In response to a comment on a previous post, here are some of the cases we have seen on neurology over the last week and a half:
* Dachshund with a herniated disk
* Beagle with a herniated disk
* Basset hound with a herniated disk (seeing a theme?)
* Cat with probably peripheral nerve or muscle disease, likely due to a congenital enzyme deficiency resulting in a storage disease
* Border collie with left-sided paralysis caused by a huge brain tumor
* Mixed breed dog with diskospondylitis (infection of the intervertebral disk and surrounding vertebrae, in this case caused by Brucella)
* Shih tzu with only the mildest neurologic dysfunction, probably due to a clot to the spinal cord
* Chesapeake Bay retriever with a left-sided weakness and inability to walk, probably due to a lesion in the cranial cervical spinal cord
* Min Pin/Chihuahua mix puppy with seizures, hypertonicity in all 4 limbs, a severely extended neck, inability to walk, and neck pain -- probably one or more congenital defects
* Maltese with a right-sided weakness and concurrent knee injury
* Australian shepherd with hindlimb paralysis (probably a clot to the spinal cord)
* Shepherd mix with constant tremors in the hindlimbs when standing still
* Bulldog puppy with spinal cord empyema (pus-filled spinal cord)
Pretty exciting, eh?
Tuesday, July 5, 2011
Is neuro over yet?
3 more weekdays of neuro rotation (not that I'm counting), +/- 2 weekend days if I'm unlucky and manage to snare an inpatient for the 4th weekend in a row.
Sigh.
I did get to visit the VTH on each of the 3 mornings of this past holiday weekend (self-pity much?). My inpatient was a 12 year old Beagle who had an acute onset of inability to walk on her hindlimbs on Thursday, which is when she came to the VTH. MRI on Friday showed spinal cord compression, probably due to an acute disk herniation, so off to surgery we went on Friday afternoon. What with 12 year old dogs not healing quite as fast as 3 year old dogs, and all that, the dear Beagle got to spend a "bonus night" in CCU, beyond the usual 2 nights post-op. She went home with her owners yesterday, just in time for me to start my second (and final!!!) week of neuro.
Last week was okay in some ways and annoying/frustrating/irritating in others. The "okay" part was that we got done pretty early in the day (and by "early" I mean that I usually left between 5:30 and 6:30). My weekly hours from Monday through Sunday totaled a mere 54 -- positively relaxing!
I guess that's all I can think of for the "okay" part. On to the irritating parts: The doctors (1 faculty neurologist and 1 neuro resident in her last week of residency) had very little interest in teaching us. They showed up late almost every morning, whether that was late to rounds or late to a morning meeting time we'd agreed upon over the weekend. They would blithely rush through procedures and exams with nary a word of explanation to us students, and often with a great sigh or eye roll if we dared to ask a question about what the heck they were doing.
The faculty neurologist in particular had a horrendous attitude toward just about everybody else in the VTH -- clients, interns, lab personnel, receptionists, other departments, etc. I'm not sure I ever heard him speak to or about somebody else without a tone of arrogance, condescension, and derision. As an example, one of the patients we saw had been referred to the teaching hospital by another board-certified neurologist about an hour's drive away. Upon hearing her name, instead of saying, "She's not one of my favorite people" or "I prefer not to work with her," our faculty neurologist stated, "God, I hate that f***ing woman." Professionalism, where are you??
This attitude continued: About a prospective client trying unsuccessfully to send digital video of her dog's neurologic signs, he commented "Are they stupid or idiots or just trying to make my day even worse?" There was a huge fiasco when the doctors were only able to obtain a small amount of spinal fluid during a spinal tap, and thus had to submit several slides of the fluid to the lab rather than vials of fluid, as is usually preferred. On the lab report, there was a comment about the results being limited because the submitted sample came in the form of slides, not actual fluid to work with. Our faculty neurologist flipped out, raging about how condescending the clinical pathologists were, how it was so out of line for them to imply that he was stupid or incompetent, and how he was sick of people trying to tell him how to do his job. When he received a page from someone saying "If you're not busy or you have a moment, could you please call code #11," he derided the caller, muttering "Oh, like I'm not busy? Like I'm just sitting here twiddling my thumbs just waiting for someone to page me?" One of my favorite occurrences was when the faculty neurologist and the resident walked into the (approximately 10' square) neuro rounds room, loudly discussing how the senior students that come onto neuro rotation are never prepared and can't remember even basic information and how frustrating it is to deal with all of us, when us 3 seniors were already sitting in the rounds room, and the doctors continued their conversation about our incompetence as though we weren't even there. (Never mind that they are the ones that have been teaching us neurology for the last 3 years; never mind that theirs is one of the only specialty departments in the VTH that doesn't provide an orientation handout or list of topics to review before starting the rotation; never mind that, although we are still student doctors with a great deal to learn, we are nonetheless human and don't enjoy being mocked.)
Teaching moments last week were very sporadic; we never had afternoon rounds and only had limited morning rounds due to the doctors' tardiness and disinterest in going through learning topics. After the first couple days, we gave up trying to ask questions and get explanations for things.
Well, fortunately both of those doctors are off clinics this week and we have the other faculty neurologist on with us. He certainly has his own quirks and isn't perfect by any means, but in relative terms, it's a complete 180 from last week. We spent probably 4 hours during the course of today just sitting as a group and discussing cases and topics. He asked us to start a list on the board of things we'd like to discuss in morning rounds. We actually had case rounds this afternoon. We were invited to come along to help with neuro consultations for other departments, rather than being left in the rounds room to wonder where the doctors had disappeared to. Best of all, there was no mocking or deriding anybody all day!
Neuro is still not my favorite rotation, and I'm greatly looking forward to its conclusion. But it's nice to see how a simple change in faculty can make all the difference in a rotation.
Sigh.
I did get to visit the VTH on each of the 3 mornings of this past holiday weekend (self-pity much?). My inpatient was a 12 year old Beagle who had an acute onset of inability to walk on her hindlimbs on Thursday, which is when she came to the VTH. MRI on Friday showed spinal cord compression, probably due to an acute disk herniation, so off to surgery we went on Friday afternoon. What with 12 year old dogs not healing quite as fast as 3 year old dogs, and all that, the dear Beagle got to spend a "bonus night" in CCU, beyond the usual 2 nights post-op. She went home with her owners yesterday, just in time for me to start my second (and final!!!) week of neuro.
Last week was okay in some ways and annoying/frustrating/irritating in others. The "okay" part was that we got done pretty early in the day (and by "early" I mean that I usually left between 5:30 and 6:30). My weekly hours from Monday through Sunday totaled a mere 54 -- positively relaxing!
I guess that's all I can think of for the "okay" part. On to the irritating parts: The doctors (1 faculty neurologist and 1 neuro resident in her last week of residency) had very little interest in teaching us. They showed up late almost every morning, whether that was late to rounds or late to a morning meeting time we'd agreed upon over the weekend. They would blithely rush through procedures and exams with nary a word of explanation to us students, and often with a great sigh or eye roll if we dared to ask a question about what the heck they were doing.
The faculty neurologist in particular had a horrendous attitude toward just about everybody else in the VTH -- clients, interns, lab personnel, receptionists, other departments, etc. I'm not sure I ever heard him speak to or about somebody else without a tone of arrogance, condescension, and derision. As an example, one of the patients we saw had been referred to the teaching hospital by another board-certified neurologist about an hour's drive away. Upon hearing her name, instead of saying, "She's not one of my favorite people" or "I prefer not to work with her," our faculty neurologist stated, "God, I hate that f***ing woman." Professionalism, where are you??
This attitude continued: About a prospective client trying unsuccessfully to send digital video of her dog's neurologic signs, he commented "Are they stupid or idiots or just trying to make my day even worse?" There was a huge fiasco when the doctors were only able to obtain a small amount of spinal fluid during a spinal tap, and thus had to submit several slides of the fluid to the lab rather than vials of fluid, as is usually preferred. On the lab report, there was a comment about the results being limited because the submitted sample came in the form of slides, not actual fluid to work with. Our faculty neurologist flipped out, raging about how condescending the clinical pathologists were, how it was so out of line for them to imply that he was stupid or incompetent, and how he was sick of people trying to tell him how to do his job. When he received a page from someone saying "If you're not busy or you have a moment, could you please call code #11," he derided the caller, muttering "Oh, like I'm not busy? Like I'm just sitting here twiddling my thumbs just waiting for someone to page me?" One of my favorite occurrences was when the faculty neurologist and the resident walked into the (approximately 10' square) neuro rounds room, loudly discussing how the senior students that come onto neuro rotation are never prepared and can't remember even basic information and how frustrating it is to deal with all of us, when us 3 seniors were already sitting in the rounds room, and the doctors continued their conversation about our incompetence as though we weren't even there. (Never mind that they are the ones that have been teaching us neurology for the last 3 years; never mind that theirs is one of the only specialty departments in the VTH that doesn't provide an orientation handout or list of topics to review before starting the rotation; never mind that, although we are still student doctors with a great deal to learn, we are nonetheless human and don't enjoy being mocked.)
Teaching moments last week were very sporadic; we never had afternoon rounds and only had limited morning rounds due to the doctors' tardiness and disinterest in going through learning topics. After the first couple days, we gave up trying to ask questions and get explanations for things.
Well, fortunately both of those doctors are off clinics this week and we have the other faculty neurologist on with us. He certainly has his own quirks and isn't perfect by any means, but in relative terms, it's a complete 180 from last week. We spent probably 4 hours during the course of today just sitting as a group and discussing cases and topics. He asked us to start a list on the board of things we'd like to discuss in morning rounds. We actually had case rounds this afternoon. We were invited to come along to help with neuro consultations for other departments, rather than being left in the rounds room to wonder where the doctors had disappeared to. Best of all, there was no mocking or deriding anybody all day!
Neuro is still not my favorite rotation, and I'm greatly looking forward to its conclusion. But it's nice to see how a simple change in faculty can make all the difference in a rotation.
Monday, June 27, 2011
Adios, Internal Medicine: On to Neurology
My first two weeks of Internal Medicine ended on a happy note, when my very sick little patient of colonoscopy fame who spent a full 12 days in CCU was finally discharged.
Unfortunately, that kiddo's discharge to his loving family didn't happen until I'd spent a personal record of 73 hours at the VTH in a 7 day time period, including 9 hours this weekend.
It's okay, sleep is overrated. At least that's what I'm telling myself to keep from sobbing in the corner. Thank goodness for the 5 hours of naps I logged this weekend.
Internal Medicine started as a pretty stressful rotation for me. The cases are multifaceted and complicated. Internists have to have a vast knowledge base that encompasses clinical pathology, surgery, radiology, pharmacology, neurology, and many other subjects. Plus it was my first specialty rotation, having only been on community practice previously.
However, I really settled into Internal Medicine well after the first couple days, if I do say so myself. I put in long hours at school (averaged 12-13 hours on weekdays), and often spent an additional 1-2 hours studying up at home in the evening on the things from that day that I needed a refresher on.
So it was gratifying when the head internal medicine clinician from last week pulled me aside on Friday to tell me how much I had impressed him, that my medical knowledge at this stage in my career is "amazing," and that I was "leaps and bounds" ahead of my classmates on this rotation. I'll also admit to a little extra pride when one of my rotation-mates said to me at the end of the weeks "So this is what you're going to do after vet school, right?" and I said no, I want to do general practice, and they said "But you're so awesome at this!"
OK, let's move on to neurology and bring on the humility.
It's always a little challenging to start a new rotation (haha, as though I really know what I'm talking about, this being only my 3rd rotation -- maybe it gets easier as the year progresses?).
Each rotation is staffed by completely different doctors, nurses, and support staff. They have different procedures, different forms, different paperwork to complete. Appointment schedules are different; procedures for new patients versus rechecks versus inpatients vary widely. I've heard the senior year of vet school compared to starting a brand new job every 2 weeks, and that's really what it feels like sometimes. Just when you've had a good 10-14 days to settle into knowing how to deal with the clinicians and nurses, which forms go where, who calls the owners every day, and where all of the supplies live, it's time to up and move on to something totally different. It's frustrating.
Neurology started this morning with both of the doctors arriving late, then doing a very brief orientation, then shuffling us off to handle transfers, inpatients, and new appointments.
While I have to admit that I've not been looking forward to my neuro rotation since neuro has historically not been one of my favorite subjects, I nonetheless feel that that attitude toward neurology has not colored the following opinion I developed after my first day of neuro today: The neuro doctors are some of the pissiest, whiniest clinicians I've ever met.
I'm serious. The day started off with a round of bitching about clients that want to come visit at "inopportune" times for the doctors (i.e. any time on weekends other than 8-9 am), how the other services always want neuro to help with their cases that have neurologic dysfunctions, how the CCU nurses call them at night (when one of the CCU patients meets the "call the clinician if" criteria written down by the clinicians themselves, I might add) to ask about how to handle an exceedingly painful inpatient, etc. There was no end to the things that these people found to complain about (and not very nicely).
It was pretty funny to hear the contrast between the neuro doctors, who seem to have an attitude of "I am the almighty doctor and I will say what hours you can visit your dog and if you show up at a different time then God be with your soul," versus the internal medicine doctors, who, in my opinion, were much better at caring for clients in addition to caring for pets, and were willing to stay an extra hour or two on a Saturday morning so an owner could come visit, or discharge a hospitalized patient at 6:30 pm after the owners got off of work instead of insisting on a 4:30 discharge appointment.
I'm trying (and I think succeeding) not to take the bitchy attitudes personally. I feel that certainly on the first day of any rotation, it's reasonable to give the new students a little leeway and help them along and overlook (or point out politely) minor errors that have been made in procedures. And yes, we'll all become more efficient within a couple days of being neuro students -- hey, we were a lot faster by the end of the first day already.
So take a chill pill, docs! Otherwise it's gonna be one heck of a rotation...
Unfortunately, that kiddo's discharge to his loving family didn't happen until I'd spent a personal record of 73 hours at the VTH in a 7 day time period, including 9 hours this weekend.
It's okay, sleep is overrated. At least that's what I'm telling myself to keep from sobbing in the corner. Thank goodness for the 5 hours of naps I logged this weekend.
Internal Medicine started as a pretty stressful rotation for me. The cases are multifaceted and complicated. Internists have to have a vast knowledge base that encompasses clinical pathology, surgery, radiology, pharmacology, neurology, and many other subjects. Plus it was my first specialty rotation, having only been on community practice previously.
However, I really settled into Internal Medicine well after the first couple days, if I do say so myself. I put in long hours at school (averaged 12-13 hours on weekdays), and often spent an additional 1-2 hours studying up at home in the evening on the things from that day that I needed a refresher on.
So it was gratifying when the head internal medicine clinician from last week pulled me aside on Friday to tell me how much I had impressed him, that my medical knowledge at this stage in my career is "amazing," and that I was "leaps and bounds" ahead of my classmates on this rotation. I'll also admit to a little extra pride when one of my rotation-mates said to me at the end of the weeks "So this is what you're going to do after vet school, right?" and I said no, I want to do general practice, and they said "But you're so awesome at this!"
OK, let's move on to neurology and bring on the humility.
It's always a little challenging to start a new rotation (haha, as though I really know what I'm talking about, this being only my 3rd rotation -- maybe it gets easier as the year progresses?).
Each rotation is staffed by completely different doctors, nurses, and support staff. They have different procedures, different forms, different paperwork to complete. Appointment schedules are different; procedures for new patients versus rechecks versus inpatients vary widely. I've heard the senior year of vet school compared to starting a brand new job every 2 weeks, and that's really what it feels like sometimes. Just when you've had a good 10-14 days to settle into knowing how to deal with the clinicians and nurses, which forms go where, who calls the owners every day, and where all of the supplies live, it's time to up and move on to something totally different. It's frustrating.
Neurology started this morning with both of the doctors arriving late, then doing a very brief orientation, then shuffling us off to handle transfers, inpatients, and new appointments.
While I have to admit that I've not been looking forward to my neuro rotation since neuro has historically not been one of my favorite subjects, I nonetheless feel that that attitude toward neurology has not colored the following opinion I developed after my first day of neuro today: The neuro doctors are some of the pissiest, whiniest clinicians I've ever met.
I'm serious. The day started off with a round of bitching about clients that want to come visit at "inopportune" times for the doctors (i.e. any time on weekends other than 8-9 am), how the other services always want neuro to help with their cases that have neurologic dysfunctions, how the CCU nurses call them at night (when one of the CCU patients meets the "call the clinician if" criteria written down by the clinicians themselves, I might add) to ask about how to handle an exceedingly painful inpatient, etc. There was no end to the things that these people found to complain about (and not very nicely).
It was pretty funny to hear the contrast between the neuro doctors, who seem to have an attitude of "I am the almighty doctor and I will say what hours you can visit your dog and if you show up at a different time then God be with your soul," versus the internal medicine doctors, who, in my opinion, were much better at caring for clients in addition to caring for pets, and were willing to stay an extra hour or two on a Saturday morning so an owner could come visit, or discharge a hospitalized patient at 6:30 pm after the owners got off of work instead of insisting on a 4:30 discharge appointment.
I'm trying (and I think succeeding) not to take the bitchy attitudes personally. I feel that certainly on the first day of any rotation, it's reasonable to give the new students a little leeway and help them along and overlook (or point out politely) minor errors that have been made in procedures. And yes, we'll all become more efficient within a couple days of being neuro students -- hey, we were a lot faster by the end of the first day already.
So take a chill pill, docs! Otherwise it's gonna be one heck of a rotation...
Friday, June 17, 2011
Artificial sphincter to the rescue!
Yesterday I participated in my first canine colonoscopy (okay, my first colonoscopy with any species) and debuted in the role of "artificial sphincter."
To explain: a colonoscopy is a small camera on an approximately 1/2-inch diameter cable placed into the rectum and advanced through the colon, and into the small intestine if possible.
Normally, the colon and intestines are pretty collapsed down on themselves, not just sitting wide open. So in order to be able to look around and visualize the inner surfaces of the bowel, it's necessary to blow a substantial quantity of air into the colon using the endoscope, to inflate everything.
The patient receives multiple enemas before the procedure to help clean things out, since it's a lot harder to see what the intestine looks like if there's poop all over it, but there is invariably a small amount of fecal material left, which is remedied by rinsing with water or saline through the endoscope.
Under the influence of general anesthesia, sphincters relax. It's possible to have spontaneous release of bladder and bowels. This makes it easier to pass the endoscope through the anus, but it also means that the water and air that are being infused into the colon through the endoscope have an easy means of escape through the loosened sphincter.
This is where I come in: artificial sphincter to the rescue!
No, it's not as exciting as it sounds.
Yes, it is absolutely as disgusting as it sounds.
Step #1: Wear your clinic smock over your nice clothes. Remove watch. Don latex gloves.
Step #2: Use your fingers to pinch the anus closed around the endoscope cable.
Step #3: Ignore the vibrations and farting sounds as small amounts of air leak out from the anus. Ignore the liquid fecal matter dripping out onto your (gloved) fingers.
Step #4: Smile idiotically as your rotation-mate, who is going to do her grand rounds presentation on this patient, snaps photos.
Step #5: Blog about it. (Oops, forgot Step #4a: remove gloves, wash hands.)
Yes, it was a once-in-a-lifetime experience, which is just fine, because it's not an experience that I ever need to have again. That was just a little more intimate with a dog's anal sphincter than I usually prefer to be.
(As an aside: this dog has been my patient since his arrival in hospital on Wednesday, and I'm hoping he can go home tomorrow. He is my favorite patient so far in senior year, and by far my most interesting and involved case. I'm hoping to have some time this weekend to blog about the cute little fellow!)
To explain: a colonoscopy is a small camera on an approximately 1/2-inch diameter cable placed into the rectum and advanced through the colon, and into the small intestine if possible.
Normally, the colon and intestines are pretty collapsed down on themselves, not just sitting wide open. So in order to be able to look around and visualize the inner surfaces of the bowel, it's necessary to blow a substantial quantity of air into the colon using the endoscope, to inflate everything.
The patient receives multiple enemas before the procedure to help clean things out, since it's a lot harder to see what the intestine looks like if there's poop all over it, but there is invariably a small amount of fecal material left, which is remedied by rinsing with water or saline through the endoscope.
Under the influence of general anesthesia, sphincters relax. It's possible to have spontaneous release of bladder and bowels. This makes it easier to pass the endoscope through the anus, but it also means that the water and air that are being infused into the colon through the endoscope have an easy means of escape through the loosened sphincter.
This is where I come in: artificial sphincter to the rescue!
No, it's not as exciting as it sounds.
Yes, it is absolutely as disgusting as it sounds.
Step #1: Wear your clinic smock over your nice clothes. Remove watch. Don latex gloves.
Step #2: Use your fingers to pinch the anus closed around the endoscope cable.
Step #3: Ignore the vibrations and farting sounds as small amounts of air leak out from the anus. Ignore the liquid fecal matter dripping out onto your (gloved) fingers.
Step #4: Smile idiotically as your rotation-mate, who is going to do her grand rounds presentation on this patient, snaps photos.
Step #5: Blog about it. (Oops, forgot Step #4a: remove gloves, wash hands.)
Yes, it was a once-in-a-lifetime experience, which is just fine, because it's not an experience that I ever need to have again. That was just a little more intimate with a dog's anal sphincter than I usually prefer to be.
(As an aside: this dog has been my patient since his arrival in hospital on Wednesday, and I'm hoping he can go home tomorrow. He is my favorite patient so far in senior year, and by far my most interesting and involved case. I'm hoping to have some time this weekend to blog about the cute little fellow!)
Tuesday, June 14, 2011
Goodbye Community Practice, hello Internal Medicine
Community Practice is done, which is somewhat bittersweet. Sure, there were a lot of things about CP that I didn't like or that got old after a whole month, but overall it was an enjoyable rotation (which is good, since I think that my career goal after vet school is basically CP-type employment).
My first two days on Small Animal Internal Medicine (SAIM) have provided an interesting compare-and-contrast to Community Practice (CP). Here are a few of the variations:
CP clients are, overall, pretty nice but usually come with a financial limit. There's plenty of haggling over which heartworm medication to prescribe ($35 for 6 months versus $45 for 6 months), whether diagnostics like cytology of a skin mass (~$35) fit into the budget today, that sort of thing. CP clients are to always be advised of the cost of everything before we do any procedures or diagnostics -- even things as simple as vaccines or a nail trim.
SAIM clients arrive at the VTH having already been informed of the ~$90 exam fee. That means that they are aware that, just by walking in the door to see a specialist, they will be spending roughly a hundred dollars before we get to any bloodwork, urinalysis, xrays, ultrasounds, CT, MRI, anesthesia, surgery, endoscopy, cytology, biopsies, or myriad treatments. Most SAIM clients have already had their pet's problem(s) worked up by their referring DVM (rDVM), meaning they've likely already shelled out quite a bit of money before arriving at the VTH.
CP clients tend to be intelligent people who are not overly familiar with veterinary medicine, wellness care such as vaccine schedules, and the benefits of screening tests such as annual bloodwork and fecal exams. Their level of compliance with such recommendations is quite variable.
SAIM clients have typically done a lot of research into their pet's suspected illness, whether through the Internet, their rDVM, or multiple other consults before they came to us. They tend to be familiar with causes, complications, and treatments for their pet's disease, and are often quite comfortable with medical terminology.
CP sets a time limit for appointments: a goal of getting the client from the front desk checking to the client service desk checking out in under an hour. This goal is not always met, if CP is very busy or if the pet has complicated medical problems requiring diagnostics, but it is a goal just the same. CP clients tend to keep one eye on the clock throughout the entire visit and will readily inform you if you took 25 minutes instead of the 20 minutes you told them they would have to wait.
SAIM clients often spend an entire morning or afternoon in the waiting area or exam room while their pet is seen by one or more students and one or more doctors, in addition to diagnostics such as bloodwork and imaging. They tend not to bat an eye when they've already been at the VTH for 2 hours and you tell them you'll need to borrow their pet for yet another 30 minutes so you can take radiographs.
CP students can see quite a few patients in one day. On our very busiest CP days, we probably saw 35-40 appointments with 7-9 students sharing the case load.
SAIM students see generally 1 or 2 new cases per day, plus maybe some rechecks in the afternoon for ongoing cases. They may also have 1 or 2 hospitalized animals that are housed at the VTH overnight and on weekends to manage an illness or for owners' convenience the night before a procedure.
CP students have "topic rounds" in the morning, lasting about an hour and covering such themes as "new puppy visit," "new kitten visit," "heartworm disease," and "feline upper respiratory infections." CP students have "case rounds" in the afternoon, lasting 20-60 minutes and briefly discussing all of the appointments from the day.
SAIM students have topic/case rounds in the morning, lasting 60-90 minutes and including updates on all of the inpatients from the previous night, as well as often discussing one or two internal medicine topics (like diabetes or renal failure). SAIM students have afternoon/evening case rounds, lasting 1-2 hours and discussing most of the day's cases, especially any patients staying in the hospital overnight.
Two of the most stressful things about SAIM are (1) presenting cases to clinicians and (2) discussing cases in rounds.
Presenting a case to a clinician goes something like this: The SAIM student retrieves the paperwork, client, and pet from the waiting area, escorts them to an exam room, and spends 20-30 minutes (less if a recheck) getting a history and physical exam completed. The student then leaves the client and pet in the room, pages the clinician to the rounds room, then tells them about the case. You start with the signalment (pet's name, species/breed, sex, reproductive status, and age), then the presenting complaint, then the history, and finally your physical exam findings. Next the clinician asks for your problem list -- the list of each thing that is wrong with the animal (e.g. vomiting, coughing, lethargy, elevated liver enzymes on bloodwork from rDVM, etc.). Then you go through each problem one at a time and tell the clinician your "differential diagnoses" (what possible diseases could be causing the problem), rank your differential diagnoses from most to least likely based on the other findings, and discuss what further diagnostic steps you would need to take to prove or disprove each differential diagnosis.
Presenting cases to clinicians is somewhat harrowing because, for some reason, your brain tends to completely shut off when you are sitting down one-on-one with somebody with much more education and experience than you. It's something that I'm sure gets easier with practice, but at this point in our senior year we find that it's altogether too easy to misspeak, second guess ourselves, and overthink even simple problems.
Discussing cases in rounds is probably even more stressful. This means you're sitting in the cramped rounds room with 8 other senior students, the head faculty clinician, and 4 other doctors (interns and residents). The head clinician basically grills you, in front of everyone else, on the nitty gritty details of your case, the pathophysiology of the pet's disease, the pharmacological actions of the drugs you've chosen, the possible causes for all the abnormalities on the labwork, and anything else they can think of. There is lots of awkward silence while everyone avoids eye contact to minimize the chance of being asked about someone else's case -- and lots of empathy toward the poor individual stuck in the spotlight until their case has been thoroughly dissected.
Overall SAIM is a lot less physically exhausting than CP, because, for one thing, the rounds room and treatment area are right next to the lobby rather than at the farthest end of the hospital where CP is located. Second, seeing only 1-2 new patients a day means a lot less animal handling. Third, there is a group of 4-5 technicians who are dedicated to SAIM and extremely capable of obtaining blood and urine samples or restraining for procedures while you go off to research your case or discuss it with the clinician. So it's nice not to be on my feet quite as much, not to be racing around the hospital all the time, and not to be wrestling large dogs everywhere I turn.
However, SAIM is undoubtedly a much greater mental challenge than CP. It's a struggle sometimes to recall all of the important yet very detailed information I've learned about anatomy and physiology and disease processes over 3 intense years of classroom teaching, and to put it into practice when much of our previous style of exams has been more about regurgitation of facts than about decision making with real life case examples. And I just want to point out that many of the cases that we've seen in the last 2 days are referrals from rDVMs who had already tried and failed to diagnose the pet's illness. So it's not like they're just run-of-the-mill cases.
In any case, it's definitely going to be a fantastic learning experience and a challenge to my brain -- and I think I'll feel like it's been a rewarding experience at the end of my 2 weeks when (hopefully) I've become a little better at planning my case work-ups and thinking of logical differentials and diagnostics to pursue.
My first two days on Small Animal Internal Medicine (SAIM) have provided an interesting compare-and-contrast to Community Practice (CP). Here are a few of the variations:
CP clients are, overall, pretty nice but usually come with a financial limit. There's plenty of haggling over which heartworm medication to prescribe ($35 for 6 months versus $45 for 6 months), whether diagnostics like cytology of a skin mass (~$35) fit into the budget today, that sort of thing. CP clients are to always be advised of the cost of everything before we do any procedures or diagnostics -- even things as simple as vaccines or a nail trim.
SAIM clients arrive at the VTH having already been informed of the ~$90 exam fee. That means that they are aware that, just by walking in the door to see a specialist, they will be spending roughly a hundred dollars before we get to any bloodwork, urinalysis, xrays, ultrasounds, CT, MRI, anesthesia, surgery, endoscopy, cytology, biopsies, or myriad treatments. Most SAIM clients have already had their pet's problem(s) worked up by their referring DVM (rDVM), meaning they've likely already shelled out quite a bit of money before arriving at the VTH.
CP clients tend to be intelligent people who are not overly familiar with veterinary medicine, wellness care such as vaccine schedules, and the benefits of screening tests such as annual bloodwork and fecal exams. Their level of compliance with such recommendations is quite variable.
SAIM clients have typically done a lot of research into their pet's suspected illness, whether through the Internet, their rDVM, or multiple other consults before they came to us. They tend to be familiar with causes, complications, and treatments for their pet's disease, and are often quite comfortable with medical terminology.
CP sets a time limit for appointments: a goal of getting the client from the front desk checking to the client service desk checking out in under an hour. This goal is not always met, if CP is very busy or if the pet has complicated medical problems requiring diagnostics, but it is a goal just the same. CP clients tend to keep one eye on the clock throughout the entire visit and will readily inform you if you took 25 minutes instead of the 20 minutes you told them they would have to wait.
SAIM clients often spend an entire morning or afternoon in the waiting area or exam room while their pet is seen by one or more students and one or more doctors, in addition to diagnostics such as bloodwork and imaging. They tend not to bat an eye when they've already been at the VTH for 2 hours and you tell them you'll need to borrow their pet for yet another 30 minutes so you can take radiographs.
CP students can see quite a few patients in one day. On our very busiest CP days, we probably saw 35-40 appointments with 7-9 students sharing the case load.
SAIM students see generally 1 or 2 new cases per day, plus maybe some rechecks in the afternoon for ongoing cases. They may also have 1 or 2 hospitalized animals that are housed at the VTH overnight and on weekends to manage an illness or for owners' convenience the night before a procedure.
CP students have "topic rounds" in the morning, lasting about an hour and covering such themes as "new puppy visit," "new kitten visit," "heartworm disease," and "feline upper respiratory infections." CP students have "case rounds" in the afternoon, lasting 20-60 minutes and briefly discussing all of the appointments from the day.
SAIM students have topic/case rounds in the morning, lasting 60-90 minutes and including updates on all of the inpatients from the previous night, as well as often discussing one or two internal medicine topics (like diabetes or renal failure). SAIM students have afternoon/evening case rounds, lasting 1-2 hours and discussing most of the day's cases, especially any patients staying in the hospital overnight.
Two of the most stressful things about SAIM are (1) presenting cases to clinicians and (2) discussing cases in rounds.
Presenting a case to a clinician goes something like this: The SAIM student retrieves the paperwork, client, and pet from the waiting area, escorts them to an exam room, and spends 20-30 minutes (less if a recheck) getting a history and physical exam completed. The student then leaves the client and pet in the room, pages the clinician to the rounds room, then tells them about the case. You start with the signalment (pet's name, species/breed, sex, reproductive status, and age), then the presenting complaint, then the history, and finally your physical exam findings. Next the clinician asks for your problem list -- the list of each thing that is wrong with the animal (e.g. vomiting, coughing, lethargy, elevated liver enzymes on bloodwork from rDVM, etc.). Then you go through each problem one at a time and tell the clinician your "differential diagnoses" (what possible diseases could be causing the problem), rank your differential diagnoses from most to least likely based on the other findings, and discuss what further diagnostic steps you would need to take to prove or disprove each differential diagnosis.
Presenting cases to clinicians is somewhat harrowing because, for some reason, your brain tends to completely shut off when you are sitting down one-on-one with somebody with much more education and experience than you. It's something that I'm sure gets easier with practice, but at this point in our senior year we find that it's altogether too easy to misspeak, second guess ourselves, and overthink even simple problems.
Discussing cases in rounds is probably even more stressful. This means you're sitting in the cramped rounds room with 8 other senior students, the head faculty clinician, and 4 other doctors (interns and residents). The head clinician basically grills you, in front of everyone else, on the nitty gritty details of your case, the pathophysiology of the pet's disease, the pharmacological actions of the drugs you've chosen, the possible causes for all the abnormalities on the labwork, and anything else they can think of. There is lots of awkward silence while everyone avoids eye contact to minimize the chance of being asked about someone else's case -- and lots of empathy toward the poor individual stuck in the spotlight until their case has been thoroughly dissected.
Overall SAIM is a lot less physically exhausting than CP, because, for one thing, the rounds room and treatment area are right next to the lobby rather than at the farthest end of the hospital where CP is located. Second, seeing only 1-2 new patients a day means a lot less animal handling. Third, there is a group of 4-5 technicians who are dedicated to SAIM and extremely capable of obtaining blood and urine samples or restraining for procedures while you go off to research your case or discuss it with the clinician. So it's nice not to be on my feet quite as much, not to be racing around the hospital all the time, and not to be wrestling large dogs everywhere I turn.
However, SAIM is undoubtedly a much greater mental challenge than CP. It's a struggle sometimes to recall all of the important yet very detailed information I've learned about anatomy and physiology and disease processes over 3 intense years of classroom teaching, and to put it into practice when much of our previous style of exams has been more about regurgitation of facts than about decision making with real life case examples. And I just want to point out that many of the cases that we've seen in the last 2 days are referrals from rDVMs who had already tried and failed to diagnose the pet's illness. So it's not like they're just run-of-the-mill cases.
In any case, it's definitely going to be a fantastic learning experience and a challenge to my brain -- and I think I'll feel like it's been a rewarding experience at the end of my 2 weeks when (hopefully) I've become a little better at planning my case work-ups and thinking of logical differentials and diagnostics to pursue.
Saturday, June 11, 2011
I can only tell you so many times
I saw a sweet little lab mix last Tuesday named Copper, after she was seen by our emergency department last weekend for an exam after one of the small children in the family accidentally closed Copper's tail in a door. Much of the skin on the end of Copper's tail had been pulled off in the injury, and she had soft tissue and bone sticking out the end of her tail with not enough skin left to do a surgical closure over the exposed bone and tissue.
CCU bandaged Copper's tail and sent her home with an e-collar, antibiotics, and pain meds, with instructions to have the bandage changed on Tuesday at the owner's regular vet or at Community Practice. They also advised the owner that it was entirely possible that the tail injury would not heal on its own and may require surgical amputation, but the family had financial constraints that limited them to a bandage and supportive care at this point.
Copper arrived at Community Practice on Tuesday, tail cautiously wagging and e-collar banging into everything in the waiting room, surrounded by a gaggle of children under 5 (four kids, to be exact) and a rather exhausted looking mom.
It was a good thing Copper had a bandage change already scheduled, because her bandage had fallen off that morning anyway.
On physical exam, Copper's tail was very clearly painful and didn't appear to be healing, although it was still a little early to tell, being only 3-4 days out from her injury. We placed a sterile nonstick pad over the exposed end of the tail and wrapped the tail in a sticky, stretchy bandaging material called elasticon.
I sent Copper home with mom & children, with an agreement to see her back for a bandage change and recheck on Friday (3 days later). The hospital has a system for readmitting patients during a Monday-through-Friday time frame called "orange sheeting." Normally, when a patient's visit is concluded, the student turns in the fee sheet to the business office (oops, we are supposed to call it "client services" now), and the billing staff put the charges into the computer then have the client pay for the day's fees and close out the invoice. Every time an animal has a new appointment, there must be an associated charge (unless we do something special to write it off) -- the exception being orange sheeting, where you fill out an orange sheet for your patient and turn it in to the receptionist with a time written on it that the patient will be coming back for a "readmit" appointment later that same week -- then you just keep the fee sheet until all of that patient's appointments for that week are concluded, and turn it in at the end of the week when they have their final checkout -- thus saving the client recheck fees or exam fees or whatever else would have been charged for opening a new set of paperwork every day.
So Copper's mom & I agreed to see her at noon on Friday, meaning I kept Copper's fee sheet and other paperwork and put in an appointment for her at the reception desk.
On Wednesday, I made a quick follow-up phone call to Copper's mom to see if the bandage had stayed on and to ask how Copper was doing overall. There was no answer, so I left a voicemail, concluding with "Please call if you have any questions or concerns, otherwise we will see Copper at noon on Friday."
On Thursday, one of the Community Practice technicians went through the schedule for Friday appointments and called each of the clients to confirm their appointment time on Friday (i.e. "I'm calling to confirm Copper's appointment for a bandage change at noon on Friday, please call back if you need to change this.").
On Friday, noon rolled around and I waited for Copper's appointment to turn green (we have a flat screen TV in each of the rounds rooms that displays that service's appointment calendar; appointments are initially purple or yellow or some other color that denotes what kind of appointment it is, then the front desk makes the appointment color change to green whenever the client checks in at the front desk).
By 12:10 pm, the Copper's appointment wasn't green, so I went up to the waiting area to check and see if Copper had arrived, just in case the receptionists had forgotten to turn her appointment green, or if there was a computer glitch, which is not unheard of. No Copper, no Copper's mom.
I got caught up helping a classmate with their patient for a few minutes, and at 12:30 I finally had a chance to call Copper's mom.
"Hello, I'm calling from the veterinary teaching hospital. We had Copper down for a 12 pm appointment?"
"Oh!" said Copper's mom, clearly surprised. "I was sure her appointment was at 3."
"Hmmm... Can you bring her in any earlier?" I asked, knowing that our last Friday appointment is typically at 1:30 pm, and all the students and clinicians skedaddle as fast as humanly possible once the last appointment and afternoon rounds are over.
"I don't know -- my husband has Copper right now -- let me call his cell phone and I'll get right back to you," replied Copper's mom. I made sure she had the correct phone number for the direct line to Community Practice, and hung up.
By 1 pm, Copper's mom still had not called back, so I tried her number again (the only phone number in her record). No answer, so I left a voicemail asking her to please call back as soon as possible.
By 1:30 pm, my next patient (and the last scheduled appointment of the day) had arrived, so I left one last voicemail for Copper's mom, advising her that we were at the end of our appointment schedule, and I had tried repeatedly to get a hold of her, and unfortunately, she would just have to reschedule Copper's bandage change for Monday and call CCU or Urgent Care over the weekend if Copper needed treatment before that.
I was bummed, first of all because I was interested to see how the bandage I had applied had held up and if Copper's tail had started to show any inclination to heal on its own.
But I was also sorry that Copper's mom will almost assuredly end up paying far more in fees for Copper's care because of missing her Friday appointment. We would have saved her at least $25-35 just from orange sheeting Copper this week, plus we had bought a whole roll of elasticon on Copper's account, and kept it at the hospital, planning to use more of it to rebandage Copper's tail on Friday and teach mom how to do it at home. If Copper needs a bandage change over the weekend, she'll not only have to pay the $89 exam fee but also a bandage change fee and the cost of new bandaging material.
It's really too bad that we apparently had some kind of miscommunication about Copper's appointment time, but I can't for the life of me figure out how that happened. It was Copper's mom who, on Tuesday, selected what time would work for her best to come back on Friday. In addition to us agreeing on noon when she left on Tuesday, she had 2 voicemails after that that both told her the appointment was at noon -- which is one more than most owners get, and most clients still manage to remember the correct appointment time.
Just hope Copper is feeling okay this weekend, and that she hasn't run out of the pain meds that we planned to refill for her yesterday...
CCU bandaged Copper's tail and sent her home with an e-collar, antibiotics, and pain meds, with instructions to have the bandage changed on Tuesday at the owner's regular vet or at Community Practice. They also advised the owner that it was entirely possible that the tail injury would not heal on its own and may require surgical amputation, but the family had financial constraints that limited them to a bandage and supportive care at this point.
Copper arrived at Community Practice on Tuesday, tail cautiously wagging and e-collar banging into everything in the waiting room, surrounded by a gaggle of children under 5 (four kids, to be exact) and a rather exhausted looking mom.
It was a good thing Copper had a bandage change already scheduled, because her bandage had fallen off that morning anyway.
On physical exam, Copper's tail was very clearly painful and didn't appear to be healing, although it was still a little early to tell, being only 3-4 days out from her injury. We placed a sterile nonstick pad over the exposed end of the tail and wrapped the tail in a sticky, stretchy bandaging material called elasticon.
I sent Copper home with mom & children, with an agreement to see her back for a bandage change and recheck on Friday (3 days later). The hospital has a system for readmitting patients during a Monday-through-Friday time frame called "orange sheeting." Normally, when a patient's visit is concluded, the student turns in the fee sheet to the business office (oops, we are supposed to call it "client services" now), and the billing staff put the charges into the computer then have the client pay for the day's fees and close out the invoice. Every time an animal has a new appointment, there must be an associated charge (unless we do something special to write it off) -- the exception being orange sheeting, where you fill out an orange sheet for your patient and turn it in to the receptionist with a time written on it that the patient will be coming back for a "readmit" appointment later that same week -- then you just keep the fee sheet until all of that patient's appointments for that week are concluded, and turn it in at the end of the week when they have their final checkout -- thus saving the client recheck fees or exam fees or whatever else would have been charged for opening a new set of paperwork every day.
So Copper's mom & I agreed to see her at noon on Friday, meaning I kept Copper's fee sheet and other paperwork and put in an appointment for her at the reception desk.
On Wednesday, I made a quick follow-up phone call to Copper's mom to see if the bandage had stayed on and to ask how Copper was doing overall. There was no answer, so I left a voicemail, concluding with "Please call if you have any questions or concerns, otherwise we will see Copper at noon on Friday."
On Thursday, one of the Community Practice technicians went through the schedule for Friday appointments and called each of the clients to confirm their appointment time on Friday (i.e. "I'm calling to confirm Copper's appointment for a bandage change at noon on Friday, please call back if you need to change this.").
On Friday, noon rolled around and I waited for Copper's appointment to turn green (we have a flat screen TV in each of the rounds rooms that displays that service's appointment calendar; appointments are initially purple or yellow or some other color that denotes what kind of appointment it is, then the front desk makes the appointment color change to green whenever the client checks in at the front desk).
By 12:10 pm, the Copper's appointment wasn't green, so I went up to the waiting area to check and see if Copper had arrived, just in case the receptionists had forgotten to turn her appointment green, or if there was a computer glitch, which is not unheard of. No Copper, no Copper's mom.
I got caught up helping a classmate with their patient for a few minutes, and at 12:30 I finally had a chance to call Copper's mom.
"Hello, I'm calling from the veterinary teaching hospital. We had Copper down for a 12 pm appointment?"
"Oh!" said Copper's mom, clearly surprised. "I was sure her appointment was at 3."
"Hmmm... Can you bring her in any earlier?" I asked, knowing that our last Friday appointment is typically at 1:30 pm, and all the students and clinicians skedaddle as fast as humanly possible once the last appointment and afternoon rounds are over.
"I don't know -- my husband has Copper right now -- let me call his cell phone and I'll get right back to you," replied Copper's mom. I made sure she had the correct phone number for the direct line to Community Practice, and hung up.
By 1 pm, Copper's mom still had not called back, so I tried her number again (the only phone number in her record). No answer, so I left a voicemail asking her to please call back as soon as possible.
By 1:30 pm, my next patient (and the last scheduled appointment of the day) had arrived, so I left one last voicemail for Copper's mom, advising her that we were at the end of our appointment schedule, and I had tried repeatedly to get a hold of her, and unfortunately, she would just have to reschedule Copper's bandage change for Monday and call CCU or Urgent Care over the weekend if Copper needed treatment before that.
I was bummed, first of all because I was interested to see how the bandage I had applied had held up and if Copper's tail had started to show any inclination to heal on its own.
But I was also sorry that Copper's mom will almost assuredly end up paying far more in fees for Copper's care because of missing her Friday appointment. We would have saved her at least $25-35 just from orange sheeting Copper this week, plus we had bought a whole roll of elasticon on Copper's account, and kept it at the hospital, planning to use more of it to rebandage Copper's tail on Friday and teach mom how to do it at home. If Copper needs a bandage change over the weekend, she'll not only have to pay the $89 exam fee but also a bandage change fee and the cost of new bandaging material.
It's really too bad that we apparently had some kind of miscommunication about Copper's appointment time, but I can't for the life of me figure out how that happened. It was Copper's mom who, on Tuesday, selected what time would work for her best to come back on Friday. In addition to us agreeing on noon when she left on Tuesday, she had 2 voicemails after that that both told her the appointment was at noon -- which is one more than most owners get, and most clients still manage to remember the correct appointment time.
Just hope Copper is feeling okay this weekend, and that she hasn't run out of the pain meds that we planned to refill for her yesterday...
Tuesday, June 7, 2011
I forgot Zeke!
I meant to post a picture of last Thursday's doggie castration: Zeke, another humane society kiddo!
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