Moving on

With graduation today, my vet school journey has officially come to an end.

It's been a long 4 years -- at times fun, fascinating, invigorating, inspiring, informative, educational, emotional, frustrating, challenging, exhausting. Thank you to all of my friends and family who have supported me, kept me sane, and given me someone to laugh with or a shoulder to cry on after a long day.

And thank you to my readers, who have inspired me to chronicle these past few years in a written format that I know I will enjoy looking back on in upcoming years.

Vet school may have ended, but my blogging has not. I invite you all to join me in the next stage of this journey, at DVM Year One: http://dvmyearone.blogspot.com/. Thank you for reading!

Urgently caring for 2 more days!

After Hours Urgent Care has been a long, hectic, challenging, and emotionally and physically exhausting rotation. I've had multiple days when I'm on from 3 pm till 1 or 2 am, then have to come in at 7 am for an hour or two to check on hospitalized patients, then come back at 3 or 4 pm for my next 8-12 hour shift.

But you don't want to listen to me whining, so here are some of the cases I've seen:

1. The young vomiting Labrador from my first night did indeed have a GI foreign body, which was surgically removed at another clinic.

2. Wes, the poodle with huge lymph nodes and circulating lymphoblasts, was definitively diagnosed with leukemia/lymphoma and euthanized when he failed to improve at all after another day in the hospital. Necropsy showed severe diffuse cancer in most of his organs.

3. Kevin, the Pyrenees with an abdominal mass and hindlimb neurologic disease, stayed in the hospital for almost a week, undergoing a splenectomy for a splenic hematoma, and leaving with about the same ability to stand/walk as when he came in.

4. Ethel, a one-year-old rabbit, came in for not wanting to eat that evening. She seemed totally normal on physical exam so we sent her home for syringe-feeding with instructions to return if she wasn't eating on her own in the next 24 hours. She wasn't, so she came back to see the Exotics department, and unfortunately died during a blood draw (she was a lot sicker by that point).

5. Drew, a middle-aged lab mix, was driven to us from several states away for some pretty serious illness. We ended up diagnosing him with huge tumors in his heart, and he was sent to heaven.

6. Wanda, an elderly St Bernard, presented for "bleeding from mouth" -- which she wasn't, by the time she got to us. All we found on a sedated oral exam was a little abrasion at one corner of her excessive lip folds, probably where she just got her huge lips stuck in her mouth while chewing on something.

7. Shaggy, a spastic middle-aged shepherd mix, presented for distended abdomen and nonproductive retching. I happened to be in the lobby with another patient when Shaggy arrived as a walk-in, and you could diagnose a GDV ("bloat") from across the room. Fortunately, her owners had the funds for corrective surgery. Shaggy did well and left the hospital after just a couple days.

8. George, an elderly Lab, presented for seizures. We monitored him overnight then sent him on his way when his owners were uninterested in further diagnostics like MRI. Odds are good that George has brain cancer.

9. Annie, a middle-aged, medium-sized, completely mixed breed dog, presented for anorexia and inability to swallow. We palpated a mass near her larynx, which was confirmed on radiographs. Ultrasound the next day showed that the mass was likely growing off the wall of the esophagus, and we recommended a surgery consultation, +/- feeding tube placement.

10. Pia, an elderly Papillon, presented for seizures. On further discussion with her owner, though, I determined that her "seizures" were actually syncopal episodes (fainting, probably due to heart disease). Radiographs showed Pia to be in heart failure. She was stabilized overnight then transferred to Cardiology.

11. Hershey, a middle-aged lab, presented for drinking and urinating excessively. Based on his physical exam, we strongly suspected hyperadrenocorticism ("Cushing's syndrome"), but bloodwork revealed diabetes mellitus (in addition to probable Cushing's). We sent Hershey home with insulin, and unfortunately his owner won't return any of my follow-up calls to see how he's doing.

12. Violet, a young Shih Tzu, presented for inability to urinate, after she'd been seen several days earlier for the same problem, diagnosed with bladder stones, and had a urinary catheter placed to relieve the obstruction then was sent home. Her owners had finally come up with funds for surgery, and when we couldn't pass a u-cath, the need for surgery became emergent and Violet had a cystotomy at about 2 am.

13. Jimmy, a young-ish Yorkie, presented for vomiting blood, and began having blow-out bloody diarrhea when he got to the hospital. He was transferred to Internal Medicine, diagnosed with hemorrhagic gastroenteritis, and discharged after a couple days of supportive care.

14. Lizzie, a middle-agred Rottie, presented for irritation and drainage from a surgical incision from a tumor removal several days earlier. We diagnosed her with a likely incisional infection, and sent her home with antibiotics and additional pain medications.

15. Gracie, a young cat, presented for vomiting and anorexia of 2 days' duration. Though her belly wasn't painful at presentation, we palpated a probable mass or foreign body in her cranioventral abdomen, and radiographs showed a suspicious gas pattern. Emergency surgery revealed a small intestinal foreign body (a tassel that Gracie had eaten off of a piece of furniture), and Gracie recovered well.

16. Dozer, a young Boxer, presented for swelling on one of his ears, which we diagnosed as an aural hematoma, likely due to Dozer's severe yeast infection in that ear, which was probably due to underlying allergies. Dozer went home with pain meds and ear drops.

17. Willie, an elderly border collie mix, presented for difficulty breathing, with a history of previously controlled diabetes mellitus. We suspected early pneumonia based on lung sounds and radiographs, and Willie was hospitalized on treatment for presumptive pneumonia and started feeling much better within a couple days.

18. Sage, an elderly heeler mix, presented for a suspected gallbladder obstruction based on severe bloodwork changes at her rDVM. We performed an emergency ultrasound, which showed the gallbladder to be pretty normal but the pancreas to be extremely angry. Sage was hospitalized on supportive care for severe pancreatitis.

19. Kodiak, an older Lab, presented for possible stick in his esophagus, after the owners saw him trip and hit the ground while carrying a stick in his mouth. Radiographs didn't reveal much of anything (as we suspected they might not), so Kodiak went home with antacids and pain meds for presumed esophagitis.

20. Taco, a young Chihuahua, presented for possible allergic reaction to a bee sting. However, on presentation Taco was only somewhat responsive and very ataxic, had a low heart rate, was hyper-reactive to loud stimuli, and was dribbling urine -- all classic signs of marijuana toxicity. Taco was hospitalized on IV fluids and activated charcoal to help the pot get out of his system, while we all laughed hysterically at his stoned antics.

Yes, your dog has neurologic disease

Yesterday I saw an enormous elderly Great Pyrenees named Kevin.

Kevin had been feeling just fine in his old age, until yesterday morning when he was unable or unwilling to stand and walk in his hind end. Kevin's mom took him to her vet, where an abdominal mass was diagnosed. With bloodwork, chest radiographs, and abdominal radiographs in hand, and with the assumption that pain from Kevin's abdominal mass was the cause of him being "down in the hind," Kevin's mom brought him to the VTH for further work up and monitoring.

At presentation, Kevin really was pretty down in the hind. A big guy at over 100 pounds, we had to hoist him out of his owner's van and onto a gurney to take him to the treatment area.

Once we began to evaluate Kevin further, though, it became clear that more was going on than just an abdominal mass. With the support of a belly sling and about 4 people hoisting, we got Kevin to his feet for a neurologic and orthopedic assessment.

What we found was that Kevin was actually willing to try to walk with his right hindlimb, but his left hindlimb appeared to be almost totally useless. A test of conscious proprioception (whether the brain and body can feel where the limbs are in space) revealed zero proprioception in the left hindlimb and minimal proprioception in the right hind. We laid Kevin down on his side for additional assessment. His forelimbs were almost totally normal -- he could walk on them and move them normally, with normal muscle tone and reflexes.

Kevin's hindlimbs, however, were another story. Both limbs were neurologically impaired, with the left more severely affected than the right. Muscle tone was extremely decreased in both limbs, meaning Kevin's muscles offered almost no resistance to manipulation of his limb. His thigh musculature was moderately atrophied on both sides. When we extended either hindlimb and pinched a toe, Kevin could feel the obnoxious sensation but could offer only the weakest of attempts to physically withdraw the limb away from the pinch. Finally, Kevin's patellar reflexes ("knee jerk" reflexes) were very decreased.

All of these findings pointed to neurologic disease within Kevin's lumbosacral spinal cord, with worse disease on the left than the right. Additionally, we could feel a grapefruit-sized mass in Kevin's belly, but he gave us no sign of any pain when we palpated around this mass or elsewhere in his abdomen. In other words, we could find no reason in Kevin's belly for him to be painful enough not to walk.

When we went to discuss these findings with Kevin's owner, however, it became clear that she was convinced that he was orthopedically and neurologically sound. She assured us that his abdomen was painful and that was why he was down.

Fortunately, Kevin's mom seems like a great lady, and she readily agreed to hospitalize him overnight for IV fluids, monitoring, and supportive care, with abdominal ultrasound and thoracic rads in the morning. We also put in a request for a neurology consultation to be done today for Kevin, in the hopes that they can further pinpoint his neurologic disease and determine if it might be related to his abdominal mass. I'm hopeful that with a little more time to process the information, Kevin's owner will come to realize that he has potentially multiple issues.

In other news, poor Wes from Wednesday night was sent on his way to doggie heaven yesterday afternoon. Given that his owners didn't really want to pursue any treatment once they'd gotten the diagnosis of either lymphoma with an acute leukemic crisis, or acute lymphoblastic leukemia, it was probably for the best. It's just nice when you can get them feeling better for a few days before you let them go...

Lymphoma sucks

One of my Urgent Care patients last night was a 4 year old standard poodle named Wes who almost certainly has lymphoma.

Wes had about a 10 day history of some nonspecific clinical signs: lethargy, decreased appetite, and occasional vomiting and diarrhea. Wes's owners felt the need to bring him to their regular vet yesterday afternoon when Wes started sneezing blood (epistaxis).

The rDVM ran some bloodwork that showed a very low platelet count of 23,000. Normal platelet numbers are 200-500,000. This thrombocytopenia could have one of several causes and could certainly be the cause of Wes's epistaxis.

However, the CBC that showed the thrombocytopenia had another concerning finding -- a white blood cell count of almost 70,000 (normal being less than 12,000).

Wes's rDVM was suspicious of lymphoma, so submitted another CBC to an outside laboratory to have a pathologist examine a blood smear and give a definitive "yes or no" on lymphoma by this morning.

But Wes's epistaxis hadn't stopped, and out of concern that he might hemorrhage to death overnight, Wes's owners brought him to the VTH.

On presentation Wes was extremely dull and dumpy. He would wag his tail on occasion, but otherwise had no energy for anything other than lying in a heap on the floor. His gums were pale and dry. His heart rate was very elevated (190 beats per minute, normal in a dog his size being probably 80-100) and he was panting heavily with some obvious difficulty breathing. He was febrile at 103.8 (normal 100-102.5).

Unfortunately, the most pertinent finding was that all of Wes's peripheral lymph nodes were significantly enlarged. Additionally, Wes also had a large mass in his cranial abdomen, which I suspect was an enlarged spleen.

Based on Wes's clinical presentation, we absolutely agreed with his rDVM's top rule-out of lymphoma. We looked at a blood smear, which had a huge population of abnormal cells that I'm 99.9% sure were lymphoblasts (cancerous precursors of a type of white blood cell affected in lymphoma). We offered to do fine needle aspirates of some of Wes's lymph nodes and have them examined by a pathologist at the VTH, so that Wes's owners could have an answer immediately instead of waiting until morning.

However, Wes's owners were hellbent on doing as little as possible until morning when they got their test results -- just enough to keep Wes "comfortable" overnight. Our eventual compromise was to hospitalize Wes on IV fluids and place him in an oxygen cage. His heart rate declined somewhat overnight, though it was still elevated at 150 this morning. Wes still struggled to breathe, even in oxygen. He was still mildly dehydrated this morning. His fever, at least, had come down to 102.9.

After I came in to check on Wes this morning, his owners were still trying to make up their minds what to do with him, having not received their tests results from his rDVM yet. They had pretty much ruled out the recommended aggressive chemotherapy protocol which would probably buy them about a year of quality time with Wes but could cost $4-5000. (And I'm not passing any judgment on that. It's a lot of money for a gamble at getting a few months to a year.) It's just tough to see lymphoma in a dog so young -- Wes will only just turn 4 next month. While it's "nice" that lymphoma is one of the few cancers that responds more readily and reliably to chemotherapy than other cancers, it just plain sucks that it hits dogs so young. Last time I was on Urgent Care last fall, I had another 4 year old poodle freshly diagnosed with lymphoma. I hope that Wes's owners will at least put him on some oral steroids for awhile, to buy him a few weeks or months of feeling good at minimal expense.

Never fails

Last night was my first night of "After Hours Urgent Care." What that means is that I (along with 2 other seniors and an intern) see emergent, urgent, and/or walk-in patients from 4-11 pm on weeknights, and either 7 am-4 pm or 3-11 pm on weekends. What that also means is that a patient that arrives at 10:59 pm is my responsibility, and a patient that arrives at 11:00 pm is dealt with by the overnight students on CCU. So, imagine my surprise (sarcasm) when yesterday I saw not a single patient between orientation at 3 pm and almost the end of my shift at 10:50 pm -- when, of course, a young vomiting Labrador with a history of dietary indiscretion walked in the door. Of course, he needed x-rays of his belly as well as some bloodwork, all of which took a couple hours, then I had to set him up for hospitalization for the rest of the night and finish his paperwork. So after sitting around killing time for 7+ hours, I got to stay 2.5 hours past the end of my shift! And woke up at 11:30 this morning with a killer headache. The only upside is that, for some cases that are admitted in the evening and stay in the hospital until morning, the urgent care student whose case it is has to come back at 7 am to re-evaluate the patient, complete morning paperwork, call the owner with an update, and transfer the case to a specialty service within the hospital. At least I got out of that with this dog. The next 2 weeks could be a lot of "fun"!

I'm ready for some minions

Since returning from my externship at LIAH, I've been unusually annoyed by the many varied intricacies of trying to get simple tasks done at the VTH.

On my current Dentistry & Oral Surgery rotation, I am the only student. There is also only one clinician -- both of which are a little unusual. Generally the DOS service has 2 clinicians and 2 senior students to handle a full caseload (which can consist of up to 8 appointments on consult days and up to 4 procedures on procedure days). We still have that busy schedule, but since I'm the only senior student, I get to do all the busy work.

I think the "busy work" aspect of it is really catching up to me because I greatly enjoyed a full 2 weeks at LIAH with an extremely skilled, competent, and independently functioning technical staff. Don't get me wrong, the technical staff at the VTH are highly educated and extraordinarily capable in their jobs -- but their job description doesn't include a lot of the nitty-gritty things that technicians take care of in private practice.

Let's compare, for instance, how you get a CBC and chemistry panel sent to the lab at the VTH compared to LIAH.

At the VTH: I fetch the patient from the exam room at the south end of the building and bring him to the treatment area at the north end of the building. I gather alcohol, syringes, needles, blood collection tubes, and a Clinical Pathology submission form. If the treatment area is out of syringes, needles, or blood tubes, I walk to Central Supply at the north end of the building to request more supplies. I fill out the Clin Path form, including placing patient ID stickers on both of the carbon copy pages. If I don't have enough stickers, I walk to the east end of the building where I can use the computer program to print more stickers, then to the west end of the building to pick up the stickers from the printer, then I go back to the treatment area at the north end. If the sticker printer is out of paper, I walk over to Medical Records at the east end to request more paper. If the treatment area is out of Clin Path forms, I walk up to the southeast corner of the building and hope there are extra forms in the cabinet. I wait until the dentistry technician is off the phone or the dentistry clinician has finished whatever she is doing, so one of them can restrain the patient for me. I draw the blood myself. I fill out 2 of the smaller patient ID stickers for the 2 blood tubes. I walk the patient back to his owner in an exam room in the south end of the building (or try to convince the technician or clinician to hold the patient for me, or place the patient in a cage, which requires writing up a cage card and getting a blanket for the cage), then go back to the north end to pick up my blood samples and form from the treatment area, then take the samples and form to the Clinical Pathology department (which is about a 4-5 minute walk away, in another building), time stamp the form, and turn in the blood samples, then walk back to the treatment area in time to start the next appointment.

When you've got 4 appointments in 4 hours, and every one of them needs blood submitted, you can see how this gets tedious. It is tedious just to think about it.

Let's compare to how I get my blood submitted at LIAH: I let the owner know that I'm going to collect some blood, and walk about 10 feet from the exam room to the treatment area with the patient. I place the patient in a cage. I write his name on the whiteboard on the wall, along with what tests I want run. In about 5-10 minutes, the team of technicians has drawn the blood, returned the patient to his owner, and gotten everything ready to go to the lab. In that time, I've been doing doctor-type things, like seeing the next appointment, writing up charts, researching a case on VIN, or scrubbing into a surgery.

Now let's see how I submit a urine sample at the VTH: Again, I walk the patient from the exam room (south end) to the treatment area (north end). I wake up my computer, spend a couple minutes logging into the radiology request website, and another 2 minutes filling out an online request for an ultrasound-guided cystocentesis (collecting a sterile urine sample by placing a needle directly into the bladder). I gather a syringe, 2 needles, a sterile tube, a Clin Path form, and 2 large and 2 small patient ID stickers. If any of those supplies aren't in the treatment area, I proceed to Central Supply (north end), the forms cabinet (southeast), and/or the label printer (east and west ends) to gather them. My patient and I walk over to Ultrasound (east end) where we wait for an open ultrasound machine, another person to restrain, and someone to collect the urine sample. Once collected, I walk the patient back to his owner (south end), drop off a tube of urine in the fridge in the Medicine pit (southwest), and again hike to Clin Path in another building to time stamp my form and turn in the urine.

At LIAH: I let the owner know that I'm going to collect some urine, and walk about 10 feet from the exam room to the treatment area with the patient. I place the patient in a cage. I write his name on the whiteboard on the wall, along with what sample I want collected and why. In about 5-10 minutes, the team of technicians has collected the urine, returned the patient to his owner, and gotten everything ready to go to the lab.

I'm sure this post sounds whiny, and it kind of is. And in no way do I mean to speak unkindly of the wonderful technical staff at the VTH, or to imply that me having to do all of the above steps means somehow that the technicians at the VTH aren't doing their jobs. I fully believe that a capable, dedicated, responsible technician is worth his or her weight in gold. Veterinary technical staff are too frequently undervalued, underrecognized, and underpaid for the often unpleasant, exhausting, and behind-the-scenes work that they do. And certainly any veterinarian who is a true team player is happy to do some of the busy work on occasion.

However, since I'll have the letters "DVM" after my name 3 weeks from tomorrow, I'd rather be treated more like a doctor at this point than a technician.

Zombie pets strike again

Remember how much I enjoyed cutting eyeballs out of a soaking wet whole dead cat?

Extracting teeth from a decapitated Beagle has been only marginally more enjoyable on Dentistry & Oral Surgery this weak. Blargh.

How to treat malignant mammary cancer on a $65 budget

I spent the last 2 weeks an hour away from home in a large metro area, externing at what we'll call Low Income Animal Hospital (LIAH). LIAH is run by the state VMA's charity branch. It's a non-profit hospital that employs about 3 full-time veterinarians to provide lower-cost care for low-income clients. All services come with a fee, but those fees are discounted to some degree based on how poor an individual client is.

My 2 weeks at LIAH were a huge learning opportunity. For one thing, I gained (re-gained?) some confidence that I will kind of know what I'm doing when I graduate in a month(!). We senior student externs are given pretty much free rein to see cases and formulate diagnostic and treatment plans.

LIAH is also a great opportunity to be reminded about what type of clientele many vets see out in the "real world" (i.e. not in the "silver tower" of a referral institute). The VTH and LIAH are pretty much polar opposites in terms of the financial ability of their clients. Those who visit the VTH (at least the specialty services) are pretty well self-selected to be willing to pay hundreds or often thousands of dollars for veterinary care. In contrast, the clients at LIAH are basically self-selected as very low-income, with common circumstances such as disability, unemployment, or foreclosure.

It's very sobering to have clients come in who have to choose between a rabies vaccine or a distemper-parvo vaccine for their dog, because they can't afford the $25 for both vaccines in addition to the $35 exam fee.

Or, like one of my patients on Thursday, the pet has a serious medical condition that could possibly be cured, if only it were in the budget. This particular patient was a 10 year old, un-spayed, female kitty named Patty.

Patty presented to LIAH with the complaint of "check lump on belly." The technician went into the appointment initially to record Patty's vitals and get a brief history from her owners, and when she came back to tell me about the case, it was clear we were dealing with badness.

Patty had a very large (about 1.5 inches across) mammary tumor in her caudal mammary chain, which had grown through the skin and was ulcerated and abscessed. Upon further examination, Patty also had about 20 other smaller tumors up and down her mammary tissue. Though these tumors had a characteristic feel to them (often described as feeling like BBs within the breast tissue), Patty's owners had been so distracted by the larger tumor (which, by the way, had been growing for about 4-5 months) that they didn't realize anything else was going on.

Unfortunately, about 90% of mammary tumors in female cats are malignant. Had Patty presented to the VTH's oncology department, we'd have recommended doing some thoracic rads to check for metastasis, sedating Patty for FNA of some of her masses and the lymph nodes that drained them, and, depending on the findings of the previous tests, scheduling a bilateral radical mastectomy.

And I still discussed those steps with Patty's owner. Just because someone doesn't have the money to pursue advanced treatment doesn't mean that you shouldn't give them every option. Is it an awkward conversation to have with clients that you are 99.5% sure cannot afford such a workup? Of course -- but you still have to bring it up. It's considered negligence to not offer the "gold standard" plan, because there are still that 0.5% of clients that will surprise you with what level of treatment they can and will pay for.

However, Patty's owners had scraped together $65 for that day's appointment. It was enough to cover the exam fee (about $35 after their discount), and maybe some meds to go home. My discussion with them moved almost immediately to a chat about palliative or hospice care, rather than delving into curative intent therapy. Patty needed antibiotics to try to treat her infected tumor (though such therapy may or may not be successful in controlling infection), and she needed pain meds because, let's face it, a giant infected tumor on your belly bleeding all over the place can't feel good. Unfortunately, even with the cheapest antibiotic selection and a lower dose of pain meds than I wanted to use, we were still $8 over Patty's owners' budget.

So the technician and I each kicked in $4, and sent Patty on her way for what will hopefully be a more comfortable few days at home before Patty's owners are ready to euthanize her. During our discussion, Patty's female owner also revealed that she herself is in Stage 4 ovarian cancer -- so Patty's owners know all too well what lies in store for Patty, and I think they feel some relief that they will be able to give her a peaceful passing when she is no longer able to be comfortable.

It's a case that will stick with me.

Ophthalmology

I just finished 2 weeks of ophthalmology. And I tried to blog about it. I really did.

But ophthalmology is such a boring and frustrating subject that living through cases once was enough for me, and I couldn't bring myself to re-hash any of them for you!

I saw a lot of corneal ulcers, cataracts, glaucoma. The usual eye stuff. Watched a bunch of cataract surgeries (which is cool to see the first time, then you never need to see one again because they are all the same).

We had a pig eye lab last Friday, where we sutured corneal lacerations and did conjunctival grafts on eyeballs. It was okay. Yesterday our lab was done on whole dead cats. We sutured eyelid lacerations, did third eyelid flaps, performed temporary tarsorraphies, and finally enucleated one or both eyes. It was disgusting.

I think I still hated necropsy more than ophthalmology, but ophtho was probably my least favorite of all of my clinical rotations involving clients and appointments. I'd even rather repeat orthopedics than spend another 2 weeks on ophtho!

So, adios, ophthalmology. I'm so done with you!

Slow learner

Remember Emmie, my oh-so-naughty rock-eating retriever?

Right, the one who was seen on SAIM for her third offense of rock ingestion requiring medical or surgical intervention?

Well, unfortunately we failed to find any underlying medical condition that would explain Emmie's propensity for gobbling rocks. And we had a stern heart-to-heart with Emmie's mom about how to manage Emmie's bad habit. And it seemed to take.

But today I looked back through the records of all of my SAIM patients, including Emmie. And much to my chagrin, I noticed that Emmie was seen 3 days ago at the VTH. For surgery. For eating rocks.

Sigh. *headdesk*

Apparently Emmie's owners aren't getting it. I think they are the slow learners in this scenario. Poor Emmie!

And the job search continues

I had 4 interviews in Minnesota and Wisconsin this week -- 2 initial interviews at hospitals in the Twin Cities area, and 2 all-day working interviews at hospitals in Wisconsin.

The working interviews are definitely a huge help in getting to know a practice. I'd previously had phone interviews with both of the Wisconsin practices, but that just isn't the same as spending all day with a hospital owner, their associates, office/practice manager, technical staff, and receptionists. It's a nice opportunity to see how everyone functions as a team (and how much yelling there is).

The shorter interviews I had in Minnesota were also helpful because it's nice to talk to people in-person instead of on the phone, even if it's only for half an hour or an hour. In both cases I got to talk to the practice owner along with either several associates or the practice manager, and in one case they showed me around their building too. Though I quite liked one of those two hospitals based on that brief interview, I would certainly want to arrange a working interview before committing to anything.

I could probably type for 3 days about all my interviews this week, but instead I'll summarize some of the "DOs" and "DON'Ts" I encountered this week:

Things I like to see or hear:

* Performing "COHATs" (Comprehensive Oral Health Assessment and Treatment) instead of "dentals" (#2)
* Having digital dental radiographs and actually using them (#2)
* Having ultrasound and using it (#2)
* A well-trained technical staff that is comfortable starting out the appointment, getting a TPR, obtaining a relatively accurate medical history, and doing a ton of client education (#1 > #2)
* A working relationship with the local humane society, within reasonable bounds (#2)
* Requiring or strongly recommending pre-anesthetic bloodwork on all patients (#2 > #1)
* A dedicated CVT assigned to every anesthetic case (whether surgical or dental) solely to monitor anesthesia (#1)
* Multi-parameter monitors including SPO2, EKG, pulse, and blood pressure (#1 > #2)
* Regular use of opioids as pre-emptive and peri-operative analgesia (#1 = #2)
* Hospitalizing patients overnight with no staff present as long as clients give informed consent (#1 = #2)
* Willingness to adjust anesthetic protocols based on an individual patient's needs (#2 > #1)
* Approach to diagnosis and treatment that actually includes seeking a diagnosis before randomly trying a trial treatment (#1)
* Recommending (with decent client compliance) screening bloodwork on healthy patients (#1)
* 3-year vaccine protocols (#1 > #2)
* When I ask why something is done a certain way, the reply includes a reference to a peer-reviewed study or a discussion with a specialist (#1 > #2)
* Ability to run a lot of bloodwork in-house, combined with daily pick-up service from an outside laboratory (#1 = #2)
* A lobby that smells delicious (#1)
* AAHA accreditation (#2)
* Being within a 1 hour drive from the nearest referral 24-hour care facility (#1)
* Having a technician on-call every night to help the DVM on call (#2)

Things I don't like to see or hear:

* Not performing an otoscopic exam on two patients in a row where such an exam was clearly indicated (a dog presenting for scratching the ears, and a cat presented for routine physical but with a lot of otitis found on PE) and instead saying "maybe next time" (#2)
* Giving all SQ injections between the shoulder blades, even in cats (#1)
* Having digital dental radiographs but admitting they are rarely used (#1)
* "The other practices around here don't really like us." (#1)
* Placing an IV catheter but not using IV fluids for "routine" surgeries (#1)
* Watching 3 certified technicians take about 6 total attempts to place a 24g IV catheter on a well-behaved cat (#2)
* Dentals performed by one lone technician in charge of monitoring anesthesia while also performing the dental cleaning and taking all the xrays (#2)
* Ignoring really crappy blood pressure readings on a patient based on the fact that their pulses feel okay; never monitoring blood pressure at all during a cat spay (#2)
* No place in the main treatment area to house hospitalized pets so someone can actually monitor and observe them (#2)
* Not having anywhere in exam rooms for the doctor to sit, resulting in either squatting on the floor or looming over the client (#1 = #2)
* A lobby that smells like eau-du-disinfectant-over-cat-pee (#2)
* Being 2 1/2 hours from the nearest referral 24-hour care facility (#2)
* Having an on-call schedule that includes 2 weeknights every week and every 3rd weekend (#2)
* Having an on-call schedule that includes 1 weeknight every week and every 4th weekend (#1)
* Not having a technician on-call to help with overnight and weekend emergencies (#1)
* The possibility of being expected to work a regular Sunday shift (#2)
* Observing a technician doing the initial check-in on a wellness exam and providing the client with complete misinformation about the hospital's puppy vaccine schedule and when to spay/neuter, and being repeatedly unable to convert between "14 weeks" and "3 1/2 months" (#2)

Both hospital #1 and hospital #2 had a lot of the pros and some of the cons. Overall, though, I liked hospital #1 better. I just feel like more of the "cons" that I found with hospital #1 are things that I could work around or do my own way. If I'm the one giving vaccinations, I can control where on patient's body I give the injection. If the practice has the physical capability for dental radiographs, I can talk to my clients about how important they are and see that they are used when needed (at least on my patients). As long as IV catheter is placed, fluids are available, and blood pressure is monitored, I guess I could live with not actually having fluids running in a young healthy patient with adequate blood pressure during a short procedure.

But with regards to hospital #2, I'm not sure how I feel about a hospital owner who feels it isn't "worth the effort" to do an otoscopic exam on a well-behaved, friendly pet with ear disease. I don't know how much I could do about a team of 3 CVTs who require 30 minutes to place and IV catheter on a health, friendly pet. I think it's incredibly dangerous to have a single technician trying to do a dental and monitor anesthesia at the same time, especially when my own observation shows that the CVT is ignoring (or just not noticing) some potentially alarming things with the anesthesia. Similarly, I think blood pressure is (in many cases) the most important parameter to monitor during anesthesia, particularly in cats, and particularly in the cat I watched who received acepromazine (which induces hypotension) as a pre-med and propofol (which also induces hypotension) as an induction drug and isoflurane (which also induces hypotension) as a maintenance inhalant.

Anyhow, I guess it's all moot unless I get offered both of these jobs at the same time. It sure goes to show the importance of working interviews, though, since I liked both of these practices quite a bit based on brief phone interviews and wouldn't have guessed at some of their differences.

I hate DKA

One of my final patients on internal medicine last week was a sweet little kitty named Jewel.

Jewel's owner brought her to the VTH because for the last 6-8 weeks Jewel had been peeing a lot more than usual. Her owner also suspected Jewel had lost some weight during that same period of time.

Somewhat surprisingly, Jewel had never seen a vet except for when she was spayed. For an 8 year old cat, I wish I could tell you that was unusual -- but it's not. The surprising part is that, instead of taking Jewel to a regular general practice vet, she made a specialty appointment to see internal medicine. This is the type of presenting complaint that can often be handled easily or at least initially worked up by a GP, but hey, we were happy to see Jewel if that's what her owner wanted.

The top 3 differentials for a middle-aged to elderly cat with PU/PD (polyuria [urinating excessively] and polydipsia [drinking excessively]) +/- weight loss are (1) kidney disease, (2) hyperthyroidism, and (3) diabetes mellitus. Fortunately, all of those diseases can be ruled in or out pretty simply by doing a CBC, chemistry, urinalysis, and T4 (thyroid).

Which we did in Jewel's case, and which showed a blood glucose of almost 400 (normal is about 80-120, though upset cats can get up to about 300 just from the stress of being in the hospital) and 4+ glucose in her urine (normal = no glucose). These results, in combination with Jewel's clinical signs, were highly suspicious of diabetes. To confirm, we submitted a fructosamine measurement. This measures a type of protein that gets extra glucose added onto it when the blood sugar is very high for a prolonged period of time. Thus, you can get an assessment of how well a patient's diabetes is controlled during the last 2-3 weeks. Jewel's fructosamine was 790, with a normal cat's being 200-350!

Jewel's owner handled the diagnosis like a champ. The day after we ran the lab tests that diagnosed Jewel's diabetes, her owner returned with her for a lesson in giving insulin injections. At that second appointment, Jewel's owner mentioned that Jewel had seemed very stressed after the previous day's visit and had hid in her carrier all night -- extremely unusual behavior for Jewel. We were not surprised, given that Jewel had basically never been in a carrier, car, or to the vet before.

We sent Jewel home with twice-daily insulin, urine ketone/glucose monitoring strips, and a gradual diet change to a prescription diet for diabetes -- along with extensive client education about diabetes and how it is managed. The next day, however, Jewel's owner called to let us know that Jewel had refused to eat her last 2 meals and had been vomiting overnight. These are never good signs in any cat, and especially in a diabetic, so we of course recommended that she bring Jewel in right away.

Jewel arrived through Urgent Care shortly before we left for the day. She was very lethargic and dehydrated. Repeat bloodwork and urinalysis showed that Jewel was now in diabetic ketoacidosis (DKA). Also known as a "diabetic crisis," DKA occurs in a diabetic when the animal undergoes excessive stress or has another underlying disease process such as cancer or an untreated infection. The body becomes unable to utilize glucose appropriately, so starts breaking down other tissues as a food source. Ketones are produced as a result (the "keto" in diabetic ketoacidosis), and the patient's body because very acidotic (the "acidosis" in diabetic ketoacidosis). Acid-base balance (pH) is extremely crucial to survival. All of the enzymes that control every process in the body only function at a certain pH, so if the body becomes very acidotic, those enzymes can stop working, resulting in organ failure and death.

DKA can be an ugly, labor-intensive, and costly condition to treat. However, if the underlying disease process that kicked off the crisis can be discovered and treated, and if the owner can commit to a multiple-day stay in the hospital and potentially $2-5000, DKA is often treatable. Fortunately, Jewel's owners seem to be in it for the long haul.

Unfortunately, Jewel's case has another complicating factor. Because Jewel refused to eat for several days, she developed a secondary condition called hepatic lipidosis ("fatty liver disease"). Somewhat similar to DKA, hepatic lipidosis occurs when a cat is not eating, so the body utilizes fat stores. If this goes on for long enough, the liver gets overwhelmed by fatty deposits and becomes unable to function appropriately. The treatment for hepatic lipidosis is supportive care (which often means force-feeding, using a nasoesophageal tube, or an esophageal or gastric feeding tube), but even then some of these patients still die and we don't know why.

The good news is that Jewel seems to be improving, after 5-6 days in the hospital. She still doesn't want to eat but has been getting some nutrition from a tube placed through her nostril into her esophagus.

The bad news is that Jewel's primary clinician and I both feel terrible about her developing DKA. We have blood and urine results from Jewel's first visit that prove that Jewel was not in DKA at that time -- her pH balance was normal and there were no ketones in her urine. But when she came back 2 days later, inappetant and vomiting, she was absolutely in DKA as evidenced by huge changes in her labwork.

The frustrating part is that the massive stress alone from Jewel's first visit (where we ran the initial diagnostics that revealed her diabetes) was probably enough to kick her into DKA. Once we diagnosed her DKA, we went on a "hunt" for an underlying cause, including other lab tests, ultrasounds, and x-rays, but found nothing. I feel bad that we didn't have a suspicion of underlying illness on Jewel's second visit to us, when we showed her owner how to give insulin shots and she mentioned that Jewel had hid in her carrier all night. However, I doubt there would have been much we could have done differently at that point anyway, other than potentially catch Jewel's DKA a day earlier -- though that probably wouldn't have changed the outcome.

This case was very educational for me (as was almost every case I saw on internal medicine -- one of the benefits of that service!). It taught me a lot about the initial management of a newly diagnosed diabetic, as well as treatment of DKA. And, especially, it taught me never to underestimate the sensitivity of a diabetic patient to stress and illness, and not to assume that a patient's odd behavior can be attributed solely to a known stressful event the day before.

Internal medicine = busy (again)

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

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

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

Lesson #895: Don't eat rocks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Aaaaaaaand.... off my soapbox!)

Since we last spoke

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

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

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

3. Found out I passed NAVLE. Huzzah!

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

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

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

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

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

Uncomfortable

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

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

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

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

Which we completed.

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

Awkward.

Then ultrasounded him again. And called it quits.

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