Thursday, February 24, 2011

What I killed this week

Several veterinarians I know keep track of "What I killed today" (or "this week"), either on a public blog or as a private exercise.

I think it's a nice way to acknowledge the sacrifice made by the many animals who die for teaching purposes -- as well as the pets we put to sleep for various reasons.

So here's what I killed this week:

Tuesday: An adult male rat who was a "retired" research animal slated for euthanasia one way or another, but used in my Rabbit & Rodent Medicine curriculum to teach us rodent handling, restraint, venipuncture, and intraperitoneal/intracardiac injections while he was alive, and physical exam, castration, and necropsy after I euthanized him.

Thursday: An old white female New Zealand rabbit who was "donated" for teaching purposes by a local breeder who produces rabbits for meat. We learned rabbit handling and restraint on her, practiced giving SQ injections and placing catheters in ear veins, cephalic veins, and medial saphenous veins. After I euthanized her, we practiced spays and necropsy.

Both of the animals I killed this week were sweet and friendly, which made it a little tougher. However, I really don't have a personal problem with small mammals being used in ethical research and for humane teaching purposes -- and all the animals used in this week's labs were essentially destined to die in some form or fashion in the end. But I'm thankful that we were able to make good and thorough use of their deaths in helping us to better handle and treat similar species in the future -- and hopefully help those future animals survive.

Monday, February 21, 2011

Rats and rabbits and mousies, oh my!

This week's exciting(?) rotation is Rabbit & Rodent Medicine!

RRM is the first rotation of the year that I haven't been all that enthused about. I'm not entirely sure why I even got it as an elective, since I ranked it 11/23 for the fall and 15/25 for the spring. But oh well?

I'm not entirely opposed to the idea of knowing something about how to handle and treat healthy and ill rabbits and rodents. However, I've focused my elective course choices on other areas (like business) so have missed out on much of the exotic animal curriculum offered so far as electives.

Plus, I have almost zero experience working with this little critters in a clinical setting.

Today we had a tour of the lab animal facility on main campus, that took about 30 minutes after our 15 minute orientation. After that, our group of 5 juniors was set free to work on about a dozen sample cases that we'll discuss on Wednesday morning. We were done with all of that by 9:45 or so, though the rotation was scheduled to end at noon -- so, yeah, there will be plenty of free time this week.

Tomorrow is rat handling, anesthesia, surgery, and necropsy. Thursday is the same, but with rabbits instead of rats. Wednesday is the aforementioned case discussions, and our 4 hours on Friday are set aside for "case presentations" where each of us 5 students gives a 5 minute presentation on a topic of our choosing (how exactly that adds up to 4 hours, I'm not quite sure yet).

I've already learned that when rabbits get an upper respiratory infection, the lay term is "snuffles" (how CUTE!) and that you shouldn't grab a chinchilla by its fur because when chinchillas are scared, their defensive mechanism is for their fur to fall out if someone pulls on it. Other than that, I guess I can say I had plenty of time to look at apartments today!

Once-in-a-career case

Last week's rotation was oncology.

The oncology patient I saw with a senior student on Tuesday morning with a senior student was strongly suspected to have lymphangiosarcoma.

Lymphangiosarcoma is a super-rare malignant cancer derived from the endothelial cells that line the lymphatic vessels. The lymphatic system drains excess fluid from the tissues all around the body and helps that fluid get back into the blood vessel circulation where it belongs.

Of the 5 or so veterinary oncologists on the rotation with us students last week, only 1 of them had ever seen another case of lymphangiosarcoma -- and there are only 16 cases of it documented in the veterinary literature.

The patient, "Sunny," was a sweet, medium-sized, portly 6-year-old mutt. She came in from her owners' backyard a few weeks ago with what looked like an abrasion on her hind leg -- which was unusual, because it spanned most of the inner surface of the leg -- a strange place to have gotten a large abrasion without any other obvious trauma.

Over the next few days, the suspected abrasion developed a lot of bruising around it and appeared to spread -- not only on the inner surface of the leg, but up into the inguinal and caudal abdominal tissue as well.

Even though Sunny's regular vet put her on antibiotics for possible infection, her leg just continued to get worse. After a few more days, the vet decided Sunny had a bad case of vasculitis and referred her to the vet school.

Sunny presented to the VTH's Dermatology service a week before she ended up at Oncology. The clinicians in Derm that week agreed that Sunny probably had a very bad case of vasculitis and cellulitis that would just take awhile to resolve. But, they pointed out to Sunny's owners that they couldn't rule out a cancerous process just by the way things looked.

So the dermatologists offered Sunny's owners a biopsy to definitively diagnose the condition that was causing horrible swelling and oozing all up and down her hind leg. Fortunately, Sunny's mom and dad agreed to the procedure, because the biopsy results (taken from 4 different locations on Sunny's leg and inguinal region) showed "angiosarcoma."

"Angiosarcoma is a semi-broad term that can encompass 2 different types of cancer: (1) Hemangiosarcoma, a cancer of the cells that line the blood vessels, or (2) lymphangiosarcoma, cancer of the cells lining the lymphatic vessels. Because both types of vessels are lined by endothelial cells, it can sometimes be difficult to differentiate their origin when you look at a cancerous tissue sample microscopically.

Hemangiosarcoma (HSA) is much more common than lymphangiosarcoma. Actually, HSA is one of the more common types of cancer seen in dogs. However, HSA is usually found in the organs -- the spleen, liver, and heart. It less commonly appears in a skin or subcutaneous form, like what Sunny might have.

But after consulting with all of the experienced oncologists, and reviewing what little information is available in case reports and textbooks pertaining to lymphangiosarcoma, it was felt that that was more likely to be the cancer that poor Sunny was facing.

So what to do for Sunny? Unfortunately, not cure her illness. Her disease had an extremely rapid onset and progression of her disease (over just a couple weeks' time). The inability to differentiate neoplastic lymphatic vessel cells from neoplastic blood vessel cells on her biopsies indicated that the cancer was probably a very progressive form. If it weren't so aggressive, or had been treated within a couple days of appearing, perhaps Sunny could have been treated by amputating her affected leg and hoping the cancer hadn't spread locally or metastasized. But with biopsy samples confirming the spread of disease past her leg and onto her abdomen, amputation couldn't cure her.

This was a really sad case. Sunny's owners were not only faced with a dog who had at best 6 months to live even with the best medical treatment, but also had financial concerns about how they would be able to afford her treatment. Not including the money spent at their referring vet and in Dermatology for her workup and biopsy, they faced a $120 consult fee with Oncology, plus around $170 for thoracic radiographs to check for metastasis to the lungs and $300 for abdominal ultrasound to look for abdominal organ involvement.

One of the toughest things Sunny's mom and dad had to handle was the fact that, from a hygienic point of view, Sunny's quality of life wasn't great. Her affected leg was very swollen and constantly oozed a copious amount of reddish fluid -- to the point that Sunny's mom would apply compresses to her leg multiple times a day and drain out maybe a half cup of fluid, but the leg would fill back up again with the same amount of fluid within 10-15 minutes.

Because of her messy leg, poor Sunny was restricted to certain parts of the house -- the dining room with hard floors, a carpeted section of the house where her owners had laid down plastic sheeting, and the patio and backyard. Sunny wasn't happy being away from her owners, and they weren't happy being apart from her, and not being able to have her sleep in bed with them.

One of the sort of neat treatments that Sunny's owners opted to try with her was some palliative radiation treatment. Radiation therapy can be used in one of two ways: (1) with "curative intent," or (2) to make the animal more comfortable. Radiation can reduce pain and inflammation and also sometimes dries up the irradiated tissue, which the oncologists hoped would help with the constant oozing and dripping from Sunny's leg.

Other than that, there wasn't a whole lot that even my university's renowned animal oncology department could offer Sunny and her family. She was enrolled in a clinical trial for a new chemotherapy drug that she's scheduled to start this week, but nobody was too optimistic about that.

Sunny's case was tough to handle emotionally, but provided some good insight into the type of cases that the oncologists see every day -- or at least every week. They kept telling me that "not all cases are this sad!" but it sure seemed like I just got luck of the draw with the bad ones all week.

My case on Monday was an older miniature Schnauzer who came in because her owners were worried about 7 skin masses. We aspirated 6 of the masses which turned out to be lipomas (benign fatty tumors). The 7th came back as a nerve sheath tumor. However, on physical exam, the oncology resident detected some liver and spleen enlargement during her abdominal palpation. Little Schnauzer headed over to radiology for an ultrasound, and went to emergency surgery just a couple hours later to have her huge, cancerous spleen removed -- later diagnosed as a hemangiosarcoma. It was sort of funny (in a morbid way) that this little dog presented for skin masses, one of which turned out to be bad, but the thing that would have killed her (the splenic tumor) was something the owners and referring vet had no idea about.

My Wednesday case was a sweet little 13 year old terrier mix -- tan in color but shaped and sized like a largish Jack Russell. He showed up at his regular vet about 5 months previously for a mass on his hip. He went on antibiotics and the mass went away; he stopped antibiotics and after a few weeks the mass came back; he had more antibiotics and the mass shrunk but didn't disappear this time. Finally his rDVM did a fine needle aspirate to look at some of the cells from the mass microscopically. As the owner put it, "Dr. RDVM said he had no idea what the cells were and he said that meant we should go to the teaching hospital." Sadly, by the time the little terrier presented to us, he had multiple other masses and enlarged prostatic lymph nodes indicating that his disease had already spread beyond the point of much treatment. He's probably also headed for some palliative radiation, mostly to shrink his sublumbar lymph nodes enough to let him defecate comfortably for as long as possible. At the time I left the case, his mass was suspected to be histiocytic in origin.

After 3 depressing cases (hey, some dogs come in with a leg tumor, get it amputated, and they're all better!), I opted to spend all of Thursday morning hanging out with the radiation technicians in the radiation therapy department. I got to meet some cool patients who were having either intensity-modulated-radiation-therapy (usually treated 5 days a week for 3 or 4 weeks) or stereotactic-radiation-therapy (treated 3 days in a row, then that's it). I got to see the difference between the palliative therapy and the 'curative-intent' treatments. And I got to meet the dog with the huge skull tumor between his eyes who is affectionately referred to by the oncology staff as "our unicorn"!

Tuesday, February 15, 2011

All hail the end of Practice Management!

At long (LONG) last, Practice Management has reached its conclusion! Our last morning of lectures was last Friday.

I admit that I learned a couple useful things during our 80 hours of lectures and presentations. However, I'll add that just about every single morning made me feel even more strongly that I never want to own or manage a practice. Their theory on getting us all to be practice owners seems to be:

1. Tell them how far they are in debt and how terribly their meager little lives will be affected by the enormous loan payments that will be heaped upon them at graduation.

2. Show them fancy charts displaying how much more money you can make as a practice owner rather than just an associate veterinarian.

3. Gloss over most of the negative aspects of actually having to own and manage a business. Let's instead focus on things like where on your display shelves in your lobby is the best place to put your most popular items for sale!

I'll say that the most positive aspect of the course, at least for me, was the fact that all of the instructors and the course coordinator seem very receptive to feedback. We're told that Practice Management is the course in the curriculum that changes more rapidly than any other course, based mainly on student input about what they want to learn less or more of.

However, my feeling is that Practice Management should be offered as a 2-week elective course in the Junior Practicum -- i.e. would be blended into the same curriculum as our morning clinical rotations. One of the four weeks of this year's version of the course was a series of mandatory accreditation lectures by the state vets, that is required to get a state license to practice veterinary medicine. So everyone could take that during the first week of the semester, then they could trim the remaining 3 weeks of "actual" practice management topics to a more reasonable 2 weeks, and then stop forcing everyone to take it. After all, I don't want to be an equine vet or a food animal practitioner, and I'm not forced to take elective courses this semester on those topics if I don't want to. Why should it be any different if I just want to be an associate vet rather than a practice owner?

In any case, what's done is done, and I'm looking forward to the opportunity to participate in a focus group to give additional feedback about the course. For now, though I'm on Oncology!

(Yes, that's right: An actual clinical rotation where I am working with clinicians, residents, interns, senior students, real live patients, and real live clients! A rotation where I'm actually learning applicable things and getting to practice some hands-on skills! What a novel idea!)

Oncology is, however, a little depressing, what with the whole "oncology-means-the-study-of-cancer" thing. I've seen a couple neat patients already this week, and I'm sure some of them will be appearing in subsequent blog posts.

But I just can't tell you how great it is to be back on my feet and applying what I've spent 2.5 years sitting in lecture halls absorbing from a didactic standpoint. Hooray for clinics!

Tuesday, February 1, 2011

Classes and life continue

This is only my second blog post of the semester because this semester has contained just barely enough information and activity to be worthy of a full two blog posts in two weeks.

Sigh.

Don't get me wrong -- my classes have improved over the last week or so. Practice Management is, at time, positively tolerable to attend. We've had better speakers recently, with more animation and enthusiasm, lectures that could actually qualify as organized, and several specific topics that are relevant even to the 75% of the students in my class who don't want to own or manage a practice someday.

I'm enjoying applied animal behavior. We had our 3rd day of lectures today. I respect the instructor and her ideas about dog (and cat) training. She keeps lectures light and entertaining by interspersing a fair number of YouTube videos (all related to the lecture material yet still almost invariably amusing) in between her PowerPoint slides. Unfortunately, I was so involved with the school's behavior club (for which she is the faculty advisor) last year, that I've basically already heard these lectures from her before.

Small Animal Medicine & Surgery is progressing decently. I really enjoyed the dentistry section we started with, which was followed by about a week of meandering, hilarious-yet-disorganized presentations by a gastroenterology faculty member who hasn't lectured to us much before. We've now moved on to liver disease taught by one of our best professors, which is a subject for which I could definitely use some review.

I've not yet managed to convince myself to sit through any of the equine or food animal medicine lectures that I thought I might attend in my free time. (I know, I can tell you're surprised.) I haven't had the opportunity to go to any of the small mammal disease lectures, which I guess means it's a good thing I dropped my enrollment from that class.

I've had plenty of non-class things on my mind. I trained 5 new tour guides the week before the semester started, and 2 more last Monday. It's been quite an 'experience' getting them all up to speed, and primarily helping them jump through all of the university's hoops required for official employment (which include a formal application, background check, sexual harassment training, sharps policy form, and meeting with the personnel director -- and that's in addition to my 2-hour tour guide orientation followed by several practice tours and shadowing experienced guides). However, I'm thankful that 7 of my original 10 recruits have stuck with it to this point. The added new guides are really taking some of the stress off of my experienced guides who were overworked last semester.

In addition to routine coordination of tours (including scheduling regular guides and scrambling to find replacements when I get last minute emails announcing "I have the flu" or "My dog's in CCU so I can't make it this afternoon"), I'm trying to arrange two more special extended tours for the university's pre-vet club, which will take place in March. These tours have big groups (20-30 students) requiring 2 guides, last longer than usual (1.5-1.75 hours), and include special exhibits (ophthalmology, anesthesia, junior surgery models, and necropsy presentation), all of which I have to coordinate.

Outside of school, we have handbells. Oh, handbells. We do 3-4 concerts plus an open dress rehearsal at the end of every season, which in the spring means May. Unfortunately, we don't actually know any of our concert dates yet, which is unusual and, especially for me, problematic. You see, by the time our spring bell concerts roll around, I'll most likely be a senior vet student for most if not all of the performances. Sure, I'll be on Community Practice which doesn't require weekend attendance at school, but any weeknight evening concerts (2 of which we have tentatively scheduled) may pose a serious conflict. Here's hoping we can figure that all out soon.

Then there's the house. For those who don't know me personally, the hubby and I are in the process of selling our condo. Why? Because it's currently about a 35-minute drive in morning and evening traffic from home to the VTH. Aside from the fact that I'll be on call a lot during senior year, which has a mandatory arrival time of 20 minutes from the time they call you in (which I could potentially make from our current location if all the stoplights, weather, and traffic were on my side, and if it was the middle of the night), I fear for my sanity if I were to try to commute 35 minutes each way for much (or any) of my senior year.

So the basic steps to selling the house are done. We have a realtor recommended by several of my classmates. We have had the house interior measured to create a basic floorplan. A professional home stager was consulted and I did my best to follow her recommendations. Photographs were done last week. During the entire month of January, we have been fairly consumed with deep house cleaning, organizing, packing, and moving anything not immediately needed over to our newly rented storage unit.

And.... drum roll.... as of yesterday afternoon we have a 'for sale' sign out front, a lockbox on the door, and an MLS listing on the web. Now to just wait for those oh-so-lucky buyers who want to make us a terrific offer based on the extremely excellent nature of our condo. Well, that is if the cats haven't just dropped a huge load in the litter box anytime within the 4 hours or so prior to a showing...

There's also that little matter of taxes. We've gotten almost all of our required tax documents -- except for a W2 that's gone missing, a tax form for CLH's health savings account that we can't find, a form from the mortgage company that hasn't been sent yet, and the fact that due to changes in billing practices, my school tuition tax statement will have 1 semester of tuition for 2010 and 3 for 2011...

Throw in a few potlucks to bake for and attend, and you can imagine why I'm glad that this semester doesn't seem to be too intense as far as coursework goes. I'm sure things will pick up once we get back into junior practicum, but for now it's a good thing that I have extra hours in my day to devote to the house and everything else going on.