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.
Showing posts with label On School. Show all posts
Showing posts with label On School. Show all posts
Thursday, April 19, 2012
Thursday, April 12, 2012
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.
Extracting teeth from a decapitated Beagle has been only marginally more enjoyable on Dentistry & Oral Surgery this weak. Blargh.
Monday, April 9, 2012
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.
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.
Saturday, March 24, 2012
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!
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!
Monday, March 12, 2012
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!
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!
Friday, March 9, 2012
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.
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.
Thursday, March 1, 2012
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.
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.
Thursday, February 16, 2012
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...
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...
Wednesday, February 15, 2012
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!
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!
Sunday, January 22, 2012
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!)
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!
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!
Monday, January 2, 2012
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!
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!
Saturday, December 3, 2011
Welcome to Radiation Vacation
I've had my first week of "radiation vacation," more officially known as Diagnostic Imaging rotation. It's another 3 week rotation, for which I'll get a "bonus" partial week before Christmas.
And, yeah. There's not that much to say about it. Basically we sit around the radiology department, waiting for requests for radiographs to come in. Sometimes we walk over to the patient wards to retrieve a dog or cat; sometimes the animal is brought to us. Sometimes the pet is sedated or anesthetized for radiographs; sometimes they don't need to be; sometimes they aren't sedated but should be. Sometimes we take abdominal rads or extremities (quite a few stifles), but mostly we take "met checks" (3-view thoracic radiographs).
Sometimes we take radiographs pretty much non-stop for a period of several hours. And then there are days like yesterday, when we took 3 sets of rads in 5 hours. Blechh.
On the one hand, it's nice to have a chill rotation requiring arrival at 8 am and from which we usually get to leave at 4, but always by 5. However, I'm already anticipating an extreme worsening of my current level of boredom by the time another 2.5 weeks have passed. Oh, well -- should give me some time to polish up my resume and start job-hunting!
And, yeah. There's not that much to say about it. Basically we sit around the radiology department, waiting for requests for radiographs to come in. Sometimes we walk over to the patient wards to retrieve a dog or cat; sometimes the animal is brought to us. Sometimes the pet is sedated or anesthetized for radiographs; sometimes they don't need to be; sometimes they aren't sedated but should be. Sometimes we take abdominal rads or extremities (quite a few stifles), but mostly we take "met checks" (3-view thoracic radiographs).
Sometimes we take radiographs pretty much non-stop for a period of several hours. And then there are days like yesterday, when we took 3 sets of rads in 5 hours. Blechh.
On the one hand, it's nice to have a chill rotation requiring arrival at 8 am and from which we usually get to leave at 4, but always by 5. However, I'm already anticipating an extreme worsening of my current level of boredom by the time another 2.5 weeks have passed. Oh, well -- should give me some time to polish up my resume and start job-hunting!
NAVLE, shmAVLE
I took the North American Veterinary Licensing Exam, aka NAVLE, aka "boards" 2 days ago. And it went pretty well. I've spent about 3 months doing practice questions and practice exams regularly on VetPrep, and I felt like I was pretty well prepared.
NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.
My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.
However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.
I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!
NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.
I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.
I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.
Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.
The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.
It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!
NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.
My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.
However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.
I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!
NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.
I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.
I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.
Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.
The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.
It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!
Sunday, November 27, 2011
Groundbreaking news
I did NOT get called in yesterday.
What?
You heard me.
A full 12 hours on call with no calls.
Which is common for most of my classmates, but virtually unheard-of for me.
Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!
What?
You heard me.
A full 12 hours on call with no calls.
Which is common for most of my classmates, but virtually unheard-of for me.
Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!
Saturday, November 26, 2011
Anesthesia: Almost done!
It's been a long, long month of Anesthesia.
Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.
What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:
Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.
Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.
Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!
Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!
Along the way, some of my more interesting patients included:
1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?
2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")
3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.
4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!
5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!
Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!
Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.
What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:
Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.
Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.
Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!
Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!
Along the way, some of my more interesting patients included:
1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?
2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")
3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.
4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!
5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!
Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!
Tuesday, November 8, 2011
Anesthesia on-call
Last night was my second on-call shift for Anesthesia. Here's my schedule for the last 2 days:
Monday:
6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep
Tuesday:
1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!
As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!
Monday:
6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep
Tuesday:
1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!
As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!
Saturday, November 5, 2011
Anesthesia, Week 1
I've just finished my first of several weeks of Anesthesia. It's typically a 3 week rotation, but since mine falls over Thanksgiving, I get an extra 3 regular days plus a "bonus" fourth on-call shift.
Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.
It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.
So, to review my first case:
1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.
Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.
That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.
On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.
Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.
My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.
The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.
Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.
Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.
Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.
However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.
Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.
However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!
Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.
Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!
Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.
It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.
So, to review my first case:
1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.
Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.
That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.
On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.
Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.
My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.
The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.
Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.
Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.
Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.
However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.
Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.
However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!
Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.
Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!
Thursday, October 27, 2011
"Fleas make everything worse," or "Why I hate bureaucracy"
Today I had another cardiology patient whose main problem wasn't really cardiac-related. (See: The case of Mr. Beagle.)
My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.
When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.
However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.
Sigh.
I hate fleas.
To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).
In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.
And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.
Oh my Lord. I was so wrong.
Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.
Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).
I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.
So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.
The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.
All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.
The moral(s) of this story:
1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.
2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.
3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.
4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?
5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)
6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.
7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.
8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.
Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.
My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.
When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.
However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.
Sigh.
I hate fleas.
To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).
In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.
And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.
Oh my Lord. I was so wrong.
Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.
Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).
I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.
So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.
The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.
All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.
The moral(s) of this story:
1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.
2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.
3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.
4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?
5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)
6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.
7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.
8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.
Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.
Sunday, October 23, 2011
I killed a little old lady's only companion
By "killed," I mean "humanely euthanized." By "little old lady," I mean the cutest 90-year-old woman you've ever met, who loves to tell hilarious stories. And by "only companion," I hope I'm wrong.
Ever-talented and CCU-loving student that I am, I managed a feat that few cardiology students ever achieve: I had a CCU inpatient while on cardiology rotation. (Yeah, I'm that good.)
My patient, a 13-year-old Beagle, arrived as a referral from a local clinic for what the rDVM felt was a cardiac arrhythmia (3rd degree AV block), with the intent of having the dog evaluated by the vet school's cardiology department for the feasibility of placing a pacemaker.
However, upon arrival Mr. Beagle was laterally recumbent, breathing quickly and shallowly, and had bluish purple gums and tongue. So, good student that I am, I immediately brought Mr. Beagle back to the cardiology department for some wonderful oxygen, then headed up to take a history from his owner.
Mr. Beagle's mom was the aforementioned elderly woman, accompanied (and driven, thankfully) by her son (who doesn't live with her). Mr. Beagle had started coughing several months ago, was diagnosed with an enlarged heart a month prior by his rDVM, and was placed on a diuretic that hadn't improved the cough at all. The night before presenting to the vet school, Mr. Beagle had experienced an acute onset of respiratory distress, which improved slightly overnight but not much, so Mr. Beagle headed to his rDVM that next morning.
Long story short, Mr. Beagle ended up in CCU in an oxygen cage overnight, along with several other treatments, none of which did anything to help his breathing. It turns out that his cardiac disease, while present, was rather minor. His arrhythmia was actually atrial standstill, not AV block, and was most likely incidental. His real problem was very severe respiratory disease, and we couldn't figure out the cause. Mr. Beagle's chest x-rays looked horrendous; a variety of diagnostics failed to show why. The next step would have been general anesthesia with airway endoscopy and possibly a bronchoalveolar lavage, but Mr. Beagle was just too unstable and probably would have died under anesthesia.
So Mr. Beagle's owner elected to do the unselfish thing and euthanize him. Tears were shed by all involved, but Mr. Beagle went peacefully with his owner telling us stories about the time he brought a live rabbit into the house and chased it around, how he once scared off a raccoon in the backyard, how he sleeps by his owner's feet in the living room every night before bed. When Mr. Beagle had passed, the cardiology resident and client counselor escorted Mr. Beagle's owner and her son out of CCU while I stayed behind to escort Mr. Beagle's remains down to necropsy. It broke my heart.
Ever-talented and CCU-loving student that I am, I managed a feat that few cardiology students ever achieve: I had a CCU inpatient while on cardiology rotation. (Yeah, I'm that good.)
My patient, a 13-year-old Beagle, arrived as a referral from a local clinic for what the rDVM felt was a cardiac arrhythmia (3rd degree AV block), with the intent of having the dog evaluated by the vet school's cardiology department for the feasibility of placing a pacemaker.
However, upon arrival Mr. Beagle was laterally recumbent, breathing quickly and shallowly, and had bluish purple gums and tongue. So, good student that I am, I immediately brought Mr. Beagle back to the cardiology department for some wonderful oxygen, then headed up to take a history from his owner.
Mr. Beagle's mom was the aforementioned elderly woman, accompanied (and driven, thankfully) by her son (who doesn't live with her). Mr. Beagle had started coughing several months ago, was diagnosed with an enlarged heart a month prior by his rDVM, and was placed on a diuretic that hadn't improved the cough at all. The night before presenting to the vet school, Mr. Beagle had experienced an acute onset of respiratory distress, which improved slightly overnight but not much, so Mr. Beagle headed to his rDVM that next morning.
Long story short, Mr. Beagle ended up in CCU in an oxygen cage overnight, along with several other treatments, none of which did anything to help his breathing. It turns out that his cardiac disease, while present, was rather minor. His arrhythmia was actually atrial standstill, not AV block, and was most likely incidental. His real problem was very severe respiratory disease, and we couldn't figure out the cause. Mr. Beagle's chest x-rays looked horrendous; a variety of diagnostics failed to show why. The next step would have been general anesthesia with airway endoscopy and possibly a bronchoalveolar lavage, but Mr. Beagle was just too unstable and probably would have died under anesthesia.
So Mr. Beagle's owner elected to do the unselfish thing and euthanize him. Tears were shed by all involved, but Mr. Beagle went peacefully with his owner telling us stories about the time he brought a live rabbit into the house and chased it around, how he once scared off a raccoon in the backyard, how he sleeps by his owner's feet in the living room every night before bed. When Mr. Beagle had passed, the cardiology resident and client counselor escorted Mr. Beagle's owner and her son out of CCU while I stayed behind to escort Mr. Beagle's remains down to necropsy. It broke my heart.
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