Nerdiness continues

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

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!

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"

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

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?)

Sigh

Nothing brightens your morning quite like getting up 10 minutes early to read about fecal flotation techniques.... how many more days till winter break??

Take-home messages

Here are a few other miscellaneous lessons learned this week on cadaver/bone specimen lab:

1. Horse head soup smells exactly the same as dog and cat head soup.

2. It hurts when you stab yourself with the drill bit.

3. If it takes you an hour to wire together your first dog skull, it will only take 10 minutes for the second one.

4. There is just no good way to put into words the way the slimy-sticky-oily-gummy coating on the lunch trays that are used to hold the cadaver bits feels on your hands.

And finally, my #1 source of entertainment for this week:

Watching the looks on other people's faces as you walk around campus holding a box full of dog bones.

(Yes, I could have crammed them into the box so nobody could see, but where's the fun in that? I love seeing people's eyes bug out of their heads...)

Third time's the charm?

Last weekend I submitted my third vet school scholarship application in as many years.

And, as the financial section of the application so kindly reminded me, my tuition next year will be around $51,000.

Come on, scholarship committee! It's been 2.5 years with no scholarship (okay, except the $2500 incentive scholarship that was offered to me with my "Hey, you can come to our vet school if you want!" letter).

They tell us that there are more scholarships available for juniors than any other class.

Of course, they told us the same thing about sophomores last year.

But in any case, my student loan debt just keeps increasing each semester, so in that regard I've probably got more loans at this point than at least most of the freshmen.

I won't find out if I got a scholarship until next spring, so until then, keep those fingers crossed!

You can make soup out of anything (really, you can)

Warning: graphic post to follow.

My independent study rotation this week is a cadaver lab at the end of which I will have some preserved bone specimens to keep for my future educational and client needs.

Bones, right? Sounds fun. And not too messy.

Well, yeah, as long as somebody else gets the bones out of the dog for you.

Which was what had happened when we showed up yesterday morning for the first day of our rotation (there are 7 of us this week, 2 others besides me working on small animal skeletons). The instructor had graciously boiled a batch of canine hindlimbs for us on Friday night, hydrogen peroxide-d them on Saturday night, and left them out to dry on Sunday night so they would be all clean and white for us on Monday morning.

Good deal.

Except the instructor has been extra busy with a lot of other things going on. So last night he made some cat & dog soup for us (no joke, we are talking mesh laundry sacks full of dog and cat bits [skin, muscles, tendons, bones, eyeballs, and all] in a commercial soup cooker), and we got to clean the flesh off this morning.

OK, I knew this would be our first task of the day, so I arrived garbed in coveralls, overboots, and dissection smock.

I was also fully prepared to encounter an aroma similar to that referenced in a previous post during small animal surgical anatomy.

However, I was alarmed, and perhaps even more disgusted, to find that our bone soup looked and (especially) smelled almost exactly like pot roast.

(Note to self: I will not be eating pot roast any time soon.)

Now, that's not quite true. Yes, it definitely smelled like pot roast. (One of the worst feelings I've ever had in vet school is getting hungry during an anatomy lab.)

But from the outside it didn't really look like pot roast. The heads looked like, well, a dog head that had been dunked in a pot of water. Didn't look that different from a sleeping dog with a wet head (well, and decapitated, of course).

Until you try to pull the heads out of the mesh laundry bags (4 heads per bag). And the skin and muscles fall off in your fingers. And you just keep grabbing at things till you get through all the musculature and finally reach bone. And then you get the big part of the skull out, but you still have to fish around in the melting pile of flesh for the two mandibles and two cervical vertebrae.

And then you try not to throw up, and wish you hadn't eaten breakfast.

Once you get the bones out, it's not that bad. Yes, it still smells horrible (or horribly delicious, however you prefer to see it). But you just wash off the bones in a nearby sink to remove any tenacious bits of flesh.

But then there's the skull. And what does the skull have inside? The brain.

For any aspiring veterinarians out there, let me share with you a valuable life lesson I learned today -- something I will never forget for the rest of my career:

When using a high-pressure water sprayer to flush a cat's brain out the back of its skull, keep your mouth closed.

Another important lesson I learned in small animal surgical anatomy, and thankfully retained through this point is: double-glove. Then your hands will smell like death for merely 24 hours or (with some luck) less.

On a brighter note, I can use power tools! What we started yesterday and finished this morning was wiring together all the bones of the canine hindlimb: ilia, ischium, pubis, sacrum, 3-4 lumbar vertebrae, all of the tail vertebrae, femur, tibia, patella, fibula, fabella, tarsal bones, metatarsals, phalanges, and sesamoids.

Which requires drilling holes into the bones so you can pass wire.

Which means that, yes, *I* used a power drill. And I didn't even hurt myself (much)! Nor did I crack or shatter any of the bones in my dog's skeleton (unlike the 2 guys I was working with).

My dog leg is pretty much done, just needs to sit overnight so the glue on the sesamoids can dry, then it will be coming home to live in the attic (away from the cats) until such time as I can use it to teach my clients things.

Well, that's about as positive as I can be about this week's lab. At least it's all uphill from here, i.e. we have our bones in H2O2 for the day, they'll dry overnight, and then we'll be back to nice clean bony specimens for the rest of the week. No more face full of flesh-filled water spray!

The Toilet Paper

"The Toilet Paper" ("Get the Scoop While You Poop") is my class's new monthly bulletin started earlier this semester. You can guess where it's posted.

It contains such monthly features as:

* The Two Flusher ("This Month's Really Big News")
* Queen (or King) of the Throne
* What the Deuce is That? ("Testing your poo ID skills one scat at a time")
* The Last Gas

You may be thinking, Aren't vet students really busy? Particularly juniors, with both clinics and classes? How did they have time to put this together with their heavy course schedule?

Well, I am 90% sure that most of the work that goes into publishing this fine piece of literature each month is actually done during class.

I remain amused by the endlessly creative activities my classmates and I can come up with to kill time.

Pet Hospice rocks

I'm sure I've posted about it before (and if I weren't too lazy, I'd go back on my blog and link my previous posts -- but hey, it's Thanksgiving break, what do you want from me?) but I love, love, love my school's Pet Hospice program.

I start a new Pet Hospice case -- my fourth -- on Tuesday. The patient is a sweet little old man dog, a 14-year-old Pekingese/Poodle cross. (I refuse to call him a Peekapoo. I will not do it.)

As with my last hospice dog, this guy is in kidney and liver failure -- unlucky him. Unlike my last hospice dog, this guy is doing about a thousand times better. He's had kidney problems for over 2 years, and the liver issues are just a recent development.

Hospice Dog #4 (HD4) is supposed to be having SQ fluids every 2-3 days, which for awhile HD4's mom had been driving to a clinic 15 miles away to have done, but the drive and the time at the hospital were really stressful for poor little HD4, so his rDVM put his mom in contact with Pet Hospice -- enter me and my hospice partner.

And what a world of different. We've visited twice now, and HD4 does fantastically with his fluids at home. He sits quietly in his mom's lap, winces when the needle goes in, and then is perfectly happy for the next 2-3 minutes while we load him up with fluids. It's all over in less than 5 minutes, with almost zero stress for HD4.

To make things even more rewarding, I talked to HD4's mom on Wednesday, after our first visit the evening before, and she reported that HD4 was like a completely different dog. He'd been up and about, asking for attention, eating well, and even playing with the other dog (well, as much as he can, since he's pretty wobbly and prone to fall down any time the 18-month-old Chihuahua jumps on him).

It's a neat example of how much difference something as seemingly minor as staying well-hydrated can make. I'm sure HD4 feels like crap when he just can't drink enough water to keep up with the amount of uber-dilute urine that's coming through his failed kidneys, so when we can give him just a couple hundred cc's of fluid SQ, it's like he's a new dog.

As with all my hospice cases, I know it won't last forever. After all, HD4 is 14 years old. Even if he didn't already have known renal and hepatic failure, he'd still only have a couple more years at most. And HD4's mom feels like HD4 has had a good last few years, especially since she was told at the time of his diagnosis of renal disease >2 years ago that he would only have 6 months to at most 2 years to live.

But for now it's pretty heartwarming to see how much Pet Hospice can help HD4 to stay happy and comfortable in his own home. Based on what I've learned from all the hospice families and patients I've worked with, every vet student should get the opportunity to have these kinds of experiences before getting out into practice. It's too easy to see the sick old dogs and cats in the clinic and then just send them out the door without really knowing how life is for them (and their owners) at home.

P.S. This is my 4th hospice case in the last 9 months. And before that, it was about 14 months until I got my first case last February! Guess I'm packin' 'em in junior year....

Clin Path = meh

Sorry no posts for awhile. As you might have guessed from said lack of posts, last week's Clinical Pathology rotation wasn't super-exciting.

Which is too bad. Because Clin Path was pretty much my favorite class from sophomore year. If you know me, you can guess why: reports with lots of concrete numerical values that all have a given set of explanations that you have to piece together like a puzzle and (at least in class) there's usually one right answer? Yes, please!

Junior clin path rotation was basically an intensive 18-hour review of the most relevant points from sophomore year. And since I pretty much remembered everything from sophomore year since I loved the class, that meant that junior rotation was pretty boring.

We did get to do some fun microscope stuff. It included red blood cell pathology, white blood cell pathology, WBC differential counts, platelet evaluation, fluid cytology, and mass cytology. The last thing we were supposed to do on microscopes was learn how to do urine sediment exams (which, out of all the microscopy, was the one thing I need the most practice in) -- but the darned sophomores had to use the microscope lab, so we basically just watched a PowerPoint presentation about urine sediments -- which is totally not the same as doing it yourself. But oh well.

I did gain a bit of a reputation in this rotation for being a clin path know-it-all. Since there were only 25 people, I felt a little more comfortable speaking up and offering answers than I usually do in our massed class of 135. Everybody was amazed when I came up with the answer that, yes, a 3+ positive blood pad on a urine dipstick with a specific gravity of 1.003 and no red blood cells seen on urine sediment could in fact have been hematuria (rather than only myoglobinuria or hemoglobinuria) because the specific gravity was so dilute that the osmotic forces would result in lysis of the RBCs within the urine. So there. Go me.

I guess it was a useful rotation -- well, it would be especially for anybody that didn't like or didn't do well in clin path lecture class as sophomores.

But now on to bigger and better things! I've got my first independent study coming up next week -- I'm doing a cadaver project with the semi-creepy instructor in charge of the anatomy lab and obtaining all of the 'specimens.' If all goes well, though, I'll have my own canine skull, feline skull, and canine hindlimb and forelimb to keep for my very own self at the end of next week.

Stop beating the cats!

Poor Johnny has had an acute onset of conjunctivitis in one eye (and a dendritic ulcer, as I learned today when I brought him to school). Looks like somebody sucker-punched him.

Wait -- black eyes are badass, right? Then that makes 2 of us in the family!

High five

When I blogged about my internal medicine rotation last week, I can't believe I forgot to mention the most exciting part of the week.

On Tuesday, a middle-aged large dog came in with a 9 month history of lameness and stiff, painful joints. He was accompanied by about a thousand xrays taken by his referring vet over the previous months.

The senior student and I headed over to the radiology department with the dog's xrays, to see if we could con a radiologist into helping us interpret them.

As luck would have it, one of the first-year residents (who is a very, very nice person but comes across as a total geek [not saying I don't identify with him]) wasn't busy and offered to give us a hand.

As we pondered the various shades of black, grey, and white comprising this dog's ouchy stifle, the senior student pointed out a lucency on the femur and asked what it was.

The resident said, "It's a normal anatomical structure. Any ideas what?"

I offered, "The attachment fossa for the long digital extensor muscle?"

To which the resident replied, "Badass!" and gave me a high five.

For the remainder of the week I was known as a radiology nerd, as I came up with several other correct answers to various semi-esoteric questions.

But I'm okay with it: Because nobody else got a high five.

Quackery

Most of my "Complementary & Alternative Medicine" lectures this semester have focused on particular "alternative" treatment methods, and why they are completely invalid.

Today, we talked about homeopathy.

There are several underlying principles to homeopathy.

1. You can cure your symptoms by ingesting a small amount of something that, in a larger amount, would cause those same symptoms. Case in point: If you have a cold (runny nose and watery eyes), you can ingest a tincture of onion (since onion also causes runny nose and watery eyes).

2. The substances that you use for your remedy are to be diluted greatly in water.

3. The more diluted the substance is, the more powerful it is.

Let's continue with the "I have a cold, I better take some onion" example. Here's how you make your homeopathic onion remedy.

Step 1: Grind up some onion to make onion juice. You now have a "mother tincture."

Step 2: Take 1 drop of the mother tincture and add it to 99 drops of water. Shake thoroughly. You now have a 1:100 dilution of onion tincture in water. This is called a "1C" dilution, as you have diluted your mother tincture 1 time in a 100-part (C being the Roman numeral for 100) dilution.

Step 3: Take 1 drop of the 1C dilution and add it to 99 drops of water. Shake thoroughly. You now have a 1:10,000 dilution. This is the 2C dilution.

Steps 4-infinity: Repeat the dilutions, adding 1 drop of the previous dilution to 99 drops of water. You can continue until you have anywhere from about a 6C to a 30C dilution.

Note, clever readers, that at some point before you get to a 30C dilution, you have a less than 1 in a billion chance of having even a single molecule of onion left in your dilution.

Once you have reached the desired level of dilution, you can "prescribe" the onion remedy for your cold-suffering patient with instructions such as "Take 15 drops under the tongue 4 times daily." As a seasoned homeopath, you will of course recognize that the "stronger" dilutions (30C being much stronger than 6C) can only be "prescribed" by the experts.

And voila, of course your cold will be gone!

I hope I've convinced you that this type of homeopathy is utter nonsense and can clearly have no effect other than as a placebo (which, granted, can be pretty awesome).

And, of course, when you've diluted onion (or whatever more dangerous substance you choose to use, such as lead, rabies virus, arsenic, or tuberculosis-infected cow tissue) to this degree, the odds of it doing you any harm are very slim. So a lot of mainstream veterinarians, when their clients inquire about the use of homeopathy in their pets, will advise the clients that they probably won't be hurting their animals.

The problem comes when a pet owner (or even a veterinarian or self-proclaimed homeopath) chooses to use strictly homeopathic remedies instead of pursuing a traditional diagnosis or treatment for their animal's condition.

You have got to watch this hilarious spoof video of a homeopathic ER doctor unsuccessfully treating a patient, followed by some commiserating with a fellow doctor at the bar after his patient dies. It's only 2.5 minutes long and it's totally worth your time! Click here.

Internal medicine

Try as I might, I just could not come up with a witty title for this post. Check back after winter break...

This past week's rotation was small animal internal medicine.

I'd heard from friends and classmates that internal med was a cool rotation, that you would get to see some neat cases, and learn interesting stuff.

Well, that was and wasn't true.

Here's the basic layout of internal med:

There are 2 "teams," called Med-1 and Med-2. Each team has 1 clinician (usually a faculty member, but in my case a 3rd-year resident) who is in charge. Then each team has 2 other DVMs (usually 1 resident and 1 intern), 4 senior students, and 1 or 2 juniors. The seniors get assigned to either Med-1 or Med-2; we juniors just get to pick on the first morning of our rotation (usually based on seeing the names of the clinicians on the doors of the 2 rounds room, and picking whomever you like better).

Med-1 and Med-2 function basically separately from Monday through Thursday. As internal medicine cases arrive at the hospital or are transferred from other services, they get assigned to either Med-1 or Med-2, and that same team will deal with that case for the remainder of its visit that week.

The general schedule, Monday through Thursday, is as follows: Inpatient rounds from 8:30-9:30 am (which was pushed back a little later on Monday since we started with a brief orientation). From 9:30 to approximately 1 pm, the team sees cases and attends to inpatients. The afternoon (while us poor juniors are in class, of course) is reserved for a few appointments but mostly procedures (like endoscopy or biopsies).

The 2 main ways that Med-1 or Med-2 get cases is by either new patients coming in (usually referrals from an rDVM who has tried to work up a case but the patient needs diagnostics or procedures that are beyond the rDVM's ability or scope of knowledge), or from transfers (a large number of the cases that come in on emergency overnight get transferred to internal med in the morning, and periodically throughout the day the Urgent Care service will transfer some of the more complicated cases to internal med; there is also an occasional transfer from Community Practice, such as a case this week of an apparently healthy dog that had a huge number of abnormalities on routine bloodwork).

On Monday and Wednesday, Med-1 gets all of the transfers and Med-2 takes the new cases arriving at the VTH. On Tuesday and Thursday, it's switched. On Friday, everybody teams up and sees things together. Also on Friday, we start with Grand Rounds from 8:30-9:30 and then inpatient rounds from 9:30 till 10:30 or 11.

Overall the thing that surprised me most about my internal med rotation was the amount of time we spent sitting around and discussing cases. On an average morning this week, there would be perhaps 1 or 2 inpatients, and 2 or 3 new cases: for a team of 8 people to work up. So perhaps 80% of the time, we weren't actually doing anything with the animals: we were sitting around the table talking about histories, physical exams, problem lists, differential diagnoses, and potential treatment plans.

That being said, I did get to do basically one cool thing each day of the week:

Monday: Watched part of an echo on a cat with acromegaly. Aspirated an enlarged superficial cervical lymph node on a sweet dog named Mack suspected of having malignant histiocytosis (yucky cancer). I didn't get a good sample from the LN, but neither did the 2 people who tried after me, so there.

Tuesday: Performed a buccal mucosal bleed time (BMBT) on the dog from Monday who was supposed to be going to surgery to have a lung mass biopsied. Unfortunately, Mack had been having some issues with thrombocytopenia (lack of platelets = badness) for a few weeks, and on CBC on Monday his platelets were only 40,000 (normal is 200-500,000). The BMBT basically tests how well the platelets are working -- you can have a normal number of platelets, but if the platelets don't function correctly, then you still can't clot your blood. The BMBT entailed laying Mack on his side, taping his upper lip to his muzzle so that the underside of the lip was exposed, then making a small cut in the mucous membrane of the lip and waiting to see how long it took to stop bleeding. Normal BMBT is less than 5 minutes; we called it a day (and an abnormal test result) when Mack was still bleeding at 14 minutes. Needless to say, the poor guy did not go to surgery.

Wednesday: Wednesday morning was extra slow case-wise, but I did get to feel a thyroid slip on another service's kitty. A thyroid slip is one way of tentatively diagnosing hyperthyroidism, which is an overactive thyroid gland usually caused by a benign tumor in older cats. The thyroid gland often physically enlarges, which you can sometimes feel on physical exam as a "popping" feeling as you slide your thumb and index finger down either side of the cat's trachea.

Thursday: I got pretty involved with a case on Thursday. The patient was Charlotte, a 3 year old Boston Terrier with a 2 week history of regurgitation, and a chronic history of well-controlled IBD. Charlotte had been worked up at her rDVM with bloodwork, survey radiographs, and a barium study -- all of which were basically normal, and yet Charlotte had been able to hold down almost no food or water in the last 2 weeks, and was losing weight. Charlotte's mom was in nursing school so had been giving Charlotte sq fluids every day, and syringe feeding her, but Charlotte needed some answers soon. We repeated a CBC, chemistry panel, urinalysis, and survey chest and abdominal radiographs, performed an abdominal ultrasound, and did a barium contrast esophagram -- all of which were, again, essentially normal.

Friday: Charlotte came back in on Friday morning for endoscopy of her upper GI tract. I was unfortunately in rounds so didn't get to observe the procedure, but Charlotte's esophagus actually looked normal (we were expecting esophagitis or a mass or stricture or foreign body). Her stomach and duodenum, however, were horribly inflamed -- the resident doing the scoping said that he had never seen such inflamed mucosae. So Charlotte got some biopsies and I'm very interested to see what they show next week.

So that was internal med. I'm sure it will be more interesting as a senior (well, it better be more interesting, because I have it for 4 weeks!) when I can be more involved in the cases and be around in the afternoons to watch the procedures.

Next week: on to Clinical Pathology! A subject that I love on paper (i.e. interpreting lab results), but unfortunately most of our 4 hours a day next week will be spent at microscopes -- which I also don't mind, but tend to get a bad headache after more than an hour or so of looking into the microscope. So Advil, here I come!

Subject lines

"Bottoms up: Things you can Learn from a Rectal Exam"

It's when I get emails with subject lines like the above that I just have to step back and marvel at the strangeness of my life.

Distraction wanted (but not needed)

I'm studying dermatology right now.

(Okay, not technically right now, because I need a break before my brain explodes.)

Dermatology is so boring. So, so boring.

And the most annoying part is, most general small animal practitioners will tell you that about 50% of their cases they see on a day-to-day basis are derm cases.

So it's important. And I have to learn it.

But come on. Acute pyotraumatic moist dermatitis, otitis externa, dermatophytosis, glucocorticoid use, and that's not even getting into the entire 50-minute lecture that was devoted 100% to shampoos.

Shampoos!

Gaahhhh.... guess I'd better get back to it, since I still have to get through pemphigus, lupus, and the ever-dreaded shampoo notes tonight...

Consider me fully vaccinated

Hey, between heading up to bed at 8:30 on Friday night and the 10 (yes, count 'em, ten) vaccines I've had in the last 2.5 years, there's not that much difference between me and a baby!

I got a meningitis booster on Friday -- which added to the MMR, tetanus, H1N1, 3 influenza, and 3 rabies vaccines I've had since starting vet school in August 2008.

Some people get all upset about various vaccination guidelines for dogs and cats. The standard used to be, basically, every dog (and every cat that actually went to the vet, which wasn't that many) got all of its vaccines every year. For dogs that would be a distemper-parvo combo, rabies, and maybe something like lepto or bordetella or corona.

Well, nowadays people have done more research and proved that in adult animals, most of those vaccines create solid immunity for at least 3 years -- so current recommendations are generally to vaccinate adult dogs for distemper-parvo every 3 years, and rabies as far apart as legal guidelines will allow (ranges from requiring annual vaccination to every 3 years).

However, even still some pet owners (and some vets) are hugely reluctant to vaccinate their adult animals (or even their puppies and kittens) that much.

To be fair, when selecting a vaccine protocol for an individual animal, you need to take in risk assessment. Maybe that dog that goes to the groomer every month, plays at the dog park every weekend, and hangs out at doggie day care 3 afternoons a week is more at risk for getting contagious diseases like distemper or parvo. Versus "mommy's little lap dog" who is white and fluffy and whose feet never touch the ground, much less actually leave the backyard.

And there are some serious risks to vaccination, don't get me wrong. A prime example would be vaccine-associated fibrosarcoma in cats -- wherein a cat can develop a huge, nasty, aggressive, malignant soft tissue tumor at the site of injection, which has often spread to the body wall by the time the tumor is diagnosed, and then bye bye kitteh.

Now, if you're the owner of the one cat in however many thousand that actually develops FSA after a vaccine, then I don't blame you for being super head-shy about vaccinating other or future animals you have. Or if your pet has anaphylactic reactions to vaccines.

However, for most of those run-of-the-mill cases where people don't have a great reason for not vaccinating (and I've heard some "great" reasons such as "Well, vaccines cause autism in children, so I don't want to hurt Sparky's brain"), I'm all for the vaccines.

And now I can point out my personal experience with getting more vaccines in a 2.5-year timeframe than I would ever intend to give to an adult dog or cat. And look at me, I'm doing fine! (Well, you could argue that point, but please don't.)

Anyhow, I got my meningitis vaccine at a huge vaccine clinic held on my university's campus. There have been 7 cases of meningitis in the county this year, with the most recent case killing an undergrad student who worked evenings and weekends as a receptionist at the VTH. Hence, there was an enormous push by the administration to get as many students vaccinated (or boostered) as possible.

I knew it was going to be a big affair, but I was mildly alarmed when, as I was driving to school on Friday morning, they said on the radio that over 4000 students had pre-registered for the vaccine clinic in the preceding 48 hours. Yikes. And who knows how many people showed up as walk-ins.

So I felt glad I'd planned ahead and brought a book to pass the time until I got my vaccine. After all, even when I'm the only patient in the immunization department at student health, it can sometimes take 10-15 minutes to get a flu shot.

However, I was totally amazed upon arriving at the student rec center about 5 minutes before my 3:10 appointment. There were signs up for blocks around the center, directing foot traffic to the appropriate entrance. Volunteers wearing astonishingly neon yellow vests directed us as we entered the rec center, and herded us into the appropriate lines. I had to wait for about 5 minutes to print out my registration ticket (I didn't have access to a printer when I registered on Wednesday), but after that it was just a short walk down a hallway to a huge gym, which was Vaccine Central.

There were about 10 "screening stations" set up on tables along one wall. As you walked into the gym, you took your registration ticket to whichever screener was open. They asked the requisite questions ("Are you feeling well?" "Have you eaten today?"), then took your ticket and gave you a vaccine form to take to the next station.

Station #2 was the actual vaccinations. There were about 10 groups of tables set up on the other side of the gym. Each group of tables seated 4 nurses, each of whom was administering vaccines, and a fifth person who was helping draw up vaccines and complete paperwork. Yes, that's 40-some nurses doing vaccines at once.

I was pointed almost immediately to an open nurse's station, got stabbed in the arm, and shuffled with the other vaccinated students over to a food-and-water station aimed as prophylaxis to avoid fainting.

It was literally no more than 12 or 13 minutes between the time that I entered the rec center and when I was walking out the door on the other side. I was completely floored by the efficiency and organization of this undertaking, and said so to several of the volunteers -- they must have been having a long day, because they perked up right away and said "Thank you for sharing that! We really appreciate it!"

This wasn't really a vet med story, but in a way it was: with all the bureaucracy, rules, guidelines, and procedures you encounter every day in a great big organization or business (such as a university), it's always refreshing to see that they can sometimes get things right (even if it doesn't really happen in the vet school per se...).

P.S. The vaccinations were FREE! My last vaccine was as a freshman or sophomore undergrad, and it cost $90-something. Heck yes, I'll take a free booster!

6 lessons learned today

#1: If I never again in my life eviscerate a cadaver dog, I will still have done it one too many times.

#2: As bad as you think the stench can get, just leave the cadavers alone in a cooler for 24 hours then open them back up again. Decomposition is a stunning process.

#3: Double glove. Two layers of latex = half as much unavoidable death smell on your hands for the rest of the day.

#4: Removing the heart, lungs, esophagus, diaphragm, kidneys, liver, spleen, bladder, intestines, stomach, gallbladder, colon, and major blood vessels, fat, mesentery, and other connective tissue from a Rottweiler does not make the remaining cadaver a whole lot lighter.

#5: You can spread apart a dog's ribs an incredible distance before they crack (but they do eventually crack).

#6: I never, EVER plan to do heart surgery on a living animal (or, hopefully, on another dead one).

Pet peeve of the day (off-topic)

(Disclaimer: I love having a blog. One of the neatest things about your own blog is that you can choose to write about whatever you want. Sure, the general topic of my blog is vet school, but now I'm going to write a post about something completely unrelated, and I can, because it's my blog. When you have a blog, you too can write whatever you want. So there!)

I got all riled up today during a midday trip to the grocery store. (I wanted to hit up the discounted post-Halloween sale candy and was particularly in search of candy corn, because I'm going to make these cute cupcakes for our next bake sale, that have yellow frosting with candy corn all around the edges to make a sun. But I digress.)

As I pulled into the supermarket parking lot, lo! I espied a prime spot almost immediately adjacent the door.

There was a woman parked into the spot next to my desired parking location. She had just finished loading her groceries from her cart into her car. As I waited patiently not 10 feet away, the woman pushed her empty shopping cart into the space I was waiting for, and leisurely strolled around to the other side of her vehicle and got in.

Now, come on.

The spot this woman had parked in was literally the second closest non-handicapped parking spot to the entrance to the grocery store. The spot I was aiming for was the closest spot, aside from its adjoining handicapped spot, which was now also semi-blocked by this woman's cart.

I cannot stand it when people do this.

How difficult is it for you to walk the extra 20 feet to bring the cart back to the store entrance? Or even to walk the 10-15 feet away from the store to bring the cart to the nearest "cart corral"?

Why block not one but TWO free, desirable parking spots, one of which is a handicapped spot??!!

What is wrong with people?

(Okay, time to step off the soapbox. Just don't let it happen again, lazy, irritating woman!)

Eau de rotten Rottweiler

I have smelled like death all day.

It is not a good start to my week.

This morning I started Small Animal Surgical Anatomy (SAA). In contrast to last week's pig lab, this week's procedures are all practiced on cadavers.

Fresh cadavers.

Well, "fresh" in the sense that I mean "unembalmed." Not "fresh" as in "lack-of-stinkyness" or even "recently dead."

Although I did read the syllabus section on what to bring and wear to this morning's lab, I gravely underestimated the horribleness I was going to face.

Today we practiced spays and cystotomies on our cadavers. The recommendation was to select a shorthaired dog, for ease of seeing the structures we were looking for under the skin with only minimal clipping.

My partner and I were among the last students into the dissection room. So, unfortunately, we ended up with the last shorthaired dog: an 80-lb or so female Rottweiler.

I knew the day could only go uphill when, as the two of us (both short in stature) struggled to carry this uncooperative beast of a canine over to our "surgery" table, giant strands and globs of bloody froth from the dog's mouth and nose were flung all over my lab smock and unprotected jeans.

Ahhhh... nothing quite like the feeling of cold goo from a dead dog soaking through your pants and making itself at home on your skin.

If you thought that was bad, then be glad you weren't there for the rest of the lab.

Suffice it to say, when an animal dies, one of the first parts of it to decompose is the GI tract. Obviously, our GI tracts are full of nice friendly bacteria that, in life, help us digest our food into bits that we can absorb and use in our bodies. After death, however, those same bacteria go wild breaking down all the tissue they can get their grubby little non-existent hands on (anthropomorphize much?).

So when the 22 students nearly simultaneously cut open 11 rotting abdomens, the ensuing stench was truly almost vomit-inducing.

As I spent the next several hours with my hands almost elbow-deep in this dead dog's frigid, soggy, slimy, stinky abdomen, I kept thinking to myself over and over: "I want last week's pigs again!"

Here's the bright side: we sutured up the abdomens at the end of the morning, and tomorrow we're just working on chests (should be less offensive, odor-wise), with a brief entrance back into the abdomen at the end of lab to practice gastropexies. After our pexy, we get to eviscerate both the thoracic and abdominal cavities, and use the limbs for orthopedic surgery practice on Wed, Thurs, & Fri.

Don't you wish you were in vet school?

Surreal

I have to write more about junior surgery lab.

I simply cannot wrap my mind around the fact that I cut open a live pig this week (multiple pigs), removed some of its organs, and put it back together.

I have no cognition at this point to really grasp that that's what I did.

It's the weirdest feeling -- on the one hand, for many of the procedures we did (especially the nephrectomy and splenectomy), I have this sense that it really, really shouldn't be that simple to remove an organ from a living creature. In the most basic sense, once you've opened up the abdomen, it's a matter of manually breaking down some connective tissue, tying knots around some big veins and arteries, and pulling the kidney or spleen out.

On the other hand, I have to remind myself that it's taken 2+ years of intense vet school education to get me to this point -- starting with basic anatomy and physiology during my first year, progressing through basic instrument handling and surgical technique as a sophomore, to working on models and cadavers in the beginning of my third year, and now here I am.

Am I trying to say that I feel competent as a surgeon at this point? That I could tackle anything in the abdomen? That I'd be okay going into a surgery on my own, without a partner or supervision?

Heck, NO!

But I also really can't believe that I did what I did over the past 5 days. It's a very strange sort of power that I'm not psychologically ready for yet. I wonder when I'll finally get to the point where I can tell myself, "Yes, I did that surgery. I can do these surgeries. I have learned enough that that's just what I do now, and it doesn't faze me."

I'll let you know!

The saddest patient ever

Our 8-week Clinical Sciences 3 course covered 5 main topics in the small animal section:

1. Orthopedics
2. Reproduction
3. Neurology
4. Lower urinary tract
5. Upper urinary tract

Our final exam this past week was "case-based," meaning they gave us a theoretical patient (thankfully a fictitious animal, which you'll realize is a great thing once I tell you everything that was wrong with this poor dog).

We had physical exam findings, xrays, and lab work for "Daisy," our non-existent dog, who came to us with a history of hit-by-car. Since we were presented with only 1 case, and there were 5 body systems that we'd covered in lecture and needed to be examined on, that meant that poor, poor Daisy had something wrong in each section. Let's look:

1. Orthopedics: craniodorsal coxofemoral luxation (i.e. her hip had popped out of its socket and was wandering around where it shouldn't be)

2. Reproduction: during Daisy's recovery from her HBC, we notice that she has a purulent vaginal discharge (which ends up being a pyometra)

3. Neurology: spinal cord lesion affecting bilaterally the sciatic and pudendal nerves

4. Lower urinary tract: urinary tract infection during recovery

5. Upper urinary tract: ruptured bladder inducing azotemia; upon surgical exploration, Daisy had a traumatized kidney and ureter that required nephrectomy (hey, I could do that surgery!)

Although all of these things could happen to a dog after experiencing a major trauma, or during recovery in hospital, I'm pretty sure they should have given Daisy an ironic name like "Lucky" instead.

Whirlwind week

(Also, I absolutely adore alliteration.)

Even though we are 10 weeks into our junior year, all of my classmates are still commenting about how much more intense third year is compared to the first two.

(And, to be fair, they are completely correct.)

But over the past week, I think I got a little taste of what senior year will be like.

Last week happened to be a busy week, and it would have been busy even if I'd been on a slacker rotation, like radiology or EED.

That's because we had 2 final exams (yes, you heard me right: 2 final exams in October), plus starting a new course (Clin Sci 4), plus I cleverly decided to engage in some interesting yet time-consuming extracurricular activities.

And then there's junior surgery lab: undoubtedly the most fascinating and enjoyable rotation I've had this year, but also the most mindboggling, complicated, and time-consuming, with perhaps the exception of Community Practice-Medicine.

So here's a brief run-down of a few days of my schedule since last weekend:

Sunday night: study small animal material for the final exam open from Monday through Wednesday. Review suture patterns, surgical techniques for skin closure, etc. in JSL notes packet and my wonderful surgery textbook (so worth the $200 or whatever I paid for it last spring).

Monday:

6:00 am: Wake up, eat a good breakfast, drink lots of OJ & water, etc.
6:40 am: Leave for school
7:15 am: Arrive at school, change into scrubs, wrap surgery packs, fold and wrap gowns, etc.
7:30 am: JSL orientation
8:00 am: Head down to the surgery suite and have at it! 4 hours of cutting off chunks of our pig's skin, then sewing it back up
12:00 pm: Done in time for a lunch break
1:00 pm: 3 hours of class
4:00 pm: 1 hour of studying for small animal final exam
5:00 pm: 1 hour of class
6:00 pm: Head home; try desperately to stay focused (always tough on Mondays - such a long day); study up on tomorrow's surgical procedures (abdominal explore, splenectomy, gastropexy); end up going to bed at a reasonable our (i.e. before 11 or so)

Tuesday: the LONG day!
6:10 am: Wake up and get ready for the day
6:50 am: Leave for school
7:25 am: Arrive at school, change into scrubs, wrap surgery packs, etc.
7:45 am: Lab orientation
8:00 am: Surgery time! Clip, scrub, and prep our pig. Approach the abdomen (i.e. make the incision). Abdominal explore takes a good 45 minutes, then 30 minutes or so for splenectomy, and we decided to spay our pig instead of gastropexy (took an hour and 15 minutes for that)
11:00 am: Start our abdominal closure (i.e. suturing the abdomen back together)
12:15 pm: Finally done with closure and clean-up. Time for lunch!
1:00 pm: 2 hours of class
3:00 pm: 45 minutes of study time for small animal final
3:45 pm: Check to see if junior surgery, ophtho, and necropsy displays are set up for pre-vet tours (they are)
4:00 pm: Start pre-vet tours, including extra displays
5:45 pm: Tours over; head home
6:20 pm: Home; time for dinner!
7:10 pm: Leave for handbell rehearsal
7:20 pm: Handbells
9:15 pm: Home from handbells
9:30 pm: Shower and try to reenergize
10:00 pm: Start small animal final exam
11:00 pm: Done with SA final; start studying tomorrow's JSL procedures (gastrotomy, enterotomy, intestinal resection & anastomosis)
11:45 pm: Time to get ready for bed
12:15 am: Asleep!

Wednesday:

6:00 am: Wake up! (How in the heck is it 6 already??)
etc.
etc.
etc.

So that's a little bit of how my week went. Thankfully, things calmed down toward the end; we didn't have any new surgical procedures to learn for Friday; I did pretty well on my small animal final; I didn't do great on my large animal final but did manage to pass it on Thursday night; and for once I had a Wednesday-through-Friday exam done before Friday afternoon, leaving me free to completely veg once I got home from birthday shopping for CLH at 4:15 yesterday.

Next week's rotation is Small Animal Surgical Anatomy (SAA). It's a cadaver lab on dogs and cats, which will be nice because it takes off some of the pressure of working on a live animal, i.e. leaving you to concentrate on your surgical technique instead of panicking because your partner lacerated a renal vein about 2 mm from the caudal vena cava and there's blood gushing everywhere...

It will also be a bit more relaxing because we are starting on Monday with some things that I just practiced last week -- spays and cystotomies. We are also doing neuters (castrations) which we didn't get to do on our piggies because they were already testicle-free.

Plus, I don't have to show up on Monday until 8:30 am. So awesome. So, so awesome.

(And also a little sad that I'm so excited about sleeping in till 7 am, since over the last 2 years I frequently didn't have class until 9 or even 10 or 11 am...)

2 more days of JSL

I'm tired and busy, so this will be brief.

Yesterday performed a full abdominal exploratory surgery, then cut out a pig's spleen, then spayed it (removed ovaries and uterus). Then closed our 14-16 inch long abdominal incision (takes forever!).

This morning I cut open another pig's stomach, then sewed it back up. Then assisted my partner with an intestinal resection and anastomosis (cutting out a "diseased" portion of the intestine, then suturing the 2 healthy ends together). Then, again, we had to close our incision (which we kept closer to 12 inches today -- clever us!).

Tomorrow brings nephrectomies (cutting out kidneys and ureters) and cystotomies (cutting into the bladder, e.g. to remove a bladder stone).

Friday is "mystery" surgery day (although I cheated by scrubbing in with the JSL group a few weeks ago, so I am already prepared to find GI Joes and toy dinosaurs hidden among the intestines, iatrogenic intussusceptions, blocked ureters, and superglue in the bladder).

Here's what I learned today: I can handle a 12 hour day at school (including 4 hours of surgery, a lunch presentation, 3 hours of class, 2 hours of studying, and an hour-long lecture about the American Board of Veterinary Practitioners) on a mere 5.75 hours of sleep. Though I'd prefer not to.

I promise further updates about JSL and my hectic week within the next few days (or at least over the weekend [which can't come soon enough!]).

JSL Day 1: Survived

Today's Day 1 of Junior Surgery Lab was a ton of fun.

We started off the morning at 7:30 with a brief lab introduction/orientation (including a speech about flagging somebody down if you feel sick or woozy; I was totally like "Been there, done that").

We also got a pep talk about not feeling bad for the pigs who were destined to die at noon today, at the conclusion of the lab. After all, pretty much all pigs are born to be slaughtered anyway, so isn't it nice that we can use these guys to further our educations, right?

Then we headed down to lab at 8 to meet our poor little piggies. They were all anesthetized and covered with cute little pink blankets to keep them warm in the freezing climate of the surgery lab (which is kept at nearly subzero temperatures to avoid excess numbers of vet students overheating and passing out).

Seriously, I want to know how early in the morning the surgery prep team has to get there to have 11 pigs anesthetized, IV catheters placed in ear veins, on IV fluids, intubated and on ventilators, and with some degree of monitoring equipment going on each of them. It can take us juniors on anesthesia rotation a solid 1-1.5 hours to get a dog or cat from kennel to surgery table. I'm impressed.

Today was all about skin suturing, and learning how to relieve tension when closing skin defects (whether lacerations or iatrogenically induced incisions).

We started with elliptical incisions -- almond-shaped cuts down through the skin layer in an outline, then cutting out all the tissue in the center.

Here's one nice thing about pigs: they have lots of extra skin. Which is good when you are trying to close an elliptical incision for the first time.

Actually, it went fairly well. If I'm being modest (okay, I'm not), my elliptical incision was absolutely beautiful when I was done. I did a simple continuous subcutaneous suture pattern, with 2 or 3 skin cruciates thrown on top to close the bits that didn't appose as well as I'd hoped.

Next we were supposed to learn how to correct "dog ears" or "puckers." We did that by creating a half-circle incision (straight across on one side, with a half circle connecting the 2 ends of the straight line). Normally with that kind of incision, you'd want to space your sutures closer together on the straight side and farther apart on the curved side, to gradually take the slack out of the tissue a little bit at a time. But since we wanted to create a dog ear, we just sutured it straight across so we had a nice little pucker at the end that had nowhere to go.

Then we got to practice some techniques for fixing puckers, namely cutting out a triangle of skin to make it lay correctly, or doing a couple extra incisions to make the main incision end at a right angle.

Finally, we practiced advancement flaps. We created a rectangular "wound" but left one side of the tissue connected, so that there was a rectangular flap you could pull up. Then we cut out part of the flap, so that we would have to practice getting the smaller-than-desired flap to align with the larger original incision. That involved a couple of extra triangular incisions, and a lot of creative suturing.

Think that sounded fun? Here's the plan for tomorrow:

Cut open our pig's abdomen (different pig) and cut out its spleen. Hooray!

This little piggie went to market (but ended up anesthetized at the vet school)

Tomorrow is my first day of "pig lab," known more officially as Junior Surgery Lab.

With 22 students in the class, we pair up and each team of 2 students works on an anesthetized piggie.

Tomorrow is some simpler stuff -- suturing skin incisions, elliptical incisions, practicing different suture patterns, etc. -- getting us used to some basics, reminding us about aseptic technique, and introducing us to the difference between working with live tissue versus the cadavers we've gotten to know pretty well over the last 2+ years.

Here's hoping I don't feel like passing out! A large breakfast plus extra snacking and lots of water is in my future in approximately 12 hours.

I'm thinking pig lab is really going to be a blast. But I'll admit I'm not thrilled about having to leave the house around 6:45 am every day this week... Thanksgiving break, here I come!

Playing doctor

This week's rotation, Community Practice-Medicine, is one of my favorite rotations so far this year. It's also been definitely the most demanding and most challenging rotation, and the rotation on which I've learned the most.

You already heard about CP-Surgery in September, so let me give you a brief rundown of how CP-Medicine works:

This week there are 7 senior students on Community Practice, 4 juniors on CommPrac-Medicine, and 5 juniors on CommPrac-Surgery.

Tuesday, Wednesday, and Thursday are surgery days. There are 6 surgeries scheduled each day, so 6 senior students are on surgery in the morning, with the 5 surgery juniors along with them.

That leaves 1 senior student and 4 juniors to handle all the morning appointments (which start at 9 am and happen every 15-30 minutes until 12 pm; actually appointments go all day with the last appt at 6 pm, but juniors don't take any appts after 11:30 so we can get to class). With 5-10 appointments every morning, that means that each of the 5 students has been handling 1-2 appointments a day.

(On Monday and Friday, there are no surgeries, so all of the juniors and seniors help with morning appointments.)

On Monday, we juniors mostly paired up with seniors to follow them through appointments and learn the system of checking them in, where to way the dogs, what exam rooms to use, how to take a good history, how to present treatment options, do physicals, present cases to the supervising clinicians in the treatment areas, fill out fee sheets, and complete electronic medical records.

On Tuesday and subsequently, we got thrown in on our own. What you do is this:

* Sign up for appointments before rounds at 8 am; read up on your assigned case's history if you have time and they've been here before
* Watch the appointment schedule on the computer; appointments turn from yellow or pink to green when the client has checked in
* Head up to the reception area
* Get the day's paperwork from the receptionist
* Get the patient's chart from Medical Records if the animal has been to the VTH before
* Find the patient and owner in the lobby
* If a dog, take them over to the scale and get a weight (cats get weighed in the back)
* Find an exam room (unoccupied and preferably clean)
* Get a thorough history of the animal's general environment and wellbeing, and anything specific to a particular complaint that caused the owner to bring the pet to the VTH
* Do an initial physical exam (sometimes a challenge if it's just you and the owner, and the dog is fidgety or hyper)
* Present any initial exam findings or proposed diagnostics or treatment to the owner
* Have the owner wait in the exam room or lobby
* Take the dog or cat back to the Community Practice treatment area
* "Present" the case to the supervising clinician (i.e.: "This is Johnny. Johnny is a 3 1/2 year old castrated male domestic short hair cat. Johnny presented today for routine wellness exam and vaccines. Johnny is kept as an indoor-only cat with one other cat in the home. His vaccines up to this point have been up to date. His diet is Z/D dry food due to possible allergies or IBD... [yada yada yada])
* Discuss any abnormal physical findings with the clinician
* Clinician repeats the physical to see if you missed anything
* Clinician asks what you want to do (vaccines? blood work? other diagnostics?)
* You agree on a treatment plan, then run back up to the owner to get approval (sometimes this entails 3-4 back-and-forth trips while you get questions answered)
* Head back to Community Practice
* Get whatever you need ready: draw up vaccines, fill out vaccine consent form, fill out rabies certificate, draw and process blood or urine samples, run chemistry profiles or heartworm tests, vaccinate the animal, etc.
* Fill out prescription requests; take to pharmacy
* Fill out fee sheet; take to business office
* Return pet to owner
* Go over any physical exam findings, client education, recommendations for treatment or changes at home, etc.
* Answer any questions the client has
* Go back to Community Practice after client leaves and valiantly attempt to get a head start on writing up the medical records for the last visit before your next appointment shows up
* The following day, make a follow-up phone call to every appointment from yesterday

And an additional goal is to teach us how to manage appointments efficiently, i.e. a goal of getting clients out the door within 60 minutes. Gaaaahhhh...

Here have been some of my appointments this week:

Monday: 2 year old cat for vaccines; 8 year old cat for vaccines, bloodwork, and urinalysis (which we did ultrasound-guided: cool!)

Tuesday: a 3-dog family (9 year old border collie mix, recheck from respiratory illness 2 weeks ago associated with autoimmune disease; 5 year old golden, heartworm test and preventive; 13 year old golden, heartworm test and preventive, CBC/chemistry panel, NSAIDs for stiffness [probable arthritis] [did not happen due to elevated liver enzymes on her chemistries], and oral joint supplements); then a 16 month old golden who came in for routine vaccines

Wednesday: rectal prolapse!

Thursday: 6 year old Airedale belonging to one of my sophomore-year pharmacology professors (his wife brought in the dog), needed heartworm test plus CBC/chemistry for NSAID prescription for joint disease (thankfully the blood results on this one were fine)

Friday: who knows! I'm hoping that since there will be 16 of us to handle the morning appointments, I won't get stuck with any on my own, and preferably will be paired with a senior student so that I don't have any personal responsibilities as far as writing up records. And so that I get done by noon and actually get a lunch break.

Let's talk a little more about what it's like psychologically to be a student on Community Practice.

As the students, we act 95% as the veterinarian. In most cases (all routine, healthy animals, and most mildly ill pets), I as the student am the only person who interacts with the client. The doctors rarely leave the treatment area, and merely give us suggestions (if we need them) on what issues to address with the client or how to present our proposed treatment plan.

When I bring back a dog to present to a clinician, I am responsible for having established a positive relationship with the client. I must have obtained an accurate history (another mantra for this year: "Your history provides 60-80% of what you need to make a diagnosis"). I should have completed at least a cursory physical exam in the client's presence, and am responsible for a full, thorough PE, even if I have to do part of it in the back with someone's assistance.

I am in charge of raising any concerns the client has brought up, or any issues I've found on PE.

I propose the plan for the day: what vaccines will we be doing? Does the client want a heartworm test? What kind of heartworm preventive do they want? Do they want flea/tick preventive? Do they want a fecal exam? Deworming? Want to sign up for a wellness plan? Are they interested in routine wellness bloodwork?

If it's a sick animal, that can get more complicated. Say the dog presents with what the owner perceives to be a urinary tract infection. I should know and be prepared to tell my clinician that I want to obtain a urine sample via cystocentesis and submit it to the diagnostic lab for urinalysis and urine culture. I should know which antibiotic I want to prescribe for the dog in the meantime, until the culture results come back. I should be prepared to look up dosages and write prescription requests for said antibiotics, and discuss how to administer the meds and potential adverse side effects with the owner.

I have to keep a list of any issues that have come up in either my history-taking or physical exam. Does the dog need a dental? If so, how will I present that to the owner? How will I explain dental disease and its consequences? What details will I give them about the dental cleaning itself? Is the dog overweight? If so, what diet recommendations do I have? What kind of exercise can they do? What will they substitute as treats for the high-calorie commercial dog cookies they've been giving? How will they be able to monitor the dog's weight loss?

If I forget to talk about anything during the appointment, it's my responsibility to get in touch with the client later that day or tomorrow, and go over anything I left out.

It's my job to make sure the lab gets the blood and urine tests done, check on the results, and relay them to the owner.

I am responsible for following up with a phone call the next day to see if the dog had any side effects from vaccines, if they came up with any questions, if they've been able to administer oral meds successfully to that annoyed cat, etc.

Whew. I'm exhausted just thinking about it.

I guess this is one of those areas where the more you do it, the more you improve. Even in just the last 4 days, I already feel so much more comfortable in appointments than I did at the beginning of the week. But that doesn't mean I don't have a looooong way to go.

Here's another thing: Even while you are supposed to be acting as the doctor, a lot of what you do is tech stuff. The thing is, Community Practice is a great place to practice some technical procedures -- stuff like jugular and cephalic blood draws, cystocentesis, administer subQ/IM/IV injections, expressing anal glands, etc. It's stuff we HAVE to be able to do as doctors, and things that most of us need a lot of practice on, but in reality, it's possible to find a job at a great hospital that has fantastic techs who can do all of that stuff for you. However, you've got to be able to do it yourself in a pinch. It's the vet who has to get the blood sample from the sick 17 year old dehydrated emaciated cat when nobody else can.

As students, we're also supposed to be getting familiar with some other sorts of procedures -- drawing up vaccines, running chemistry panels, calculating drug dosages, filling out rabies certificates, completing fee sheets, etc. Again, a lot of that is stuff that competent techs can legally do for you in a practice setting.

So that's one reason that appointments can take so long. You might be thinking, "Wow, striving to stay under an hour for a routine vaccine appointment? My dog is healthy and just needs one shot! How long can it take?"

Well, it makes a heckuva lot of difference when you've got a tech doing 90% of the miscellaneous tasks for you, and you can concentrate on your 4 "doctor areas": diagnosis, prognosis, prescription, and surgery.

For example, after my prolonged 3-dog-family appointment on Tuesday morning, I ended up having to take an 11:30 am vaccine appointment by myself. I spent about 10 minutes getting a history on the dog and doing a brief physical. When I got back to the treatment area, the supervising doctor (who was acting as my "tech"; as she describes herself, "I'm the best-paid tech in the whole hospital") had already gone through the dog's record and found out he needed a second vaccine in addition to what the owner thought was due. She had drawn up my rabies and distemper vaccines. She had filled out the rabies certificate and vaccine consent form and the fee sheet. All I had to do was present the dog, wait while the doctor repeated my physical, let her know of my plan for the day (renew the wellness plan, deworm, vaccinate, send home a fecal sample collection container, and educate about dental health and maintaining the dog at an ideal weight), pop the vaccines in the dog, give him some deeeelicious dewormer, and get him back up to mom. Piece of cake: only 35 minutes from in to out.

I guess the moral of that story is: A good technician is invaluable. Don't forget how important your techs are, and give them the credit they deserve. They can make your life so much easier if you trust them and know they are competent.

Well, since I've wasted enough time blogging, I suppose it's time to head to bed. Friday bonus: show up for Grand Rounds at 8:30 instead of regular M-Th rounds at 8 am!

Having a bad day? It's all relative

So you've been having a bad Wednesday.

When your alarm went off at 6:15 am, the window had been open all night and it was in the 30s, so the bedroom was freezing.

As you entered the equally frozen bathroom, you found about 20 feet of shredded toilet paper unraveled on the floor. (Thank you, cats.)

You had cinnamon raisin toast for breakfast instead of your regular wheat toast with peanut butter; it was tasty but you worried it wouldn't be enough to get you through the morning, and sure enough, it's 10 am and you're starving.

The intern you've been working with all week seems constantly cranky; today is no exception.

It's seemed like a really long, demanding week already, and you're only a couple days into it.

You've got 2 exams due by Friday, for which you haven't studied at all yet.

You're sick of paperwork and writing up medical records and not knowing if you're doing things right.

You've been staying late over the lunch hour and after class is over in the afternoon to complete various tasks for your morning appointments.

All in all, it's not been a fantastic day so far.

.......

.......

.......

Let's take a step back for a moment, and get some perspective:

At least it's your 10 am appointment, and not you, that has a prolapsed rectum.

My sole appointment yesterday morning on Community Practice - Medicine (this week's rotation) was a 1.5 year old female Shiba Inu who we'll call Kahlua (name changed to protect the cute).

Kahlua presented with her fantastic owner to the VTH's emergency service for a rectal prolapse.

Let's take a minute to talk about rectal prolapse. What that basically means is that a variable amount of the dog's rectum is protruding through the anus. (Just to get things straight: the "rectum" is the last part of the intestine and the "anus" is the sphincter on the outside.)



(The above picture is from Google images, and obviously is not actually Kahlua, since she is not a Boston Terrier!)

Rectal prolapse is usually caused by straining -- and whatever is causing the straining is what you need to diagnose and fix. It can be caused by diarrhea, constipation, GI parasites, intussusception, GI foreign body, partial or complete obstruction, or just about anything causing blockage and/or inflammation of the intestinal tract. It can also be caused by dystocia (difficulty giving birth) or straining to urinate (e.g. with a stone in the urethra).

So you can treat a rectal prolapse (basically sedate the dog, push all the rectal tissue back in through the anus, and sew the anus shut for a few days so nothing pops out again). But unless you've found the underlying reason why the prolapse occurred in the first place, your patient may be back with a recurrence in the future.

Which, unfortunately, was the case with poor little Kahlua.

Kahlua actually came to the VTH in August with her first rectal prolapse. She'd been straining a little bit and having some diarrhea, for unknown reasons. Since she was young, one of the primary recommendations was a thorough fecal exam to check for any GI parasites that could be causing irritation. Even though Kahlua's fecal exam showed no parasite eggs, she was dewormed extensively anyway, just in case (fecal exams are not foolproof and can sometimes miss worm eggs).

In August, Kahlua also had abdominal xrays, which showed a normal abdomen.

Kahlua got some happy-making drugs, and had her rectum replaced and sewn shut for a few days.

And all was well.

Then, about a week after presenting with her prolapse, Kahlua's owner called the VTH and said that Kahlua had started vomiting up some pieces of carpet.

Mystery solved.

(Or was it???)

The theory in August was that Kahlua's first and only rectal prolapse had probably been due to a partial GI obstruction caused by foreign body ingestion which could not be seen on xrays.

That was all well and good, until Tuesday evening, when Kahlua went outside to defecate and came back in with a prolapsed rectum.

Kahlua's dad brought her in to the VTH as soon as possible, but even so, her prolapse had spontaneously reduced (i.e. the prolapse had fixed itself by the time Kahlua saw the vet). Nonetheless, Kahlua was put on a stool softener and wet food, and sent home at midnight with an appointment to see community practice the following day (Wednesday).

Unfortunately, when Kahlua went out to potty on Wednesday morning, her poor little rectum prolapsed again, and was hanging in the breeze when I went up to check her in for her 10:30 am appointment.

Now, I should tell you that Kahlua actually had a very mild rectal prolapse, both in August and this week. She only prolapsed 1-2 cm in August, and probably less than 1 cm yesterday. Compared with some pictures I've seen online, this is pretty darn good.

However, even a minor prolapse is an issue. For one thing, it's irritating and painful. Kahlua was adamant that we not touch her bottom area at all (and I can understand why). Obviously the longer the rectal tissue is out in the environment, the greater chance for contamination and trauma to a delicate structure. Additionally, some dogs will actually chew off the part that's hanging out if you don't keep a close eye on them (or an e-collar on them), and/or blood flow to the prolapsed portion can be cut off for so long that the prolapsed part becomes necrotic and dies (big mess).

So the plan today was an even more thorough work-up of Kahlua's potential underlying disease. She got some heavy-duty drugs on board for a rectal exam (feel if there is any foreign material or colonic intussusception, which there wasn't). She got abdominal radiographs to check for foreign bodies or obstruction (rads were 100% normal). She got an abdominal ultrasound to check for intestinal health and possible intussusception (100% normal). The only abnormal thing we found at all was some overgrowth of abnormal bacteria on her fecal cytology, which is usually a secondary change to some sort of GI upset, and was probably not the cause of her straining and prolapse.

So, no good answers for Kahlua. While sedated, her prolapse was reduced (replaced inside her body), and it stayed in for the rest of the afternoon even while she was having diarrhea all over the place. She went home with some tranquilizer pills that her owner could give if she prolapsed again, to keep her calm and ideally decrease her straining.

It's hard to say what her underlying disease is. Apparently in some cases, no obvious cause is ever found -- but it's still hugely important to investigate the possibilities, because some very serious diseases can cause the kind of straining that induces prolapse. Maybe in a few days Kahlua will start vomiting more carpet pieces. Who knows.

All in all, this was a very cool case (and, I might add, I worked it up as the only student on the case -- all but 1 senior student was in surgery, so with 5 of us juniors on to help with a full morning of appointments, we were all busy and taking cases on our own). And Kahlua is the nicest little Shiba Inu I've ever met.

I got to do a lot of neat things -- practice my physical exam, of course; take an axillary temperature; lots of owner interaction; learn how to create estimates for treatment costs; submit radiology requests for rads and ultrasound; decide on a sedation protocol, dosages, fill out a prescription request, and submit it to the pharmacy; and take a look at Kahlua's radiographs.

I gave Kahlua's dad a quick call this morning to see how she'd been doing, but I had to leave a message. Fingers crossed that little Kahlua's rectum stays put, or she's potentially looking at some not-so-fun surgery in the near future.

I heart EED (mostly)

This week's rotation is EED: Exotic and Emerging Diseases. Also known as "foreign animal diseases" (FADs) or "transboundary diseases."

I like this rotation for a few reasons:

1. It is low-stress. Other than some online, open-book, take-as-many-times-as-you-want quizzes, all we have to do is show up and listen. After last week's multiple exams, and 2-3 exams for each of the next 2 weeks, I can use a rotation that doesn't add anything else to that.

2. We get to start late sometimes. Class started at 8 am on Monday and Friday, 8:30 am on Tuesday/Thursday, and 9:30 yesterday (which was totally awesome).

3. A lot of it is self-guided, self-paced learning. We have 1.5-2.5 hours of lecture every morning, in which we cover a different type of FADs each day, and then the rest of the time is for us to go online and complete a series of modules and associated exams that is part of initial accreditation training for us to become certified after graduation in issuing health certificates and certificates of veterinary inspection for animals traveling across state lines.

We are learning about some cool, and really scary, diseases -- most of which are not currently present in the U.S. but have been eradicated in the last 50 years or so and/or are rampant in other parts of the world and could easily get into the U.S. and wreak havoc on our food animal and equine populations. Those would be diseases like:

* Highly pathogenic avian influenza
* Exotic Newcastle disease
* Contagious equine metritis
* Foot and mouth disease
* Vesicular stomatitis
* Swine vesicular disease
* Vesicular exanthema
* Dourine
* Surra
* Nipah virus
* African horse sickness
* Glanders
* Venezualan equine encephalitis
* Equine piroplasmosis
* African and classical swine fever

Pretty exciting stuff, no? Actually, it's quite interesting. And it's really alarming to realize how easily a terrorist (or just someone stupid) could visit a foreign country, be on a farm or ranch or livestock sale, pick up something highly contagious, and 24 hours later be back in the U.S. on one of our farms or ranches or livestock sales. It's actually surprising that it hasn't happened a lot more often. Our instructor pointed out that a lot of terrorists are interested in actions that will make a big splash and get lots of media attention (e.g. bombings, anthrax), whereas the spread of a foreign animal disease to the U.S. national herd could be hugely devastating both economically and with loss of food and animal life -- but fortunately(?) it's a little more insidious and not as splashy as blowing up a building.

The only thing I really haven't liked this week was watching a video yesterday of animals infected with foot and mouth disease (FMD).

There are a couple locations in the U.S. where these big scary diseases are researched and tested for -- the National Veterinary Services Laboratory in Ames, IA, and the NVSL on Plum Island, which is near New York.

The folks on Plum Island are always having U.S. vets and FAD researchers come out to spend time on the island and see what these FADs look like in a real live animal -- fortunately most of the FADs are still actually foreign, so U.S. vets don't have the opportunity to see outbreaks in the country very often. So they go to Plum Island and watch cows, pigs, etc. being infected with these various diseases in a lab setting.

FMD is not a disease that in and of itself is very fatal to infected animals. It basically causes horrible blistering in and around the mouth, on the tongue, and in between the "toes" of cloven-hooved animals. That means it really hurts for the animals to walk, and they aren't super-excited about eating, either, since they have blisters all over their tongues. The disease itself actually runs its course in a few days, and the blisters start to heal, and the animal then has some degree of immunity from future infection. But until then, the animal might be so lame that it can't or won't walk over to a feed trough or water tank, so can have complications from anorexia and dehydration. They can also get teat lesions which can develop into mastitis, which might either make the cow really sick, or result in her being culled due to decreased production from her infected/scarred mammary gland.

Anyway, the video we saw was a recording of the progression of disease in cows and pigs over about a 10-day period. It was so sad! In a realistic outbreak with actual disease in an animal population, of course you'd be treating the animals with supportive care -- pain relievers, helping them get to food and water, etc. But I guess to make it the best teaching demonstration of what FMD can actually do to these animals, the infected cows and pigs don't really get that stuff.

I know that there are reasons to purposely infect animals with horrible diseases (i.e. so we can see what happens and be prepared to treat or control such diseases in a real-life outbreak; so we can research different means of diagnosis and treatment; etc.). But it's tough to watch a video of these guys suffering when we're all in vet school because we want to help animals and relieve their pain.

But other than that, good rotation!

Rockin' the exams

Since an initial bump or two at the beginning of the semester, I've been doing exceptionally well on exams this semester.

(Side note: One of the awesome things about writing your own blog is that you can be as self-centered as you want and talk on and on about your awesomeness. So there. I am not ashamed of my ego!)

The only exam I've really botched was equine orthopedics (77.5%).

Other than that, it's been all A's:

SA orthopedics: 92.2%
SA neurology: 96.2%
EQ repro: 91.5%
FA repro: 92.5%
Radiology: 94.4%

I'm pretty excited that even with all of the busy-ness and unpredictability that junior practicum entails, I've been able to keep doing well in my classes (okay, except maybe equine orthopedics; still don't know what happened there).

Playing surgeon? Eat your Wheaties!

Because it really sucks to be 2 hours into surgery and start getting woozy and feel like you're about to black out.

(Lesson learned.)

All throughout this year as we've been learning about surgery (and even in the past two years, when we've had surgical principles lectures and labs), they have emphasized to us that it takes some practice to get used to being in surgery.

"Every year," they repeat, "some students pass out. Don't be the student that passes out! Tell us right away if you start overheating or getting dizzy or feeling funny! Nobody will catch you and we don't like picking up vet students off the floor!"

Okay, I figured. Apparently there are students in the class who haven't had the opportunity to be in a surgery environment or observe surgeries before. Too bad for them. After all, I have spent years as a technician monitoring surgeries.

Well, I'm here to tell you that being in a surgical suite monitoring anesthesia for a surgery performed in a private practice setting does NOT mean you know how to be in a vet school teaching hospital surgical environment.

And I sort of knew that. So even with my past experiences, I've tried to be extra careful this year when I knew I'd be scrubbing in for surgery. During my community practice week, for example, I paid extra attention to what I ate for breakfast, made sure to drink lots of water, and ate a quick granola bar right before scrubbing in. I was conscious of my body position during surgery, made sure I wasn't locking my knees, etc. And all was well.

This past Friday, however, I had the opportunity to scrub in with last week's Junior Surgery Lab since one of my classmates was out sick with a self-described "dysentery." (Sounds thrilling.)

I'll be having JSL ("pig lab") at the end of October, so you'll hear about it in much greater detail then, but here's a brief overview: There are 22 students in the lab at a time, divided into pairs, and working on 11 anesthetized pigs. The first day of the lab is suturing skin incisions. Days 2-4 include intestinal resection and anastomosis, nephrectomy, splenectomy, cystotomy, gastrotomy, enterotomy, etc. Day 5 (Friday) is an abdominal exploratory -- meaning the instructors have already cut open the pigs before you get there, and created problems -- marbles hidden in the abdomen, superglue injected into the bladder, an intussusception, etc.

So it was on a Friday that I jumped into the lab.

But before I got to lab, I woke up at 6:15, had my usual piece of toast and OJ for breakfast at 6:30, had a doctor appointment at 7:45, got to the VTH at 8:20 and found that the JSL students were about to start scrubbing. The sick student hadn't arrived but there was still a chance she would make it. So I ran up to my locker to put my stuff away, then hurried down to the soft tissue rounds room to make sure it was okay for me to ditch SD and go to JSL, and make sure the other junior on the SD rotation didn't mind me leaving, then headed back up to the locker room to change into surgical scrubs, and finally made it back to JSL as they were finished scrubbing. Needless to say, I didn't have quite enough notice or time to get my brain in order and mentally prepare for the upcoming 3.5 hours of surgery.

Everything was okay for the first 2 hours or so. Since I hadn't done the first 4 days of the lab yet, my role in the surgery was basically holding intestines out of the way for my partner -- which was fine. After a couple hours, though, it was getting boring. And I was getting hot.

(Let me take a minute to tell you about our surgical attire. First, in private practice settings, vets often perform routine, non-complicated surgeries wearing scrubs or even their everyday doctor clothes. They sometimes wear a cap or bouffant [like a hairnet] over their hair; sometimes not. They sometimes wear a surgical mask over their face; sometimes not. In a vet school setting, however, they want to teach us the higher standard -- which means we wear booties over our shoes, caps or bouffants over our hair, a mask covering our face, AND a full cloth surgical gown, that ties multiple places in the back, goes down to at least your knees, is tight around your neck, and has long sleeves with thick 3-inch-long cuffs on the end. You pull your sterile gloves over the cuffs of your gown sleeves so that none of your un-sterile skin can get out. End result: Your wrists rapidly become soaked with sweat; your back and neck sweat; if you have a ponytail, it sits on your already overheated neck; and every breath you inhale and exhale through the mask blows hot air onto your face.)

It was a combination of multiple factors that culminated in my wooziness: (1) Overheating due to surgical attire, (2) boredom leading me to focus intently on how I was starting to feel weird, (3) eating breakfast earlier than usual due to my doctor appt, (4) not grabbing a quick bite to eat right before heading into surgery, and (5) a morning dose of an antibiotic that has been giving me some GI upset for the last week.

Here's another lesson I learned: If you want to get the instructor's full attention during a surgery lab, tell them that you feel funny and need to sit down. Let me tell you, you can get waited on hand and foot.

So I started feeling a little dizzy, vision going in and out of focus. I've experienced that feeling only once before -- during my first year or two of college when I was shadowing at a vet clinic back home, and the doctor invited me to watch surgery (the first declaw I'd ever seen) -- and that first time, I did nearly pass out. So I was eager to quietly sit down and get my nerves back while I was only feeling a little funny, rather than making a huge scene in front of 21 of my peers by collapsing to the floor.

I called over one of the 3 instructors helping in the lab and said, "I'm starting to feel a little funny. Can I sit down for a few minutes?"

He immediately looked totally alarmed and grabbed me by the shoulders, presumably to make sure I wasn't going to drop to the floor then and there. He said, "I'm going to bring you that chair. Can you stand here for a few seconds?"

I was like, "Heck yes. I don't feel that bad." The chair was literally only 8 feet or so away.

So the chair was delivered to me and I sat. The instructor advised me to take off my mask and I did, which helped a ton. He also turned on a box fan right next to my surgery station. (Oddly enough, each of the 11 surgery stations has its own box fan to cool off the student surgeons. Guess with 22 student surgeons, 3 instructors, and 11 pigs all in one room, it often gets warm in there.)

They left me alone for a couple minutes, and really I felt 90% better after sitting for about 30 seconds with my mask off. When the instructor came back to check on me, I told him I felt a lot better and thought I was ready to start again. But he said, "You still have no blood in your face. Can I get you some food? A granola bar? Some orange juice or coffee or a soda?" I said no, I felt better, but he persisted with, "Okay, but do you mind if I kick you out of lab and send you upstairs to have a snack?" Which was nice of him. Especially since my surgery partner later confirmed that I was apparently white as a sheet even though I felt fine again.

So I dutifully headed upstairs and downed a couple slugs of orange juice, a chocolate donut, and about a liter of water. Feeling completely revived, I came back down to the lab, re-gowned and gloved (the nice thing about doing a terminal surgery is that you don't have to worry about sterility, so I didn't actually have to scrub again), and completed the last 75 minutes or so of the lab without incident.

I felt pretty silly about the whole thing, because even though the other 20 students were busy with their own surgeries, they weren't so busy that they didn't notice me sitting down and later leaving. But all things considered, I would much rather have had things happen the way they did than end up out cold on the floor, in which case I'm sure everybody in my class would have heard about it, not just the 1/6th of the class in the lab. And afterward, my friend in the lab told me she got overheated on Thursday and had to take a break like I did, so I felt much better.

Anyway, the moral of this long story is at least fourfold:

1. Eat something before you go into surgery, even if you think you'll be fine.
2. It doesn't matter if you're not really participating in the surgery or under stress; just the fact that you're wearing surgical attire can be enough to do you in.
3. Sit down while you're just feeling strange; don't wait until you pass out.
4. 3.5 hours is a long time to be in surgery.