Monday, March 28, 2011

Canine rehabilitation, aka anatomy review

I have a pretty cool rotation this week -- Canine Rehabilitation, or for short, "rehab." No, it's not about those dogs that just couldn't give up their fentanyl when it was time to leave CCU, or who keep sneaking their owner's tramadol. It's actually physical therapy-type stuff, but because of legal reasons, you can't use the term "physical therapy" unless you're specifically trained as a human physical therapist.

The rehab course is only offered this week and was added as an elective option at the end of last semester. This year's seniors who took the class last year made it sound really great, so a bunch of us juniors dropped whatever elective rotation we were scheduled to have this week (cardiology, for me).

The first hour or so of class is a lecture about methods of and uses for rehabilitation in veterinary patients -- everything from goniometry (measuring the angles of the joints) to girthometry (measuring the circumference of a muscle group) to active and passive range of motion to balance exercises to underwater treadmills and other hydrotherapy.

Then we get a quick "bio break" (a term I don't particularly like), followed by about 20 minutes of discussion of whatever muscle groups we're going over for the day -- yesterday was thoracic limb muscles; today was epaxial, hypaxial, thoracic, cervical, and deep pelvic muscles.

One of the fun parts is that we then have 75-90 minutes to use muscle-colored modeling clay to "build" the muscles we just discussed onto a plastic dog skeleton model. You get blue or green clay to make tendons and ligaments.

The last 60-75 minutes of class are left for actual hands-on palpation practice with actual real live dogs (owned by the students in the course) who submit to such learning opportunities as palpating bony landmarks (like the acromion, scapular spine, styloid processes, patella, ischiatic tuberosity, etc.) as well as different muscles (biceps, triceps, deltoid, pectorals, etc.).

And while I'd love to learn about some of the rehabilitation exercises I can use in the future (near-ish future!) to help my canine (and cooperative feline) patients feel better after surgery or injuries, it is just as great at this point to be having a really intensive review of bony and muscular anatomy. It's truly amazing how much you can forget (well, not "forget" so much as "lock away in a nearly inaccessible dusty corner of your brain") in the 2 years following freshman anatomy class. I'm really optimistic that this week's lectures, labs, and exercises will help make me a better senior student doctor in just 6 weeks.

Wednesday, March 23, 2011

Back at it

Shelter medicine finished with a lot of anesthesia preparation, induction, and monitoring -- which was good for me, since I've had minimal experience giving IV injections without a catheter and performing endotracheal intubation. However, we were supposed to get to do some tom cat or male kitten castrations sometime during the week, and we only ended up with female kitties, so surgery experience was limited.

Last week was spring break, which flew by and was more exhausting than relaxing by the time it was over. We moved out of our condo and into an apartment on Friday and Saturday, spent Sunday unpacking as much as possible ("minimally functional" was the goal we achieved), and headed back to school on Monday.

My rotation this week is Orthopedics. It's been interesting, but pretty slow. One of the downsides of an economic recession for vet med is that clients have less disposable income to spend fixing their pets -- which can mean that procedures like knee, hip, and elbow repairs get postponed and the pet is just put on pain meds for the time being, rather than seeking a surgical cure. Instead of putting a plate or external fixator on a fractured leg, the owner might seek amputation instead. Owners of dogs that are only mildly lame opt for a 'wait and see' approach rather than going for radiographs and a CT scan.

What I'm trying to get at is, there hasn't been a huge caseload.

On Monday I saw one case with a senior -- a 6 year old, black miniature poodle -- who was completely sweet and adorable. He had been diagnosed with bilateral medial luxating patellas (a hugely common problem in toy breeds) by the referring vet after his owners noticed intermittent lameness. Though he was only a Grade I-II out of IV on each side, his owners seemed interested in pursuing a proactive surgical solution, knowing that MPL can progress in severity and cause pain and dysfunction.

Tuesday's case was a 4.5 month old Great Dane puppy (such a sweet thing, although almost 75 lb!). He was stepped on by his dam when he was only about 3 weeks old, and fractured his tibia and fibula. The breeder (clearly a responsible individual) neglected to seek any veterinary care for the next few weeks, and had just decided to have the puppy put down when the breeder's mother intervened and 'rescued' the dog. Unfortunately, the breeder's mom didn't get the pup to a vet quickly either, and he was eventually passed along to his current owner at about 12 weeks of age.

Thankfully, the current owner recognized immediately that the puppy needed some serious medical care, and brought him to the VTH. The plan decided by the orthopods was to monitor the puppy's growth and see him for a recheck physical and orthopedic exam, as well as serial radiographs, every 3 weeks. Long story short, what started as a pretty badly malformed tibia 6 weeks ago, was getting worse at the recheck 3 weeks ago, and had worsened so much by yesterday's visit that the dog's tibia (the shinbone) was basically bent at a 90-degree angle.

At this point, it was pretty obvious that the leg wasn't going to fix itself as the puppy grew. Though the owner had previously indicated a reluctance to pursue surgery, she was gung-ho yesterday that it was time to do whatever needed to be done -- which, in order to have a chance of saving the leg and having it be functional, meant 3-4 surgeries over the next 6-8 months, probably with placement of a circular external skeletal fixator, all with a prognosis that couldn't guarantee that the leg would be functional in the end.

My vote was for amputation, but the owner was vehemently against that as anything other than an absolutely last resort. Bummer, because the orthopedic surgeries to attempt to salvage the leg were estimated to cost $7-10K altogether, and the dog still might have to have the leg amputated if they can't fix it.

Anyway, getting off my soapbox.

Today, Day 3 of orthopedics, was totally dead. There was one appointment all day -- a bandage change in the afternoon. So we had rounds talking about elbow dysplasia for 2.5 hours, then the dozen of us headed over to surgery to watch a craniodorsal traumatic hip luxation undergo surgical repair. Unfortunately, the joint was so badly damaged that just replacing the femur into the acetabulum wasn't really an option. But since the owners apparently had plenty of money, the surgeons got to go ahead with a total hip replacement (which was admittedly pretty cool to see).

Outside of school, I've got a whole long list of errands to run, in addition to finishing unpacking and putting away plenty of stuff in the new apartment, getting back to the Windsor condo for some final cleaning, spending 8+ hours on Saturday at the shelter medicine conference, 4 hours of class on Sunday afternoon because of Open House the following weekend.... so I guess it's time for bed!

Monday, March 7, 2011

Menagerie

This week's rotation is Shelter Medicine, which is 5 mornings of various activities at the county humane society.

This morning was wildlife care and rehabilitation. Here are some of the animals I helped care for:

- 65 adult squirrels
- 3 neonatal squirrels
- Wild rabbit
- Muskrat
- Rooster
- Mallard ducks
- Coyotes
- Pigeons
- Albino dove
- Robin
- Small songbird (can't remember what species)
- Turtles
- Anoles
- Geckos
- Salamanders
- Anoles
- Mice
- Parakeets
- Lovebirds
- Snakes
- Iguana

Yep, I am ready to get back to dogs and cats. I hope I never have to replace the water bowl in a snake's tank again!

(The 64 adult squirrels living in outdoor enclosures until they can be released in the spring were definitely the cutest... we prepared their daily diet [corn on the cob, fresh apples, grapes, nuts, and squirrel pellets] and it was totally adorable to watch them eat. The hardest part of wildlife rehab was that 95% of the animals are intended to be released back into the wild, so you're not supposed to play with them or talk to them...)

Back to normal hours

After spending 34 hours between 5 pm and 2 am on my Urgent Care rotation last week, it is a relief to be back to normal daytime hours.

It was definitely interesting to work a swing-shift sort of thing. Certainly I now have a somewhat better idea of what to expect from some of my senior year rotations, including the 4 weeks I'll spend on CCU/Urgent Care, 2.5 weeks on After Hours Wards, and various on-call nights for Surgery and Anesthesia.

However, I pretty much dropped everything besides school from my life last week -- and it was even a good thing that I didn't have any homeworks or exams to do, because I wouldn't have had time to study. Basically no quality time w/CLH, no cooking, no cleaning, no handbells, no church, no choir, and I got horribly behind on emails. In exchange, I got a decent amount of sleep since I could sleep in late every morning and not get to class until 1-2 pm!

I would never have thought, though, that I would be excited to get back to an 8 am-12 pm clinical rotation...

We, we, we

WE have had an oncology professor over the last couple weeks who has been getting on OUR nerves.

Said professor has a habit of, upon hearing any tiny hint of whispering or chatter in the classroom, abruptly stopping the lecture and stating the following:

"WE are having some issues with whispering today. WE are going to need to stop the whispering, or take OUR whispers out into the hallway, because WE do not want to bother OUR colleagues who are trying to learn."

Now, I appreciate the sentiment. I'm all for respecting your peers, acting professionally, and encouraging people to pay attention to the lecture.

But besides the fact that WE are not a group of 7-year-olds (and the few class clowns who used to act like 7-year-olds as freshmen have since matured), I have several other issues with this instructor's complaint:

1. Vet students historically do not respond well to condescension from their instructors. Experienced instructors (and/or human beings with a modicum of common sense) should know this.

2. This professor is lecturing to OUR class for the first time in 2.5 years. Hence, SHE is not part of WE.

3. WE have been sitting in lecture together for multiple hours a day, 5 days a week, 16 weeks a semester, for 5 1/2 semesters. WE have developed our own methods of policing each other, settling issues of noise in the classroom, and silencing the chatterboxes. If WE had not figured out how to do this on OUR own, WE would have killed each other by now.

4. She is a terrible lecturer. She attempts (and sometimes succeeds, yet in a way that feels like failure) to get through 70+ text-heavy PowerPoint slides in each 50 minute lecture period. She speaks so quickly that she literally completely drops words out of her sentences. I have never heard anyone do that before. It's quite remarkable. While WE would all love to pay attention and learn something important about cancer, WE certainly cannot take notes because in the time it takes to jot down 2 sentences, she has sped through the next 3 slides.

Okay, time to step off soapbox. Man, venting feels good! Hooray for OUR last oncology lecture tomorrow (and let's hope WE don't feel like chatting during class).

Wednesday, March 2, 2011

I like Urgent Care (but I'm really tired!)

My rotation this week is "Evening Urgent Care." From 5-8 pm, two of us juniors assist the seniors, nurses, and interns in handling cases that present to the VTH's urgent care department. At 8 pm, Urgent Care shuts down, so we head over to assist in CCU (Critical Care Unit) and also give the seniors a hand doing 10 pm walks and treatments for every other patient anywhere in the hospital.

Monday night, my first evening of the rotation, apparently happened to be the busiest night they've had in Urgent Care/CCU in a long time. The first hour was pretty slow, but starting around 6 pm, the proverbial poop hit the proverbial fan.

With the additional burden of a senior student scheduled to be on the overnight shift calling in sick because of intractable vomiting (yes, please don't come in!), I ended up staying until about 1 am (we juniors are supposed to be done around 11 pm).

Here are a few of the many cases I saw on Monday night:

-- A 2 year old Great Dane (whose owners drove him about 8 hours from Montana to get to our VTH) with a lengthy problem list, including joint effusion; lameness; caudal abdominal pain; an allergic reaction to penicillin given by the rDVM; severely ulcerated, itchy skin lesions on his paws, abdomen, chest, face, and ears; intractable fever ranging from 103-105 degrees for the last few days, despite being on enrofloxacin, amoxicillin, doxycycline, AND prednisone; concern about possible leptospirosis infection from the rDVM; and dehydration (and I'm sure I missed a few of his issues)

-- A chameleon that presented for "lethargy" (and I still haven't figured out how you tell that a chameleon is lethargic -- it was sitting in a Tupperware container!)

-- A young black lab who was hit by a car and had some minor abrasions on her limbs (and hopefully nothing else, like broken bones or a diaphragmatic hernia, because her owners couldn't afford more than basic bandaging and pain medication)

-- A blocked male Siamese cat who was slated for euthanasia until his owner was able to scrape together a $150 deposit to treat him

-- An old Pomeranian who had a "stroke" (probably granulomatous meningoencephalitis)

-- A middle-aged Boxer presented for vomiting, ataxia, and inappropriate mental status, who proceeded to go into supraventricular tachycardia repeatedly, which was treated until his heart rate was back into a normal range, and then he repeatedly got extremely bradycardic (heart rate 30-40 beats per minute), which was nonresponsive to drug correction -- fortunately he lived through the night and had a cardio consult on Tuesday

-- An old golden retriever who had had a laminectomy and meningioma resection earlier in the day, and wasn't feeling so great

-- A great Pyrenees recovering from a TPLO on Monday morning

-- A golden retriever with a heart mass who had had a huge volume of pericardial effusion drained a few hours earlier and was at risk of her heart sac filling up with blood again

And I'm sure I forgot a few!

Tuesday night was a little calmer. We had a few repeat patients (the Great Dane, the golden with pericardial effusion, the golden post-laminectomy, the Pomeranian, and the freshly-unblocked tom cat). Otherwise, it was basically much quieter. A few of the other patients we saw were:

-- A 10 year old small-breed mutt dog (we declared her a "ShitzaCockaPoo") whose owners thought she had something stuck in her throat. She looked great on presentation, wasn't coughing/gagging/retching, and nobody could see anything in her trachea or esophagus, as much as we looked. Her owners declined sedation for a closer look.

-- A wild bunny who was brought in by some Good Samaritans after being hit by a car (the bunny was HBC, not the Good Sams). Thank you, Rabbit & Rodent Medicine! Unfortunately, the fact that two random passersby could catch this wild rabbit and bring it to the hospital without much struggle was a sign that something bad was going on -- and indeed, the poor bunny had a broken spine with complete hindlimb paralysis, so was dispatched to Bunny Heaven shortly after presentation.

-- A 3 or 4 week old puppy fostered by a community member for the local humane society. Puppy presented nonresponsive with no heart beat, and although we tried resuscitating him with oxygen via ET tube, CPR drugs, and chest compressions, the puppy had already joined the bunny in heaven.

-- A young chihuahua/Dachshund mix (might have literally been the cutest dog I have ever seen) that came in for ataxia and disorientation. Physical exam revealed incoordination, altered mental status, dilated pupils, hyperreactivity to any type of stimulus, and bradycardia. Physical exam of the owners revealed altered mental status and serious odor of marijuana. Little dog likely just got into the pot stash and needed to sleep it off -- but ran a blood gas to look for signs of antifreeze poisoning since sometimes it can present similarly.

-- 3 dogs from 2 completely separate households that came in at the same time for ingesting unknown quantities of Rimadyl (a doggie version of Advil [which you can't give to dogs!]). Though the dogs were all sweet and came in happy and friendly, they looked quite miserable after we made them vomit and then force-fed them activated charcoal. Two of the dogs stayed the night for bloodwork and IV fluids.

In addition to new patients that came in, I got to help with "wards duty," which means taking care of all of the medicine, surgery, oncology, and community practice dogs and cats that are staying the night (usually pre-surgery or post-simple-surgery, or sometimes just staying for the owners' convenience). There were about 15 dogs and a handful of cats that needed to be watered, medicated, walked (dogs only), and generally checked for any signs of problems. Additionally, I had the chance to visit a bunny staying in the exotics ward after a spay earlier in the day. And I got to learn how to give a bunny oral liquid medication (which bunny did not appreciate), as well as an intramuscular injection of opioids in the epaxial muscles (which, again, bunny did not appreciate at first, but I'm sure she was happier when the drug high hit her). There were also 6 dogs and 1 cat from the humane society that had been spayed yesterday morning -- including 2 of the cutest chihuahuas I've ever met, and an adorable little Boston terrier/Beagle mix.

Since the night was slower, I got to leave at 11:45 pm instead of 1 am!

Here's hoping for a ton of interesting cases that come in tonight, but that are all pretty much resolved by 10:30 or 11 so I can go home and get some sleep...