Today's Day 1 of Junior Surgery Lab was a ton of fun.
We started off the morning at 7:30 with a brief lab introduction/orientation (including a speech about flagging somebody down if you feel sick or woozy; I was totally like "Been there, done that").
We also got a pep talk about not feeling bad for the pigs who were destined to die at noon today, at the conclusion of the lab. After all, pretty much all pigs are born to be slaughtered anyway, so isn't it nice that we can use these guys to further our educations, right?
Then we headed down to lab at 8 to meet our poor little piggies. They were all anesthetized and covered with cute little pink blankets to keep them warm in the freezing climate of the surgery lab (which is kept at nearly subzero temperatures to avoid excess numbers of vet students overheating and passing out).
Seriously, I want to know how early in the morning the surgery prep team has to get there to have 11 pigs anesthetized, IV catheters placed in ear veins, on IV fluids, intubated and on ventilators, and with some degree of monitoring equipment going on each of them. It can take us juniors on anesthesia rotation a solid 1-1.5 hours to get a dog or cat from kennel to surgery table. I'm impressed.
Today was all about skin suturing, and learning how to relieve tension when closing skin defects (whether lacerations or iatrogenically induced incisions).
We started with elliptical incisions -- almond-shaped cuts down through the skin layer in an outline, then cutting out all the tissue in the center.
Here's one nice thing about pigs: they have lots of extra skin. Which is good when you are trying to close an elliptical incision for the first time.
Actually, it went fairly well. If I'm being modest (okay, I'm not), my elliptical incision was absolutely beautiful when I was done. I did a simple continuous subcutaneous suture pattern, with 2 or 3 skin cruciates thrown on top to close the bits that didn't appose as well as I'd hoped.
Next we were supposed to learn how to correct "dog ears" or "puckers." We did that by creating a half-circle incision (straight across on one side, with a half circle connecting the 2 ends of the straight line). Normally with that kind of incision, you'd want to space your sutures closer together on the straight side and farther apart on the curved side, to gradually take the slack out of the tissue a little bit at a time. But since we wanted to create a dog ear, we just sutured it straight across so we had a nice little pucker at the end that had nowhere to go.
Then we got to practice some techniques for fixing puckers, namely cutting out a triangle of skin to make it lay correctly, or doing a couple extra incisions to make the main incision end at a right angle.
Finally, we practiced advancement flaps. We created a rectangular "wound" but left one side of the tissue connected, so that there was a rectangular flap you could pull up. Then we cut out part of the flap, so that we would have to practice getting the smaller-than-desired flap to align with the larger original incision. That involved a couple of extra triangular incisions, and a lot of creative suturing.
Think that sounded fun? Here's the plan for tomorrow:
Cut open our pig's abdomen (different pig) and cut out its spleen. Hooray!
Monday, October 25, 2010
Sunday, October 24, 2010
This little piggie went to market (but ended up anesthetized at the vet school)
Tomorrow is my first day of "pig lab," known more officially as Junior Surgery Lab.
With 22 students in the class, we pair up and each team of 2 students works on an anesthetized piggie.
Tomorrow is some simpler stuff -- suturing skin incisions, elliptical incisions, practicing different suture patterns, etc. -- getting us used to some basics, reminding us about aseptic technique, and introducing us to the difference between working with live tissue versus the cadavers we've gotten to know pretty well over the last 2+ years.
Here's hoping I don't feel like passing out! A large breakfast plus extra snacking and lots of water is in my future in approximately 12 hours.
I'm thinking pig lab is really going to be a blast. But I'll admit I'm not thrilled about having to leave the house around 6:45 am every day this week... Thanksgiving break, here I come!
With 22 students in the class, we pair up and each team of 2 students works on an anesthetized piggie.
Tomorrow is some simpler stuff -- suturing skin incisions, elliptical incisions, practicing different suture patterns, etc. -- getting us used to some basics, reminding us about aseptic technique, and introducing us to the difference between working with live tissue versus the cadavers we've gotten to know pretty well over the last 2+ years.
Here's hoping I don't feel like passing out! A large breakfast plus extra snacking and lots of water is in my future in approximately 12 hours.
I'm thinking pig lab is really going to be a blast. But I'll admit I'm not thrilled about having to leave the house around 6:45 am every day this week... Thanksgiving break, here I come!
Thursday, October 21, 2010
Playing doctor
This week's rotation, Community Practice-Medicine, is one of my favorite rotations so far this year. It's also been definitely the most demanding and most challenging rotation, and the rotation on which I've learned the most.
You already heard about CP-Surgery in September, so let me give you a brief rundown of how CP-Medicine works:
This week there are 7 senior students on Community Practice, 4 juniors on CommPrac-Medicine, and 5 juniors on CommPrac-Surgery.
Tuesday, Wednesday, and Thursday are surgery days. There are 6 surgeries scheduled each day, so 6 senior students are on surgery in the morning, with the 5 surgery juniors along with them.
That leaves 1 senior student and 4 juniors to handle all the morning appointments (which start at 9 am and happen every 15-30 minutes until 12 pm; actually appointments go all day with the last appt at 6 pm, but juniors don't take any appts after 11:30 so we can get to class). With 5-10 appointments every morning, that means that each of the 5 students has been handling 1-2 appointments a day.
(On Monday and Friday, there are no surgeries, so all of the juniors and seniors help with morning appointments.)
On Monday, we juniors mostly paired up with seniors to follow them through appointments and learn the system of checking them in, where to way the dogs, what exam rooms to use, how to take a good history, how to present treatment options, do physicals, present cases to the supervising clinicians in the treatment areas, fill out fee sheets, and complete electronic medical records.
On Tuesday and subsequently, we got thrown in on our own. What you do is this:
* Sign up for appointments before rounds at 8 am; read up on your assigned case's history if you have time and they've been here before
* Watch the appointment schedule on the computer; appointments turn from yellow or pink to green when the client has checked in
* Head up to the reception area
* Get the day's paperwork from the receptionist
* Get the patient's chart from Medical Records if the animal has been to the VTH before
* Find the patient and owner in the lobby
* If a dog, take them over to the scale and get a weight (cats get weighed in the back)
* Find an exam room (unoccupied and preferably clean)
* Get a thorough history of the animal's general environment and wellbeing, and anything specific to a particular complaint that caused the owner to bring the pet to the VTH
* Do an initial physical exam (sometimes a challenge if it's just you and the owner, and the dog is fidgety or hyper)
* Present any initial exam findings or proposed diagnostics or treatment to the owner
* Have the owner wait in the exam room or lobby
* Take the dog or cat back to the Community Practice treatment area
* "Present" the case to the supervising clinician (i.e.: "This is Johnny. Johnny is a 3 1/2 year old castrated male domestic short hair cat. Johnny presented today for routine wellness exam and vaccines. Johnny is kept as an indoor-only cat with one other cat in the home. His vaccines up to this point have been up to date. His diet is Z/D dry food due to possible allergies or IBD... [yada yada yada])
* Discuss any abnormal physical findings with the clinician
* Clinician repeats the physical to see if you missed anything
* Clinician asks what you want to do (vaccines? blood work? other diagnostics?)
* You agree on a treatment plan, then run back up to the owner to get approval (sometimes this entails 3-4 back-and-forth trips while you get questions answered)
* Head back to Community Practice
* Get whatever you need ready: draw up vaccines, fill out vaccine consent form, fill out rabies certificate, draw and process blood or urine samples, run chemistry profiles or heartworm tests, vaccinate the animal, etc.
* Fill out prescription requests; take to pharmacy
* Fill out fee sheet; take to business office
* Return pet to owner
* Go over any physical exam findings, client education, recommendations for treatment or changes at home, etc.
* Answer any questions the client has
* Go back to Community Practice after client leaves and valiantly attempt to get a head start on writing up the medical records for the last visit before your next appointment shows up
* The following day, make a follow-up phone call to every appointment from yesterday
And an additional goal is to teach us how to manage appointments efficiently, i.e. a goal of getting clients out the door within 60 minutes. Gaaaahhhh...
Here have been some of my appointments this week:
Monday: 2 year old cat for vaccines; 8 year old cat for vaccines, bloodwork, and urinalysis (which we did ultrasound-guided: cool!)
Tuesday: a 3-dog family (9 year old border collie mix, recheck from respiratory illness 2 weeks ago associated with autoimmune disease; 5 year old golden, heartworm test and preventive; 13 year old golden, heartworm test and preventive, CBC/chemistry panel, NSAIDs for stiffness [probable arthritis] [did not happen due to elevated liver enzymes on her chemistries], and oral joint supplements); then a 16 month old golden who came in for routine vaccines
Wednesday: rectal prolapse!
Thursday: 6 year old Airedale belonging to one of my sophomore-year pharmacology professors (his wife brought in the dog), needed heartworm test plus CBC/chemistry for NSAID prescription for joint disease (thankfully the blood results on this one were fine)
Friday: who knows! I'm hoping that since there will be 16 of us to handle the morning appointments, I won't get stuck with any on my own, and preferably will be paired with a senior student so that I don't have any personal responsibilities as far as writing up records. And so that I get done by noon and actually get a lunch break.
Let's talk a little more about what it's like psychologically to be a student on Community Practice.
As the students, we act 95% as the veterinarian. In most cases (all routine, healthy animals, and most mildly ill pets), I as the student am the only person who interacts with the client. The doctors rarely leave the treatment area, and merely give us suggestions (if we need them) on what issues to address with the client or how to present our proposed treatment plan.
When I bring back a dog to present to a clinician, I am responsible for having established a positive relationship with the client. I must have obtained an accurate history (another mantra for this year: "Your history provides 60-80% of what you need to make a diagnosis"). I should have completed at least a cursory physical exam in the client's presence, and am responsible for a full, thorough PE, even if I have to do part of it in the back with someone's assistance.
I am in charge of raising any concerns the client has brought up, or any issues I've found on PE.
I propose the plan for the day: what vaccines will we be doing? Does the client want a heartworm test? What kind of heartworm preventive do they want? Do they want flea/tick preventive? Do they want a fecal exam? Deworming? Want to sign up for a wellness plan? Are they interested in routine wellness bloodwork?
If it's a sick animal, that can get more complicated. Say the dog presents with what the owner perceives to be a urinary tract infection. I should know and be prepared to tell my clinician that I want to obtain a urine sample via cystocentesis and submit it to the diagnostic lab for urinalysis and urine culture. I should know which antibiotic I want to prescribe for the dog in the meantime, until the culture results come back. I should be prepared to look up dosages and write prescription requests for said antibiotics, and discuss how to administer the meds and potential adverse side effects with the owner.
I have to keep a list of any issues that have come up in either my history-taking or physical exam. Does the dog need a dental? If so, how will I present that to the owner? How will I explain dental disease and its consequences? What details will I give them about the dental cleaning itself? Is the dog overweight? If so, what diet recommendations do I have? What kind of exercise can they do? What will they substitute as treats for the high-calorie commercial dog cookies they've been giving? How will they be able to monitor the dog's weight loss?
If I forget to talk about anything during the appointment, it's my responsibility to get in touch with the client later that day or tomorrow, and go over anything I left out.
It's my job to make sure the lab gets the blood and urine tests done, check on the results, and relay them to the owner.
I am responsible for following up with a phone call the next day to see if the dog had any side effects from vaccines, if they came up with any questions, if they've been able to administer oral meds successfully to that annoyed cat, etc.
Whew. I'm exhausted just thinking about it.
I guess this is one of those areas where the more you do it, the more you improve. Even in just the last 4 days, I already feel so much more comfortable in appointments than I did at the beginning of the week. But that doesn't mean I don't have a looooong way to go.
Here's another thing: Even while you are supposed to be acting as the doctor, a lot of what you do is tech stuff. The thing is, Community Practice is a great place to practice some technical procedures -- stuff like jugular and cephalic blood draws, cystocentesis, administer subQ/IM/IV injections, expressing anal glands, etc. It's stuff we HAVE to be able to do as doctors, and things that most of us need a lot of practice on, but in reality, it's possible to find a job at a great hospital that has fantastic techs who can do all of that stuff for you. However, you've got to be able to do it yourself in a pinch. It's the vet who has to get the blood sample from the sick 17 year old dehydrated emaciated cat when nobody else can.
As students, we're also supposed to be getting familiar with some other sorts of procedures -- drawing up vaccines, running chemistry panels, calculating drug dosages, filling out rabies certificates, completing fee sheets, etc. Again, a lot of that is stuff that competent techs can legally do for you in a practice setting.
So that's one reason that appointments can take so long. You might be thinking, "Wow, striving to stay under an hour for a routine vaccine appointment? My dog is healthy and just needs one shot! How long can it take?"
Well, it makes a heckuva lot of difference when you've got a tech doing 90% of the miscellaneous tasks for you, and you can concentrate on your 4 "doctor areas": diagnosis, prognosis, prescription, and surgery.
For example, after my prolonged 3-dog-family appointment on Tuesday morning, I ended up having to take an 11:30 am vaccine appointment by myself. I spent about 10 minutes getting a history on the dog and doing a brief physical. When I got back to the treatment area, the supervising doctor (who was acting as my "tech"; as she describes herself, "I'm the best-paid tech in the whole hospital") had already gone through the dog's record and found out he needed a second vaccine in addition to what the owner thought was due. She had drawn up my rabies and distemper vaccines. She had filled out the rabies certificate and vaccine consent form and the fee sheet. All I had to do was present the dog, wait while the doctor repeated my physical, let her know of my plan for the day (renew the wellness plan, deworm, vaccinate, send home a fecal sample collection container, and educate about dental health and maintaining the dog at an ideal weight), pop the vaccines in the dog, give him some deeeelicious dewormer, and get him back up to mom. Piece of cake: only 35 minutes from in to out.
I guess the moral of that story is: A good technician is invaluable. Don't forget how important your techs are, and give them the credit they deserve. They can make your life so much easier if you trust them and know they are competent.
Well, since I've wasted enough time blogging, I suppose it's time to head to bed. Friday bonus: show up for Grand Rounds at 8:30 instead of regular M-Th rounds at 8 am!
You already heard about CP-Surgery in September, so let me give you a brief rundown of how CP-Medicine works:
This week there are 7 senior students on Community Practice, 4 juniors on CommPrac-Medicine, and 5 juniors on CommPrac-Surgery.
Tuesday, Wednesday, and Thursday are surgery days. There are 6 surgeries scheduled each day, so 6 senior students are on surgery in the morning, with the 5 surgery juniors along with them.
That leaves 1 senior student and 4 juniors to handle all the morning appointments (which start at 9 am and happen every 15-30 minutes until 12 pm; actually appointments go all day with the last appt at 6 pm, but juniors don't take any appts after 11:30 so we can get to class). With 5-10 appointments every morning, that means that each of the 5 students has been handling 1-2 appointments a day.
(On Monday and Friday, there are no surgeries, so all of the juniors and seniors help with morning appointments.)
On Monday, we juniors mostly paired up with seniors to follow them through appointments and learn the system of checking them in, where to way the dogs, what exam rooms to use, how to take a good history, how to present treatment options, do physicals, present cases to the supervising clinicians in the treatment areas, fill out fee sheets, and complete electronic medical records.
On Tuesday and subsequently, we got thrown in on our own. What you do is this:
* Sign up for appointments before rounds at 8 am; read up on your assigned case's history if you have time and they've been here before
* Watch the appointment schedule on the computer; appointments turn from yellow or pink to green when the client has checked in
* Head up to the reception area
* Get the day's paperwork from the receptionist
* Get the patient's chart from Medical Records if the animal has been to the VTH before
* Find the patient and owner in the lobby
* If a dog, take them over to the scale and get a weight (cats get weighed in the back)
* Find an exam room (unoccupied and preferably clean)
* Get a thorough history of the animal's general environment and wellbeing, and anything specific to a particular complaint that caused the owner to bring the pet to the VTH
* Do an initial physical exam (sometimes a challenge if it's just you and the owner, and the dog is fidgety or hyper)
* Present any initial exam findings or proposed diagnostics or treatment to the owner
* Have the owner wait in the exam room or lobby
* Take the dog or cat back to the Community Practice treatment area
* "Present" the case to the supervising clinician (i.e.: "This is Johnny. Johnny is a 3 1/2 year old castrated male domestic short hair cat. Johnny presented today for routine wellness exam and vaccines. Johnny is kept as an indoor-only cat with one other cat in the home. His vaccines up to this point have been up to date. His diet is Z/D dry food due to possible allergies or IBD... [yada yada yada])
* Discuss any abnormal physical findings with the clinician
* Clinician repeats the physical to see if you missed anything
* Clinician asks what you want to do (vaccines? blood work? other diagnostics?)
* You agree on a treatment plan, then run back up to the owner to get approval (sometimes this entails 3-4 back-and-forth trips while you get questions answered)
* Head back to Community Practice
* Get whatever you need ready: draw up vaccines, fill out vaccine consent form, fill out rabies certificate, draw and process blood or urine samples, run chemistry profiles or heartworm tests, vaccinate the animal, etc.
* Fill out prescription requests; take to pharmacy
* Fill out fee sheet; take to business office
* Return pet to owner
* Go over any physical exam findings, client education, recommendations for treatment or changes at home, etc.
* Answer any questions the client has
* Go back to Community Practice after client leaves and valiantly attempt to get a head start on writing up the medical records for the last visit before your next appointment shows up
* The following day, make a follow-up phone call to every appointment from yesterday
And an additional goal is to teach us how to manage appointments efficiently, i.e. a goal of getting clients out the door within 60 minutes. Gaaaahhhh...
Here have been some of my appointments this week:
Monday: 2 year old cat for vaccines; 8 year old cat for vaccines, bloodwork, and urinalysis (which we did ultrasound-guided: cool!)
Tuesday: a 3-dog family (9 year old border collie mix, recheck from respiratory illness 2 weeks ago associated with autoimmune disease; 5 year old golden, heartworm test and preventive; 13 year old golden, heartworm test and preventive, CBC/chemistry panel, NSAIDs for stiffness [probable arthritis] [did not happen due to elevated liver enzymes on her chemistries], and oral joint supplements); then a 16 month old golden who came in for routine vaccines
Wednesday: rectal prolapse!
Thursday: 6 year old Airedale belonging to one of my sophomore-year pharmacology professors (his wife brought in the dog), needed heartworm test plus CBC/chemistry for NSAID prescription for joint disease (thankfully the blood results on this one were fine)
Friday: who knows! I'm hoping that since there will be 16 of us to handle the morning appointments, I won't get stuck with any on my own, and preferably will be paired with a senior student so that I don't have any personal responsibilities as far as writing up records. And so that I get done by noon and actually get a lunch break.
Let's talk a little more about what it's like psychologically to be a student on Community Practice.
As the students, we act 95% as the veterinarian. In most cases (all routine, healthy animals, and most mildly ill pets), I as the student am the only person who interacts with the client. The doctors rarely leave the treatment area, and merely give us suggestions (if we need them) on what issues to address with the client or how to present our proposed treatment plan.
When I bring back a dog to present to a clinician, I am responsible for having established a positive relationship with the client. I must have obtained an accurate history (another mantra for this year: "Your history provides 60-80% of what you need to make a diagnosis"). I should have completed at least a cursory physical exam in the client's presence, and am responsible for a full, thorough PE, even if I have to do part of it in the back with someone's assistance.
I am in charge of raising any concerns the client has brought up, or any issues I've found on PE.
I propose the plan for the day: what vaccines will we be doing? Does the client want a heartworm test? What kind of heartworm preventive do they want? Do they want flea/tick preventive? Do they want a fecal exam? Deworming? Want to sign up for a wellness plan? Are they interested in routine wellness bloodwork?
If it's a sick animal, that can get more complicated. Say the dog presents with what the owner perceives to be a urinary tract infection. I should know and be prepared to tell my clinician that I want to obtain a urine sample via cystocentesis and submit it to the diagnostic lab for urinalysis and urine culture. I should know which antibiotic I want to prescribe for the dog in the meantime, until the culture results come back. I should be prepared to look up dosages and write prescription requests for said antibiotics, and discuss how to administer the meds and potential adverse side effects with the owner.
I have to keep a list of any issues that have come up in either my history-taking or physical exam. Does the dog need a dental? If so, how will I present that to the owner? How will I explain dental disease and its consequences? What details will I give them about the dental cleaning itself? Is the dog overweight? If so, what diet recommendations do I have? What kind of exercise can they do? What will they substitute as treats for the high-calorie commercial dog cookies they've been giving? How will they be able to monitor the dog's weight loss?
If I forget to talk about anything during the appointment, it's my responsibility to get in touch with the client later that day or tomorrow, and go over anything I left out.
It's my job to make sure the lab gets the blood and urine tests done, check on the results, and relay them to the owner.
I am responsible for following up with a phone call the next day to see if the dog had any side effects from vaccines, if they came up with any questions, if they've been able to administer oral meds successfully to that annoyed cat, etc.
Whew. I'm exhausted just thinking about it.
I guess this is one of those areas where the more you do it, the more you improve. Even in just the last 4 days, I already feel so much more comfortable in appointments than I did at the beginning of the week. But that doesn't mean I don't have a looooong way to go.
Here's another thing: Even while you are supposed to be acting as the doctor, a lot of what you do is tech stuff. The thing is, Community Practice is a great place to practice some technical procedures -- stuff like jugular and cephalic blood draws, cystocentesis, administer subQ/IM/IV injections, expressing anal glands, etc. It's stuff we HAVE to be able to do as doctors, and things that most of us need a lot of practice on, but in reality, it's possible to find a job at a great hospital that has fantastic techs who can do all of that stuff for you. However, you've got to be able to do it yourself in a pinch. It's the vet who has to get the blood sample from the sick 17 year old dehydrated emaciated cat when nobody else can.
As students, we're also supposed to be getting familiar with some other sorts of procedures -- drawing up vaccines, running chemistry panels, calculating drug dosages, filling out rabies certificates, completing fee sheets, etc. Again, a lot of that is stuff that competent techs can legally do for you in a practice setting.
So that's one reason that appointments can take so long. You might be thinking, "Wow, striving to stay under an hour for a routine vaccine appointment? My dog is healthy and just needs one shot! How long can it take?"
Well, it makes a heckuva lot of difference when you've got a tech doing 90% of the miscellaneous tasks for you, and you can concentrate on your 4 "doctor areas": diagnosis, prognosis, prescription, and surgery.
For example, after my prolonged 3-dog-family appointment on Tuesday morning, I ended up having to take an 11:30 am vaccine appointment by myself. I spent about 10 minutes getting a history on the dog and doing a brief physical. When I got back to the treatment area, the supervising doctor (who was acting as my "tech"; as she describes herself, "I'm the best-paid tech in the whole hospital") had already gone through the dog's record and found out he needed a second vaccine in addition to what the owner thought was due. She had drawn up my rabies and distemper vaccines. She had filled out the rabies certificate and vaccine consent form and the fee sheet. All I had to do was present the dog, wait while the doctor repeated my physical, let her know of my plan for the day (renew the wellness plan, deworm, vaccinate, send home a fecal sample collection container, and educate about dental health and maintaining the dog at an ideal weight), pop the vaccines in the dog, give him some deeeelicious dewormer, and get him back up to mom. Piece of cake: only 35 minutes from in to out.
I guess the moral of that story is: A good technician is invaluable. Don't forget how important your techs are, and give them the credit they deserve. They can make your life so much easier if you trust them and know they are competent.
Well, since I've wasted enough time blogging, I suppose it's time to head to bed. Friday bonus: show up for Grand Rounds at 8:30 instead of regular M-Th rounds at 8 am!
Having a bad day? It's all relative
So you've been having a bad Wednesday.
When your alarm went off at 6:15 am, the window had been open all night and it was in the 30s, so the bedroom was freezing.
As you entered the equally frozen bathroom, you found about 20 feet of shredded toilet paper unraveled on the floor. (Thank you, cats.)
You had cinnamon raisin toast for breakfast instead of your regular wheat toast with peanut butter; it was tasty but you worried it wouldn't be enough to get you through the morning, and sure enough, it's 10 am and you're starving.
The intern you've been working with all week seems constantly cranky; today is no exception.
It's seemed like a really long, demanding week already, and you're only a couple days into it.
You've got 2 exams due by Friday, for which you haven't studied at all yet.
You're sick of paperwork and writing up medical records and not knowing if you're doing things right.
You've been staying late over the lunch hour and after class is over in the afternoon to complete various tasks for your morning appointments.
All in all, it's not been a fantastic day so far.
.......
.......
.......
Let's take a step back for a moment, and get some perspective:
At least it's your 10 am appointment, and not you, that has a prolapsed rectum.
My sole appointment yesterday morning on Community Practice - Medicine (this week's rotation) was a 1.5 year old female Shiba Inu who we'll call Kahlua (name changed to protect the cute).
Kahlua presented with her fantastic owner to the VTH's emergency service for a rectal prolapse.
Let's take a minute to talk about rectal prolapse. What that basically means is that a variable amount of the dog's rectum is protruding through the anus. (Just to get things straight: the "rectum" is the last part of the intestine and the "anus" is the sphincter on the outside.)
(The above picture is from Google images, and obviously is not actually Kahlua, since she is not a Boston Terrier!)
Rectal prolapse is usually caused by straining -- and whatever is causing the straining is what you need to diagnose and fix. It can be caused by diarrhea, constipation, GI parasites, intussusception, GI foreign body, partial or complete obstruction, or just about anything causing blockage and/or inflammation of the intestinal tract. It can also be caused by dystocia (difficulty giving birth) or straining to urinate (e.g. with a stone in the urethra).
So you can treat a rectal prolapse (basically sedate the dog, push all the rectal tissue back in through the anus, and sew the anus shut for a few days so nothing pops out again). But unless you've found the underlying reason why the prolapse occurred in the first place, your patient may be back with a recurrence in the future.
Which, unfortunately, was the case with poor little Kahlua.
Kahlua actually came to the VTH in August with her first rectal prolapse. She'd been straining a little bit and having some diarrhea, for unknown reasons. Since she was young, one of the primary recommendations was a thorough fecal exam to check for any GI parasites that could be causing irritation. Even though Kahlua's fecal exam showed no parasite eggs, she was dewormed extensively anyway, just in case (fecal exams are not foolproof and can sometimes miss worm eggs).
In August, Kahlua also had abdominal xrays, which showed a normal abdomen.
Kahlua got some happy-making drugs, and had her rectum replaced and sewn shut for a few days.
And all was well.
Then, about a week after presenting with her prolapse, Kahlua's owner called the VTH and said that Kahlua had started vomiting up some pieces of carpet.
Mystery solved.
(Or was it???)
The theory in August was that Kahlua's first and only rectal prolapse had probably been due to a partial GI obstruction caused by foreign body ingestion which could not be seen on xrays.
That was all well and good, until Tuesday evening, when Kahlua went outside to defecate and came back in with a prolapsed rectum.
Kahlua's dad brought her in to the VTH as soon as possible, but even so, her prolapse had spontaneously reduced (i.e. the prolapse had fixed itself by the time Kahlua saw the vet). Nonetheless, Kahlua was put on a stool softener and wet food, and sent home at midnight with an appointment to see community practice the following day (Wednesday).
Unfortunately, when Kahlua went out to potty on Wednesday morning, her poor little rectum prolapsed again, and was hanging in the breeze when I went up to check her in for her 10:30 am appointment.
Now, I should tell you that Kahlua actually had a very mild rectal prolapse, both in August and this week. She only prolapsed 1-2 cm in August, and probably less than 1 cm yesterday. Compared with some pictures I've seen online, this is pretty darn good.
However, even a minor prolapse is an issue. For one thing, it's irritating and painful. Kahlua was adamant that we not touch her bottom area at all (and I can understand why). Obviously the longer the rectal tissue is out in the environment, the greater chance for contamination and trauma to a delicate structure. Additionally, some dogs will actually chew off the part that's hanging out if you don't keep a close eye on them (or an e-collar on them), and/or blood flow to the prolapsed portion can be cut off for so long that the prolapsed part becomes necrotic and dies (big mess).
So the plan today was an even more thorough work-up of Kahlua's potential underlying disease. She got some heavy-duty drugs on board for a rectal exam (feel if there is any foreign material or colonic intussusception, which there wasn't). She got abdominal radiographs to check for foreign bodies or obstruction (rads were 100% normal). She got an abdominal ultrasound to check for intestinal health and possible intussusception (100% normal). The only abnormal thing we found at all was some overgrowth of abnormal bacteria on her fecal cytology, which is usually a secondary change to some sort of GI upset, and was probably not the cause of her straining and prolapse.
So, no good answers for Kahlua. While sedated, her prolapse was reduced (replaced inside her body), and it stayed in for the rest of the afternoon even while she was having diarrhea all over the place. She went home with some tranquilizer pills that her owner could give if she prolapsed again, to keep her calm and ideally decrease her straining.
It's hard to say what her underlying disease is. Apparently in some cases, no obvious cause is ever found -- but it's still hugely important to investigate the possibilities, because some very serious diseases can cause the kind of straining that induces prolapse. Maybe in a few days Kahlua will start vomiting more carpet pieces. Who knows.
All in all, this was a very cool case (and, I might add, I worked it up as the only student on the case -- all but 1 senior student was in surgery, so with 5 of us juniors on to help with a full morning of appointments, we were all busy and taking cases on our own). And Kahlua is the nicest little Shiba Inu I've ever met.
I got to do a lot of neat things -- practice my physical exam, of course; take an axillary temperature; lots of owner interaction; learn how to create estimates for treatment costs; submit radiology requests for rads and ultrasound; decide on a sedation protocol, dosages, fill out a prescription request, and submit it to the pharmacy; and take a look at Kahlua's radiographs.
I gave Kahlua's dad a quick call this morning to see how she'd been doing, but I had to leave a message. Fingers crossed that little Kahlua's rectum stays put, or she's potentially looking at some not-so-fun surgery in the near future.
When your alarm went off at 6:15 am, the window had been open all night and it was in the 30s, so the bedroom was freezing.
As you entered the equally frozen bathroom, you found about 20 feet of shredded toilet paper unraveled on the floor. (Thank you, cats.)
You had cinnamon raisin toast for breakfast instead of your regular wheat toast with peanut butter; it was tasty but you worried it wouldn't be enough to get you through the morning, and sure enough, it's 10 am and you're starving.
The intern you've been working with all week seems constantly cranky; today is no exception.
It's seemed like a really long, demanding week already, and you're only a couple days into it.
You've got 2 exams due by Friday, for which you haven't studied at all yet.
You're sick of paperwork and writing up medical records and not knowing if you're doing things right.
You've been staying late over the lunch hour and after class is over in the afternoon to complete various tasks for your morning appointments.
All in all, it's not been a fantastic day so far.
.......
.......
.......
Let's take a step back for a moment, and get some perspective:
At least it's your 10 am appointment, and not you, that has a prolapsed rectum.
My sole appointment yesterday morning on Community Practice - Medicine (this week's rotation) was a 1.5 year old female Shiba Inu who we'll call Kahlua (name changed to protect the cute).
Kahlua presented with her fantastic owner to the VTH's emergency service for a rectal prolapse.
Let's take a minute to talk about rectal prolapse. What that basically means is that a variable amount of the dog's rectum is protruding through the anus. (Just to get things straight: the "rectum" is the last part of the intestine and the "anus" is the sphincter on the outside.)
(The above picture is from Google images, and obviously is not actually Kahlua, since she is not a Boston Terrier!)
Rectal prolapse is usually caused by straining -- and whatever is causing the straining is what you need to diagnose and fix. It can be caused by diarrhea, constipation, GI parasites, intussusception, GI foreign body, partial or complete obstruction, or just about anything causing blockage and/or inflammation of the intestinal tract. It can also be caused by dystocia (difficulty giving birth) or straining to urinate (e.g. with a stone in the urethra).
So you can treat a rectal prolapse (basically sedate the dog, push all the rectal tissue back in through the anus, and sew the anus shut for a few days so nothing pops out again). But unless you've found the underlying reason why the prolapse occurred in the first place, your patient may be back with a recurrence in the future.
Which, unfortunately, was the case with poor little Kahlua.
Kahlua actually came to the VTH in August with her first rectal prolapse. She'd been straining a little bit and having some diarrhea, for unknown reasons. Since she was young, one of the primary recommendations was a thorough fecal exam to check for any GI parasites that could be causing irritation. Even though Kahlua's fecal exam showed no parasite eggs, she was dewormed extensively anyway, just in case (fecal exams are not foolproof and can sometimes miss worm eggs).
In August, Kahlua also had abdominal xrays, which showed a normal abdomen.
Kahlua got some happy-making drugs, and had her rectum replaced and sewn shut for a few days.
And all was well.
Then, about a week after presenting with her prolapse, Kahlua's owner called the VTH and said that Kahlua had started vomiting up some pieces of carpet.
Mystery solved.
(Or was it???)
The theory in August was that Kahlua's first and only rectal prolapse had probably been due to a partial GI obstruction caused by foreign body ingestion which could not be seen on xrays.
That was all well and good, until Tuesday evening, when Kahlua went outside to defecate and came back in with a prolapsed rectum.
Kahlua's dad brought her in to the VTH as soon as possible, but even so, her prolapse had spontaneously reduced (i.e. the prolapse had fixed itself by the time Kahlua saw the vet). Nonetheless, Kahlua was put on a stool softener and wet food, and sent home at midnight with an appointment to see community practice the following day (Wednesday).
Unfortunately, when Kahlua went out to potty on Wednesday morning, her poor little rectum prolapsed again, and was hanging in the breeze when I went up to check her in for her 10:30 am appointment.
Now, I should tell you that Kahlua actually had a very mild rectal prolapse, both in August and this week. She only prolapsed 1-2 cm in August, and probably less than 1 cm yesterday. Compared with some pictures I've seen online, this is pretty darn good.
However, even a minor prolapse is an issue. For one thing, it's irritating and painful. Kahlua was adamant that we not touch her bottom area at all (and I can understand why). Obviously the longer the rectal tissue is out in the environment, the greater chance for contamination and trauma to a delicate structure. Additionally, some dogs will actually chew off the part that's hanging out if you don't keep a close eye on them (or an e-collar on them), and/or blood flow to the prolapsed portion can be cut off for so long that the prolapsed part becomes necrotic and dies (big mess).
So the plan today was an even more thorough work-up of Kahlua's potential underlying disease. She got some heavy-duty drugs on board for a rectal exam (feel if there is any foreign material or colonic intussusception, which there wasn't). She got abdominal radiographs to check for foreign bodies or obstruction (rads were 100% normal). She got an abdominal ultrasound to check for intestinal health and possible intussusception (100% normal). The only abnormal thing we found at all was some overgrowth of abnormal bacteria on her fecal cytology, which is usually a secondary change to some sort of GI upset, and was probably not the cause of her straining and prolapse.
So, no good answers for Kahlua. While sedated, her prolapse was reduced (replaced inside her body), and it stayed in for the rest of the afternoon even while she was having diarrhea all over the place. She went home with some tranquilizer pills that her owner could give if she prolapsed again, to keep her calm and ideally decrease her straining.
It's hard to say what her underlying disease is. Apparently in some cases, no obvious cause is ever found -- but it's still hugely important to investigate the possibilities, because some very serious diseases can cause the kind of straining that induces prolapse. Maybe in a few days Kahlua will start vomiting more carpet pieces. Who knows.
All in all, this was a very cool case (and, I might add, I worked it up as the only student on the case -- all but 1 senior student was in surgery, so with 5 of us juniors on to help with a full morning of appointments, we were all busy and taking cases on our own). And Kahlua is the nicest little Shiba Inu I've ever met.
I got to do a lot of neat things -- practice my physical exam, of course; take an axillary temperature; lots of owner interaction; learn how to create estimates for treatment costs; submit radiology requests for rads and ultrasound; decide on a sedation protocol, dosages, fill out a prescription request, and submit it to the pharmacy; and take a look at Kahlua's radiographs.
I gave Kahlua's dad a quick call this morning to see how she'd been doing, but I had to leave a message. Fingers crossed that little Kahlua's rectum stays put, or she's potentially looking at some not-so-fun surgery in the near future.
Thursday, October 14, 2010
I heart EED (mostly)
This week's rotation is EED: Exotic and Emerging Diseases. Also known as "foreign animal diseases" (FADs) or "transboundary diseases."
I like this rotation for a few reasons:
1. It is low-stress. Other than some online, open-book, take-as-many-times-as-you-want quizzes, all we have to do is show up and listen. After last week's multiple exams, and 2-3 exams for each of the next 2 weeks, I can use a rotation that doesn't add anything else to that.
2. We get to start late sometimes. Class started at 8 am on Monday and Friday, 8:30 am on Tuesday/Thursday, and 9:30 yesterday (which was totally awesome).
3. A lot of it is self-guided, self-paced learning. We have 1.5-2.5 hours of lecture every morning, in which we cover a different type of FADs each day, and then the rest of the time is for us to go online and complete a series of modules and associated exams that is part of initial accreditation training for us to become certified after graduation in issuing health certificates and certificates of veterinary inspection for animals traveling across state lines.
We are learning about some cool, and really scary, diseases -- most of which are not currently present in the U.S. but have been eradicated in the last 50 years or so and/or are rampant in other parts of the world and could easily get into the U.S. and wreak havoc on our food animal and equine populations. Those would be diseases like:
* Highly pathogenic avian influenza
* Exotic Newcastle disease
* Contagious equine metritis
* Foot and mouth disease
* Vesicular stomatitis
* Swine vesicular disease
* Vesicular exanthema
* Dourine
* Surra
* Nipah virus
* African horse sickness
* Glanders
* Venezualan equine encephalitis
* Equine piroplasmosis
* African and classical swine fever
Pretty exciting stuff, no? Actually, it's quite interesting. And it's really alarming to realize how easily a terrorist (or just someone stupid) could visit a foreign country, be on a farm or ranch or livestock sale, pick up something highly contagious, and 24 hours later be back in the U.S. on one of our farms or ranches or livestock sales. It's actually surprising that it hasn't happened a lot more often. Our instructor pointed out that a lot of terrorists are interested in actions that will make a big splash and get lots of media attention (e.g. bombings, anthrax), whereas the spread of a foreign animal disease to the U.S. national herd could be hugely devastating both economically and with loss of food and animal life -- but fortunately(?) it's a little more insidious and not as splashy as blowing up a building.
The only thing I really haven't liked this week was watching a video yesterday of animals infected with foot and mouth disease (FMD).
There are a couple locations in the U.S. where these big scary diseases are researched and tested for -- the National Veterinary Services Laboratory in Ames, IA, and the NVSL on Plum Island, which is near New York.
The folks on Plum Island are always having U.S. vets and FAD researchers come out to spend time on the island and see what these FADs look like in a real live animal -- fortunately most of the FADs are still actually foreign, so U.S. vets don't have the opportunity to see outbreaks in the country very often. So they go to Plum Island and watch cows, pigs, etc. being infected with these various diseases in a lab setting.
FMD is not a disease that in and of itself is very fatal to infected animals. It basically causes horrible blistering in and around the mouth, on the tongue, and in between the "toes" of cloven-hooved animals. That means it really hurts for the animals to walk, and they aren't super-excited about eating, either, since they have blisters all over their tongues. The disease itself actually runs its course in a few days, and the blisters start to heal, and the animal then has some degree of immunity from future infection. But until then, the animal might be so lame that it can't or won't walk over to a feed trough or water tank, so can have complications from anorexia and dehydration. They can also get teat lesions which can develop into mastitis, which might either make the cow really sick, or result in her being culled due to decreased production from her infected/scarred mammary gland.
Anyway, the video we saw was a recording of the progression of disease in cows and pigs over about a 10-day period. It was so sad! In a realistic outbreak with actual disease in an animal population, of course you'd be treating the animals with supportive care -- pain relievers, helping them get to food and water, etc. But I guess to make it the best teaching demonstration of what FMD can actually do to these animals, the infected cows and pigs don't really get that stuff.
I know that there are reasons to purposely infect animals with horrible diseases (i.e. so we can see what happens and be prepared to treat or control such diseases in a real-life outbreak; so we can research different means of diagnosis and treatment; etc.). But it's tough to watch a video of these guys suffering when we're all in vet school because we want to help animals and relieve their pain.
But other than that, good rotation!
I like this rotation for a few reasons:
1. It is low-stress. Other than some online, open-book, take-as-many-times-as-you-want quizzes, all we have to do is show up and listen. After last week's multiple exams, and 2-3 exams for each of the next 2 weeks, I can use a rotation that doesn't add anything else to that.
2. We get to start late sometimes. Class started at 8 am on Monday and Friday, 8:30 am on Tuesday/Thursday, and 9:30 yesterday (which was totally awesome).
3. A lot of it is self-guided, self-paced learning. We have 1.5-2.5 hours of lecture every morning, in which we cover a different type of FADs each day, and then the rest of the time is for us to go online and complete a series of modules and associated exams that is part of initial accreditation training for us to become certified after graduation in issuing health certificates and certificates of veterinary inspection for animals traveling across state lines.
We are learning about some cool, and really scary, diseases -- most of which are not currently present in the U.S. but have been eradicated in the last 50 years or so and/or are rampant in other parts of the world and could easily get into the U.S. and wreak havoc on our food animal and equine populations. Those would be diseases like:
* Highly pathogenic avian influenza
* Exotic Newcastle disease
* Contagious equine metritis
* Foot and mouth disease
* Vesicular stomatitis
* Swine vesicular disease
* Vesicular exanthema
* Dourine
* Surra
* Nipah virus
* African horse sickness
* Glanders
* Venezualan equine encephalitis
* Equine piroplasmosis
* African and classical swine fever
Pretty exciting stuff, no? Actually, it's quite interesting. And it's really alarming to realize how easily a terrorist (or just someone stupid) could visit a foreign country, be on a farm or ranch or livestock sale, pick up something highly contagious, and 24 hours later be back in the U.S. on one of our farms or ranches or livestock sales. It's actually surprising that it hasn't happened a lot more often. Our instructor pointed out that a lot of terrorists are interested in actions that will make a big splash and get lots of media attention (e.g. bombings, anthrax), whereas the spread of a foreign animal disease to the U.S. national herd could be hugely devastating both economically and with loss of food and animal life -- but fortunately(?) it's a little more insidious and not as splashy as blowing up a building.
The only thing I really haven't liked this week was watching a video yesterday of animals infected with foot and mouth disease (FMD).
There are a couple locations in the U.S. where these big scary diseases are researched and tested for -- the National Veterinary Services Laboratory in Ames, IA, and the NVSL on Plum Island, which is near New York.
The folks on Plum Island are always having U.S. vets and FAD researchers come out to spend time on the island and see what these FADs look like in a real live animal -- fortunately most of the FADs are still actually foreign, so U.S. vets don't have the opportunity to see outbreaks in the country very often. So they go to Plum Island and watch cows, pigs, etc. being infected with these various diseases in a lab setting.
FMD is not a disease that in and of itself is very fatal to infected animals. It basically causes horrible blistering in and around the mouth, on the tongue, and in between the "toes" of cloven-hooved animals. That means it really hurts for the animals to walk, and they aren't super-excited about eating, either, since they have blisters all over their tongues. The disease itself actually runs its course in a few days, and the blisters start to heal, and the animal then has some degree of immunity from future infection. But until then, the animal might be so lame that it can't or won't walk over to a feed trough or water tank, so can have complications from anorexia and dehydration. They can also get teat lesions which can develop into mastitis, which might either make the cow really sick, or result in her being culled due to decreased production from her infected/scarred mammary gland.
Anyway, the video we saw was a recording of the progression of disease in cows and pigs over about a 10-day period. It was so sad! In a realistic outbreak with actual disease in an animal population, of course you'd be treating the animals with supportive care -- pain relievers, helping them get to food and water, etc. But I guess to make it the best teaching demonstration of what FMD can actually do to these animals, the infected cows and pigs don't really get that stuff.
I know that there are reasons to purposely infect animals with horrible diseases (i.e. so we can see what happens and be prepared to treat or control such diseases in a real-life outbreak; so we can research different means of diagnosis and treatment; etc.). But it's tough to watch a video of these guys suffering when we're all in vet school because we want to help animals and relieve their pain.
But other than that, good rotation!
Sunday, October 10, 2010
Rockin' the exams
Since an initial bump or two at the beginning of the semester, I've been doing exceptionally well on exams this semester.
(Side note: One of the awesome things about writing your own blog is that you can be as self-centered as you want and talk on and on about your awesomeness. So there. I am not ashamed of my ego!)
The only exam I've really botched was equine orthopedics (77.5%).
Other than that, it's been all A's:
SA orthopedics: 92.2%
SA neurology: 96.2%
EQ repro: 91.5%
FA repro: 92.5%
Radiology: 94.4%
I'm pretty excited that even with all of the busy-ness and unpredictability that junior practicum entails, I've been able to keep doing well in my classes (okay, except maybe equine orthopedics; still don't know what happened there).
(Side note: One of the awesome things about writing your own blog is that you can be as self-centered as you want and talk on and on about your awesomeness. So there. I am not ashamed of my ego!)
The only exam I've really botched was equine orthopedics (77.5%).
Other than that, it's been all A's:
SA orthopedics: 92.2%
SA neurology: 96.2%
EQ repro: 91.5%
FA repro: 92.5%
Radiology: 94.4%
I'm pretty excited that even with all of the busy-ness and unpredictability that junior practicum entails, I've been able to keep doing well in my classes (okay, except maybe equine orthopedics; still don't know what happened there).
Playing surgeon? Eat your Wheaties!
Because it really sucks to be 2 hours into surgery and start getting woozy and feel like you're about to black out.
(Lesson learned.)
All throughout this year as we've been learning about surgery (and even in the past two years, when we've had surgical principles lectures and labs), they have emphasized to us that it takes some practice to get used to being in surgery.
"Every year," they repeat, "some students pass out. Don't be the student that passes out! Tell us right away if you start overheating or getting dizzy or feeling funny! Nobody will catch you and we don't like picking up vet students off the floor!"
Okay, I figured. Apparently there are students in the class who haven't had the opportunity to be in a surgery environment or observe surgeries before. Too bad for them. After all, I have spent years as a technician monitoring surgeries.
Well, I'm here to tell you that being in a surgical suite monitoring anesthesia for a surgery performed in a private practice setting does NOT mean you know how to be in a vet school teaching hospital surgical environment.
And I sort of knew that. So even with my past experiences, I've tried to be extra careful this year when I knew I'd be scrubbing in for surgery. During my community practice week, for example, I paid extra attention to what I ate for breakfast, made sure to drink lots of water, and ate a quick granola bar right before scrubbing in. I was conscious of my body position during surgery, made sure I wasn't locking my knees, etc. And all was well.
This past Friday, however, I had the opportunity to scrub in with last week's Junior Surgery Lab since one of my classmates was out sick with a self-described "dysentery." (Sounds thrilling.)
I'll be having JSL ("pig lab") at the end of October, so you'll hear about it in much greater detail then, but here's a brief overview: There are 22 students in the lab at a time, divided into pairs, and working on 11 anesthetized pigs. The first day of the lab is suturing skin incisions. Days 2-4 include intestinal resection and anastomosis, nephrectomy, splenectomy, cystotomy, gastrotomy, enterotomy, etc. Day 5 (Friday) is an abdominal exploratory -- meaning the instructors have already cut open the pigs before you get there, and created problems -- marbles hidden in the abdomen, superglue injected into the bladder, an intussusception, etc.
So it was on a Friday that I jumped into the lab.
But before I got to lab, I woke up at 6:15, had my usual piece of toast and OJ for breakfast at 6:30, had a doctor appointment at 7:45, got to the VTH at 8:20 and found that the JSL students were about to start scrubbing. The sick student hadn't arrived but there was still a chance she would make it. So I ran up to my locker to put my stuff away, then hurried down to the soft tissue rounds room to make sure it was okay for me to ditch SD and go to JSL, and make sure the other junior on the SD rotation didn't mind me leaving, then headed back up to the locker room to change into surgical scrubs, and finally made it back to JSL as they were finished scrubbing. Needless to say, I didn't have quite enough notice or time to get my brain in order and mentally prepare for the upcoming 3.5 hours of surgery.
Everything was okay for the first 2 hours or so. Since I hadn't done the first 4 days of the lab yet, my role in the surgery was basically holding intestines out of the way for my partner -- which was fine. After a couple hours, though, it was getting boring. And I was getting hot.
(Let me take a minute to tell you about our surgical attire. First, in private practice settings, vets often perform routine, non-complicated surgeries wearing scrubs or even their everyday doctor clothes. They sometimes wear a cap or bouffant [like a hairnet] over their hair; sometimes not. They sometimes wear a surgical mask over their face; sometimes not. In a vet school setting, however, they want to teach us the higher standard -- which means we wear booties over our shoes, caps or bouffants over our hair, a mask covering our face, AND a full cloth surgical gown, that ties multiple places in the back, goes down to at least your knees, is tight around your neck, and has long sleeves with thick 3-inch-long cuffs on the end. You pull your sterile gloves over the cuffs of your gown sleeves so that none of your un-sterile skin can get out. End result: Your wrists rapidly become soaked with sweat; your back and neck sweat; if you have a ponytail, it sits on your already overheated neck; and every breath you inhale and exhale through the mask blows hot air onto your face.)
It was a combination of multiple factors that culminated in my wooziness: (1) Overheating due to surgical attire, (2) boredom leading me to focus intently on how I was starting to feel weird, (3) eating breakfast earlier than usual due to my doctor appt, (4) not grabbing a quick bite to eat right before heading into surgery, and (5) a morning dose of an antibiotic that has been giving me some GI upset for the last week.
Here's another lesson I learned: If you want to get the instructor's full attention during a surgery lab, tell them that you feel funny and need to sit down. Let me tell you, you can get waited on hand and foot.
So I started feeling a little dizzy, vision going in and out of focus. I've experienced that feeling only once before -- during my first year or two of college when I was shadowing at a vet clinic back home, and the doctor invited me to watch surgery (the first declaw I'd ever seen) -- and that first time, I did nearly pass out. So I was eager to quietly sit down and get my nerves back while I was only feeling a little funny, rather than making a huge scene in front of 21 of my peers by collapsing to the floor.
I called over one of the 3 instructors helping in the lab and said, "I'm starting to feel a little funny. Can I sit down for a few minutes?"
He immediately looked totally alarmed and grabbed me by the shoulders, presumably to make sure I wasn't going to drop to the floor then and there. He said, "I'm going to bring you that chair. Can you stand here for a few seconds?"
I was like, "Heck yes. I don't feel that bad." The chair was literally only 8 feet or so away.
So the chair was delivered to me and I sat. The instructor advised me to take off my mask and I did, which helped a ton. He also turned on a box fan right next to my surgery station. (Oddly enough, each of the 11 surgery stations has its own box fan to cool off the student surgeons. Guess with 22 student surgeons, 3 instructors, and 11 pigs all in one room, it often gets warm in there.)
They left me alone for a couple minutes, and really I felt 90% better after sitting for about 30 seconds with my mask off. When the instructor came back to check on me, I told him I felt a lot better and thought I was ready to start again. But he said, "You still have no blood in your face. Can I get you some food? A granola bar? Some orange juice or coffee or a soda?" I said no, I felt better, but he persisted with, "Okay, but do you mind if I kick you out of lab and send you upstairs to have a snack?" Which was nice of him. Especially since my surgery partner later confirmed that I was apparently white as a sheet even though I felt fine again.
So I dutifully headed upstairs and downed a couple slugs of orange juice, a chocolate donut, and about a liter of water. Feeling completely revived, I came back down to the lab, re-gowned and gloved (the nice thing about doing a terminal surgery is that you don't have to worry about sterility, so I didn't actually have to scrub again), and completed the last 75 minutes or so of the lab without incident.
I felt pretty silly about the whole thing, because even though the other 20 students were busy with their own surgeries, they weren't so busy that they didn't notice me sitting down and later leaving. But all things considered, I would much rather have had things happen the way they did than end up out cold on the floor, in which case I'm sure everybody in my class would have heard about it, not just the 1/6th of the class in the lab. And afterward, my friend in the lab told me she got overheated on Thursday and had to take a break like I did, so I felt much better.
Anyway, the moral of this long story is at least fourfold:
1. Eat something before you go into surgery, even if you think you'll be fine.
2. It doesn't matter if you're not really participating in the surgery or under stress; just the fact that you're wearing surgical attire can be enough to do you in.
3. Sit down while you're just feeling strange; don't wait until you pass out.
4. 3.5 hours is a long time to be in surgery.
(Lesson learned.)
All throughout this year as we've been learning about surgery (and even in the past two years, when we've had surgical principles lectures and labs), they have emphasized to us that it takes some practice to get used to being in surgery.
"Every year," they repeat, "some students pass out. Don't be the student that passes out! Tell us right away if you start overheating or getting dizzy or feeling funny! Nobody will catch you and we don't like picking up vet students off the floor!"
Okay, I figured. Apparently there are students in the class who haven't had the opportunity to be in a surgery environment or observe surgeries before. Too bad for them. After all, I have spent years as a technician monitoring surgeries.
Well, I'm here to tell you that being in a surgical suite monitoring anesthesia for a surgery performed in a private practice setting does NOT mean you know how to be in a vet school teaching hospital surgical environment.
And I sort of knew that. So even with my past experiences, I've tried to be extra careful this year when I knew I'd be scrubbing in for surgery. During my community practice week, for example, I paid extra attention to what I ate for breakfast, made sure to drink lots of water, and ate a quick granola bar right before scrubbing in. I was conscious of my body position during surgery, made sure I wasn't locking my knees, etc. And all was well.
This past Friday, however, I had the opportunity to scrub in with last week's Junior Surgery Lab since one of my classmates was out sick with a self-described "dysentery." (Sounds thrilling.)
I'll be having JSL ("pig lab") at the end of October, so you'll hear about it in much greater detail then, but here's a brief overview: There are 22 students in the lab at a time, divided into pairs, and working on 11 anesthetized pigs. The first day of the lab is suturing skin incisions. Days 2-4 include intestinal resection and anastomosis, nephrectomy, splenectomy, cystotomy, gastrotomy, enterotomy, etc. Day 5 (Friday) is an abdominal exploratory -- meaning the instructors have already cut open the pigs before you get there, and created problems -- marbles hidden in the abdomen, superglue injected into the bladder, an intussusception, etc.
So it was on a Friday that I jumped into the lab.
But before I got to lab, I woke up at 6:15, had my usual piece of toast and OJ for breakfast at 6:30, had a doctor appointment at 7:45, got to the VTH at 8:20 and found that the JSL students were about to start scrubbing. The sick student hadn't arrived but there was still a chance she would make it. So I ran up to my locker to put my stuff away, then hurried down to the soft tissue rounds room to make sure it was okay for me to ditch SD and go to JSL, and make sure the other junior on the SD rotation didn't mind me leaving, then headed back up to the locker room to change into surgical scrubs, and finally made it back to JSL as they were finished scrubbing. Needless to say, I didn't have quite enough notice or time to get my brain in order and mentally prepare for the upcoming 3.5 hours of surgery.
Everything was okay for the first 2 hours or so. Since I hadn't done the first 4 days of the lab yet, my role in the surgery was basically holding intestines out of the way for my partner -- which was fine. After a couple hours, though, it was getting boring. And I was getting hot.
(Let me take a minute to tell you about our surgical attire. First, in private practice settings, vets often perform routine, non-complicated surgeries wearing scrubs or even their everyday doctor clothes. They sometimes wear a cap or bouffant [like a hairnet] over their hair; sometimes not. They sometimes wear a surgical mask over their face; sometimes not. In a vet school setting, however, they want to teach us the higher standard -- which means we wear booties over our shoes, caps or bouffants over our hair, a mask covering our face, AND a full cloth surgical gown, that ties multiple places in the back, goes down to at least your knees, is tight around your neck, and has long sleeves with thick 3-inch-long cuffs on the end. You pull your sterile gloves over the cuffs of your gown sleeves so that none of your un-sterile skin can get out. End result: Your wrists rapidly become soaked with sweat; your back and neck sweat; if you have a ponytail, it sits on your already overheated neck; and every breath you inhale and exhale through the mask blows hot air onto your face.)
It was a combination of multiple factors that culminated in my wooziness: (1) Overheating due to surgical attire, (2) boredom leading me to focus intently on how I was starting to feel weird, (3) eating breakfast earlier than usual due to my doctor appt, (4) not grabbing a quick bite to eat right before heading into surgery, and (5) a morning dose of an antibiotic that has been giving me some GI upset for the last week.
Here's another lesson I learned: If you want to get the instructor's full attention during a surgery lab, tell them that you feel funny and need to sit down. Let me tell you, you can get waited on hand and foot.
So I started feeling a little dizzy, vision going in and out of focus. I've experienced that feeling only once before -- during my first year or two of college when I was shadowing at a vet clinic back home, and the doctor invited me to watch surgery (the first declaw I'd ever seen) -- and that first time, I did nearly pass out. So I was eager to quietly sit down and get my nerves back while I was only feeling a little funny, rather than making a huge scene in front of 21 of my peers by collapsing to the floor.
I called over one of the 3 instructors helping in the lab and said, "I'm starting to feel a little funny. Can I sit down for a few minutes?"
He immediately looked totally alarmed and grabbed me by the shoulders, presumably to make sure I wasn't going to drop to the floor then and there. He said, "I'm going to bring you that chair. Can you stand here for a few seconds?"
I was like, "Heck yes. I don't feel that bad." The chair was literally only 8 feet or so away.
So the chair was delivered to me and I sat. The instructor advised me to take off my mask and I did, which helped a ton. He also turned on a box fan right next to my surgery station. (Oddly enough, each of the 11 surgery stations has its own box fan to cool off the student surgeons. Guess with 22 student surgeons, 3 instructors, and 11 pigs all in one room, it often gets warm in there.)
They left me alone for a couple minutes, and really I felt 90% better after sitting for about 30 seconds with my mask off. When the instructor came back to check on me, I told him I felt a lot better and thought I was ready to start again. But he said, "You still have no blood in your face. Can I get you some food? A granola bar? Some orange juice or coffee or a soda?" I said no, I felt better, but he persisted with, "Okay, but do you mind if I kick you out of lab and send you upstairs to have a snack?" Which was nice of him. Especially since my surgery partner later confirmed that I was apparently white as a sheet even though I felt fine again.
So I dutifully headed upstairs and downed a couple slugs of orange juice, a chocolate donut, and about a liter of water. Feeling completely revived, I came back down to the lab, re-gowned and gloved (the nice thing about doing a terminal surgery is that you don't have to worry about sterility, so I didn't actually have to scrub again), and completed the last 75 minutes or so of the lab without incident.
I felt pretty silly about the whole thing, because even though the other 20 students were busy with their own surgeries, they weren't so busy that they didn't notice me sitting down and later leaving. But all things considered, I would much rather have had things happen the way they did than end up out cold on the floor, in which case I'm sure everybody in my class would have heard about it, not just the 1/6th of the class in the lab. And afterward, my friend in the lab told me she got overheated on Thursday and had to take a break like I did, so I felt much better.
Anyway, the moral of this long story is at least fourfold:
1. Eat something before you go into surgery, even if you think you'll be fine.
2. It doesn't matter if you're not really participating in the surgery or under stress; just the fact that you're wearing surgical attire can be enough to do you in.
3. Sit down while you're just feeling strange; don't wait until you pass out.
4. 3.5 hours is a long time to be in surgery.
Subscribe to:
Posts (Atom)
