Moving on

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

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

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

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

Urgently caring for 2 more days!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes, your dog has neurologic disease

Yesterday I saw an enormous elderly Great Pyrenees named Kevin.

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

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

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

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

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

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

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

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

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

Lymphoma sucks

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

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

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

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

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

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

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

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

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

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

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

Never fails

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

I'm ready for some minions

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

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

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

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

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

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

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

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

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

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

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

Zombie pets strike again

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

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