Yep, it's gonna be one of those weeks

2 days into this week and I'm already completely ready for another weekend.

Yesterday was my second Monday spent surgerizing at the county humane society. Actually, before we even got down there, we spent much of the morning at the VTH taking care of the patients who had dropped off from a different humane society for surgery on Tuesday. That meant walking, feeding, watering, setting up cages, weighing, doing physicals, taking temperatures, checking testicles, shaving for spay scars, and drawing blood on 6 friendly but exuberant doggies.

After getting those guys set up, we headed down to the shelter. Three of us went. We had 4 dogs on the schedule -- 2 black lab/pointer cross puppies, a tiny terrier cross puppy, and a large terrier cross puppy -- all spays. The lab/pointers were around 20 lb each, and nice and passive in their complete fear of everything (makes for cooperative patients!). The tiny terrier was, well, tiny (only 5 lb!) and wanted nothing more than to just be held. The large terrier was a complete nutjob (in a crazy happy sort of way), requiring just a "touch" of additional sedative pre-surgery.

Of us 3 students, I was the only one who had been to the humane society from Community Practice before, so I'll admit it was kind of fun to actually have a semblance of an idea what was going on and be able to answer the other guys' questions.

We started with anesthesia on my classmate's lab/pointer spay ("Annie Oakley"), which was relatively uneventful, then induced my lab/pointer spay ("Ariat"). This was my first time since junior year to be the one to do all of the induction stuff -- meaning premedication, IV catheter placement, induction with injectable anesthetic drugs, intubation, connecting monitoring equipment, shaving, etc. Since I've generally been a stress case about anesthesia stuff, and have had some struggles with technical skills like intubation and IV catheters, it was rewarding to do it all myself without any mistakes.

Ariat's spay went pretty well -- about an hour and a half in length -- and she recovered nicely (unlike her brother, neutered by the shelter's staff vet, who woke up screaming bloody murder).

Toward the end of my spay, the surgery instructor came by to ask if I was interested in doing the last spay (since there were 4 dogs and 3 students). I kind of didn't want to, but the answer to such a question is always "Sure!" -- I offered repeatedly to let my classmate (a general tracker with only 2 weeks on Community Practice instead of 4) to take the last spay, but the instructor insisted we flip a coin to make it "fair." Flip we did, and I was soon informed that I "won."

Sigh. Though I'm getting faster and more efficient in surgery, and gaining comfort with the procedures, I'm still at the point where a single spay (especially a dog spay) leaves me fairly well exhausted. It's partly physical -- standing over a surgery table, body tense with general worry about slicing into something that will hemorrhage everywhere, and holding arms and hands in a strange position to keep everything sterile -- and partly mental (that same sort of thing with the not wanting to cut a giant artery and watch the dog bleed to death).

But sometimes you've just gotta push on -- hunger, thirst, headache, and full bladder be darned.

So I finished up Ariat's spay, got her to the recovery area, and stepped out of the surgery suite -- only to find my classmate waiting expectantly with Shiloh, the tiny terrier, already premed-ed and out in the prep room, IV catheter and induction supplies at the ready. I did excuse myself for a big drink of water, but there wasn't time for much more than that.

It's been a long post so far -- so here's a cute puppy picture of Shiloh to keep you entertained:



So Shiloh was smoothly induced (again, a nice catheter placement and intubation) and I scrubbed in, again. Shiloh's teensy weensy ovaries and uterus were out and she was closed up and in recovery with a skin-to-skin surgery time of 1 hour on the dot -- my fastest dog spay yet! I started Shiloh's surgery well after one of my other classmates had started his spay, and I finished about 45 minutes before he was done. I don't mean to gloat or anything (keeping in mind that my first spay was at least 2.5 hours), but it was just a nice reminder of how far I've come surgery-wise with 2 more weeks' experience.

We got back to the VTH around 5:15, at which point I grabbed a quick bite of dinner, made some follow up phone calls from last week, helped out with a couple appointments (just restraint and that sort of thing), and did a proper PE on my surgery dog for Tuesday and got his paperwork going. I got home around 6:30 pm.

Today turned out to be a loooooonger day that Monday (even though I was thoroughly exhausted after Monday). I rolled into the VTH shortly after 7 am to get another good look at today's surgery patient and make sure everything was set up for his surgery before 8 am rounds. Today's doggie was a 6 month old red miniature Dachshund -- just about the sweetest and silliest hound dog you've ever met. His name is Mickey and if you sit on the ground he loves to race toward you and try to launch himself into your lap, but he just can't make it most of the time on account of his stubby little legs. He also loves to roll over and wait for belly rubs.

Anyway, Mickey's surgery and anesthesia were extraordinarily efficient today. I checked on him at 10:05 am, when the tech students had just brought him into the anesthesia prep room but hadn't started working on him yet, and when I came back 10 minutes later, he was catheterized, induced, and ready to be shaved for surgery. (And 10 minutes may seem like a plenty long time, but in the world of brand-new anesthetists, that's almost a world record.)

Mickey was in the surgery suite by 10:25 am and I started cutting at 10:35 and finished my last intradermal suture at 10:55 am -- a 20 minutes neuter, skin to skin, which totally beats my 40-60 minute neuters I've done previously. The nice thing about neutering young dogs is you can almost just rip those testicles right of them without having to mess with the scrotal ligament that attaches the testicle to the inside surface of the scrotum very strongly in older dog.

Mickey recovered well (though he was pretty chilly -- he got down to 94 degrees in surgery, with 100-102 being normal body temp). Since I had no appointments until 4:30 pm, I tackled about 8 phone messages that had been left over the course of the morning.

After all the lovely phone calls, it was a quick bite to eat and then a surprise 1 pm appointment. One of my rotation-mates has a dog of his own who has been battling lymphoma for a few months and recently going downhill -- the poor thing is only 4 years old -- and my classmate got some really bad news about his beloved doggie today, so he headed home around noon.

Which left me with his 1 pm surgery intake -- a client-owned animal dropping off for surgery on Wednesday. The patient is a pretty little yellow lab, about 6 months old, who's in for a laparoscopic spay and gastropexy. She's a bit shy, especially around men, but overall a good girl and very cute. And she finally went potty for me outside at her last walk of the evening!

Aside from the surgery puppy for tomorrow, I helped out with some blood draws, vaccine administration, nail trims, anal gland expression... basically a full afternoon of assisting with other people's patients when they were in the treatment room.

My 4:30 appointment was an 8 year old Chesapeake Bay retriever due for some vaccines, needing a nail trim and anal gland expression, and also with a long complicated history of urinary incontinence, right forelimb lameness, multiple skin and subcutaneous masses, etc. etc. etc. They also arrived at 3:55 pm for their 4:30 schedule appointment and seemed a bit put off when it was 4:05 pm before I came up to get them (my bad, I guess I should have been more than 25 minutes early to come see you).

My 6:00 was a sweet, happy 1.5 year old shepherd cross due for her annual boosters on her puppy vaccines. Her owner was super nice and signed her up on the VTH's wellness plan, started her on a lepto vaccine in addition to her DA2PP and rabies, consented to a heartworm test and sending home preventive, and allowed deworming and promised to bring back a fresh poop sample for a parasite screen.

When they left at 6:45, I was left with a couple records to write up, then feeding, walking, and medicating (ear meds) my lab spay for tomorrow, and feeding and walking my Dachshund neuter for today. With an arrival at home at 8 pm, it was nearly one of my longest days on Community Practice -- and there's no sign that the rest of the week will be any slower!

Weekends: so much better as a senior

The transition from junior vet student to senior vet student has been abrupt and very interesting.

Though we're only 2.5 weeks into senior clinics, junior year seems so long ago. Was it really just a month earlier that I was sitting in class for half the day, taking at least 1 exam every weekend, and stressing out about capstone?

And was it only a month ago that the hospital was filled with confident, knowledgeable, soon-to-be-DVM former seniors? Now it seems like it's always been the norm to see my own classmates sitting in the rounds rooms, running the anesthesia cases, dealing with all the clients in the lobby, and striding around purposefully discussing cases with the clinicians.

I do miss having a few hours every day to sit back in class and engage in passive learning, taking notes on whatever topic the lecturer throws at us. It was nice to know that if I really had too much stuff going on outside of school, if I got sick, or if I was just running late, missing a few minutes of afternoon classes would go unnoticed.

However, despite the massive increase in hours spent at school (from 20 hr/wk of junior rotation + 10 hr/wk of classes, to 50-55 hr/wk of senior clinics), I am enjoying senior year so much more than junior year.

One thing I particularly love is the fact that, for the most part, when I come home from school, my time is my own. At this point, NAVLE studying hasn't started yet and Community Practice as a senior rotation doesn't require much studying other than the several hours I spent reviewing the surgery handbook. It's awesome to be able to relax and watch a little TV or hang out on Facebook or (gasp!) sit on the couch and read a book without the nagging feeling that I'm wasting what should be precious study time.

Weekends are fantastic too. The same sort of thing goes -- I don't feel bad sleeping in, hanging out with CLH, running errands. Spending Sunday morning at church doesn't give me the sense that I'll have to cram my study time into just a few afternoon hours. And no exams! No exams!

As a senior it's also more interesting to have primary case responsibility. As a junior, there were a few times when I was the one leading the appointment, but more often it was following along with senior and then finally learning enough about a given case to really be interested in it, only to have to leave at noon to grab a bite of lunch and make it to class on time -- then come back the following day and try to catch up on everything that happened the previous afternoon and overnight.

I love the opportunities to interact with clients. It's been pointed out to us students that the clientele at a veterinary teaching hospital is generally fairly self-selected to be the more dedicated clients who have intense bonds with their pets and are willing to educate themselves about the things we tell them. It's really fun to talk to these clients and learn about their dogs and cats and leave almost every appointment feeling like we had a successful visit and everyone left satisfied.

I really like that we still have another 3 months to "practice" being seniors before the new juniors will join us in late August and early September. Though we're gaining confidence every day, there is still a lot to be learned before we take the overly eager juniors under our wings and try to answer all of their questions fresh from 2+ years of book-learning that we will have pushed somewhat to a back corner of our minds by then.

Though Community Practice has been full of very long and very busy weekdays, with 12+ hour days on Tues/Wed/Thurs being basically the norm, I'm glad this is where I started my senior year experience. And I'm glad I have another 2 weeks to go before I get thrown into internal med with its caseload of hugely complicated medical diseases, hours spent writing detailed SOAPs for patients with 15-20 different problems, and increased likelihood of having hospitalized patients to care for in the evenings and weekends. For now, I'll keep my free time to myself, thanks very much.

Client drama

I have a feeling that 11.5 months from now I will have had about a hundred blog posts that could have had this title. Sigh.

Today's dramatic client was actually a pretty sad situation. Mrs. A is an elderly, disabled client with extremely limited income. She has a 14 year old dog named Timber that she loves very much.

Timber has very severe arthritis in his hips and stifles (knees). He's been on carprofen, a non-steroidal anti-inflammatory drug [NSAID] kind of like a doggie version of Advil, for many years. He also has ulcerative bullous keratopathy, an eye condition that causes him some pain unless he is medicated daily, and has caused him to go basically blind.

Mrs. A started bringing Timber to the VTH this past January to see Ophthalmology for his eye problems. Given Mrs. A's severe financial constraints, Ophtho basically wrote off everything in the $150 visit except about $20 worth of fees.

Since then, Timber had several more rechecks with Ophtho (again, all but $10-20 of the bill written off) and a couple appointments with Community Practice (and again, tons of write offs).

Timber's most recent visit at Community Practice was to check bloodwork to see if his organs were doing okay with his chronic NSAIDs, since carprofen can sometimes cause liver problems in particular. Timber's liver values looked pretty okay for a 14 year old dog, so he was sent on his way with 3 more months of carprofen, instructions to come back in 3 months to repeat bloodwork, and a bill that had Mrs. A paying only the cost of the medication and not the $39 exam fee or the $45 of bloodwork.

Fast forward to this afternoon. Being a kindly, congenial student who likes to work as a team with my classmates, I jumped up from my chair to answer the Community Practice phone when it rang. I found myself conversing with Mrs. A, who started crying almost immediately, and told me all about her life, her financial problems, her health issues, Timber's health issues, and how she had made an appointment in 10 days to recheck bloodwork but would have to know in advance exactly how much she would be expected to pay.

Ugh. This is my favorite kind of random phone call-slash-complicated situation to wander into.

I went on my way to do some investigating. I first discussed the case with the head doctor in Community Practice, who said we really couldn't write off any more services for Mrs. A, but that it would really be an ethical concern to continue prescribing carprofen for Timber without checking his bloodwork to see if the drugs we were giving him were hurting his body ("first do no harm," and all that).

My next stop was Ophthalmology to consult with the specialist that Timber saw in January to learn at least a little something about ulcerative bullous keratopathy and whether it would be necessary for Timber to keep having his eyes medicated twice daily, at a cost of $30 per tube of ointment. The answer was "Um... I guess not? As long as he doesn't seem painful?" Ooookay, then.

Stop #3 was back to Community Practice to pull up the Walmart $4 drug list on my laptop to see if we could get either Timber's eye meds or his NSAIDs at a lower cost than through the VTH pharmacy. Unfortunately, his eye meds weren't on the list and carprofen is not a drug that's used in humans. It might have been possible to switch Timber from carprofen to meloxicam (another NSAID), but the dose of meloxicam he would need was about 1/7 of the smallest size tablet carried in human pharmacies, so he'd have to have it compounded into a special liquid formulation which would end up being more expensive than the carprofen anyway.

My last stop was to our fantastic client support institute, staffed by wonderful people who are highly skilled in talking to all manner of angry, sad, bereaved, frustrated, or confused client, in addition to giving us students advice on how to handle difficult situations. I mostly knew what I needed to tell Mrs. A, but it was just nice to let somebody know about the situation I was dealing with and get their opinion.

Finally I called Mrs. A back (by this time, all my classmates had left for the weekend and most of the hospital was shutting down). We talked for about 20 minutes (well, mostly she talked) and she told me about her beloved cat that she had for 20 years that died a couple years ago and she has never gotten over it, how she has had problems with severe depression and has a lot of health problems and takes many medications, how she has stopped taking her own meds at times so that she can afford care for Timber, how she cannot take him to the low-cost vet clinic in the large metro area an hour away because she doesn't have money for gas, etc. etc. etc.

She was very sincere and I got the feeling that this is a client in a truly difficult situation, not somebody who's just out to manipulate us into giving them free services. The complicating factor is that the medical records from Timber's most recent visits seem to indicate that he is not in very good shape despite the medications he's on, and that the students and doctors that have seen him in the past have been concerned about his quality of life.

Long story short, we eventually got to the point where Mrs. A said she has spent the last 3 months saving up the $94 that will cover Timber's $45 blood test, his $18 carprofen prescription, and his $31 eye ointment. So she can bring him in for a check up as long as we can waive the office visit fee. I guess it's my job next week to figure out how to convince somebody to do that before she comes in.

I did get into a bit of a discussion with Mrs. A about quality of life issues, although she would get very teary whenever we mentioned Timber's age or his serious health issues. I offered to have one of our client support people call her next week to chat about some of these things, which, fortunately, she readily agreed to.

All in all, it was a pretty emotionally draining afternoon. Mrs. A's situation raised two of my own fears -- at some point not being able to afford the care I'd like to provide for my pets, and getting to the point where it's time to let them go and not being able to recognize it. It's so unfortunate in veterinary medicine that we have to deal with this kind of financial situation all the time (fortunately not often to quite this degree of severity). Life would be a lot easier if care could be cheaper and pets were insured.

In other news, 4 of the 9 members of our Community Practice student team are leaving us after today. Next week we'll gain 2 new students who will join me on my "Team B" to make a 3 person team, versus 4-person "Team A." I'm sure it'll be fine, except for maybe Tuesday, when Team A will be down at the local shelter gettin' their surgery on, and my 2 new Team A-mates (who have no experience with how Community Practice does things) and I will be left at the VTH to handle a full schedule of 9am-6pm appointments, plus a double-booked afternoon from 1-3pm with surgery intake appointments every half hour in addition to the regularly scheduled 1, 1:15, 1:30, 1:45, etc. visits! Should be an interesting (and long) day. Hooray for the 3 day weekend!

Surgery & me

We're approaching the end of our second full week of Community Practice, and let me tell you, as much as I've enjoyed it, I am SO glad we'll have a 3 day weekend!

My surgery confidence has been improving. I have thus far met my goal of not vomiting before, during, or after any one of my surgeries. My nerves have decreased quite a bit, although I still have to occasionally quell some panic when I'm actually in surgery.

Last week I had a dog neuter (4 mo Chi from the humane society) and a dog spay (5 mo client-owned hound x). This week I did an 8 week old kitten spay on Monday, a 1 yo cat spay on Tuesday, and a 5-10 year old Chi X spay named Cheeto today (all from various humane societies). Here's my Monday kitten, Celine, who has already found a home:



Cheeto's spay today was by far my most harrowing surgery. I was pretty stressed out for my very first dog spay last week, but that stress was due more to never having done a spay before and general concerns about cutting open an abdomen and yanking out parts. Today's spay was stressful because things started going wrong.

First of all, the anesthesia left something to be desired. Our anesthetists are technician students from one of the local community colleges, and although they have all been through several semesters of classroom learning and are all very nice people, they have a wide range of technical abilities, experience with animals, and experience with anesthesia. Still, I don't fault them for any error or oversight because I know they are still learning and I can't help but think back just a few weeks to my own introduction to anesthesia as a junior.

So Cheeto was pre-medicated, had an IV catheter placed, and was induced into general anesthesia. At this point the tech student intubated her and we connected all of her monitoring devices and I clipped her and we moved her to surgery.

Fast forward to about 20 minutes after arrival in the surgical suite. I've just started cutting, and Cheeto just isn't doing well under anesthesia. Her CO2 level is high, her oxygen level is low, she seems lighter than she should be given the relatively high % of gas anesthetic she's on, and.... wait... do I smell isoflurane?

The supervising anesthesia tech came over to help the student with Cheeto's anesthesia, and quickly ascertained that the endotracheal tube placed in Cheeto's trachea was too small -- meaning that it was not big enough to create a complete seal in Cheeto's trachea, so she was breathing a mixture of anesthetic through the tube and room air around the tube.

Really the only solution for this problem is to place a bigger ET tube. So, with her guts poking out, lying on her back, Cheeto was successfully reintubated and the remainder of her anesthesia was relatively uneventful (except for some hypotension and bradycardia -- oh, and when she kept trying to wake up every time I pulled on her ovaries).

On my end of the surgery table, I found myself dealing with a large, flabby uterus surrounded by an incredible amount of slippery fat that would not stay out of my way. Once I finally had the first ovary dealt with, I had to go fishing for the second horn of the uterus. Having found Side #2, I started to gently break down the suspensory ligament connecting the ovary to the kidney (which is a tough structure that usually takes quite a bit of effort to tear) -- and the thing snapped almost immediately. Uh oh.

Okay, then, guess it's time to start tying off blood vessels! I placed my clamp below Cheeto's left ovary, and was halfway through my first ligature around her ovarian vessels when the tissue between my ligature and the clamp just tore -- with no warning at all. Commence msasive amounts of bleeding. (Okay, in retrospect, it probably wasn't that much bleeding. I'm sure the surgery instructor laughs to herself when we freak out about these things. But hey, I don't like seeing blood everywhere!)

Fortunately, the bleeding was coming from a vessel in Cheeto's uterus which I was about to remove anyway, so I was able to clamp it off. When I'd at last removed both ovaries and most of both uterine horns, there was still more blood in the abdomen than I liked to see, so I worried that something was still oozing. However, I took the advice of the surgery instructor ("Doesn't look like that much blood to me!") and just closed the abdomen.

We close the abdomen in dogs in 3 layers. The first and most important layer is through the body wall -- the muscles and connective tissue that sit on the bottom of the abdomen and are the strongest thing we can suture. The second layer is the subcutaneous tissues, which we suture together mainly to eliminate dead space where fluid can accumulate. Finally, we place a third line of suture within the skin, the idea being to be able to bring the skin edges together over the incision without any suture sticking out.

I've been working hard on my intradermal suturing (the third and final layer). On my first dog, I didn't start or end the suture line well but it closed okay in the middle, so I had to place skin sutures at both ends of my incision. On my second spay, the middle and last end of the incision closed great but I needed a skin suture at the first end. On my third spay, both ends closed great but I had some gapping in the middle. This time, everything closed well but my knot at the end of the intradermal suture line, which is supposed to end up buried under the skin, would not bury itself no matter what I tried. So, I avoided any skin sutures, but did have to use some tissue glue on top.

In my 4 spays, the thing I've found to be most difficult each time is actually cutting into the abdomen and finding the parts I want. The incision through the skin is easy -- but then underneath there can be a hugely variable quantity of fat and subcutaneous tissues before you get to the linea alba -- the connective tissue structure we want to cut through to get into the abdomen. It's just very difficult to know how deep you're going with your gradual incisions in the same general region, although I'd imagine it gets a lot easier with time.

Once you're in the abdomen and have access to the guts, the next thing you have to do is actually locate the uterus. (Well, first you should make sure the spleen is out of the way. The spleen likes to sit right beneath the linea alba that you cut through to get into the abdomen, and the spleen is easily angered if you cut or poke it.)

The body of the uterus (the part connected to the cervix) sits between the bladder and the colon in dogs and cats. So with a dog lying on her back in surgery, the organ closest to the surface we're cutting into is the bladder, with the uterine body beneath the bladder, and the colon even further down. The two horns of the uterus are semi-mobile, so there isn't one exact place you can go to find them. So we use an instrument called a spay hook to fish around till we find what we want.

And even when you "catch" something on your spay hook, it isn't all that easy to identify it. There's a whole lot of intestines in every animal's abdomen, and in some cases they look very similar to the uterus (at least to us beginning surgeons -- again, something else that probably gets much easier with experience). So I had one spay where I kept pulling up intestine after intestine after intestine, and since I didn't know for sure that it was intestine and not uterus, I had to try to follow it one way or the other to find the uterine body or the ovary. Conversely, I had a cat spay this week when I kept pulling up uterus over and over and pushing it back, thinking it was intestine, until finally my surgery instructor came over and said "...Why do you keep letting go of the uterus?"

I've found that once the uterus is located, everything is pretty straightforward from there, because it's all a matter of ligating and transecting the things you need to ligate and transect, then sewing everything back up and waking up the pooch or kitty. It just seems funny that it takes so much time and effort to (a) get into the abdomen and (b) find the organs we're actually looking for.

I do think I've gotten over the feeling that I'm not ready to do these kinds of surgeries. It's true that I'm not yet ready to do them on my own with no supervision or assistance, but as long as I can keep from panicking, I do feel comfortable handling most of the complications I might encounter. All of our surgery patients stay in the hospital overnight after surgery, so it's gratifying to see how great they look the next morning and to reassure yourself that no, they didn't bleed to death overnight.

With 2 weeks of surgery left (which will probably be 4-5 more surgeries), I'm hoping to get in a couple more neuters as well as however many more spays I can do. The scary thing is, after this rotation is over, I'm pretty much done with primary surgery experience except for my externship rotation in the spring at a high-volume, low-cost hospital. Yes, I'll be scrubbing into plenty of surgeries between now and then, but mostly to handle the suction tip, pass instruments to the clinician, or maintain traction on the leg they're trying to fix.

Ah well, I guess that's why they call it veterinary "practice"!

Busy and tired

Time to get to bed soon, so just a brief update:

As expected, activity at school has really picked up this week.

Monday was a full day of medicine appointments. I arrived at school around 8:45 am and left once all the paperwork and visits were complete -- around 7:45 pm. Nothing too exciting -- mostly well pet check ups.

Tuesday was my first surgery day -- my patient was a 4 mo Chihuahua mix from the humane society, whom I castrated quite successfully (I was totally freaked out about my first solo surgery but it went much better than I'd expected). Got to the hospital at 6:45 am after waking up at 5 am after tossing and turning all night. Left at 7 pm and drove straight to Windsor for handbell rehearsal. Medicine appointments and surgery intakes in the afternoon once my neuter was done.

Today was Day 2 of surgery -- I got to the VTH around 6:40 this morning to care for my neuter from yesterday and my spay doggie (client-owned -- nerve-wracking!) for today. Spay got going around 10:20 am and I finished closing just before 1 pm. Not the world's longest spay by any means, but I'm certainly going to be faster on my next one when I don't have to wait around for the supervising surgery doctor to assist the other 5 students before it's my turn to ask her questions again. Overall surgery was uneventful, other than being really long. Doggie goes home tomorrow. She's a 5 mo hound mix.

Lots of ups and downs -- it's fun to apply the knowledge we've spent 3+ years acquiring, but the random details bog us down -- like what forms to fill out and where to turn them in, which boxes to check on the fee sheets, which vaccines require a prescription to be turned into the pharmacy -- that sort of boring stuff. Tons and tons of paperwork, especially with the surgery dogs.

Tomorrow I'm the "relief" person meaning I don't sign up for surgeries, I just stick around the surgery recovery area, the treatment room, and the rounds room, and assist where needed. I'll probably take a couple morning appointments, and maybe some in the afternoon if the schedule fills up.

Having fun but looking forward to the weekend!

Here we go

(Blogger was down all day yesterday, so here's my post from yesterday evening.)

Day 1 of senior year started out pretty gently. They eased us into what will soon become a demanding schedule with a laidback 3 hour orientation starting at 9 am. From there we hung around, chatted, ate lunch, etc. until our appointments began at 1 pm. With 9 appointments and 8 seniors, the work was evenly distributed and I ended up with just a single appointment at 2:20 pm.

First I got over the initial shock of introducing myself as, "Hi, I'm ____, I'm a senior vet student"(!!!) and noticed with great relief that my client seemed to have no idea that, had he made an appointment for yesterday rather than today, his dog would have been cared for by a student with 364 days more experience than me.

On my way up to meet the client in the lobby, I developed this paranoia that this client would be exactly like my first actor-client in communications rotation this spring -- i.e. antsy, impatient, and eager to get in and out with a minimum of talking and money spent. Fortunately my real client was completely the opposite -- he had a sense of humor, gave the impression of having all the time in the world to sit and wait for me to get things done, readily accepted all of my vaccination and preventive health recommendations, and was an all-around nice guy.

My patient was a huge fluffy black-and-white teddy bear of a dog (possibly a Newfie/border collie cross, or at least that was the best guess from the rescue that adopted him out as a puppy). Not quite two years old, he was in need of some vaccines and some serious weight loss. We enrolled him on the VTH's adult dog wellness program; vaccinated him for rabies, distemper/parvo, lepto, and bordetella; ran a heartworm test (negative); sent home 6 months of heartworm prevention; and threw in a lovely fecal sample cup to bring back a fresh "deposit" for parasite testing, given that this sweet doggie has a revolting habit of ingesting raccoon feces (and probably any other feces he can find -- I doubt he discriminates). He'll be back for a lepto booster and deworming in 3-4 weeks.

Each of us new seniors set several goals today for our time on Community Practice. One of mine was to improve my proficiency and confidence with jugular vein blood draws -- something I've always found difficult and that I'll use any excuse to avoid, even though it's something I really need to get good at. Unfortunately, a terribly obese and long-haired dog who didn't feel like sitting still turned out not to be the greatest candidate for a needle poke in the neck. But at least I gave it a shot!

Following the appointment (which took me 75 minutes from door-to-door -- which I consider respectable in light of the goal of 60 minute appointments, given that it was my first day and we got a ton of stuff done), it was time to sit down with the paperwork. Throughout his appointment, my teddy bear dog accumulated: a treatment consent form signed by the owner; a medical discharge summary; a heartworm test form; a vaccination reaction information sheet; 3 carbon copies of his rabies certificate; a history/physical exam form; a prescription for his heartworm meds; 2 pages of patient ID stickers; 2 patient ID cards; 2 fee sheets; and all of the electronic records forms I had to fill out in the computer system. I know it'll get a lot easier and faster the more appointments I do, but yeesh. No wonder last year's seniors griped constantly about paperwork.

Speaking of last year's seniors, the hospital feels empty without them. I saw one of the graduating-tomorrow seniors walking through the hall showing his family around, and he just seemed out of place. As I traipsed back and forth from the lobby to Community Practice (which is the farthest department from the reception area and exam rooms), it was so strange to see my classmates sitting in all of the rounds rooms. Yes, I'm used to seeing them in there during junior rotations, but we juniors are usually relegated to a chair in the corner or perching on a desk along the wall, rather than sitting at the rounds tables. Now it's just us.

I'm terribly thankful that we new seniors get three entire months to learn the ways of the hospital before we have new juniors tagging along with us. I remember thinking last fall, "I wonder how it is that we inexperienced juniors will magically become these total rockstar seniors" -- I now know that at least part of the answer is that we'll have 90+ days to mess up, get lost, fill out forms incorrectly, and fail 4 times in a row to dial a long-distance number (true story -- laugh all you want) before we have eager juniors sticking to us like glue.

I'm also grateful that the Community Practice clinicians and technical staff seem truly excited to have us there. After hearing many comments over the last few weeks from clinicians and interns about how much they're going to miss the old seniors, along with the occasional only-semi-joking exclamation of "Look out! The juniors are coming!", I really feel like we former juniors can offer, if not extraordinary technical competence and thorough knowledge of the inner workings of the VTH, then at least a bright-eyed and bushy-tailed enthusiasm for being out of the classroom and working full-time with real animals and clients -- an eagerness to participate in twice-daily rounds -- a positive attitude toward teamwork and stepping in to lend a hand to a classmate whenever needed. It can't be entirely fun to start basically from scratch with a group of students, but the clinicians seem to recognize that our ineptitude isn't entirely our fault, and that our ability to learn has not been totally damaged by the past 3 years of classroom teaching.

Now, I'll admit that I'm pretty tired after today, which was only an 8 hour day with plenty of downtime and merely a single appointment of my own. So I certainly can't blame the former seniors for the apathy and sullenness that reared its head starting a couple months ago. I hope, though, that we new seniors can maintain our energy and good spirit for awhile. (I say that now, when I don't have to come in until 10(!) am tomorrow -- but check back at the end of next week when I've been at the hospital 12 hours a day caring for my surgery patients and seeing appointments.)

Speaking of which: surgery. My first "goal" I mentioned during orientation today went something like this: "I'd like to be able to just think about doing surgery without wanting to throw up." And that's pretty much how I feel. I was a little panicked last week as I started to realize that senior year was so close, and it occurred to me that Community Practice isn't just medicine appointments (which I love), but also that pesky little thing called surgery. Fortunately, I've been spared from too much anxiety by knowing that I won't have a surgery of my own until at least Tuesday.

Surgery, surgery, surgery. Yes, I'm going to do it. Yes, I'll probably even do a good job. Yes, there will be plenty of people around to help me if I freeze or get confused or make a mistake. And yes, I'm sure my patients will survive and go home to their happy owners (or to happy adopters at one of the shelters). But I'm still not at the point where I can psychologically handle the idea that I will soon be cutting open the abdomen of a living, breathing creature (which I would like to stay that way), removing organs, and sewing everything back up as good as new. It just seems like a lot of power that I don't feel ready for (but I'd better be soon!).

Last thing to mention -- I got to file my first incident report today! Incident reports are the hospital's way of keeping track of any mistakes, errors, complaints, or malfunctions that occur in any way or shape in the hospital. You file incident reports for everything from a client complaining about having to wait too long, to the fluoroscope settings not working correctly, to the wrong dose of medication being sent home with a patient, etc.

Each of us new seniors got "callbacks" to do today (every case seen in Community Practice gets a follow-up call the next day, so we got all the cases seen by the old seniors yesterday). Mine was a puppy who came in on Monday for vaccines and follow-up from a rectal prolapse a few weeks earlier, likely caused by its heavy parasite load that was diagnosed and treated at the prior visit. The owners were instructed to bring in a stool sample, which they did on Tuesday, and the results from the lab on Wedneday showed a persistent Giardia infection. The senior student wrote a prescription for fenbendazole, which was picked up by the owner on Wednesday afternoon.

My follow-up call found the puppy feeling great after vaccines and deworming, but the owner was a little confused about the deworming instructions. Her prescription label for her 5 doses of dewormer indicated to give one dose every 5 days. After speaking with her, I investigated a little, having not much personal experience with fenbendazole, and learned that it is usually given 5 days in a row, one dose a day. I then called the Pharmacy, who looked up the handwritten prescription that was turned in yesterday and found out that the pharmacy technician had written the wrong instructions in the computer, which were then printed incorrectly on the Rx label. This was an innocuous mistake to have happen -- but had the owner not asked me to clarify the instructions for administering the fenbendazole, and had I not followed up on it, the puppy would have gotten possibly an ineffective course of dewormer. I'm glad it wasn't something more serious -- it's scary to think about how tiny things like that can potentially have a huge effect on a patient's health.

So close

All that stands between me and senior year is a pesky behavior final tomorrow afternoon, and what I'm sure will be an exciting and informative eight hours of senior orientation on Wednesday.

The voice of reason inside my head tells me I should study for tomorrow's behavior exam, but I really, really don't want to. Sigh. I'll probably end up studying a little anyway, which is a good idea since I skipped about 6 of the latest behavior lectures.

Wednesday's orientation contains such thrilling topics as "Wildlife Regulations," "Biosecurity," and "SCAVMA Announcements." I'm just positive that they will manage to sneak some actually helpful information in there somewhere, like what time to show up to clinics on Thursday and how to use our pagers. Just kidding.

In the meantime, it's been a nice 3.5 day weekend with not much to do other than a dermatology exam and putting off studying for behavior. It certainly feels like the proverbial calm before the storm, since I'll be heading into 3 nonstop months of 50-60 hour weeks on Thursday.

Hope I'll have some time for blogging!