Japan," which was met by widespread giggling with a not-so-subtle edge of hysteria throughout the student attendees.

"My," he commented. "Aren't we giddy today?" Cue more inappropriately long and loud laughter.

Thankfully, the lecture was about things like how not to let your male cockatoo masturbate on your arm, how to feed your sugar glider correctly so it doesn't have the body figure of a bulldog, and ways to stop zoo-kept polar bears from pacing obsessively -- i.e. a lecture with just the level of information we could handle.

Everyone is so completely fatigued, mentally and physically, this week that the idea of continuing to have afternoon lectures is pretty much a joke.

At least our instructors seem to realize that and are doing their best to speak slowly in simple, short sentences. (That's right, just call me Ms. Silver Lining!)

Capstone, oh Capstone, I hate you, you stink

2011-05-03T19:52:00.003-06:00

(Credit given to a classmate for a fitting adaptation of the poem "Homework, oh homework, I hate you, you stink.")

I'm 1/3 done with this year's charming Capstone exam. Yesterday was the "practical" portion covering the first half of this semester's small animal courses.

Really, it wasn't that bad. By which I mean, it could have been a lot worse.

Monday's exam consisted of 12 cases that we had to work through, covering everything from dental disease to GI disease to various types of cancer to feline cardiology to liver disease to causes of red eyes and sudden blindness to suture selection for enterotomy closures to the calculation of A-a gradients for an electrocuted dog with non-cardiogenic pulmonary edema (thanks a lot, professor-who-has-insisted-for-the-last-3-semesters-that-we-shouldn't-bother-to-memorize-all-the-equations-for-interpreting-blood-gas-data-and-then-didn't-give-us-those-equations-on-this-exam).

Each case had 2, 3, 4, or 5 parts. You had to start with the first part, fill out your answer sheet, and turn it in before moving on to the second part, and so forth. Unlimited amount of time for each case (within the constraints that you had to be done with everything in 4 hours). It took me about 2 hours and 15 minutes to get through the cases.

All of the questions were written, i.e. no multiple choice -- everything from answering with a single word or sentence to writing your complete radiographic interpretation of some chest films or penning a paragraph justifying your choice of diagnostic tests to perform.

Overall, it was indeed a "practical" exam which presented us with the kind of cases we will see as seniors in the clinic and as new vets in practice -- and the questions we were asked were designed to prompt us to make the kind of decisions about diagnostic pathways and treatment choices that we'll have to figure out as student doctors and real doctors. So it was nice that at least everything was applicable.

Tomorrow's exam is a more typical written exam covering all of fall semester's courses (radiology II, plus clinical sciences III/IV) plus this semester's applied behavior and practice management classes. It's rumored to be 70 pages of questions (mostly multiple choice, but some short answer as well). I'm more worried about Wednesday's exam than Monday's or Friday's because (a) the material was covered a longer time ago, and (b) it's half large animal information, which is not my strong suit. However, I figure that my skill at answering multiple choice questions will (I hope) outweigh those cons. I did actually get through a review of all of the large animal material from ClinSci III and half the large animal stuff from CSIV, as well as all the radiology slides (1181 slides about radiology, by my calculation. Gah.).

Friday's morning exam will be like Monday's -- a practical, case-based, no-multiple-choice-question exam -- but it will cover the small animal course material from the second half of this semester, including critical care/emergency, dermatology, endocrine disease, genitourinary disease, infectious/immune disease, neurology, and orthopedics. Since all of that material is relatively fresh, I'm counting on not having to review much (haha, I'll let you know how that goes).

Anyhow, as my derm prof would say, "The long and the short of it is," I'll be done with Capstone in 3 days and done with all of my junior year exams within 8 days, if not sooner. Bring it on, senior year!

Q: How many small animal trackers does it take to set up a horse stall?

2011-04-27T16:38:00.002-06:00

A: Only 5. As long as there is an equine medicine resident around to supervise.

Yes, at long last, I had my first adventure in the equine barn this morning!

Thanks to the fact that horses have eyes and I am on ophthalmology, I headed out with the platoon of other wary small animal trackers, led by one semi-confident mixed animal senior, to meet a beautiful black and white paint horse being dropped off for surgical removal of his ocular squamous cell carcinoma tomorrow.

I felt better once I found out that 2 of the 3 seniors in the group had never been to the barn, either -- and they're graduating in 2 weeks!

True, all we needed to do was pick a stall, put an ID card on the front, fill up the tub with water, and spread a bunch of straw on the ground. And yes, that's probably just as easy as it sounds. But I'm proud to say that the 5 of us banded together to git 'er done (as some of the equine medicine juniors and seniors looked on in amusement, and the expression on the equine resident's face plainly said "And how did you guys get into vet school?"). In our defense, breaking up a big bale of straw seems to be a lot more fun when you're not doing it alone.

In other ophtho news, I watched an enucleation (cutting out the eyeball) on an Airedale with chronic uveitis and a recently detached retina. I also saw an entropion correction (cutting out part of the eyelid that is causing the eyelid to roll in and the eyelashes to scrape on the eye) and watched a senior student tack a cherry eye.

Although all these surgeries have been cool to see (and I'm glad I got a chance to venture into the equine facilities), I do wish that they had appointments in the morning sometimes instead of surgery -- I thought I was signing up to help work up eye problems during this week of independent study, not just stand around in surgery on my tip toes trying to see a miniscule surgical field with 3 surgeons' heads blocking my view. Oh well!

COOL-slash-Ewwwwwww

2011-04-26T15:59:00.002-06:00

During my independent study ophthalmology rotation this morning, I got to watch a cataract removal surgery called phacoemulsification.

In a nutshell, it involves cutting a hole in the cornea, inserting a probe into the diseased lens where the cataract has formed, using ultrasound waves to "chew" up the lens, and then placing an artificial lens.

And it was simultaneously just about the most awesome and the most horrifying surgery I've ever watched.

The 'ewwwww' factor was not helped by the fact that we were watching the surgical field magnified on a huge video screen, so the eyeball was about a foot and a half across.

And I absolutely had to turn away when they were starting on the first eye and you could see a huge-looking but actually very miniature scalpel blade slicing into the eye, with aqueous fluid gushing out around it.

But once you stop thinking of the eye as an actual eyeball attached to an actual living dog that ideally wants to be able to use its eyeball after it's been sliced-and-diced, then this surgery is so, SO cool to watch.

It's also so neat to think that after just 30-45 minutes per eye, this dog, who has been blind since becoming a diabetic a year ago, will have basically "good as new" vision. (Okay, there's also the $3000 the owners are coughing up for the phacoemulsification, but if I had a few thousand dollars to burn, this might be a good investment.)

However, I'm afraid the 'ew' factor prevails. I'll never be an ophthalmologist!

Junioritis

2011-04-25T18:16:00.002-06:00

I'd say just about every student in my class is afflicted with a serious case of Junioritis that can only be cured with 'tincture of time.'

What I mean is, we've gotten to the point of having a visceral reaction to the thought of sitting in class any more. Studying for exams now consists of a half hour skimming through the slides from the lectures you skipped, then just winging it. Papers are written by jotting down whatever thoughts you can pluck through the exhausted haze in your mind, then going back later to find references to support what you wrote.

We have two more weeks of junior year left. And in those 2 weeks, we have 3 midterm exams, a behavior final, and 12 hours of capstone. Plus regular rotations every morning this week and regular classes every afternoon this week and next week.

Capstone (affectionately dubbed "Crapstone") seems even more pointless this year than the previous two. Our freshman-year capstone exam was given the day before we started sophomore year; the sophomore capstone was given the day before starting junior year -- i.e. at the end of a long summer with (assuming proper motivation) plenty of time to brush up on material from the previous year. Although I didn't like the last 2 Capstones, I understood that they had at least some purpose.

Capstone III, coming up in 6.5 days, has lost all purpose. With a full schedule of rotations and classes, as well as ongoing exams (basically one every weekend) and homework assignments (one or two a week), there just isn't really any time to study for Capstone. They say that the other goal of Capstone is to prepare us for a cumulative, integrative exam like NAVLE? Well, the numbers are in, and this year's seniors (the first class to have taken any Capstone exams) did worse on the NAVLE than the last few graduating classes.

So, yes. We are ready to be done with junior practicum. We are ready to be done with classes. We are ready to be done with homeworks and exams. And, most of all, we are ready to be done with Capstone.

Having seen how busy and fatigued the seniors are, I never thought that by the end of this semester I'd be just about longing for senior year to begin! Four weeks on Community Practice sounds like a veritable vacation compared to the final four weeks of spring semester. (I know -- check with me when I'm about 3 days into Community Practice, and see if that's still how I feel.)

I'm so ready to be done!

Glad that's over

2011-04-25T17:48:00.002-06:00

I have successfully (at least I think) completed Week 2 of the dreaded junior-year Client Communication Skills!

As expected, the spring semester week was less fun and more stressful and depressing than the fall semester. Our discussions focused on how to talk about end-of-life decisions, the euthanasia process, delivering bad news like a terminal diagnosis, talking about medical errors, and addressing financial concerns with clients.

So, yeah, not a lot of fun.

The simulated client scenarios they gave us were, predictably, more of a challenge. Tuesday's cases included:

-- Explaining to a reptile fanatic that the geckos he brought in were not the species he thought they were and as a result he was housing them in a desert habitat instead of a tropical habitat which was making them sick

-- Meeting with the owner of a horse after you've done a pre-purchase exam on the horse for a potential buyer, meaning the results of the pre-purchase exam are part of your confidential veterinarian-client-patient relationship with the potential buyer so you can't discuss your findings with the actual owner (and what you found caused the potential buyer to decide not to buy the horse)

-- Handling a client who brought his dog in once 6 months ago for chronic skin, ear, and eye problems (probably allergies) and now is back with "I just want to get more antibiotics and leave" (this was the case I got)

-- Discussing a physical exam finding of a fractured tooth that needs to be removed under general anesthesia with the owner of an 18 year old, hyperthyroid, chronic renal failure kitty

Tuesday's case (the allergy dog) went well for me. Knowing a little more about what to expect from having the cases in the fall semester helped to decrease the nerves a little, as did having 6 months of practice dealing with real clients on clinics.

Thursday's cases were... pretty terrible. They were:

-- A panicked horse owner who is standing in the breezeway watching her horse thrash around violently from severe colic, which isn't responsive to sedation or pain medications; you have to get the owner to sign an estimate for surgical fees *with* informed consent, meaning she truly understands the risks

-- Explaining to an owner coming to pick up his cat from CCU that the cat's IV line had been switched with another patient so that the cat had received the wrong medications for 8 hours (although thankfully there would be no lasting ill effects)

-- Delivering the news of a rapidly terminal prognosis (splenic hemangiosarcoma in the process of bleeding out) to a distraught owner, and deciding whether to euthanize or pursue treatment

-- Discussing a dog with severe maggot infestation with your technician, who wants to report the owners for animal cruelty/neglect even though there were extenuating circumstances

-- A young, previously healthy dog with serious sepsis and less than a 5% chance of leaving the hospital alive, and owners who can in no way, shape, or form put down any part of the $1000 deposit required to initiate treatment beyond emergency stabilization

I had the splenic hemangiosarcoma dog, and was that ever a doozy. The added problem (besides just giving a terminal diagnosis) was that owners often have no idea their dog has this type of cancer because the dog just grows a blood-filled tumor in its abdomen and doesn't act very sick -- until one day the tumor breaks open and bleeds and bleeds and bleeds into the dog's abdomen -- and usually the dog gets very weak or collapses. So this dog's simulated owner had no idea that the dog was even sick, and now had to get the news that without surgery and other complicated treatments that might not even fix the problem, her dog would probably bleed out and die within the next few hours.

Yep, fun times. I was nervous enough about the complicated cases (and they didn't tell us which case we would get until right before each of us started). It made me feel sick to read some of the case descriptions earlier in the week and imagine myself (a) trying to deliver this news to a client or (b) being the client getting the news.

And the case description I was given implied that the dog's owner had been told what was going on (i.e. the diagnosis) and was given some time to sit with the dog and decide what she wanted to do, and I was supposed to go in and support her through the decision. One of my first questions to the owner was "What has the doctor told you is going on with Penny?" and the answer was "Nothing." Great. Have another obstacle.

Mostly the difficulty for me with this case came from having never delivered this kind of news before and having to do it with an owner that was very in shock and emotionally shut down. I'm not great with allowing spaces and pauses in my conversations with clients, and that was exactly what this owner needed -- time to process what I was saying. And before I had had a chance to explain anything other than "Penny has cancer," she was asking me questions like "What do we do?" and "So I can just take her home now and then in a few days it might be time to put her to sleep?" -- questions that I felt I couldn't answer adequately or fairly without even given her a little bit more of an idea about what was going on with the dog.

In the end, I was the "someone always cries" person among my group of five students. It was so intensely frustrating to feel so sorry for this owner and what she was going through; to want so badly to help her through this process and yet not be able to connect with her; and to struggle to answer her questions directly without deviating off along my own path of "what I think she should know" versus "what she's telling me she wants to know." (And don't forget -- I was being videotaped and watched by my 4 classmates, my coach, and my coach's coach. No pressure, though.)

So I held it together during the actual interaction with the client -- which I was thankful for. There are plenty of stories on VIN posted by vets who've ended up with a client comforting them during a euthanasia or tough conversation, rather than the other way around -- and I didn't want that to happen, at least not on my first try.

But once the "acting" part of it was over and it was time to debrief and discuss the interaction, I did lose it a little bit. Thankfully, there was already Kleenex right there in the room for the actors who were crying! I certainly didn't have a total meltdown or anything, but there were a few tears and shaky voice for the next 15 minutes or so.

In the end, although it was a thoroughly sucky experience, I'm so glad that I had it in a simulated setting. I can't imagine what it would be like to go through that for the first time with a real client -- not able to pause when you lose direction, not able to rewind when you mess up, not able to get direct feedback from the client about how your words and actions made them feel, and not able to get support and suggestions from a great group of classmates and a coach.

And I definitely learned a lot for next time!

(Now, I'm just hoping there won't be a "next time" other than the regular stuff we have to do during senior year... but the decision about who fails their video reflection paper at the end of the rotation seems completely arbitrary this semester, so who knows -- I may 'get' another shot

Senior year countdown

2011-04-15T17:47:00.002-06:00

We are frighteningly close to senior year, as we are reminded just about daily by the faculty who used to say "When you're in the clinics next year" and now say "When you're in the clinics in a few weeks." (At which we cringe in unison, cover our ears, and go to a happy place.)

Here are some numbers to give you an idea of what the rest of my semester looks like:

2 more weeks of junior practicum in the morning, including 5 mornings of client communications and 5 mornings of independent study in ophthalmology

2 papers to be written next week for client communications

3 more weeks of classes in the afternoon, including 30 more hours of lecture

4 more exams in Small Animal Med/Sx II

4 more "closed-book homework assignments" (= "quizzes") in Small Animal Med/Sx II

1 final in animal behavior

1 animal behavior case study paper to write

17 days(!) until our 12 hours of capstone exam begin (OK, I'm freaking out just a little bit)

125 lectures from last semester that I'd love to at least pretend to study before capstone (13 down -- gotta start somewhere)

27 days(!!!) until our first day in the clinics as seniors

Which for me means potentially 31-32 days until I start spaying and neutering dogs and cats all by my very lonesome. Yeek.

And a partridge in a pear tree.

Squeeee

2011-04-15T17:36:00.003-06:00

I had the keeee-yoo-test little itty bitty baby puppy to anesthetize yesterday. Teensy "Molson," pictured here:

is a 9 week old, 4 1/2 lb sweet little German shepherd(?)-Husky(?) mix who came to the VTH in dire need of removal of his eensy-weensy testicles.

My other 5 cases on clinical anesthesia and Surgery C were all basically adult animals ranging from 12-180 lb, so I was a little nervous about anesthetizing such a tiny pediatric.

Fortunately, Molson did great with an atropine/hydromorphone pre-med, ketamine/valium induction, lidocaine intratesticular block, and some meloxicam and more hydro post-op. I got a 22g IV catheter into him after a couple tries (he got ferocious when I swabbed his leg with alcohol! What a tough puppy!) and successfully intubated him with a wee little 4.5 ET tube. He stayed pretty warm (thanks to a warm water blanket and a handy dandy heat lamp) and kept his heart rate up between 130 and 170. His blood pressure even stayed in a decent range, which can be an issue with pediatric patients. He was lounging in a pile of blankets and towels, basking in the glow of another heat lamp when I left him in the humane society ward. He's going to find an awesome home and grow up to be a fantastic doggie, I just know it!

Of course he's cute!

2011-04-15T17:32:00.005-06:00

Bullwinkle, my sweet little anesthesia case from Tuesday, is now up for adoption and looking ever so darling (OK, maybe "darling" is a matter of opinion) in his adoption photo:

He's cute, I swear! I know he'll find a great family who appreciates his one-of-a-kind looks.

Bullwinkle!

2011-04-11T18:24:00.005-06:00

I'm on surgery C for anesthesia this week, meaning I'm assigned to my very own humane society anesthetic case tomorrow and Thursday, and my very own client-owned spay/neuter patient on Wednesday.

Tomorrow's patient, "Bullwinkle," is a scruffy little mutt dog, about 12 pounds, mostly black with a little white on his chest, with long wiry hair and two very large testicles. He's about a year old -- estimated only, because he was left overnight at one of the local humane societies. :(

I have to say: Bullwinkle's only chance at upcoming adoption is for someone to fall in love with his "quirky" appearance. I say "quirky," because it doesn't seem very politically correct to say what my anesthesia rotation-mate said when she saw him: "Oh my god! Your dog looks like a retard!"

True, Bullwinkle must have come from a motley line of cross-bred dogs, with nary a purebred ancestor in sight. True, his eyes do bug out of his head, one more than the other. And yes, he has one ear that stands straight up and one ear that flops over. And I'll admit that when he looks directly at you, you can't avoid a shiver of crazy running down your spine.

But he's sweet! Okay, he's really scared and doesn't want to look at you, or come near you. And if you put a leash or collar on him, he melts to the floor and magically weighs 80 pounds. But he let me pick him up and put him on my lap, and didn't try to get away. He's one of those "I'm so freaked out I can't move but I don't think I'm going to bite you" dogs. So I'm not sure anyone will fall in love with him based on his personality, unless he really warms up once he gets de-testicled.

I have a sterling anesthetic management plan worked out for him, including some acepromazine, atropine, and morphine as pre-meds; ketamine/diazepam for induction; isoflurane maintenance; an intratesticular lidocaine block; and carprofen/morphine injections post-op with his senior Community Practice student choosing what oral NSAIDs he'll take home with him. Doses and rates are calculated out for oxygen flow, IV fluids, and atropine/dobutamine/ephedrine if needed to help with his heart rate or blood pressure. He'll get a pulse oximeter, capnograph, EKG, Doppler blood pressure, and temperature probe to make sure he's doing well while asleep.

Here's hoping Bullwinkle's surgery goes well tomorrow, and that he doesn't try to give me a heart attack while I'm managing his anesthesia! Despite his "unique" looks, I'm starting to like him...

Why yes, I WOULD like a scholarship!

2011-04-11T18:14:00.002-06:00

After last year's traumatic non-scholarship-experience detailed here, and an even-more-pathetic-than-usual essay submitted with my scholarship application last November, I finally got a scholarship!

OK, now that you're done cheering, the relevant details are: $2200 (yes! would have been happy with $50!), 9 other people got the same scholarship as me (holy rich people), it's only for junior students, and the criteria were "superior scholarship, initiative, perseverance, potential for leadership, and financial need." I'm going to pretend that I qualified for more of that than just "financial need."

So I joined many of my fellow junior, sophomore, and freshman classmates, as well as some biomedical sciences undergrads, to nosh on a pretty display of fruit, cheese, crackers, and cookies, accompanied by "golden punch" (which I'm 97% sure was straight orange juice) and listen to a 25-second congratulatory speech by the dean of the vet school.

Interesting statistic: apparently there are 440-some scholarships given out every year to vet students and biomed undergrads, totally some $1.6 million dollars annually. Wow. (And also, why haven't I seen some of this money before?? That comes out to about $2700/year per student!)

Anyway, I'm thoroughly satisfied by my scholarshippiness and look forward to the receipt of $2200 to help offset my upcoming tuition bill of $51,000 for senior year.

Welcome to anesthesia

2011-04-10T14:35:00.002-06:00

I'm in between my 2 consecutive weeks of junior anesthesia rotation -- our only junior practicum rotation other than client communications that comprises more than a single week during the year.

Anesthesia is reputed to be one of the more challenging, time-consuming, and stressful, yet thought-provoking, interesting, and rewarding rotations we get to have during junior year. My 2-week block is the second-to-last of the academic year, meaning I've heard feedback from almost all of my classmates up to this point.

The dozen of us who started anesthesia last week showed up outside of room D107D shortly before 8 am, as instructed by the first page of our orientation packet that was delivered to our mailboxes the previous week, with "8 am on Monday, room D107D" highlighted for us in bright yellow.

Unfortunately, by 8 am, no instructor had arrived to unlock the door to the room we were supposed to be in, much less give us an actual orientation. Being good little vet students and understanding that clinicians and support staff can be very busy and the hospital has a priority to patient care as well as student learning, we sat patiently in the hallway for another 15 minutes.

At 8:15, I walked across the hospital to the anesthesia induction/recovery area to see if anyone might know what we were supposed to be doing. I found the anesthesia prep room as well as the rounds room completely unoccupied, so went to rejoin my classmates in our continuing exercise in patience.

At 8:30, nothing had changed, so I made the rounds again, and again found the prep room and rounds room with nary an anesthesia clinician or nurse in sight. Back I went to room D107D.

At 8:50 am, the surgical instructor who works with the spay/neuter cases seen on Community Practice came walking down our hallway, and we pretty much pounced on her to help us. Being a helpful person, she first let us into the room we were waiting in front of, and then paged the nurse who was supposed to be leading our orientation. The news she found out was that said orientation nurse had called in sick and advised whomever she talked to that she would be unable to lead junior orientation and they would have to find someone else to do it. Seems that message never got conveyed to anyone who might actually be interested in leading our orientation.

The kindly surgical instructor marched upstairs to where she knew all of the anesthesia faculty and nurses were listening to a guest lecturer give a presentation, hoping to snag one of them to come give us a hand. However, she returned at 9 am with the news that, despite having interrupted their meeting and advised them that a dozen juniors had been waiting for over an hour for the anesthesia orientation they had been commanded to appear for by an annoyingly highlighted orientation packet, the meeting was apparently so important and/or interesting that not a single person would be able to break away from it to come orient us. Word was that the meeting would be over at 9:30 am and orientation would commence at that point.

Fast forward after killing time for half an hour. We dozen students again await an instructor at 9:30 am. Finally, at 9:50 am (bearing in mind that we all showed up roughly 2 hours before this point), a couple of anesthesia nurses walked in nonchalantly with no apologies and proceeded to give us their version of "orientation" ("Keep in mind that we've never done an orientation before and we don't really know what they tell you... but we can show you where the equipment is"). An hour and 15 minutes later (including a 30 minute antiquated video of how to place an IV catheter and induce anesthesia, using protocols that probably haven't been used at the teaching hospital in the last 15 years), we had apparently received all of the orientation we needed.

The nurses asked if there were any questions, and we proceeded to spend another 30 minutes asking them about tons of relevant information they had neglected to mention during "orientation." We then went on our merry way, thoroughly confused about anesthesia rotation.

In discussing with some of my other classmates over lunch, almost all of them said their orientation was very thorough and had taken the full 4 hours allotted, sometimes even spilling over into the lunch hour, and leaving the juniors confident in how the following two weeks would go. Haha. I'm sure we didn't miss anything in our 75 minute "we don't know how to do orientation" orientation. Good thing it's not like anesthesia is a department in which patients' lives are at risk and juniors are expected to devise their own anesthetic protocols and run anesthesia on their own. Oh wait.

Long story short, we clinical juniors (6 of us, including me, spent the past week shadowing seniors on more complicated cases, while the other 6 were on 'surgery C' -- the humane society spay/neuter cases) figured out what we were doing after sort of muddling our way through it on the first day.

On Tuesday I had a 50kg female great Dane undergoing a laparoscopy-assisted gastropexy (preventative surgery for bloat/GDV). She was totally anxious and freaked out when her owner dropped her off (sexually intact because "I want to show her and breed her" -- good luck getting her into a show ring without biting anyone). She fortunately sedated well with her pre-meds, and went down easily at induction. The surgery and anesthesia were uneventful, but she totally flipped out in recovery, 110 lb of panicked, disoriented dog flailing around and trying to bite. Hooray for alpha2 agonists that knocked her right out again.

On Wednesday my case was another great Dane -- this time 80kg (176 lb) -- in through Community Practice for the removal of a couple of probably benign but totally gnarly-looking skin masses growing on stalks off of his elbows. He was somewhat friendlier than the previous day's Dane, but still nervous, and didn't sedate as well before induction. However, he went under smoothly and recovered smoothly, which was a huge relief after seeing the previous day's recovery.

On Thursday I followed along with a 9 year old Australian cattle dog cross undergoing surgical repair for an acutely ruptured ACL. She had a TPLO (a procedure in which the bone of the tibia is cut and a steel plate is put on it) as well as a lateral suture to add stability to her knee. Those are potentially very painful procedures, so it was lovely that she received a femoral and sciatic nerve block on the affected leg, which kept her from feeling anything at all during surgery and kept her anesthesia very smooth. Like Wednesday's Dane, this dog didn't sedate especially well with pre-meds, but did induce smoothly. Her surgery went on for a long time so I didn't get to see her recovery.

This week I'm heading into my surgery C cases. Monday and Friday will be case discussions and rounds all morning, and I'll manage my own cases (with no assistance from a senior student) on Tues-Wed-Thurs. Tuesday and Thursday are humane society animals that go back to be adopted; Wednesday is client owned animals. They should all be spays or neuters on relatively young, healthy patients, which can theoretically make the anesthesia more straightforward, but we're still learning and there are always plenty of things that can go wrong in any anesthetic case, so it will be a challenging but hopefully rewarding experience (and I'm trying to put out of my mind my classmate whose very first surgery C case last fall died under anesthesia and couldn't be recovered... la la la, I can't hear you!). The downside is that on surgery days, I'll have to have my anesthetic plan approved BY 7 am (which means I have to get to school in time to put away my stuff, change into scrubs, get my clinic smock/thermometer/stethoscope/watch/etc., and get downstairs to have the nurse look over my anesthetic plan by 7 am). Sleep is overrated. Or so I keep telling myself.

Canine rehabilitation, aka anatomy review

2011-03-28T12:09:00.004-06:00

I have a pretty cool rotation this week -- Canine Rehabilitation, or for short, "rehab." No, it's not about those dogs that just couldn't give up their fentanyl when it was time to leave CCU, or who keep sneaking their owner's tramadol. It's actually physical therapy-type stuff, but because of legal reasons, you can't use the term "physical therapy" unless you're specifically trained as a human physical therapist.

The rehab course is only offered this week and was added as an elective option at the end of last semester. This year's seniors who took the class last year made it sound really great, so a bunch of us juniors dropped whatever elective rotation we were scheduled to have this week (cardiology, for me).

The first hour or so of class is a lecture about methods of and uses for rehabilitation in veterinary patients -- everything from goniometry (measuring the angles of the joints) to girthometry (measuring the circumference of a muscle group) to active and passive range of motion to balance exercises to underwater treadmills and other hydrotherapy.

Then we get a quick "bio break" (a term I don't particularly like), followed by about 20 minutes of discussion of whatever muscle groups we're going over for the day -- yesterday was thoracic limb muscles; today was epaxial, hypaxial, thoracic, cervical, and deep pelvic muscles.

One of the fun parts is that we then have 75-90 minutes to use muscle-colored modeling clay to "build" the muscles we just discussed onto a plastic dog skeleton model. You get blue or green clay to make tendons and ligaments.

The last 60-75 minutes of class are left for actual hands-on palpation practice with actual real live dogs (owned by the students in the course) who submit to such learning opportunities as palpating bony landmarks (like the acromion, scapular spine, styloid processes, patella, ischiatic tuberosity, etc.) as well as different muscles (biceps, triceps, deltoid, pectorals, etc.).

And while I'd love to learn about some of the rehabilitation exercises I can use in the future (near-ish future!) to help my canine (and cooperative feline) patients feel better after surgery or injuries, it is just as great at this point to be having a really intensive review of bony and muscular anatomy. It's truly amazing how much you can forget (well, not "forget" so much as "lock away in a nearly inaccessible dusty corner of your brain") in the 2 years following freshman anatomy class. I'm really optimistic that this week's lectures, labs, and exercises will help make me a better senior student doctor in just 6 weeks.

Back at it

2011-03-23T21:46:00.002-06:00

Shelter medicine finished with a lot of anesthesia preparation, induction, and monitoring -- which was good for me, since I've had minimal experience giving IV injections without a catheter and performing endotracheal intubation. However, we were supposed to get to do some tom cat or male kitten castrations sometime during the week, and we only ended up with female kitties, so surgery experience was limited.

Last week was spring break, which flew by and was more exhausting than relaxing by the time it was over. We moved out of our condo and into an apartment on Friday and Saturday, spent Sunday unpacking as much as possible ("minimally functional" was the goal we achieved), and headed back to school on Monday.

My rotation this week is Orthopedics. It's been interesting, but pretty slow. One of the downsides of an economic recession for vet med is that clients have less disposable income to spend fixing their pets -- which can mean that procedures like knee, hip, and elbow repairs get postponed and the pet is just put on pain meds for the time being, rather than seeking a surgical cure. Instead of putting a plate or external fixator on a fractured leg, the owner might seek amputation instead. Owners of dogs that are only mildly lame opt for a 'wait and see' approach rather than going for radiographs and a CT scan.

What I'm trying to get at is, there hasn't been a huge caseload.

On Monday I saw one case with a senior -- a 6 year old, black miniature poodle -- who was completely sweet and adorable. He had been diagnosed with bilateral medial luxating patellas (a hugely common problem in toy breeds) by the referring vet after his owners noticed intermittent lameness. Though he was only a Grade I-II out of IV on each side, his owners seemed interested in pursuing a proactive surgical solution, knowing that MPL can progress in severity and cause pain and dysfunction.

Tuesday's case was a 4.5 month old Great Dane puppy (such a sweet thing, although almost 75 lb!). He was stepped on by his dam when he was only about 3 weeks old, and fractured his tibia and fibula. The breeder (clearly a responsible individual) neglected to seek any veterinary care for the next few weeks, and had just decided to have the puppy put down when the breeder's mother intervened and 'rescued' the dog. Unfortunately, the breeder's mom didn't get the pup to a vet quickly either, and he was eventually passed along to his current owner at about 12 weeks of age.

Thankfully, the current owner recognized immediately that the puppy needed some serious medical care, and brought him to the VTH. The plan decided by the orthopods was to monitor the puppy's growth and see him for a recheck physical and orthopedic exam, as well as serial radiographs, every 3 weeks. Long story short, what started as a pretty badly malformed tibia 6 weeks ago, was getting worse at the recheck 3 weeks ago, and had worsened so much by yesterday's visit that the dog's tibia (the shinbone) was basically bent at a 90-degree angle.

At this point, it was pretty obvious that the leg wasn't going to fix itself as the puppy grew. Though the owner had previously indicated a reluctance to pursue surgery, she was gung-ho yesterday that it was time to do whatever needed to be done -- which, in order to have a chance of saving the leg and having it be functional, meant 3-4 surgeries over the next 6-8 months, probably with placement of a circular external skeletal fixator, all with a prognosis that couldn't guarantee that the leg would be functional in the end.

My vote was for amputation, but the owner was vehemently against that as anything other than an absolutely last resort. Bummer, because the orthopedic surgeries to attempt to salvage the leg were estimated to cost $7-10K altogether, and the dog still might have to have the leg amputated if they can't fix it.

Anyway, getting off my soapbox.

Today, Day 3 of orthopedics, was totally dead. There was one appointment all day -- a bandage change in the afternoon. So we had rounds talking about elbow dysplasia for 2.5 hours, then the dozen of us headed over to surgery to watch a craniodorsal traumatic hip luxation undergo surgical repair. Unfortunately, the joint was so badly damaged that just replacing the femur into the acetabulum wasn't really an option. But since the owners apparently had plenty of money, the surgeons got to go ahead with a total hip replacement (which was admittedly pretty cool to see).

Outside of school, I've got a whole long list of errands to run, in addition to finishing unpacking and putting away plenty of stuff in the new apartment, getting back to the Windsor condo for some final cleaning, spending 8+ hours on Saturday at the shelter medicine conference, 4 hours of class on Sunday afternoon because of Open House the following weekend.... so I guess it's time for bed!

Menagerie

2011-03-07T21:41:00.002-07:00

This week's rotation is Shelter Medicine, which is 5 mornings of various activities at the county humane society.

This morning was wildlife care and rehabilitation. Here are some of the animals I helped care for:

- 65 adult squirrels
- 3 neonatal squirrels
- Wild rabbit
- Muskrat
- Rooster
- Mallard ducks
- Coyotes
- Pigeons
- Albino dove
- Robin
- Small songbird (can't remember what species)
- Turtles
- Anoles
- Geckos
- Salamanders
- Anoles
- Mice
- Parakeets
- Lovebirds
- Snakes
- Iguana

Yep, I am ready to get back to dogs and cats. I hope I never have to replace the water bowl in a snake's tank again!

(The 64 adult squirrels living in outdoor enclosures until they can be released in the spring were definitely the cutest... we prepared their daily diet [corn on the cob, fresh apples, grapes, nuts, and squirrel pellets] and it was totally adorable to watch them eat. The hardest part of wildlife rehab was that 95% of the animals are intended to be released back into the wild, so you're not supposed to play with them or talk to them...)

Back to normal hours

2011-03-07T21:38:00.002-07:00

After spending 34 hours between 5 pm and 2 am on my Urgent Care rotation last week, it is a relief to be back to normal daytime hours.

It was definitely interesting to work a swing-shift sort of thing. Certainly I now have a somewhat better idea of what to expect from some of my senior year rotations, including the 4 weeks I'll spend on CCU/Urgent Care, 2.5 weeks on After Hours Wards, and various on-call nights for Surgery and Anesthesia.

However, I pretty much dropped everything besides school from my life last week -- and it was even a good thing that I didn't have any homeworks or exams to do, because I wouldn't have had time to study. Basically no quality time w/CLH, no cooking, no cleaning, no handbells, no church, no choir, and I got horribly behind on emails. In exchange, I got a decent amount of sleep since I could sleep in late every morning and not get to class until 1-2 pm!

I would never have thought, though, that I would be excited to get back to an 8 am-12 pm clinical rotation...

We, we, we

2011-03-07T21:28:00.002-07:00

WE have had an oncology professor over the last couple weeks who has been getting on OUR nerves.

Said professor has a habit of, upon hearing any tiny hint of whispering or chatter in the classroom, abruptly stopping the lecture and stating the following:

"WE are having some issues with whispering today. WE are going to need to stop the whispering, or take OUR whispers out into the hallway, because WE do not want to bother OUR colleagues who are trying to learn."

Now, I appreciate the sentiment. I'm all for respecting your peers, acting professionally, and encouraging people to pay attention to the lecture.

But besides the fact that WE are not a group of 7-year-olds (and the few class clowns who used to act like 7-year-olds as freshmen have since matured), I have several other issues with this instructor's complaint:

1. Vet students historically do not respond well to condescension from their instructors. Experienced instructors (and/or human beings with a modicum of common sense) should know this.

2. This professor is lecturing to OUR class for the first time in 2.5 years. Hence, SHE is not part of WE.

3. WE have been sitting in lecture together for multiple hours a day, 5 days a week, 16 weeks a semester, for 5 1/2 semesters. WE have developed our own methods of policing each other, settling issues of noise in the classroom, and silencing the chatterboxes. If WE had not figured out how to do this on OUR own, WE would have killed each other by now.

4. She is a terrible lecturer. She attempts (and sometimes succeeds, yet in a way that feels like failure) to get through 70+ text-heavy PowerPoint slides in each 50 minute lecture period. She speaks so quickly that she literally completely drops words out of her sentences. I have never heard anyone do that before. It's quite remarkable. While WE would all love to pay attention and learn something important about cancer, WE certainly cannot take notes because in the time it takes to jot down 2 sentences, she has sped through the next 3 slides.

Okay, time to step off soapbox. Man, venting feels good! Hooray for OUR last oncology lecture tomorrow (and let's hope WE don't feel like chatting during class).

I like Urgent Care (but I'm really tired!)

2011-03-02T12:15:00.003-07:00

My rotation this week is "Evening Urgent Care." From 5-8 pm, two of us juniors assist the seniors, nurses, and interns in handling cases that present to the VTH's urgent care department. At 8 pm, Urgent Care shuts down, so we head over to assist in CCU (Critical Care Unit) and also give the seniors a hand doing 10 pm walks and treatments for every other patient anywhere in the hospital.

Monday night, my first evening of the rotation, apparently happened to be the busiest night they've had in Urgent Care/CCU in a long time. The first hour was pretty slow, but starting around 6 pm, the proverbial poop hit the proverbial fan.

With the additional burden of a senior student scheduled to be on the overnight shift calling in sick because of intractable vomiting (yes, please don't come in!), I ended up staying until about 1 am (we juniors are supposed to be done around 11 pm).

Here are a few of the many cases I saw on Monday night:

-- A 2 year old Great Dane (whose owners drove him about 8 hours from Montana to get to our VTH) with a lengthy problem list, including joint effusion; lameness; caudal abdominal pain; an allergic reaction to penicillin given by the rDVM; severely ulcerated, itchy skin lesions on his paws, abdomen, chest, face, and ears; intractable fever ranging from 103-105 degrees for the last few days, despite being on enrofloxacin, amoxicillin, doxycycline, AND prednisone; concern about possible leptospirosis infection from the rDVM; and dehydration (and I'm sure I missed a few of his issues)

-- A chameleon that presented for "lethargy" (and I still haven't figured out how you tell that a chameleon is lethargic -- it was sitting in a Tupperware container!)

-- A young black lab who was hit by a car and had some minor abrasions on her limbs (and hopefully nothing else, like broken bones or a diaphragmatic hernia, because her owners couldn't afford more than basic bandaging and pain medication)

-- A blocked male Siamese cat who was slated for euthanasia until his owner was able to scrape together a $150 deposit to treat him

-- An old Pomeranian who had a "stroke" (probably granulomatous meningoencephalitis)

-- A middle-aged Boxer presented for vomiting, ataxia, and inappropriate mental status, who proceeded to go into supraventricular tachycardia repeatedly, which was treated until his heart rate was back into a normal range, and then he repeatedly got extremely bradycardic (heart rate 30-40 beats per minute), which was nonresponsive to drug correction -- fortunately he lived through the night and had a cardio consult on Tuesday

-- An old golden retriever who had had a laminectomy and meningioma resection earlier in the day, and wasn't feeling so great

-- A great Pyrenees recovering from a TPLO on Monday morning

-- A golden retriever with a heart mass who had had a huge volume of pericardial effusion drained a few hours earlier and was at risk of her heart sac filling up with blood again

And I'm sure I forgot a few!

Tuesday night was a little calmer. We had a few repeat patients (the Great Dane, the golden with pericardial effusion, the golden post-laminectomy, the Pomeranian, and the freshly-unblocked tom cat). Otherwise, it was basically much quieter. A few of the other patients we saw were:

-- A 10 year old small-breed mutt dog (we declared her a "ShitzaCockaPoo") whose owners thought she had something stuck in her throat. She looked great on presentation, wasn't coughing/gagging/retching, and nobody could see anything in her trachea or esophagus, as much as we looked. Her owners declined sedation for a closer look.

-- A wild bunny who was brought in by some Good Samaritans after being hit by a car (the bunny was HBC, not the Good Sams). Thank you, Rabbit & Rodent Medicine! Unfortunately, the fact that two random passersby could catch this wild rabbit and bring it to the hospital without much struggle was a sign that something bad was going on -- and indeed, the poor bunny had a broken spine with complete hindlimb paralysis, so was dispatched to Bunny Heaven shortly after presentation.

-- A 3 or 4 week old puppy fostered by a community member for the local humane society. Puppy presented nonresponsive with no heart beat, and although we tried resuscitating him with oxygen via ET tube, CPR drugs, and chest compressions, the puppy had already joined the bunny in heaven.

-- A young chihuahua/Dachshund mix (might have literally been the cutest dog I have ever seen) that came in for ataxia and disorientation. Physical exam revealed incoordination, altered mental status, dilated pupils, hyperreactivity to any type of stimulus, and bradycardia. Physical exam of the owners revealed altered mental status and serious odor of marijuana. Little dog likely just got into the pot stash and needed to sleep it off -- but ran a blood gas to look for signs of antifreeze poisoning since sometimes it can present similarly.

-- 3 dogs from 2 completely separate households that came in at the same time for ingesting unknown quantities of Rimadyl (a doggie version of Advil [which you can't give to dogs!]). Though the dogs were all sweet and came in happy and friendly, they looked quite miserable after we made them vomit and then force-fed them activated charcoal. Two of the dogs stayed the night for bloodwork and IV fluids.

In addition to new patients that came in, I got to help with "wards duty," which means taking care of all of the medicine, surgery, oncology, and community practice dogs and cats that are staying the night (usually pre-surgery or post-simple-surgery, or sometimes just staying for the owners' convenience). There were about 15 dogs and a handful of cats that needed to be watered, medicated, walked (dogs only), and generally checked for any signs of problems. Additionally, I had the chance to visit a bunny staying in the exotics ward after a spay earlier in the day. And I got to learn how to give a bunny oral liquid medication (which bunny did not appreciate), as well as an intramuscular injection of opioids in the epaxial muscles (which, again, bunny did not appreciate at first, but I'm sure she was happier when the drug high hit her). There were also 6 dogs and 1 cat from the humane society that had been spayed yesterday morning -- including 2 of the cutest chihuahuas I've ever met, and an adorable little Boston terrier/Beagle mix.

Since the night was slower, I got to leave at 11:45 pm instead of 1 am!

Here's hoping for a ton of interesting cases that come in tonight, but that are all pretty much resolved by 10:30 or 11 so I can go home and get some sleep...

What I killed this week

2011-02-24T11:45:00.004-07:00

Several veterinarians I know keep track of "What I killed today" (or "this week"), either on a public blog or as a private exercise.

I think it's a nice way to acknowledge the sacrifice made by the many animals who die for teaching purposes -- as well as the pets we put to sleep for various reasons.

So here's what I killed this week:

Tuesday: An adult male rat who was a "retired" research animal slated for euthanasia one way or another, but used in my Rabbit & Rodent Medicine curriculum to teach us rodent handling, restraint, venipuncture, and intraperitoneal/intracardiac injections while he was alive, and physical exam, castration, and necropsy after I euthanized him.

Thursday: An old white female New Zealand rabbit who was "donated" for teaching purposes by a local breeder who produces rabbits for meat. We learned rabbit handling and restraint on her, practiced giving SQ injections and placing catheters in ear veins, cephalic veins, and medial saphenous veins. After I euthanized her, we practiced spays and necropsy.

Both of the animals I killed this week were sweet and friendly, which made it a little tougher. However, I really don't have a personal problem with small mammals being used in ethical research and for humane teaching purposes -- and all the animals used in this week's labs were essentially destined to die in some form or fashion in the end. But I'm thankful that we were able to make good and thorough use of their deaths in helping us to better handle and treat similar species in the future -- and hopefully help those future animals survive.

Rats and rabbits and mousies, oh my!

2011-02-21T20:46:00.003-07:00

This week's exciting(?) rotation is Rabbit & Rodent Medicine!

RRM is the first rotation of the year that I haven't been all that enthused about. I'm not entirely sure why I even got it as an elective, since I ranked it 11/23 for the fall and 15/25 for the spring. But oh well?

I'm not entirely opposed to the idea of knowing something about how to handle and treat healthy and ill rabbits and rodents. However, I've focused my elective course choices on other areas (like business) so have missed out on much of the exotic animal curriculum offered so far as electives.

Plus, I have almost zero experience working with this little critters in a clinical setting.

Today we had a tour of the lab animal facility on main campus, that took about 30 minutes after our 15 minute orientation. After that, our group of 5 juniors was set free to work on about a dozen sample cases that we'll discuss on Wednesday morning. We were done with all of that by 9:45 or so, though the rotation was scheduled to end at noon -- so, yeah, there will be plenty of free time this week.

Tomorrow is rat handling, anesthesia, surgery, and necropsy. Thursday is the same, but with rabbits instead of rats. Wednesday is the aforementioned case discussions, and our 4 hours on Friday are set aside for "case presentations" where each of us 5 students gives a 5 minute presentation on a topic of our choosing (how exactly that adds up to 4 hours, I'm not quite sure yet).

I've already learned that when rabbits get an upper respiratory infection, the lay term is "snuffles" (how CUTE!) and that you shouldn't grab a chinchilla by its fur because when chinchillas are scared, their defensive mechanism is for their fur to fall out if someone pulls on it. Other than that, I guess I can say I had plenty of time to look at apartments today!

Once-in-a-career case

2011-02-21T20:21:00.002-07:00

Last week's rotation was oncology.

The oncology patient I saw with a senior student on Tuesday morning with a senior student was strongly suspected to have lymphangiosarcoma.

Lymphangiosarcoma is a super-rare malignant cancer derived from the endothelial cells that line the lymphatic vessels. The lymphatic system drains excess fluid from the tissues all around the body and helps that fluid get back into the blood vessel circulation where it belongs.

Of the 5 or so veterinary oncologists on the rotation with us students last week, only 1 of them had ever seen another case of lymphangiosarcoma -- and there are only 16 cases of it documented in the veterinary literature.

The patient, "Sunny," was a sweet, medium-sized, portly 6-year-old mutt. She came in from her owners' backyard a few weeks ago with what looked like an abrasion on her hind leg -- which was unusual, because it spanned most of the inner surface of the leg -- a strange place to have gotten a large abrasion without any other obvious trauma.

Over the next few days, the suspected abrasion developed a lot of bruising around it and appeared to spread -- not only on the inner surface of the leg, but up into the inguinal and caudal abdominal tissue as well.

Even though Sunny's regular vet put her on antibiotics for possible infection, her leg just continued to get worse. After a few more days, the vet decided Sunny had a bad case of vasculitis and referred her to the vet school.

Sunny presented to the VTH's Dermatology service a week before she ended up at Oncology. The clinicians in Derm that week agreed that Sunny probably had a very bad case of vasculitis and cellulitis that would just take awhile to resolve. But, they pointed out to Sunny's owners that they couldn't rule out a cancerous process just by the way things looked.

So the dermatologists offered Sunny's owners a biopsy to definitively diagnose the condition that was causing horrible swelling and oozing all up and down her hind leg. Fortunately, Sunny's mom and dad agreed to the procedure, because the biopsy results (taken from 4 different locations on Sunny's leg and inguinal region) showed "angiosarcoma."

"Angiosarcoma is a semi-broad term that can encompass 2 different types of cancer: (1) Hemangiosarcoma, a cancer of the cells that line the blood vessels, or (2) lymphangiosarcoma, cancer of the cells lining the lymphatic vessels. Because both types of vessels are lined by endothelial cells, it can sometimes be difficult to differentiate their origin when you look at a cancerous tissue sample microscopically.

Hemangiosarcoma (HSA) is much more common than lymphangiosarcoma. Actually, HSA is one of the more common types of cancer seen in dogs. However, HSA is usually found in the organs -- the spleen, liver, and heart. It less commonly appears in a skin or subcutaneous form, like what Sunny might have.

But after consulting with all of the experienced oncologists, and reviewing what little information is available in case reports and textbooks pertaining to lymphangiosarcoma, it was felt that that was more likely to be the cancer that poor Sunny was facing.

So what to do for Sunny? Unfortunately, not cure her illness. Her disease had an extremely rapid onset and progression of her disease (over just a couple weeks' time). The inability to differentiate neoplastic lymphatic vessel cells from neoplastic blood vessel cells on her biopsies indicated that the cancer was probably a very progressive form. If it weren't so aggressive, or had been treated within a couple days of appearing, perhaps Sunny could have been treated by amputating her affected leg and hoping the cancer hadn't spread locally or metastasized. But with biopsy samples confirming the spread of disease past her leg and onto her abdomen, amputation couldn't cure her.

This was a really sad case. Sunny's owners were not only faced with a dog who had at best 6 months to live even with the best medical treatment, but also had financial concerns about how they would be able to afford her treatment. Not including the money spent at their referring vet and in Dermatology for her workup and biopsy, they faced a $120 consult fee with Oncology, plus around $170 for thoracic radiographs to check for metastasis to the lungs and $300 for abdominal ultrasound to look for abdominal organ involvement.

One of the toughest things Sunny's mom and dad had to handle was the fact that, from a hygienic point of view, Sunny's quality of life wasn't great. Her affected leg was very swollen and constantly oozed a copious amount of reddish fluid -- to the point that Sunny's mom would apply compresses to her leg multiple times a day and drain out maybe a half cup of fluid, but the leg would fill back up again with the same amount of fluid within 10-15 minutes.

Because of her messy leg, poor Sunny was restricted to certain parts of the house -- the dining room with hard floors, a carpeted section of the house where her owners had laid down plastic sheeting, and the patio and backyard. Sunny wasn't happy being away from her owners, and they weren't happy being apart from her, and not being able to have her sleep in bed with them.

One of the sort of neat treatments that Sunny's owners opted to try with her was some palliative radiation treatment. Radiation therapy can be used in one of two ways: (1) with "curative intent," or (2) to make the animal more comfortable. Radiation can reduce pain and inflammation and also sometimes dries up the irradiated tissue, which the oncologists hoped would help with the constant oozing and dripping from Sunny's leg.

Other than that, there wasn't a whole lot that even my university's renowned animal oncology department could offer Sunny and her family. She was enrolled in a clinical trial for a new chemotherapy drug that she's scheduled to start this week, but nobody was too optimistic about that.

Sunny's case was tough to handle emotionally, but provided some good insight into the type of cases that the oncologists see every day -- or at least every week. They kept telling me that "not all cases are this sad!" but it sure seemed like I just got luck of the draw with the bad ones all week.

My case on Monday was an older miniature Schnauzer who came in because her owners were worried about 7 skin masses. We aspirated 6 of the masses which turned out to be lipomas (benign fatty tumors). The 7th came back as a nerve sheath tumor. However, on physical exam, the oncology resident detected some liver and spleen enlargement during her abdominal palpation. Little Schnauzer headed over to radiology for an ultrasound, and went to emergency surgery just a couple hours later to have her huge, cancerous spleen removed -- later diagnosed as a hemangiosarcoma. It was sort of funny (in a morbid way) that this little dog presented for skin masses, one of which turned out to be bad, but the thing that would have killed her (the splenic tumor) was something the owners and referring vet had no idea about.

My Wednesday case was a sweet little 13 year old terrier mix -- tan in color but shaped and sized like a largish Jack Russell. He showed up at his regular vet about 5 months previously for a mass on his hip. He went on antibiotics and the mass went away; he stopped antibiotics and after a few weeks the mass came back; he had more antibiotics and the mass shrunk but didn't disappear this time. Finally his rDVM did a fine needle aspirate to look at some of the cells from the mass microscopically. As the owner put it, "Dr. RDVM said he had no idea what the cells were and he said that meant we should go to the teaching hospital." Sadly, by the time the little terrier presented to us, he had multiple other masses and enlarged prostatic lymph nodes indicating that his disease had already spread beyond the point of much treatment. He's probably also headed for some palliative radiation, mostly to shrink his sublumbar lymph nodes enough to let him defecate comfortably for as long as possible. At the time I left the case, his mass was suspected to be histiocytic in origin.

After 3 depressing cases (hey, some dogs come in with a leg tumor, get it amputated, and they're all better!), I opted to spend all of Thursday morning hanging out with the radiation technicians in the radiation therapy department. I got to meet some cool patients who were having either intensity-modulated-radiation-therapy (usually treated 5 days a week for 3 or 4 weeks) or stereotactic-radiation-therapy (treated 3 days in a row, then that's it). I got to see the difference between the palliative therapy and the 'curative-intent' treatments. And I got to meet the dog with the huge skull tumor between his eyes who is affectionately referred to by the oncology staff as "our unicorn"!

All hail the end of Practice Management!

2011-02-15T12:39:00.002-07:00

At long (LONG) last, Practice Management has reached its conclusion! Our last morning of lectures was last Friday.

I admit that I learned a couple useful things during our 80 hours of lectures and presentations. However, I'll add that just about every single morning made me feel even more strongly that I never want to own or manage a practice. Their theory on getting us all to be practice owners seems to be:

1. Tell them how far they are in debt and how terribly their meager little lives will be affected by the enormous loan payments that will be heaped upon them at graduation.

2. Show them fancy charts displaying how much more money you can make as a practice owner rather than just an associate veterinarian.

3. Gloss over most of the negative aspects of actually having to own and manage a business. Let's instead focus on things like where on your display shelves in your lobby is the best place to put your most popular items for sale!

I'll say that the most positive aspect of the course, at least for me, was the fact that all of the instructors and the course coordinator seem very receptive to feedback. We're told that Practice Management is the course in the curriculum that changes more rapidly than any other course, based mainly on student input about what they want to learn less or more of.

However, my feeling is that Practice Management should be offered as a 2-week elective course in the Junior Practicum -- i.e. would be blended into the same curriculum as our morning clinical rotations. One of the four weeks of this year's version of the course was a series of mandatory accreditation lectures by the state vets, that is required to get a state license to practice veterinary medicine. So everyone could take that during the first week of the semester, then they could trim the remaining 3 weeks of "actual" practice management topics to a more reasonable 2 weeks, and then stop forcing everyone to take it. After all, I don't want to be an equine vet or a food animal practitioner, and I'm not forced to take elective courses this semester on those topics if I don't want to. Why should it be any different if I just want to be an associate vet rather than a practice owner?

In any case, what's done is done, and I'm looking forward to the opportunity to participate in a focus group to give additional feedback about the course. For now, though I'm on Oncology!

(Yes, that's right: An actual clinical rotation where I am working with clinicians, residents, interns, senior students, real live patients, and real live clients! A rotation where I'm actually learning applicable things and getting to practice some hands-on skills! What a novel idea!)

Oncology is, however, a little depressing, what with the whole "oncology-means-the-study-of-cancer" thing. I've seen a couple neat patients already this week, and I'm sure some of them will be appearing in subsequent blog posts.

But I just can't tell you how great it is to be back on my feet and applying what I've spent 2.5 years sitting in lecture halls absorbing from a didactic standpoint. Hooray for clinics!

Classes and life continue

2011-02-01T18:22:00.003-07:00

This is only my second blog post of the semester because this semester has contained just barely enough information and activity to be worthy of a full two blog posts in two weeks.

Sigh.

Don't get me wrong -- my classes have improved over the last week or so. Practice Management is, at time, positively tolerable to attend. We've had better speakers recently, with more animation and enthusiasm, lectures that could actually qualify as organized, and several specific topics that are relevant even to the 75% of the students in my class who don't want to own or manage a practice someday.

I'm enjoying applied animal behavior. We had our 3rd day of lectures today. I respect the instructor and her ideas about dog (and cat) training. She keeps lectures light and entertaining by interspersing a fair number of YouTube videos (all related to the lecture material yet still almost invariably amusing) in between her PowerPoint slides. Unfortunately, I was so involved with the school's behavior club (for which she is the faculty advisor) last year, that I've basically already heard these lectures from her before.

Small Animal Medicine & Surgery is progressing decently. I really enjoyed the dentistry section we started with, which was followed by about a week of meandering, hilarious-yet-disorganized presentations by a gastroenterology faculty member who hasn't lectured to us much before. We've now moved on to liver disease taught by one of our best professors, which is a subject for which I could definitely use some review.

I've not yet managed to convince myself to sit through any of the equine or food animal medicine lectures that I thought I might attend in my free time. (I know, I can tell you're surprised.) I haven't had the opportunity to go to any of the small mammal disease lectures, which I guess means it's a good thing I dropped my enrollment from that class.

I've had plenty of non-class things on my mind. I trained 5 new tour guides the week before the semester started, and 2 more last Monday. It's been quite an 'experience' getting them all up to speed, and primarily helping them jump through all of the university's hoops required for official employment (which include a formal application, background check, sexual harassment training, sharps policy form, and meeting with the personnel director -- and that's in addition to my 2-hour tour guide orientation followed by several practice tours and shadowing experienced guides). However, I'm thankful that 7 of my original 10 recruits have stuck with it to this point. The added new guides are really taking some of the stress off of my experienced guides who were overworked last semester.

In addition to routine coordination of tours (including scheduling regular guides and scrambling to find replacements when I get last minute emails announcing "I have the flu" or "My dog's in CCU so I can't make it this afternoon"), I'm trying to arrange two more special extended tours for the university's pre-vet club, which will take place in March. These tours have big groups (20-30 students) requiring 2 guides, last longer than usual (1.5-1.75 hours), and include special exhibits (ophthalmology, anesthesia, junior surgery models, and necropsy presentation), all of which I have to coordinate.

Outside of school, we have handbells. Oh, handbells. We do 3-4 concerts plus an open dress rehearsal at the end of every season, which in the spring means May. Unfortunately, we don't actually know any of our concert dates yet, which is unusual and, especially for me, problematic. You see, by the time our spring bell concerts roll around, I'll most likely be a senior vet student for most if not all of the performances. Sure, I'll be on Community Practice which doesn't require weekend attendance at school, but any weeknight evening concerts (2 of which we have tentatively scheduled) may pose a serious conflict. Here's hoping we can figure that all out soon.

Then there's the house. For those who don't know me personally, the hubby and I are in the process of selling our condo. Why? Because it's currently about a 35-minute drive in morning and evening traffic from home to the VTH. Aside from the fact that I'll be on call a lot during senior year, which has a mandatory arrival time of 20 minutes from the time they call you in (which I could potentially make from our current location if all the stoplights, weather, and traffic were on my side, and if it was the middle of the night), I fear for my sanity if I were to try to commute 35 minutes each way for much (or any) of my senior year.

So the basic steps to selling the house are done. We have a realtor recommended by several of my classmates. We have had the house interior measured to create a basic floorplan. A professional home stager was consulted and I did my best to follow her recommendations. Photographs were done last week. During the entire month of January, we have been fairly consumed with deep house cleaning, organizing, packing, and moving anything not immediately needed over to our newly rented storage unit.

And.... drum roll.... as of yesterday afternoon we have a 'for sale' sign out front, a lockbox on the door, and an MLS listing on the web. Now to just wait for those oh-so-lucky buyers who want to make us a terrific offer based on the extremely excellent nature of our condo. Well, that is if the cats haven't just dropped a huge load in the litter box anytime within the 4 hours or so prior to a showing...

There's also that little matter of taxes. We've gotten almost all of our required tax documents -- except for a W2 that's gone missing, a tax form for CLH's health savings account that we can't find, a form from the mortgage company that hasn't been sent yet, and the fact that due to changes in billing practices, my school tuition tax statement will have 1 semester of tuition for 2010 and 3 for 2011...

Throw in a few potlucks to bake for and attend, and you can imagine why I'm glad that this semester doesn't seem to be too intense as far as coursework goes. I'm sure things will pick up once we get back into junior practicum, but for now it's a good thing that I have extra hours in my day to devote to the house and everything else going on.

Acupuncture: your input, please

2011-01-19T13:04:00.003-07:00

I'm trying to decide whether or not to enroll in the elective acupuncture course that is offered to senior vet students next spring.

Disclaimer: I don't have to actually sign up for the course until a solid 6-9 months from now, so it's not like I have to make this decision this week. However, if I opt out of acupuncture, I'll need to choose another elective, and the longer I wait on that, the more limited my options will be.

Here are the basic details:

The course meets for 3 weeks. The first 2 weeks occur back-to-back and are mostly didactic. The third week is a month or two later, and covers clinical application (i.e. hands-on practice) of acupuncture with small animals.

The first two weeks would count as one of my two electives I'm allowed for senior year. The third week would take place during one of my two-week vacation blocks, basically on my own vacation time.

At the end of the course, you get a certificate of completion. I'm not exactly sure how veterinary acupuncture works, but I don't believe that, as a DVM, you have to have been certified in order to legally perform acupuncture.

All of that is well and good, until you get to the cost of the course: about $4,700 if I register by October (and yes, that is already including a discount for students).

On the one hand, I tell myself that having this experience and certification with acupuncture may be the selling point that gives me an edge over other new grads competing for a limited number of jobs -- that is, if those employers value acupuncture and want to add it or build it up in their practice. On the flip side, though, there are probably plenty of practices out there that don't care much about acupuncture or don't believe it is really useful.

You can learn acupuncture on your own as a DVM, and/or attend continuing education to develop your technique. So it's not like vet school is the only opportunity I'd have to learn it. However, as a working DVM, it would be much more difficult to get enough time off to attend this sort of intensive 3-week, 120-hour course. Add in the fact that I'd probably be facing travel expenses since this type of thing is not offered everywhere in the country, as well as the fact that I'd lose the vet student discount, and the cost could go up.

I keep thinking that $4,700 is a LOT of money to invest in this course given that (a) I don't if it will be something I really enjoy doing, (b) I can't guarantee it will make any difference with potential employers, and (c) it will take up my second of two elective spots, as well as a week of my vacation (which isn't a big deal). However, I can easily put in perspective that I'm already paying about $50,000 in tuition and fees for my senior year, so as long as I'm taking out tons of student loans, why not borrow another $4,700 for something that may pay off when I'm a new grad?

I'd be interested in your thoughts, if you'll post them in the comments section below. I have repeatedly flip-flopped back and forth over the last few months about whether I want to take the course or not, so I guess it's a good thing I have a few more months to decide.

New record

2011-01-19T12:59:00.002-07:00

Classes started yesterday.

I came prepared with a positive attitude, a sense of optimism. I swear, I really did.

It took about 5 minutes of "VM712: Practice Management" to kill any shreds of enthusiasm I brought with me. Pretty sure that is a brand-spanking-new record for the amount of time required to generate this level of cynicism at the beginning of a new semester.

Before we get into the course material, let's just talk some logistics. Last fall was spent half on clinics/rotations, half in classes. Except for a few select rotations (like Emerging & Exotic Diseases), I've basically been on my feet all morning thus far this year, interacting with senior students, interns, residents, clinicians, clients, and patients. Or if not in the clinic, then at least in a lab like parasitology or clin path -- at least doing something, rather than getting talked at.

Fast forward to the first 4 weeks of this semester, and you might be able to imagine why I'm less than thrilled to be spending 4 hours every morning learning about why I want to own and manage my own veterinary practice (which I rather emphatically don't).

Additionally, we have a weird course schedule this semester. It's really the first and only semester in which the large and small animal trackers are enrolled in vastly different courses. Last fall, aside from some electives, we were basically all still in the same Clinical Sciences classes together.

Now, though, the large animal trackers are taking "Bovine Herd Medicine" and "Equine Medicine & Surgery," while the small animal trackers are taking "Small Animal Medicine & Surgery" (1 & 2).

Since we have a large number of "general" or "mixed" trackers in our class, and they need to be able to take any combination of the above courses that they want, all of the classes have to be offered at times that don't conflict with each other. So aside from Practice Management or junior rotations till noon every day, I'm in class only from 2-4 on Mondays, 1-5 Tuesdays, 2-4 Wednesdays, 3-4 Thursdays, and 2-4 Fridays. Definitely an odd schedule, with all of those extended lunch breaks in the middle of the day.

So there's that: not only have I wasted 8 hours of my week so far on fairly useless Practice Management topics, but yesterday was one heck of a long day being in class till 5, and I'm sitting here today watching the 7200 seconds of my lunch break tick by incredibly slowly.

Think I've complained enough already? Fear not; the venting shall continue.

Let's talk about some of the "course material" we've covered so far in Practice Management. About half of our lecture time on Day 1 was spent hearing the "motivational" life stories of some of our speakers, including such facts relevant to Practice Management as where they went to vet school, their favorite species to practice on, innumerable details about their nuclear and extended families, pictures of their hiking trips to Mount Everest, and how their rich relatives died and they inherited enough money to pay off their vet school loans within a couple years after graduation.

Today, Day 2, included more motivational quotes than I've honestly ever heard in the span of 4 hours' time, or probably in a single month. Add the time spent on cheery cliches to the recitation of all of those helpful quotations, and we had about 30 minutes left to actually cover Practice Management material.

And the small amount of information we did discuss was very basic financial and management advice that I've already covered in my elective business courses during vet school, and even that was mostly stuff that I had figured out on my own through common sense long before entering vet school.

We also took personality tests today and discussed the results. Never mind that we took exactly the same personality tests during our freshman orientation for vet school 2.5 years ago, and it was a waste of time then too. Gee, I'm more introverted than extroverted, more of a thinker than a feeler. Thanks for the earth-shattering news.

I'm telling myself it will get better (and I really hope it will; after all, I don't see that it can get much worse). However, it's difficult not to keep in mind that we have 56 hours of this left.

On a brighter note, I'm fairly excited about our once-a-week Applied Animal Behavior course, the first session of which was held yesterday. Yes, it's the dreaded class that will keep me at school until 5 pm on Tuesdays, but I find behavior topics really interesting, and overall it seems that vets receive an inadequate education about animal behavior during vet school. Most of the DVMs I've met offer clients behavior and training tips that the DVMs learned working as technicians or trainers before vet school, or that they've learned through CE and self-education after graduation.

Also, I have had some previous experience with the instructor for this behavior course, and I really like her and respect her ideas. She is not a DVM (although it is possible to become a board-certified veterinary behaviorist after vet school), but rather has a PhD in animal behavior. She does a great job of using science-based research to back up her recommended methods and suggestions, and cuts out a lot of the touchy-feely stuff.

My other course this semester is Small Animal Medicine & Surgery. We're in part one through March, and will cover review topics in dentistry and oral surgery, GI disease, respiratory medicine, respiratory and soft tissue surgery, cardiology, oncology, and ophthalmology. We've started with dentistry lectures, given by a clinician who is not especially popular but whom I really like. He's only been at this university for about 3 years and has become a progressively better lecturer every time we have him as an instructor.

See? I can end positively! And things will be way better in 3.5 weeks when Practice Management is over.

Senior schedule!

2011-01-12T12:41:00.002-07:00

I know my blog posting has dwindled over winter break, but hey, it's break! No vet school = not much vet school info to blog about.

To make up for it, I bring you the long-awaited (well, since October), just-published Senior Year Schedule!

Reminder: My junior year ends May 10, with senior orientation on May 11, and senior year starting on May 12. That means I'll be a senior in exactly 4 months! Yikes!

Here's an overview of my senior schedule, by weeks:

----------------------------

May 12, and weeks of May 16/23/30 and Jne 6: Community Practice (spay/neuter, dentistry, and non-referred, non-emergency appointments)

Weeks of June 13/20: small animal internal medicine

Weeks of June 27/July 4: neurology

Weeks of July 11/18: dermatology

Weeks of July 25/Aug 1: small animal orthopedic surgery

Weeks of Aug 8/15: vacation

Weeks of Aug 22/29: critical care/emergency (overnights/triage)

Weeks of Sept 5/12: oncology

Weeks of Sept 19/26: postmortem diagnosis (aka necropsy aka ugh)

Weeks of Oct 3/10: critical care/emergency (days)

Weeks of Oct 17/24: cardiology

Weeks of Oct 31/Nov 7/14/21: anesthesia

Weeks of Nov 28/Dec 5/12: diagnostic imaging

Weeks of Dec 19/26: one of these will be a vacation week; the other will be more diagnostic imaging

Weeks of Jan 2/9 (2012): vacation (this is awesome: if I have the week of Dec 26 as my vacation week, I'll get 3 weeks off in a row)

Weeks of Jan 16/23: small animal soft tissue surgery

Weeks of Jan 30/Feb 6: elective acupuncture course (debating whether I am actually going to enroll in this $4800 elective course...)

Weeks of Feb 13/20: small animal internal medicine

Weeks of Feb 27/Mar 5: more vacation

Weeks of Mar 12/19: ophthalmology

Weeks of Mar 26/Apr 2: Harrison Memorial Hospital (a huge small animal clinic in the metro area where we get to see appointments and practice spay/neuter)

Weeks of Apr 9/16: more vacation!

Weeks of Apr 23/30/May 7: small animal urgent care (a 5-11 pm, possibly extending to 8 am shift)

Then graduation, whoo hoo!

--------------------------

Items to note:

**I have four 2-week blocks of vacation, only 1 of which occurs in the first 6 months of senior year. Gulp.

**I really can't decide if I want to take the acupuncture course. It would take up my second of two elective spots, as well as requiring a week of my vacation time in the spring. Plus it costs a ton of money.

**My only elective (other than acupuncture) is the Harrison Memorial Hospital elective. I wish I had gotten the shelter medicine elective too!

**My 4 core weeks of emergency/critical care are divided up! Hallelujah for not having 4 weeks of CCU in a row!

**I definitely don't need to spend any more time volunteering in Community Practice as a junior, since I'll be starting out my senior year with 4.5 weeks of CP in a row.

**Not excited about having Anesthesia during the week of Thanksgiving... I'm a bit alarmed that that means I won't get much of a holiday.

**On the other hand, diagnostic imaging is pretty low stress, so even though I'll have to have that either the week of Christmas or the week of New Year's, I'm hopeful that will still allow me some extra time off.

**Hooray for 6 weeks of vacation in the 4 months prior to graduation!

What's the grossest thing you saw today?

2011-01-03T18:13:00.001-07:00

I'll go first:

Very alive, very mobile tapeworms crawling out of a dog's anus.

Nerdiness continues

2010-12-24T15:01:00.003-07:00

Well, I may be done with the semester, but that doesn't mean I'm staying away from school. Go ahead, laugh! I laugh at myself a little too.

Several departments within the VTH are particularly understaffed (I guess "understaffed" is the best word, even though it's not like we get paid!) over winter break when the juniors aren't in school.

So ambitious (a nicer word than "geeky," right?) 3rd year students can sign up to volunteer in those departments (community practice, internal medicine, and cardiology) to basically do the same things that the seniors do.

It's actually a cool opportunity, and one that I also took advantage of during Thanksgiving break.

During the spring and fall semesters, for example, community practice normally has 6-10 senior students and 6-10 junior students. Half of the juniors see medicine appointments all week, while the other half spend Tues/Wed/Thurs mornings in surgery. During a typical week, half of the seniors head down to the humane society for spay/neuter on Monday mornings, and all but 1 or 2 of the seniors are in surgery at the VTH on Tues/Wed/Thurs mornings, leaving 3-5 juniors and 1-2 seniors to handle the medicine appointments on those middle days of the week. Everybody does medicine appts on Friday.

On vacation weeks (i.e. this week and next week), there are no surgeries, so all of the seniors are seeing medicine appointments. However, since there are no juniors, you can imagine that things can still be a little shorthanded.

Now consider that half of the seniors get the week before Christmas as a vacation week, and the other half take off the week before New Year's.

So now you're down to 3-5 seniors and no juniors each week.

Enter the nerdy juniors who want more experience! (i.e. me)

I went in all day on Tuesday and Wednesday this week, which was great because there were only 3 seniors! The schedule was lighter than usual, but still I got to see plenty of appointments.

A couple cases I saw on Tuesday:

**An 8 year old Great Dane with vaginal discharge, arthritis, generalized pruritus (itchiness) due to food/environmental allergies, and horrible halitosis. Checked out her teeth (just the expected dental disease of a senior dog), acquiesced to the owners' request for a steroid injection to help with the allergies, re-started her on some tramadol for the arthritis pain, and gave some antibacterial/antifungal wipes for the perivulvar dermatitis.

**An 8 month old little white fluffy dog flying to Texas with her owner the following day, in need of a health certificate for the airline. (Note to anybody out there traveling with their pets: If you want a health certificate, bring proof of your pet's vaccines!)

**I was supposed to have an 11 year old Lab cross with a cough of several months' duration, but he never showed up. I spent a couple hours researching various causes of coughing in older dogs, which made it a little disappointing when I had no patient to diagnose, but was still good for my brain.

A couple cases I saw on Wednesday:

**An 18 month old Pekingese/Poodle cross (no, I will not call it a Peekapoo) with the unfortunate habit of peeing all over everything when he gets too excited. Mom wanted to know if there was any medication he could be on (apparently the dog has recently started peeing on Dad if Dad is holding him when anybody else enters the room). Dog also had a history of luxating patellas, which Mom reports were manipulated so many times at the last visit that the dog couldn't walk for "weeks" afterward (really? why didn't you call and tell us about that?) and Mom kept saying "If anybody -- ANYBODY -- touches his knees today, we're never coming back!" Little guy also needed a re-enrollment in the VTH's preventive health program, bordetella and DA2P vaccines, deworming, fecal sample to be brought in later, and a quote for a teeth cleaning. It was kind of a high maintenance appointment...

**My favorite owners of the week! Who came in with their 5 year old 90 lb Boxer for his heartworm test and vaccines. He'd only been to the VTH previously for a TPLO (ACL repair) surgery a year ago. The nicest dog, and the nicest people. We ran a heartworm test, vaccinated for bordetella and DA2P, signed him up on a preventive health plan, dewormed, sent home a fecal sample cup to be returned, gave him 6 months of heartworm/flea/tick prevention, and decided to bring him back in the spring to start lepto vaccines.

I'm signed up for a couple more days in January, before classes start again on Jan 18. I'm trying not to overdo it, but community practice is so fun, and I learn so many new things every time I volunteer there. Plus, as a junior, it's really the only place where I get to have primary case management of my patients, and I don't have any more official weeks of it in the spring! And we don't have ANY junior rotations until mid-February, so I'll be extra-deprived of hands-on contact with actual live animals! (Ok, I think I'm convincing myself to sign up for a couple more days...)

Done and.... done

2010-12-24T14:45:00.003-07:00

My 5th semester of vet school is over! Sound the trumpets! Cheers of excitement all around!

Or whatever.

Seriously, this past semester sort of flew by. Until we got to finals week. Then it slowed to serious snail pace.

From Friday (the last day of classes) to the following Tuesday (during finals week), I took 12 exams.

Yes, let's count 'em: 12

Friday:

1. Parasitology online exam (for parasitology rotation)

2. Parasitology practical exam (for parasitology rotation)

3. Swine medicine online final

Saturday:

Study, study, study, study, study....

Sunday:

4. Clinical Sciences 4 Ophthalmology/Oncology midterm

Monday:

5. Radiology final

6. ClinSci 4 Ophthalmology final

7. ClinSci 4 Oncology final

8. ClinSci 4 Critical Care final

Tuesday:

9. ClinSci 4 Dermatology final

10. ClinSci 4 Large Animal infectious/immune/systemic disease final

11. ClinSci 4 Small Animal infectious disease final

12. ClinSci 4 Small Animal immune disease final

(And I'll point out that I took #11 and #12 after arriving home at 10 pm from a handbell concert in Cheyenne.)

Whew!

Now, admittedly those finals were pretty exhausting. But I also have to say that I feel like I've accomplished greater advances in my veterinary education during this past semester than during any other term so far in my vet school career.

Through the combination of junior practicum and my Clinical Sciences courses in particular, it's been so neat to have the chance to integrate and put into practice everything that I've learned over the last 2 years.

For example, we've moved beyond 2nd-year "This is how different types of antibiotics work" to "We know that you all know how different types of antibiotics work, so let's see how we use them to treat dermatological diseases." We're past "Here are the basics of how different parts of the kidney function in a healthy animal" and on to "Here's what leptospirosis does to a cow's kidneys." From "Let's discuss the different life stages of nematodes (blah blah blah)," we've moved on to "This is the most common nematode in yearling horses and here's how you treat it." It's no longer just "Vaccines in dogs are either 'core' or 'non-core'," but "YOU decide which vaccines are most important for this particular dog which such-and-such a lifestyle."

And (drum roll, please) I've officially finished all of my core large animal courses for the remainder of vet school! On a related and somewhat alarming note, that also means that I've officially learned everything that I will supposedly need to pass all of the horse/cow/goat/sheep/pig/chicken/llama/alpaca questions on national boards...

Next spring's core classes will be Small Animal Medicine & Surgery I and II. We also have Applied Animal Behavior (which I'm sure will also include some large animal material, much to my disappointment) and Professional Practice Management (which had better be more useful than my non-vet-school business classes so far!).

But for now, it's nice to be on break. Yes, I'm continuing to be a nerd and spend time volunteering in Community Practice. And yes, I'll be itching to get back into classes within the next few weeks.

But I really feel like I've accomplished something big over the last 4 months.

I actually learned something in Parasitology!

2010-12-24T14:36:00.003-07:00

My last rotation of the fall semester was... the dreaded Parasitology!

Anyone who's been reading my blog for more than a year and a half will remember several posts about my freshman Parasitology course that indicated, well, a rather vehement dislike of the course material and the instructor.

So you can't blame me for not being excited for 20 hours of hands-on parasitology right before finals week.

However (and I am having a little trouble saying this), the Junior Practicum version of parasitology was actually interesting and, dare I say, applicable to my future career in clinical practice!

The rotation set-up was as follows:

Monday: Large and small animal ectoparasites

Tuesday: Small animal endoparasites

Wednesday: Food/fiber animal endoparasites

Thursday: Equine endoparasites

Friday: Online and practical exams

Since I spent 5 or so hours on an airplane and what seems like twice that riding in a car the weekend prior to this rotation, I took the instructor's suggestion to review all of our notes from freshman year. Yes, I'm telling you that I actually read through an entire semester's worth of notes about parasite life cycles. And I only fell asleep a couple times.

Actually, it was a good review, if only to get the most basic points about the most important parasites back in my head, and to put the species names of all of the rest of the parasites into my short-term memory for greater ease in recalling them during this rotation.

So one of the coolest parts of this rotation was that we spent 1-2 hours every morning figuring out "unknowns." That means you'd walk around the room to different stations, and each would say "Removed from the ear of an alpaca" or "Found on a dog" or "Present in the abomasum of a sheep at necropsy" and you'd look at whatever creepy crawly was in the jar and have to figure out what it was.

At first, this was frustrating, mainly because in our freshman lecture course, we never saw ANY pictures of any of the critters we learned about. No photos of worm eggs on a fecal float, no pictures of different types of ticks, no inkling of what a roundworm looks like when passed in the feces. So we were really starting from scratch.

However, by the end of the week I'd come to believe that this was one of the best strategies they could have used to teach us about this stuff. After all, I'm not going to become a parasitologist after graduation from vet school. Sure, I'll be able to identify fleas, and maybe the most common types of ticks in whatever region of the country I end up practicing. But I'll probably see weird things regularly that will send me off to find my parasitology textbooks (and somehow I've managed to accumulate 5 or 6 of those).

So all in all, parasitology rotation was more about teaching us how to look up information about the things we don't know, than learning to identify Amblyomma maculatum or Eucoleus eggs off the top of our heads. And that's the way it should be.

"Ate a lot of German food"

2010-12-12T14:12:00.004-07:00

Sometimes, when reviewing my notes from lecture before an exam, I run across something I wrote that makes me wonder exactly what my thought process was in considering it to be something relevant enough to write down.

Such as this caption I typed below a photo of a grotesquely obese Dachshund:

"Above: dog had cancer, ate a lot of German food, couldn't even walk."

Yep, that better be on the oncology exam that I'm gearing up to take in a couple hours... otherwise my note-taking will have been in vain!

Quote of the Day, Vol. 6

2010-12-10T06:58:00.002-07:00

Alas, I should have known that the post I started yesterday morning about how many things I have to do in the next 6 days and how little time/motivation I have to do them, would never get finished and posted last night. Adios, Thursday's post.

Instead, I bring you this nice little quote from one of my critical care professors, in a lecture yesterday on triage of emergency patients:

"The nice thing about eyeballs is you can live without them."

I can picture my ophthalmology profs screeching.

P.S. Happy second-to-last last-day-of-classes-of-the-semester EVER! 4 hours of parasitology exams and 2 hours of lecture, here I come! (To be followed of course by my swine med final taken this evening... because who has anything better to do on a Friday night?)