My first two weeks of Internal Medicine ended on a happy note, when my very sick little patient of colonoscopy fame who spent a full 12 days in CCU was finally discharged.
Unfortunately, that kiddo's discharge to his loving family didn't happen until I'd spent a personal record of 73 hours at the VTH in a 7 day time period, including 9 hours this weekend.
It's okay, sleep is overrated. At least that's what I'm telling myself to keep from sobbing in the corner. Thank goodness for the 5 hours of naps I logged this weekend.
Internal Medicine started as a pretty stressful rotation for me. The cases are multifaceted and complicated. Internists have to have a vast knowledge base that encompasses clinical pathology, surgery, radiology, pharmacology, neurology, and many other subjects. Plus it was my first specialty rotation, having only been on community practice previously.
However, I really settled into Internal Medicine well after the first couple days, if I do say so myself. I put in long hours at school (averaged 12-13 hours on weekdays), and often spent an additional 1-2 hours studying up at home in the evening on the things from that day that I needed a refresher on.
So it was gratifying when the head internal medicine clinician from last week pulled me aside on Friday to tell me how much I had impressed him, that my medical knowledge at this stage in my career is "amazing," and that I was "leaps and bounds" ahead of my classmates on this rotation. I'll also admit to a little extra pride when one of my rotation-mates said to me at the end of the weeks "So this is what you're going to do after vet school, right?" and I said no, I want to do general practice, and they said "But you're so awesome at this!"
OK, let's move on to neurology and bring on the humility.
It's always a little challenging to start a new rotation (haha, as though I really know what I'm talking about, this being only my 3rd rotation -- maybe it gets easier as the year progresses?).
Each rotation is staffed by completely different doctors, nurses, and support staff. They have different procedures, different forms, different paperwork to complete. Appointment schedules are different; procedures for new patients versus rechecks versus inpatients vary widely. I've heard the senior year of vet school compared to starting a brand new job every 2 weeks, and that's really what it feels like sometimes. Just when you've had a good 10-14 days to settle into knowing how to deal with the clinicians and nurses, which forms go where, who calls the owners every day, and where all of the supplies live, it's time to up and move on to something totally different. It's frustrating.
Neurology started this morning with both of the doctors arriving late, then doing a very brief orientation, then shuffling us off to handle transfers, inpatients, and new appointments.
While I have to admit that I've not been looking forward to my neuro rotation since neuro has historically not been one of my favorite subjects, I nonetheless feel that that attitude toward neurology has not colored the following opinion I developed after my first day of neuro today: The neuro doctors are some of the pissiest, whiniest clinicians I've ever met.
I'm serious. The day started off with a round of bitching about clients that want to come visit at "inopportune" times for the doctors (i.e. any time on weekends other than 8-9 am), how the other services always want neuro to help with their cases that have neurologic dysfunctions, how the CCU nurses call them at night (when one of the CCU patients meets the "call the clinician if" criteria written down by the clinicians themselves, I might add) to ask about how to handle an exceedingly painful inpatient, etc. There was no end to the things that these people found to complain about (and not very nicely).
It was pretty funny to hear the contrast between the neuro doctors, who seem to have an attitude of "I am the almighty doctor and I will say what hours you can visit your dog and if you show up at a different time then God be with your soul," versus the internal medicine doctors, who, in my opinion, were much better at caring for clients in addition to caring for pets, and were willing to stay an extra hour or two on a Saturday morning so an owner could come visit, or discharge a hospitalized patient at 6:30 pm after the owners got off of work instead of insisting on a 4:30 discharge appointment.
I'm trying (and I think succeeding) not to take the bitchy attitudes personally. I feel that certainly on the first day of any rotation, it's reasonable to give the new students a little leeway and help them along and overlook (or point out politely) minor errors that have been made in procedures. And yes, we'll all become more efficient within a couple days of being neuro students -- hey, we were a lot faster by the end of the first day already.
So take a chill pill, docs! Otherwise it's gonna be one heck of a rotation...
Monday, June 27, 2011
Friday, June 17, 2011
Artificial sphincter to the rescue!
Yesterday I participated in my first canine colonoscopy (okay, my first colonoscopy with any species) and debuted in the role of "artificial sphincter."
To explain: a colonoscopy is a small camera on an approximately 1/2-inch diameter cable placed into the rectum and advanced through the colon, and into the small intestine if possible.
Normally, the colon and intestines are pretty collapsed down on themselves, not just sitting wide open. So in order to be able to look around and visualize the inner surfaces of the bowel, it's necessary to blow a substantial quantity of air into the colon using the endoscope, to inflate everything.
The patient receives multiple enemas before the procedure to help clean things out, since it's a lot harder to see what the intestine looks like if there's poop all over it, but there is invariably a small amount of fecal material left, which is remedied by rinsing with water or saline through the endoscope.
Under the influence of general anesthesia, sphincters relax. It's possible to have spontaneous release of bladder and bowels. This makes it easier to pass the endoscope through the anus, but it also means that the water and air that are being infused into the colon through the endoscope have an easy means of escape through the loosened sphincter.
This is where I come in: artificial sphincter to the rescue!
No, it's not as exciting as it sounds.
Yes, it is absolutely as disgusting as it sounds.
Step #1: Wear your clinic smock over your nice clothes. Remove watch. Don latex gloves.
Step #2: Use your fingers to pinch the anus closed around the endoscope cable.
Step #3: Ignore the vibrations and farting sounds as small amounts of air leak out from the anus. Ignore the liquid fecal matter dripping out onto your (gloved) fingers.
Step #4: Smile idiotically as your rotation-mate, who is going to do her grand rounds presentation on this patient, snaps photos.
Step #5: Blog about it. (Oops, forgot Step #4a: remove gloves, wash hands.)
Yes, it was a once-in-a-lifetime experience, which is just fine, because it's not an experience that I ever need to have again. That was just a little more intimate with a dog's anal sphincter than I usually prefer to be.
(As an aside: this dog has been my patient since his arrival in hospital on Wednesday, and I'm hoping he can go home tomorrow. He is my favorite patient so far in senior year, and by far my most interesting and involved case. I'm hoping to have some time this weekend to blog about the cute little fellow!)
To explain: a colonoscopy is a small camera on an approximately 1/2-inch diameter cable placed into the rectum and advanced through the colon, and into the small intestine if possible.
Normally, the colon and intestines are pretty collapsed down on themselves, not just sitting wide open. So in order to be able to look around and visualize the inner surfaces of the bowel, it's necessary to blow a substantial quantity of air into the colon using the endoscope, to inflate everything.
The patient receives multiple enemas before the procedure to help clean things out, since it's a lot harder to see what the intestine looks like if there's poop all over it, but there is invariably a small amount of fecal material left, which is remedied by rinsing with water or saline through the endoscope.
Under the influence of general anesthesia, sphincters relax. It's possible to have spontaneous release of bladder and bowels. This makes it easier to pass the endoscope through the anus, but it also means that the water and air that are being infused into the colon through the endoscope have an easy means of escape through the loosened sphincter.
This is where I come in: artificial sphincter to the rescue!
No, it's not as exciting as it sounds.
Yes, it is absolutely as disgusting as it sounds.
Step #1: Wear your clinic smock over your nice clothes. Remove watch. Don latex gloves.
Step #2: Use your fingers to pinch the anus closed around the endoscope cable.
Step #3: Ignore the vibrations and farting sounds as small amounts of air leak out from the anus. Ignore the liquid fecal matter dripping out onto your (gloved) fingers.
Step #4: Smile idiotically as your rotation-mate, who is going to do her grand rounds presentation on this patient, snaps photos.
Step #5: Blog about it. (Oops, forgot Step #4a: remove gloves, wash hands.)
Yes, it was a once-in-a-lifetime experience, which is just fine, because it's not an experience that I ever need to have again. That was just a little more intimate with a dog's anal sphincter than I usually prefer to be.
(As an aside: this dog has been my patient since his arrival in hospital on Wednesday, and I'm hoping he can go home tomorrow. He is my favorite patient so far in senior year, and by far my most interesting and involved case. I'm hoping to have some time this weekend to blog about the cute little fellow!)
Tuesday, June 14, 2011
Goodbye Community Practice, hello Internal Medicine
Community Practice is done, which is somewhat bittersweet. Sure, there were a lot of things about CP that I didn't like or that got old after a whole month, but overall it was an enjoyable rotation (which is good, since I think that my career goal after vet school is basically CP-type employment).
My first two days on Small Animal Internal Medicine (SAIM) have provided an interesting compare-and-contrast to Community Practice (CP). Here are a few of the variations:
CP clients are, overall, pretty nice but usually come with a financial limit. There's plenty of haggling over which heartworm medication to prescribe ($35 for 6 months versus $45 for 6 months), whether diagnostics like cytology of a skin mass (~$35) fit into the budget today, that sort of thing. CP clients are to always be advised of the cost of everything before we do any procedures or diagnostics -- even things as simple as vaccines or a nail trim.
SAIM clients arrive at the VTH having already been informed of the ~$90 exam fee. That means that they are aware that, just by walking in the door to see a specialist, they will be spending roughly a hundred dollars before we get to any bloodwork, urinalysis, xrays, ultrasounds, CT, MRI, anesthesia, surgery, endoscopy, cytology, biopsies, or myriad treatments. Most SAIM clients have already had their pet's problem(s) worked up by their referring DVM (rDVM), meaning they've likely already shelled out quite a bit of money before arriving at the VTH.
CP clients tend to be intelligent people who are not overly familiar with veterinary medicine, wellness care such as vaccine schedules, and the benefits of screening tests such as annual bloodwork and fecal exams. Their level of compliance with such recommendations is quite variable.
SAIM clients have typically done a lot of research into their pet's suspected illness, whether through the Internet, their rDVM, or multiple other consults before they came to us. They tend to be familiar with causes, complications, and treatments for their pet's disease, and are often quite comfortable with medical terminology.
CP sets a time limit for appointments: a goal of getting the client from the front desk checking to the client service desk checking out in under an hour. This goal is not always met, if CP is very busy or if the pet has complicated medical problems requiring diagnostics, but it is a goal just the same. CP clients tend to keep one eye on the clock throughout the entire visit and will readily inform you if you took 25 minutes instead of the 20 minutes you told them they would have to wait.
SAIM clients often spend an entire morning or afternoon in the waiting area or exam room while their pet is seen by one or more students and one or more doctors, in addition to diagnostics such as bloodwork and imaging. They tend not to bat an eye when they've already been at the VTH for 2 hours and you tell them you'll need to borrow their pet for yet another 30 minutes so you can take radiographs.
CP students can see quite a few patients in one day. On our very busiest CP days, we probably saw 35-40 appointments with 7-9 students sharing the case load.
SAIM students see generally 1 or 2 new cases per day, plus maybe some rechecks in the afternoon for ongoing cases. They may also have 1 or 2 hospitalized animals that are housed at the VTH overnight and on weekends to manage an illness or for owners' convenience the night before a procedure.
CP students have "topic rounds" in the morning, lasting about an hour and covering such themes as "new puppy visit," "new kitten visit," "heartworm disease," and "feline upper respiratory infections." CP students have "case rounds" in the afternoon, lasting 20-60 minutes and briefly discussing all of the appointments from the day.
SAIM students have topic/case rounds in the morning, lasting 60-90 minutes and including updates on all of the inpatients from the previous night, as well as often discussing one or two internal medicine topics (like diabetes or renal failure). SAIM students have afternoon/evening case rounds, lasting 1-2 hours and discussing most of the day's cases, especially any patients staying in the hospital overnight.
Two of the most stressful things about SAIM are (1) presenting cases to clinicians and (2) discussing cases in rounds.
Presenting a case to a clinician goes something like this: The SAIM student retrieves the paperwork, client, and pet from the waiting area, escorts them to an exam room, and spends 20-30 minutes (less if a recheck) getting a history and physical exam completed. The student then leaves the client and pet in the room, pages the clinician to the rounds room, then tells them about the case. You start with the signalment (pet's name, species/breed, sex, reproductive status, and age), then the presenting complaint, then the history, and finally your physical exam findings. Next the clinician asks for your problem list -- the list of each thing that is wrong with the animal (e.g. vomiting, coughing, lethargy, elevated liver enzymes on bloodwork from rDVM, etc.). Then you go through each problem one at a time and tell the clinician your "differential diagnoses" (what possible diseases could be causing the problem), rank your differential diagnoses from most to least likely based on the other findings, and discuss what further diagnostic steps you would need to take to prove or disprove each differential diagnosis.
Presenting cases to clinicians is somewhat harrowing because, for some reason, your brain tends to completely shut off when you are sitting down one-on-one with somebody with much more education and experience than you. It's something that I'm sure gets easier with practice, but at this point in our senior year we find that it's altogether too easy to misspeak, second guess ourselves, and overthink even simple problems.
Discussing cases in rounds is probably even more stressful. This means you're sitting in the cramped rounds room with 8 other senior students, the head faculty clinician, and 4 other doctors (interns and residents). The head clinician basically grills you, in front of everyone else, on the nitty gritty details of your case, the pathophysiology of the pet's disease, the pharmacological actions of the drugs you've chosen, the possible causes for all the abnormalities on the labwork, and anything else they can think of. There is lots of awkward silence while everyone avoids eye contact to minimize the chance of being asked about someone else's case -- and lots of empathy toward the poor individual stuck in the spotlight until their case has been thoroughly dissected.
Overall SAIM is a lot less physically exhausting than CP, because, for one thing, the rounds room and treatment area are right next to the lobby rather than at the farthest end of the hospital where CP is located. Second, seeing only 1-2 new patients a day means a lot less animal handling. Third, there is a group of 4-5 technicians who are dedicated to SAIM and extremely capable of obtaining blood and urine samples or restraining for procedures while you go off to research your case or discuss it with the clinician. So it's nice not to be on my feet quite as much, not to be racing around the hospital all the time, and not to be wrestling large dogs everywhere I turn.
However, SAIM is undoubtedly a much greater mental challenge than CP. It's a struggle sometimes to recall all of the important yet very detailed information I've learned about anatomy and physiology and disease processes over 3 intense years of classroom teaching, and to put it into practice when much of our previous style of exams has been more about regurgitation of facts than about decision making with real life case examples. And I just want to point out that many of the cases that we've seen in the last 2 days are referrals from rDVMs who had already tried and failed to diagnose the pet's illness. So it's not like they're just run-of-the-mill cases.
In any case, it's definitely going to be a fantastic learning experience and a challenge to my brain -- and I think I'll feel like it's been a rewarding experience at the end of my 2 weeks when (hopefully) I've become a little better at planning my case work-ups and thinking of logical differentials and diagnostics to pursue.
My first two days on Small Animal Internal Medicine (SAIM) have provided an interesting compare-and-contrast to Community Practice (CP). Here are a few of the variations:
CP clients are, overall, pretty nice but usually come with a financial limit. There's plenty of haggling over which heartworm medication to prescribe ($35 for 6 months versus $45 for 6 months), whether diagnostics like cytology of a skin mass (~$35) fit into the budget today, that sort of thing. CP clients are to always be advised of the cost of everything before we do any procedures or diagnostics -- even things as simple as vaccines or a nail trim.
SAIM clients arrive at the VTH having already been informed of the ~$90 exam fee. That means that they are aware that, just by walking in the door to see a specialist, they will be spending roughly a hundred dollars before we get to any bloodwork, urinalysis, xrays, ultrasounds, CT, MRI, anesthesia, surgery, endoscopy, cytology, biopsies, or myriad treatments. Most SAIM clients have already had their pet's problem(s) worked up by their referring DVM (rDVM), meaning they've likely already shelled out quite a bit of money before arriving at the VTH.
CP clients tend to be intelligent people who are not overly familiar with veterinary medicine, wellness care such as vaccine schedules, and the benefits of screening tests such as annual bloodwork and fecal exams. Their level of compliance with such recommendations is quite variable.
SAIM clients have typically done a lot of research into their pet's suspected illness, whether through the Internet, their rDVM, or multiple other consults before they came to us. They tend to be familiar with causes, complications, and treatments for their pet's disease, and are often quite comfortable with medical terminology.
CP sets a time limit for appointments: a goal of getting the client from the front desk checking to the client service desk checking out in under an hour. This goal is not always met, if CP is very busy or if the pet has complicated medical problems requiring diagnostics, but it is a goal just the same. CP clients tend to keep one eye on the clock throughout the entire visit and will readily inform you if you took 25 minutes instead of the 20 minutes you told them they would have to wait.
SAIM clients often spend an entire morning or afternoon in the waiting area or exam room while their pet is seen by one or more students and one or more doctors, in addition to diagnostics such as bloodwork and imaging. They tend not to bat an eye when they've already been at the VTH for 2 hours and you tell them you'll need to borrow their pet for yet another 30 minutes so you can take radiographs.
CP students can see quite a few patients in one day. On our very busiest CP days, we probably saw 35-40 appointments with 7-9 students sharing the case load.
SAIM students see generally 1 or 2 new cases per day, plus maybe some rechecks in the afternoon for ongoing cases. They may also have 1 or 2 hospitalized animals that are housed at the VTH overnight and on weekends to manage an illness or for owners' convenience the night before a procedure.
CP students have "topic rounds" in the morning, lasting about an hour and covering such themes as "new puppy visit," "new kitten visit," "heartworm disease," and "feline upper respiratory infections." CP students have "case rounds" in the afternoon, lasting 20-60 minutes and briefly discussing all of the appointments from the day.
SAIM students have topic/case rounds in the morning, lasting 60-90 minutes and including updates on all of the inpatients from the previous night, as well as often discussing one or two internal medicine topics (like diabetes or renal failure). SAIM students have afternoon/evening case rounds, lasting 1-2 hours and discussing most of the day's cases, especially any patients staying in the hospital overnight.
Two of the most stressful things about SAIM are (1) presenting cases to clinicians and (2) discussing cases in rounds.
Presenting a case to a clinician goes something like this: The SAIM student retrieves the paperwork, client, and pet from the waiting area, escorts them to an exam room, and spends 20-30 minutes (less if a recheck) getting a history and physical exam completed. The student then leaves the client and pet in the room, pages the clinician to the rounds room, then tells them about the case. You start with the signalment (pet's name, species/breed, sex, reproductive status, and age), then the presenting complaint, then the history, and finally your physical exam findings. Next the clinician asks for your problem list -- the list of each thing that is wrong with the animal (e.g. vomiting, coughing, lethargy, elevated liver enzymes on bloodwork from rDVM, etc.). Then you go through each problem one at a time and tell the clinician your "differential diagnoses" (what possible diseases could be causing the problem), rank your differential diagnoses from most to least likely based on the other findings, and discuss what further diagnostic steps you would need to take to prove or disprove each differential diagnosis.
Presenting cases to clinicians is somewhat harrowing because, for some reason, your brain tends to completely shut off when you are sitting down one-on-one with somebody with much more education and experience than you. It's something that I'm sure gets easier with practice, but at this point in our senior year we find that it's altogether too easy to misspeak, second guess ourselves, and overthink even simple problems.
Discussing cases in rounds is probably even more stressful. This means you're sitting in the cramped rounds room with 8 other senior students, the head faculty clinician, and 4 other doctors (interns and residents). The head clinician basically grills you, in front of everyone else, on the nitty gritty details of your case, the pathophysiology of the pet's disease, the pharmacological actions of the drugs you've chosen, the possible causes for all the abnormalities on the labwork, and anything else they can think of. There is lots of awkward silence while everyone avoids eye contact to minimize the chance of being asked about someone else's case -- and lots of empathy toward the poor individual stuck in the spotlight until their case has been thoroughly dissected.
Overall SAIM is a lot less physically exhausting than CP, because, for one thing, the rounds room and treatment area are right next to the lobby rather than at the farthest end of the hospital where CP is located. Second, seeing only 1-2 new patients a day means a lot less animal handling. Third, there is a group of 4-5 technicians who are dedicated to SAIM and extremely capable of obtaining blood and urine samples or restraining for procedures while you go off to research your case or discuss it with the clinician. So it's nice not to be on my feet quite as much, not to be racing around the hospital all the time, and not to be wrestling large dogs everywhere I turn.
However, SAIM is undoubtedly a much greater mental challenge than CP. It's a struggle sometimes to recall all of the important yet very detailed information I've learned about anatomy and physiology and disease processes over 3 intense years of classroom teaching, and to put it into practice when much of our previous style of exams has been more about regurgitation of facts than about decision making with real life case examples. And I just want to point out that many of the cases that we've seen in the last 2 days are referrals from rDVMs who had already tried and failed to diagnose the pet's illness. So it's not like they're just run-of-the-mill cases.
In any case, it's definitely going to be a fantastic learning experience and a challenge to my brain -- and I think I'll feel like it's been a rewarding experience at the end of my 2 weeks when (hopefully) I've become a little better at planning my case work-ups and thinking of logical differentials and diagnostics to pursue.
Saturday, June 11, 2011
I can only tell you so many times
I saw a sweet little lab mix last Tuesday named Copper, after she was seen by our emergency department last weekend for an exam after one of the small children in the family accidentally closed Copper's tail in a door. Much of the skin on the end of Copper's tail had been pulled off in the injury, and she had soft tissue and bone sticking out the end of her tail with not enough skin left to do a surgical closure over the exposed bone and tissue.
CCU bandaged Copper's tail and sent her home with an e-collar, antibiotics, and pain meds, with instructions to have the bandage changed on Tuesday at the owner's regular vet or at Community Practice. They also advised the owner that it was entirely possible that the tail injury would not heal on its own and may require surgical amputation, but the family had financial constraints that limited them to a bandage and supportive care at this point.
Copper arrived at Community Practice on Tuesday, tail cautiously wagging and e-collar banging into everything in the waiting room, surrounded by a gaggle of children under 5 (four kids, to be exact) and a rather exhausted looking mom.
It was a good thing Copper had a bandage change already scheduled, because her bandage had fallen off that morning anyway.
On physical exam, Copper's tail was very clearly painful and didn't appear to be healing, although it was still a little early to tell, being only 3-4 days out from her injury. We placed a sterile nonstick pad over the exposed end of the tail and wrapped the tail in a sticky, stretchy bandaging material called elasticon.
I sent Copper home with mom & children, with an agreement to see her back for a bandage change and recheck on Friday (3 days later). The hospital has a system for readmitting patients during a Monday-through-Friday time frame called "orange sheeting." Normally, when a patient's visit is concluded, the student turns in the fee sheet to the business office (oops, we are supposed to call it "client services" now), and the billing staff put the charges into the computer then have the client pay for the day's fees and close out the invoice. Every time an animal has a new appointment, there must be an associated charge (unless we do something special to write it off) -- the exception being orange sheeting, where you fill out an orange sheet for your patient and turn it in to the receptionist with a time written on it that the patient will be coming back for a "readmit" appointment later that same week -- then you just keep the fee sheet until all of that patient's appointments for that week are concluded, and turn it in at the end of the week when they have their final checkout -- thus saving the client recheck fees or exam fees or whatever else would have been charged for opening a new set of paperwork every day.
So Copper's mom & I agreed to see her at noon on Friday, meaning I kept Copper's fee sheet and other paperwork and put in an appointment for her at the reception desk.
On Wednesday, I made a quick follow-up phone call to Copper's mom to see if the bandage had stayed on and to ask how Copper was doing overall. There was no answer, so I left a voicemail, concluding with "Please call if you have any questions or concerns, otherwise we will see Copper at noon on Friday."
On Thursday, one of the Community Practice technicians went through the schedule for Friday appointments and called each of the clients to confirm their appointment time on Friday (i.e. "I'm calling to confirm Copper's appointment for a bandage change at noon on Friday, please call back if you need to change this.").
On Friday, noon rolled around and I waited for Copper's appointment to turn green (we have a flat screen TV in each of the rounds rooms that displays that service's appointment calendar; appointments are initially purple or yellow or some other color that denotes what kind of appointment it is, then the front desk makes the appointment color change to green whenever the client checks in at the front desk).
By 12:10 pm, the Copper's appointment wasn't green, so I went up to the waiting area to check and see if Copper had arrived, just in case the receptionists had forgotten to turn her appointment green, or if there was a computer glitch, which is not unheard of. No Copper, no Copper's mom.
I got caught up helping a classmate with their patient for a few minutes, and at 12:30 I finally had a chance to call Copper's mom.
"Hello, I'm calling from the veterinary teaching hospital. We had Copper down for a 12 pm appointment?"
"Oh!" said Copper's mom, clearly surprised. "I was sure her appointment was at 3."
"Hmmm... Can you bring her in any earlier?" I asked, knowing that our last Friday appointment is typically at 1:30 pm, and all the students and clinicians skedaddle as fast as humanly possible once the last appointment and afternoon rounds are over.
"I don't know -- my husband has Copper right now -- let me call his cell phone and I'll get right back to you," replied Copper's mom. I made sure she had the correct phone number for the direct line to Community Practice, and hung up.
By 1 pm, Copper's mom still had not called back, so I tried her number again (the only phone number in her record). No answer, so I left a voicemail asking her to please call back as soon as possible.
By 1:30 pm, my next patient (and the last scheduled appointment of the day) had arrived, so I left one last voicemail for Copper's mom, advising her that we were at the end of our appointment schedule, and I had tried repeatedly to get a hold of her, and unfortunately, she would just have to reschedule Copper's bandage change for Monday and call CCU or Urgent Care over the weekend if Copper needed treatment before that.
I was bummed, first of all because I was interested to see how the bandage I had applied had held up and if Copper's tail had started to show any inclination to heal on its own.
But I was also sorry that Copper's mom will almost assuredly end up paying far more in fees for Copper's care because of missing her Friday appointment. We would have saved her at least $25-35 just from orange sheeting Copper this week, plus we had bought a whole roll of elasticon on Copper's account, and kept it at the hospital, planning to use more of it to rebandage Copper's tail on Friday and teach mom how to do it at home. If Copper needs a bandage change over the weekend, she'll not only have to pay the $89 exam fee but also a bandage change fee and the cost of new bandaging material.
It's really too bad that we apparently had some kind of miscommunication about Copper's appointment time, but I can't for the life of me figure out how that happened. It was Copper's mom who, on Tuesday, selected what time would work for her best to come back on Friday. In addition to us agreeing on noon when she left on Tuesday, she had 2 voicemails after that that both told her the appointment was at noon -- which is one more than most owners get, and most clients still manage to remember the correct appointment time.
Just hope Copper is feeling okay this weekend, and that she hasn't run out of the pain meds that we planned to refill for her yesterday...
CCU bandaged Copper's tail and sent her home with an e-collar, antibiotics, and pain meds, with instructions to have the bandage changed on Tuesday at the owner's regular vet or at Community Practice. They also advised the owner that it was entirely possible that the tail injury would not heal on its own and may require surgical amputation, but the family had financial constraints that limited them to a bandage and supportive care at this point.
Copper arrived at Community Practice on Tuesday, tail cautiously wagging and e-collar banging into everything in the waiting room, surrounded by a gaggle of children under 5 (four kids, to be exact) and a rather exhausted looking mom.
It was a good thing Copper had a bandage change already scheduled, because her bandage had fallen off that morning anyway.
On physical exam, Copper's tail was very clearly painful and didn't appear to be healing, although it was still a little early to tell, being only 3-4 days out from her injury. We placed a sterile nonstick pad over the exposed end of the tail and wrapped the tail in a sticky, stretchy bandaging material called elasticon.
I sent Copper home with mom & children, with an agreement to see her back for a bandage change and recheck on Friday (3 days later). The hospital has a system for readmitting patients during a Monday-through-Friday time frame called "orange sheeting." Normally, when a patient's visit is concluded, the student turns in the fee sheet to the business office (oops, we are supposed to call it "client services" now), and the billing staff put the charges into the computer then have the client pay for the day's fees and close out the invoice. Every time an animal has a new appointment, there must be an associated charge (unless we do something special to write it off) -- the exception being orange sheeting, where you fill out an orange sheet for your patient and turn it in to the receptionist with a time written on it that the patient will be coming back for a "readmit" appointment later that same week -- then you just keep the fee sheet until all of that patient's appointments for that week are concluded, and turn it in at the end of the week when they have their final checkout -- thus saving the client recheck fees or exam fees or whatever else would have been charged for opening a new set of paperwork every day.
So Copper's mom & I agreed to see her at noon on Friday, meaning I kept Copper's fee sheet and other paperwork and put in an appointment for her at the reception desk.
On Wednesday, I made a quick follow-up phone call to Copper's mom to see if the bandage had stayed on and to ask how Copper was doing overall. There was no answer, so I left a voicemail, concluding with "Please call if you have any questions or concerns, otherwise we will see Copper at noon on Friday."
On Thursday, one of the Community Practice technicians went through the schedule for Friday appointments and called each of the clients to confirm their appointment time on Friday (i.e. "I'm calling to confirm Copper's appointment for a bandage change at noon on Friday, please call back if you need to change this.").
On Friday, noon rolled around and I waited for Copper's appointment to turn green (we have a flat screen TV in each of the rounds rooms that displays that service's appointment calendar; appointments are initially purple or yellow or some other color that denotes what kind of appointment it is, then the front desk makes the appointment color change to green whenever the client checks in at the front desk).
By 12:10 pm, the Copper's appointment wasn't green, so I went up to the waiting area to check and see if Copper had arrived, just in case the receptionists had forgotten to turn her appointment green, or if there was a computer glitch, which is not unheard of. No Copper, no Copper's mom.
I got caught up helping a classmate with their patient for a few minutes, and at 12:30 I finally had a chance to call Copper's mom.
"Hello, I'm calling from the veterinary teaching hospital. We had Copper down for a 12 pm appointment?"
"Oh!" said Copper's mom, clearly surprised. "I was sure her appointment was at 3."
"Hmmm... Can you bring her in any earlier?" I asked, knowing that our last Friday appointment is typically at 1:30 pm, and all the students and clinicians skedaddle as fast as humanly possible once the last appointment and afternoon rounds are over.
"I don't know -- my husband has Copper right now -- let me call his cell phone and I'll get right back to you," replied Copper's mom. I made sure she had the correct phone number for the direct line to Community Practice, and hung up.
By 1 pm, Copper's mom still had not called back, so I tried her number again (the only phone number in her record). No answer, so I left a voicemail asking her to please call back as soon as possible.
By 1:30 pm, my next patient (and the last scheduled appointment of the day) had arrived, so I left one last voicemail for Copper's mom, advising her that we were at the end of our appointment schedule, and I had tried repeatedly to get a hold of her, and unfortunately, she would just have to reschedule Copper's bandage change for Monday and call CCU or Urgent Care over the weekend if Copper needed treatment before that.
I was bummed, first of all because I was interested to see how the bandage I had applied had held up and if Copper's tail had started to show any inclination to heal on its own.
But I was also sorry that Copper's mom will almost assuredly end up paying far more in fees for Copper's care because of missing her Friday appointment. We would have saved her at least $25-35 just from orange sheeting Copper this week, plus we had bought a whole roll of elasticon on Copper's account, and kept it at the hospital, planning to use more of it to rebandage Copper's tail on Friday and teach mom how to do it at home. If Copper needs a bandage change over the weekend, she'll not only have to pay the $89 exam fee but also a bandage change fee and the cost of new bandaging material.
It's really too bad that we apparently had some kind of miscommunication about Copper's appointment time, but I can't for the life of me figure out how that happened. It was Copper's mom who, on Tuesday, selected what time would work for her best to come back on Friday. In addition to us agreeing on noon when she left on Tuesday, she had 2 voicemails after that that both told her the appointment was at noon -- which is one more than most owners get, and most clients still manage to remember the correct appointment time.
Just hope Copper is feeling okay this weekend, and that she hasn't run out of the pain meds that we planned to refill for her yesterday...
Tuesday, June 7, 2011
I forgot Zeke!
I meant to post a picture of last Thursday's doggie castration: Zeke, another humane society kiddo!
Yep, it's gonna be one of those weeks
2 days into this week and I'm already completely ready for another weekend.
Yesterday was my second Monday spent surgerizing at the county humane society. Actually, before we even got down there, we spent much of the morning at the VTH taking care of the patients who had dropped off from a different humane society for surgery on Tuesday. That meant walking, feeding, watering, setting up cages, weighing, doing physicals, taking temperatures, checking testicles, shaving for spay scars, and drawing blood on 6 friendly but exuberant doggies.
After getting those guys set up, we headed down to the shelter. Three of us went. We had 4 dogs on the schedule -- 2 black lab/pointer cross puppies, a tiny terrier cross puppy, and a large terrier cross puppy -- all spays. The lab/pointers were around 20 lb each, and nice and passive in their complete fear of everything (makes for cooperative patients!). The tiny terrier was, well, tiny (only 5 lb!) and wanted nothing more than to just be held. The large terrier was a complete nutjob (in a crazy happy sort of way), requiring just a "touch" of additional sedative pre-surgery.
Of us 3 students, I was the only one who had been to the humane society from Community Practice before, so I'll admit it was kind of fun to actually have a semblance of an idea what was going on and be able to answer the other guys' questions.
We started with anesthesia on my classmate's lab/pointer spay ("Annie Oakley"), which was relatively uneventful, then induced my lab/pointer spay ("Ariat"). This was my first time since junior year to be the one to do all of the induction stuff -- meaning premedication, IV catheter placement, induction with injectable anesthetic drugs, intubation, connecting monitoring equipment, shaving, etc. Since I've generally been a stress case about anesthesia stuff, and have had some struggles with technical skills like intubation and IV catheters, it was rewarding to do it all myself without any mistakes.
Ariat's spay went pretty well -- about an hour and a half in length -- and she recovered nicely (unlike her brother, neutered by the shelter's staff vet, who woke up screaming bloody murder).
Toward the end of my spay, the surgery instructor came by to ask if I was interested in doing the last spay (since there were 4 dogs and 3 students). I kind of didn't want to, but the answer to such a question is always "Sure!" -- I offered repeatedly to let my classmate (a general tracker with only 2 weeks on Community Practice instead of 4) to take the last spay, but the instructor insisted we flip a coin to make it "fair." Flip we did, and I was soon informed that I "won."
Sigh. Though I'm getting faster and more efficient in surgery, and gaining comfort with the procedures, I'm still at the point where a single spay (especially a dog spay) leaves me fairly well exhausted. It's partly physical -- standing over a surgery table, body tense with general worry about slicing into something that will hemorrhage everywhere, and holding arms and hands in a strange position to keep everything sterile -- and partly mental (that same sort of thing with the not wanting to cut a giant artery and watch the dog bleed to death).
But sometimes you've just gotta push on -- hunger, thirst, headache, and full bladder be darned.
So I finished up Ariat's spay, got her to the recovery area, and stepped out of the surgery suite -- only to find my classmate waiting expectantly with Shiloh, the tiny terrier, already premed-ed and out in the prep room, IV catheter and induction supplies at the ready. I did excuse myself for a big drink of water, but there wasn't time for much more than that.
It's been a long post so far -- so here's a cute puppy picture of Shiloh to keep you entertained:
So Shiloh was smoothly induced (again, a nice catheter placement and intubation) and I scrubbed in, again. Shiloh's teensy weensy ovaries and uterus were out and she was closed up and in recovery with a skin-to-skin surgery time of 1 hour on the dot -- my fastest dog spay yet! I started Shiloh's surgery well after one of my other classmates had started his spay, and I finished about 45 minutes before he was done. I don't mean to gloat or anything (keeping in mind that my first spay was at least 2.5 hours), but it was just a nice reminder of how far I've come surgery-wise with 2 more weeks' experience.
We got back to the VTH around 5:15, at which point I grabbed a quick bite of dinner, made some follow up phone calls from last week, helped out with a couple appointments (just restraint and that sort of thing), and did a proper PE on my surgery dog for Tuesday and got his paperwork going. I got home around 6:30 pm.
Today turned out to be a loooooonger day that Monday (even though I was thoroughly exhausted after Monday). I rolled into the VTH shortly after 7 am to get another good look at today's surgery patient and make sure everything was set up for his surgery before 8 am rounds. Today's doggie was a 6 month old red miniature Dachshund -- just about the sweetest and silliest hound dog you've ever met. His name is Mickey and if you sit on the ground he loves to race toward you and try to launch himself into your lap, but he just can't make it most of the time on account of his stubby little legs. He also loves to roll over and wait for belly rubs.
Anyway, Mickey's surgery and anesthesia were extraordinarily efficient today. I checked on him at 10:05 am, when the tech students had just brought him into the anesthesia prep room but hadn't started working on him yet, and when I came back 10 minutes later, he was catheterized, induced, and ready to be shaved for surgery. (And 10 minutes may seem like a plenty long time, but in the world of brand-new anesthetists, that's almost a world record.)
Mickey was in the surgery suite by 10:25 am and I started cutting at 10:35 and finished my last intradermal suture at 10:55 am -- a 20 minutes neuter, skin to skin, which totally beats my 40-60 minute neuters I've done previously. The nice thing about neutering young dogs is you can almost just rip those testicles right of them without having to mess with the scrotal ligament that attaches the testicle to the inside surface of the scrotum very strongly in older dog.
Mickey recovered well (though he was pretty chilly -- he got down to 94 degrees in surgery, with 100-102 being normal body temp). Since I had no appointments until 4:30 pm, I tackled about 8 phone messages that had been left over the course of the morning.
After all the lovely phone calls, it was a quick bite to eat and then a surprise 1 pm appointment. One of my rotation-mates has a dog of his own who has been battling lymphoma for a few months and recently going downhill -- the poor thing is only 4 years old -- and my classmate got some really bad news about his beloved doggie today, so he headed home around noon.
Which left me with his 1 pm surgery intake -- a client-owned animal dropping off for surgery on Wednesday. The patient is a pretty little yellow lab, about 6 months old, who's in for a laparoscopic spay and gastropexy. She's a bit shy, especially around men, but overall a good girl and very cute. And she finally went potty for me outside at her last walk of the evening!
Aside from the surgery puppy for tomorrow, I helped out with some blood draws, vaccine administration, nail trims, anal gland expression... basically a full afternoon of assisting with other people's patients when they were in the treatment room.
My 4:30 appointment was an 8 year old Chesapeake Bay retriever due for some vaccines, needing a nail trim and anal gland expression, and also with a long complicated history of urinary incontinence, right forelimb lameness, multiple skin and subcutaneous masses, etc. etc. etc. They also arrived at 3:55 pm for their 4:30 schedule appointment and seemed a bit put off when it was 4:05 pm before I came up to get them (my bad, I guess I should have been more than 25 minutes early to come see you).
My 6:00 was a sweet, happy 1.5 year old shepherd cross due for her annual boosters on her puppy vaccines. Her owner was super nice and signed her up on the VTH's wellness plan, started her on a lepto vaccine in addition to her DA2PP and rabies, consented to a heartworm test and sending home preventive, and allowed deworming and promised to bring back a fresh poop sample for a parasite screen.
When they left at 6:45, I was left with a couple records to write up, then feeding, walking, and medicating (ear meds) my lab spay for tomorrow, and feeding and walking my Dachshund neuter for today. With an arrival at home at 8 pm, it was nearly one of my longest days on Community Practice -- and there's no sign that the rest of the week will be any slower!
Yesterday was my second Monday spent surgerizing at the county humane society. Actually, before we even got down there, we spent much of the morning at the VTH taking care of the patients who had dropped off from a different humane society for surgery on Tuesday. That meant walking, feeding, watering, setting up cages, weighing, doing physicals, taking temperatures, checking testicles, shaving for spay scars, and drawing blood on 6 friendly but exuberant doggies.
After getting those guys set up, we headed down to the shelter. Three of us went. We had 4 dogs on the schedule -- 2 black lab/pointer cross puppies, a tiny terrier cross puppy, and a large terrier cross puppy -- all spays. The lab/pointers were around 20 lb each, and nice and passive in their complete fear of everything (makes for cooperative patients!). The tiny terrier was, well, tiny (only 5 lb!) and wanted nothing more than to just be held. The large terrier was a complete nutjob (in a crazy happy sort of way), requiring just a "touch" of additional sedative pre-surgery.
Of us 3 students, I was the only one who had been to the humane society from Community Practice before, so I'll admit it was kind of fun to actually have a semblance of an idea what was going on and be able to answer the other guys' questions.
We started with anesthesia on my classmate's lab/pointer spay ("Annie Oakley"), which was relatively uneventful, then induced my lab/pointer spay ("Ariat"). This was my first time since junior year to be the one to do all of the induction stuff -- meaning premedication, IV catheter placement, induction with injectable anesthetic drugs, intubation, connecting monitoring equipment, shaving, etc. Since I've generally been a stress case about anesthesia stuff, and have had some struggles with technical skills like intubation and IV catheters, it was rewarding to do it all myself without any mistakes.
Ariat's spay went pretty well -- about an hour and a half in length -- and she recovered nicely (unlike her brother, neutered by the shelter's staff vet, who woke up screaming bloody murder).
Toward the end of my spay, the surgery instructor came by to ask if I was interested in doing the last spay (since there were 4 dogs and 3 students). I kind of didn't want to, but the answer to such a question is always "Sure!" -- I offered repeatedly to let my classmate (a general tracker with only 2 weeks on Community Practice instead of 4) to take the last spay, but the instructor insisted we flip a coin to make it "fair." Flip we did, and I was soon informed that I "won."
Sigh. Though I'm getting faster and more efficient in surgery, and gaining comfort with the procedures, I'm still at the point where a single spay (especially a dog spay) leaves me fairly well exhausted. It's partly physical -- standing over a surgery table, body tense with general worry about slicing into something that will hemorrhage everywhere, and holding arms and hands in a strange position to keep everything sterile -- and partly mental (that same sort of thing with the not wanting to cut a giant artery and watch the dog bleed to death).
But sometimes you've just gotta push on -- hunger, thirst, headache, and full bladder be darned.
So I finished up Ariat's spay, got her to the recovery area, and stepped out of the surgery suite -- only to find my classmate waiting expectantly with Shiloh, the tiny terrier, already premed-ed and out in the prep room, IV catheter and induction supplies at the ready. I did excuse myself for a big drink of water, but there wasn't time for much more than that.
It's been a long post so far -- so here's a cute puppy picture of Shiloh to keep you entertained:
So Shiloh was smoothly induced (again, a nice catheter placement and intubation) and I scrubbed in, again. Shiloh's teensy weensy ovaries and uterus were out and she was closed up and in recovery with a skin-to-skin surgery time of 1 hour on the dot -- my fastest dog spay yet! I started Shiloh's surgery well after one of my other classmates had started his spay, and I finished about 45 minutes before he was done. I don't mean to gloat or anything (keeping in mind that my first spay was at least 2.5 hours), but it was just a nice reminder of how far I've come surgery-wise with 2 more weeks' experience.
We got back to the VTH around 5:15, at which point I grabbed a quick bite of dinner, made some follow up phone calls from last week, helped out with a couple appointments (just restraint and that sort of thing), and did a proper PE on my surgery dog for Tuesday and got his paperwork going. I got home around 6:30 pm.
Today turned out to be a loooooonger day that Monday (even though I was thoroughly exhausted after Monday). I rolled into the VTH shortly after 7 am to get another good look at today's surgery patient and make sure everything was set up for his surgery before 8 am rounds. Today's doggie was a 6 month old red miniature Dachshund -- just about the sweetest and silliest hound dog you've ever met. His name is Mickey and if you sit on the ground he loves to race toward you and try to launch himself into your lap, but he just can't make it most of the time on account of his stubby little legs. He also loves to roll over and wait for belly rubs.
Anyway, Mickey's surgery and anesthesia were extraordinarily efficient today. I checked on him at 10:05 am, when the tech students had just brought him into the anesthesia prep room but hadn't started working on him yet, and when I came back 10 minutes later, he was catheterized, induced, and ready to be shaved for surgery. (And 10 minutes may seem like a plenty long time, but in the world of brand-new anesthetists, that's almost a world record.)
Mickey was in the surgery suite by 10:25 am and I started cutting at 10:35 and finished my last intradermal suture at 10:55 am -- a 20 minutes neuter, skin to skin, which totally beats my 40-60 minute neuters I've done previously. The nice thing about neutering young dogs is you can almost just rip those testicles right of them without having to mess with the scrotal ligament that attaches the testicle to the inside surface of the scrotum very strongly in older dog.
Mickey recovered well (though he was pretty chilly -- he got down to 94 degrees in surgery, with 100-102 being normal body temp). Since I had no appointments until 4:30 pm, I tackled about 8 phone messages that had been left over the course of the morning.
After all the lovely phone calls, it was a quick bite to eat and then a surprise 1 pm appointment. One of my rotation-mates has a dog of his own who has been battling lymphoma for a few months and recently going downhill -- the poor thing is only 4 years old -- and my classmate got some really bad news about his beloved doggie today, so he headed home around noon.
Which left me with his 1 pm surgery intake -- a client-owned animal dropping off for surgery on Wednesday. The patient is a pretty little yellow lab, about 6 months old, who's in for a laparoscopic spay and gastropexy. She's a bit shy, especially around men, but overall a good girl and very cute. And she finally went potty for me outside at her last walk of the evening!
Aside from the surgery puppy for tomorrow, I helped out with some blood draws, vaccine administration, nail trims, anal gland expression... basically a full afternoon of assisting with other people's patients when they were in the treatment room.
My 4:30 appointment was an 8 year old Chesapeake Bay retriever due for some vaccines, needing a nail trim and anal gland expression, and also with a long complicated history of urinary incontinence, right forelimb lameness, multiple skin and subcutaneous masses, etc. etc. etc. They also arrived at 3:55 pm for their 4:30 schedule appointment and seemed a bit put off when it was 4:05 pm before I came up to get them (my bad, I guess I should have been more than 25 minutes early to come see you).
My 6:00 was a sweet, happy 1.5 year old shepherd cross due for her annual boosters on her puppy vaccines. Her owner was super nice and signed her up on the VTH's wellness plan, started her on a lepto vaccine in addition to her DA2PP and rabies, consented to a heartworm test and sending home preventive, and allowed deworming and promised to bring back a fresh poop sample for a parasite screen.
When they left at 6:45, I was left with a couple records to write up, then feeding, walking, and medicating (ear meds) my lab spay for tomorrow, and feeding and walking my Dachshund neuter for today. With an arrival at home at 8 pm, it was nearly one of my longest days on Community Practice -- and there's no sign that the rest of the week will be any slower!
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