I've had my first week of "radiation vacation," more officially known as Diagnostic Imaging rotation. It's another 3 week rotation, for which I'll get a "bonus" partial week before Christmas.
And, yeah. There's not that much to say about it. Basically we sit around the radiology department, waiting for requests for radiographs to come in. Sometimes we walk over to the patient wards to retrieve a dog or cat; sometimes the animal is brought to us. Sometimes the pet is sedated or anesthetized for radiographs; sometimes they don't need to be; sometimes they aren't sedated but should be. Sometimes we take abdominal rads or extremities (quite a few stifles), but mostly we take "met checks" (3-view thoracic radiographs).
Sometimes we take radiographs pretty much non-stop for a period of several hours. And then there are days like yesterday, when we took 3 sets of rads in 5 hours. Blechh.
On the one hand, it's nice to have a chill rotation requiring arrival at 8 am and from which we usually get to leave at 4, but always by 5. However, I'm already anticipating an extreme worsening of my current level of boredom by the time another 2.5 weeks have passed. Oh, well -- should give me some time to polish up my resume and start job-hunting!
Saturday, December 3, 2011
NAVLE, shmAVLE
I took the North American Veterinary Licensing Exam, aka NAVLE, aka "boards" 2 days ago. And it went pretty well. I've spent about 3 months doing practice questions and practice exams regularly on VetPrep, and I felt like I was pretty well prepared.
NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.
My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.
However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.
I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!
NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.
I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.
I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.
Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.
The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.
It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!
NAVLE is a computerized exam and is given in the fall during a testing window of about a month in November and December. Around here, the nearest standardized testing center where NAVLE is offered is about 35-40 minutes away.
My exam was scheduled to start at 8 am, and we were supposed to get there half an hour early to check in. So I woke up at 6 am that morning, planning to leave around 6:30 to give myself some extra time to find the testing center.
However, awaking to a mini-blizzard, I headed out at 6:20 am, which was a good decision, because with all the snow (and mostly the terrible drivers) I didn't arrive at the testing center until 7:55 am.
I was started on my exam around 8:10 am, after locking all my belongings in a locker (including my Chapstick -- how am I supposed to pass NAVLE without compulsive application of my beloved Chapstick??), and turning out my pockets, pushing up my sleeves, and shaking out my hoodie in front of a camera and a proctor with a metal detector. Hard core!
NAVLE is comprised of 6 sections, each containing 60 multiple choice questions, with 65 minutes allowed per section. You're given 15 minutes at the beginning for a computer tutorial (which included such directions as what it means to "click" a mouse button), and 45 minutes that can be used for breaks in between any of the sections.
I took the first 3 sections then gave myself a 10 minute break around 10 am. There were about 15 vet students from my class taking the exam at the same time, so those who were on break nervously chatted and snacked until we decided we ought to get going again.
I then knocked out the final 3 sections, and finished around 11:45 am. And yes, I was somewhat mocked for leaving the testing center by walking through a group of my classmates on break in the lobby, who still had half the exam left. Whatever.
Overall, VetPrep was good practice for NAVLE. My distribution of questions on NAVLE was similar to what I'd seen on VetPrep, as far as distribution of species, topics, etc. I felt like most of the questions were fair, though there were a few poorly written questions where it could easily be argued that multiple answers were correct.
The testing program gives you the option to "mark" questions that you want to come back to at the end if you have time left. I used this to mark the questions where I wasn't sure or pretty sure I knew the right answer. I consistently marked 15-20 questions per 60-question section, which, based on rumors that a score of 55-65% correct is needed for a passing grade, should be entirely adequate.
It sure feels good to have NAVLE over with. No, I won't get my score for another month or two, but I'm 99.5% sure I passed. And if not, well, that's what the spring testing window is for!
Sunday, November 27, 2011
Groundbreaking news
I did NOT get called in yesterday.
What?
You heard me.
A full 12 hours on call with no calls.
Which is common for most of my classmates, but virtually unheard-of for me.
Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!
What?
You heard me.
A full 12 hours on call with no calls.
Which is common for most of my classmates, but virtually unheard-of for me.
Let's hope this signals the dawn of a new era in which I am not called in a ridiculous number of times on every shift. Fingers crossed!
Saturday, November 26, 2011
Anesthesia: Almost done!
It's been a long, long month of Anesthesia.
Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.
What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:
Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.
Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.
Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!
Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!
Along the way, some of my more interesting patients included:
1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?
2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")
3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.
4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!
5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!
Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!
Anesthesia is typically a 3-week rotation. I had a bonus "repeat week," where any week that is 3 business days or shorter (like Thanksgiving) can't be counted as a full week for a rotation, so is added on to whatever group was on that rotation prior to the repeat week. This means that my rotation-mates and I got an extra 3 days in the clinic, and an extra 1-2 shifts on call.
What I'd heard previously from classmates who'd already had Anesthesia was that the rotation tended to go like this:
Week 1: You are stressed, not very comfortable with anesthesia, still trying to figure out where all the equipment is / what drug protocols you like / how to handle complications.
Week 2: You are starting to feel much more comfortable; the nurses and doctors generally start to leave you on your own for much longer periods of time; you feel better about experimenting with different drug choices.
Week 3: You've been doing the same thing day in and day out for 2 weeks now, and you're getting bored!
Well, I got to experience a rare Week 4, which I can tell you only accentuated to an astonishing degree the boredom and I'm-so-over-this-ishness of Week 3. Whee!
Along the way, some of my more interesting patients included:
1. A 16 year old white tiger from a big cat sanctuary who came to the VTH for assessment of a hindlimb lameness, including an MRI, CT scan, nerve and muscle testing, and ultimately an amputation. (Okay, so he wasn't actually my patient, but I got to watch!) Mr. Tiger's entourage included (required by law) a member of the county sheriff's office who followed him around with a huge loaded rifle to protect all the humans if Mr. Tiger suddenly woke up. Fun?
2. An elderly and extraordinarily vicious Great Dane with bone cancer, who was so aggressive that his owner couldn't muzzle him and nobody could get him out of the car without being bitten for two hours(!) and eventually they kind of just darted him (like the tiger!) and he stayed under anesthesia the entire time he was in the VTH building. He was so aggressive that we put him in the back of his owner's car while he was still anesthetized, and woke him up there. (Though we didn't let him wake up very much before we shut the hatch and said "Adios!")
3. An old Australian shepherd presented in severe respiratory distress and with a great deal of neck pain. Neurology assessed the dog and quickly localized a cervical spinal lesion that had impaired the phrenic nerve (the nerve that innervates the diaphragm) on both sides, causing the dog to have to breathe solely by moving its abdominal muscles, without any assistance from its diaphragm. It was in such distress and unable to ventilate itself that we anesthetized it almost immediately, though it wasn't until about 3 hours later that the dog's MRI showed some really ugly multifocal untreatable tumors in the vertebrae and spinal cord. It would have probably been a disaster to try to wake the poor dog up, so I got to sit with him (anesthetized) for another 3 hours while his owners drove back to the VTH to say goodbye before we euthanized him under anesthesia. That was a depressing Friday night.
4. A middle-aged cat who was one of the sickest kitties I've ever seen. He presented with a pyothorax (an accumulation of pus and infection within the chest cavity, which can be so severe that the fluid takes up all the space normally occupied by the lungs, and the animal dies from an inability to breathe, if not treated). This cat was hypothermic, hypoglycemic, hypotensive, and basically unresponsive when we arrived to anesthetize him to place tubes into his chest to drain the fluid. Thankfully, the critical care resident was so worried about this kitty that he called in not only the anesthesia nurse and me, but also one of the anesthesia doctors. And he also told the owners beforehand that the cat had a high likelihood of dying under anesthesia, which was a realistic thing to say and good for them to know. In the end, though, the kitty survived his chest tube placement and anesthesia, and even headed home after about another 5 days in the hospital!
5. An old Saint Bernard with a history of previous laryngeal paralysis (a condition [thought to be degenerative in nature] where the nerve that supplies the muscles that move the laryngeal cartilages stops working, so the larynx doesn't open at the appropriate time [like when you inhale], leading to respiratory difficulties). Ms. StB had already had surgery to correct her lar par 3 months earlier, but the surgeons suspected the surgery had failed, since Ms. StB's clinical signs had returned. The way to diagnose lar par is by a laryngeal exam, which means sedating/lightly anesthetizing the dog just enough that you can stick a laryngoscope waaaay back in their throat to visualize their larynx, without anesthetizing them so deeply that you lose their natural laryngeal function that you're trying to observe. Thus, we only gave Ms. StB the one drug needed to induce this plane of anesthesia. Normally, we give a combination of tranquilizers and opioids ("pre-meds") to sedate the dog prior to anesthesia induction, which makes for smoother anesthesia overall and allows us to greatly reduce the dose of the induction drug that we need to use. For example, we anesthetized Ms. StB with propofol and had to use a dose of almost 7 mg/kg, whereas we usually only need 1-3 mg/kg in a sedated dog. Unfortunately, whopping doses of propofol can cause some unpleasant side effects (like really low blood pressure), and when the surgeons determined that Ms. StB's previous surgery had indeed failed, and we headed into surgery for a correction, I got to ride the anesthesia rollercoaster with Ms. StB for another 2 hours. Moral of the story: I love pre-meds!
Today, I'm over 2 hours into my last on-call shift (8 am to 8 pm today), and (KNOCK ON WOOD) I haven't been called in yet! However, I'm predicting it's only a matter of time, since I am traditionally called in for an average of 2-3 procedures whenever I'm on surgery or anesthesia call. Plus, there are plenty of disasters for pets to have around the holidays -- I'm thinking maybe some bad dogs who ate turkey bones will show up later today. We'll see!
Tuesday, November 8, 2011
Anesthesia on-call
Last night was my second on-call shift for Anesthesia. Here's my schedule for the last 2 days:
Monday:
6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep
Tuesday:
1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!
As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!
Monday:
6:15 am: Wake up
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for my first patient of the day (a young German shepherd requiring heavy sedation for dental x-rays); set up for the case
8:00 am: Rounds
9:00 am: Sedate said German shepherd for his procedure
10:00 am: A little VetPrep in preparation for upcoming NAVLE
11:30 am: Head to CCU to formulate anesthetic plan for my second patient of the day (young male Chihuahua with urethral stones, headed for a cystourethrogram with possible cystotomy to follow, and castration)
1:00 pm: Anesthetize said Chihuahua
4:45 pm: Following cystourethrogram, cystotomy, and castration, pass Chihuahua off to a rotation-mate for recovery; step out of surgery for a brief break and a bite to eat
5:00 pm: On-call time officially begins! Head straight into an abdominal explore for a hemoabdomen due to a bleeding splenic mass in a middle-aged golden retriever
7:00 pm: Euthanize golden retriever intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen
7:15 pm: Anesthetize elderly beagle for an abdominal explore for a hemoabdomen due to a bleeding splenic mass (sounds familiar, eh?)
9:00 pm: Euthanize beagle intra-op at owner's request due to gross evidence of metastatic cancer in the abdomen (familiar again)
9:30 pm: Arrive home
10:30 pm: Fall asleep
Tuesday:
1:45 am: Awakened by manic techno ringtone by the overnight intern calling me in to anesthetize an Australian shepherd with pyometra
2:00 am: Arrive at school and formulate anesthetic plan
2:30 am: Anesthetize said Aussie
4:30 am: End of surgery; recover Aussie (slowly) in CCU
5:15 am: Arrive home
5:45 am: Give up trying to fall asleep; eat a PB&J sandwich; watch an episode of "House"
6:45 am: Leave for school
7:00 am: Formulate anesthetic plan for young Toy Poodle requiring upper GI endoscopy and colonoscopy
8:00 am: Rounds
9:00 am: Poodle is expected to be ready to go around noon; time for more VetPrep
10:15 am: Poodle has been pushed back to late afternoon because he hasn't yet had sufficient enemas (poor guy); get permission from supervising anesthesiologist to go home and sleep for awhile
11:00 am: Asleep!
2:00 pm: Awakened by annoying alarm clock; have a little lunch (breakfast? dinner?)
2:45 pm: Arrive back at school; learn that Poodle's procedure has been pushed back to tomorrow
3:00 pm: Take over anesthetic monitoring of a canine thyroid mass resection from a rotation-mate who was at school all night as well (though he was admittedly here by choice, as a paid surgery technician)
5:30 pm: Recover thyroid mass dog in CCU; formulate anesthetic plan for my second patient for tomorrow (Dachshund needing a dental and skin mass removal)
6:00 pm: Leave school, again (this routine is getting old); swing by Culver's for a proper dinner of cheeseburger and fries, followed by some brain deactivation time (watched an episode of "Pan Am" on Hulu), then house cleaning
9:30 pm: Gearing up to go to bed; might get 8 hours tonight!
As a junior I remember overhearing the then-seniors talking about their schedules, hours put in during evenings and weekends, plus on-call shifts, and wondering how they did it. The answer I've learned is, you just do it. There's not really much of a choice, anyhow, and you can only hope that when you spend all night at school during an on-call shift, the heads of your rotation are merciful enough to let you take a couple hours for a nap or send you home early. I'm not envious of whoever's on-call for anesthesia tonight because there were several surgeries already lined up when I left this evening, and we have 19 anesthetics scheduled for tomorrow (there are typically 9-12 procedures a day, with 9 students) -- yeesh!
Saturday, November 5, 2011
Anesthesia, Week 1
I've just finished my first of several weeks of Anesthesia. It's typically a 3 week rotation, but since mine falls over Thanksgiving, I get an extra 3 regular days plus a "bonus" fourth on-call shift.
Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.
It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.
So, to review my first case:
1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.
Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.
That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.
On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.
Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.
My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.
The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.
Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.
Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.
Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.
However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.
Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.
However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!
Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.
Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!
Anesthesia kind of freaks me out (and always has). So I was fairly petrified before my first case on Monday. Mondays are usually slower days on Anesthesia, because many of our patients later in the week end up scheduled for anesthesia the day after an appointment for a surgery consult, neurology assessment, internal medicine consult, etc.
It didn't look like I was going to even have a case on Monday, until an ophthalmology emergency arrived at 3 pm. It was an elderly small-breed dog with a raging heart murmur (probable mitral valve disease) whose attempt at medically managing her infected corneal ulcer had completely failed, resulting in what would very soon be a ruptured eyeball without surgical intervention.
So, to review my first case:
1. Emergency. No time to plan or look things up in my notes.
2. Old dog (12 years).
3. Heart disease that the ophthalmology service didn't even notice (apparently they only deal with eyeballs?) and which had never been worked up with any diagnostics like chest x-rays, echo, or EKG.
4. Ophthalmology patient, meaning a likely need to paralyze the dog while under anesthesia to keep the eye from moving at all while they worked on it. Paralyzing the eye muscles also means you happen to paralyze the diaphragm, meaning you are then responsible for breathing for the patient. Plus, the things you would normally look at to determine if the patient is adequately anesthetized (do they have a blink reflex, how loose is their jaw tone, what is the position of their eye) go away, so you have to use special monitoring equipment that I've never used before.
Anyhow, all ended up going well. Fortunately, we didn't need to paralyze this little girl, which gave me much less to deal with. There were a few ups and downs at the beginning of her anesthesia (there usually are), and by the time things finally settled down, it was 5 pm and the on-call student arrived to relieve me.
That's one of the nice things about Anesthesia: One student is on call every weeknight from 5 pm until 8 am the next morning, so if your anesthesia is still going at 5 pm, you get to take off and someone else takes over for you. Also, they really care about us getting a few minutes' break to eat lunch or a snack or go to the bathroom if we have a lengthy anesthesia.
On Tuesday, I anesthetized a 150-lb St Bernard with probably osteosarcoma (aggressive bone cancer) in one of his forelimbs. He was massively obese (would have looked good at 120 lb), making amputation not a great option, so his anesthesia was for a CT scan so they could plan radiation therapy.
Aside from needing about 9 people to move Mr. St Bernard from ground to induction table to gurney to CT table to gurney to recovery, everything went quite well and it was a quick anesthesia (only about 90 minutes total), which I loved.
My patient on Wednesday was a middle-aged Chesapeake Bay retriever scheduled for a dental. (Oops -- the veterinary dentist/oral surgeon gets mad if we call it a dental instead of a "periodontal treatment.") Ms. Chessie was a friendly girl, but a little anxious. I tried a combination of pre-medications I hadn't used before, which took the edge off but didn't really knock her out. It was enough to allow us to place an IV catheter, though.
The dentistry suite, while not far from the anesthesia department, is enough out of the way that the anesthesia nurses and doctors don't come by to check on you all that often. It was thus a good opportunity for me to get a bit more comfortable handling issues and complications on my own as much as I could, and to feel okay about calling someone in to help me when I needed it.
Ms. Chessie's dental took forever, though. It usually takes somewhere in the neighborhood of 30 minutes once the patient is induced to get them intubated, attach all of their monitoring equipment (pulse oximeter, EKG, capnograph, Doppler crystal, oscillometric blood pressure, and temperature probe), and move them to the department they're headed for. After that, it took 3 hours for the dentistry student to take full-mouth x-rays and chart the dental disease. It was another four hours of cleaning, pulling teeth, and recovery time before she was finally extubated. Fortunately, I got to sneak away for about 20 minutes in the middle to get a bite to eat.
Thursday's patient was an elderly lab mix with a previously removed anal sac tumor that had since spread to her abdominal lymph nodes, so the surgery was intended to remove the lymph nodes to give her some palliative relief. Pre-medication and induction were uneventful, as was surgery, until the surgeons nicked a large artery and Ms. Lab Mix started hemorrhaging.
Which showed me that us anesthesia students sure don't need to worry about being left alone when something bad is happening! A bunch of surgery support staff flooded into the room, as well as 2 of the anesthesiologists and 2 anesthesia nurses. We pushed fluids into Ms. Lab Mix to keep her blood pressure up, gave her another shot of pain meds so we could lower the amount of gas she was breathing (which causes low blood pressure), and sent someone to get blood products from the pharmacy for a probable transfusion.
However, Ms. Lab Mix is a rockstar and pulled through with hardly a drop in blood pressure below the normal range. We didn't need to transfuse her, and she recovered like a champ. It probably helped that we were proactive about treating her for blood loss as soon as the hemorrhage started, but still, everyone was surprised by how well she did.
Thursday night was my first night on call, and much to my chagrin I was called in at 6 pm to anesthetize a colicking horse. There was some immediate and striking nausea on my part when I got the call, because horses are SO not my thing.
However, upon arriving at the barn (yes, I found my way out there all by myself!), the anesthesia nurse on call advised me that I didn't have to do anything other than keep the anesthesia record if I wanted. Other than taking a long time to wake up, the mare did quite well, and I survived too!
Friday's 2 cases were a 9 month old Doberman having what was probably a very malignant tumor removed from his skin, and a very sickly 3 month old Boston terrier with pneumonia who needed to be lightly anesthetized for a tracheal wash to collect a sample of her mucus. That second one sure was exciting, starting with a lengthy attempt to place an IV catheter (she ended up with a jugular catheter) and concluding with a puppy whose lungs did not appreciate having a bunch of saline flushed into them.
Overall it was an interesting week. I feel about 10 times better about anesthesia than I did on Monday, but I still have a long way to go -- that's why we have 2.5 more weeks!
Thursday, October 27, 2011
"Fleas make everything worse," or "Why I hate bureaucracy"
Today I had another cardiology patient whose main problem wasn't really cardiac-related. (See: The case of Mr. Beagle.)
My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.
When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.
However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.
Sigh.
I hate fleas.
To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).
In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.
And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.
Oh my Lord. I was so wrong.
Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.
Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).
I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.
So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.
The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.
All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.
The moral(s) of this story:
1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.
2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.
3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.
4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?
5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)
6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.
7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.
8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.
Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.
My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.
When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.
However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.
Sigh.
I hate fleas.
To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).
In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.
And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.
Oh my Lord. I was so wrong.
Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.
Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).
I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.
So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.
The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.
All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.
The moral(s) of this story:
1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.
2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.
3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.
4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?
5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)
6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.
7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.
8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.
Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.
Sunday, October 23, 2011
I killed a little old lady's only companion
By "killed," I mean "humanely euthanized." By "little old lady," I mean the cutest 90-year-old woman you've ever met, who loves to tell hilarious stories. And by "only companion," I hope I'm wrong.
Ever-talented and CCU-loving student that I am, I managed a feat that few cardiology students ever achieve: I had a CCU inpatient while on cardiology rotation. (Yeah, I'm that good.)
My patient, a 13-year-old Beagle, arrived as a referral from a local clinic for what the rDVM felt was a cardiac arrhythmia (3rd degree AV block), with the intent of having the dog evaluated by the vet school's cardiology department for the feasibility of placing a pacemaker.
However, upon arrival Mr. Beagle was laterally recumbent, breathing quickly and shallowly, and had bluish purple gums and tongue. So, good student that I am, I immediately brought Mr. Beagle back to the cardiology department for some wonderful oxygen, then headed up to take a history from his owner.
Mr. Beagle's mom was the aforementioned elderly woman, accompanied (and driven, thankfully) by her son (who doesn't live with her). Mr. Beagle had started coughing several months ago, was diagnosed with an enlarged heart a month prior by his rDVM, and was placed on a diuretic that hadn't improved the cough at all. The night before presenting to the vet school, Mr. Beagle had experienced an acute onset of respiratory distress, which improved slightly overnight but not much, so Mr. Beagle headed to his rDVM that next morning.
Long story short, Mr. Beagle ended up in CCU in an oxygen cage overnight, along with several other treatments, none of which did anything to help his breathing. It turns out that his cardiac disease, while present, was rather minor. His arrhythmia was actually atrial standstill, not AV block, and was most likely incidental. His real problem was very severe respiratory disease, and we couldn't figure out the cause. Mr. Beagle's chest x-rays looked horrendous; a variety of diagnostics failed to show why. The next step would have been general anesthesia with airway endoscopy and possibly a bronchoalveolar lavage, but Mr. Beagle was just too unstable and probably would have died under anesthesia.
So Mr. Beagle's owner elected to do the unselfish thing and euthanize him. Tears were shed by all involved, but Mr. Beagle went peacefully with his owner telling us stories about the time he brought a live rabbit into the house and chased it around, how he once scared off a raccoon in the backyard, how he sleeps by his owner's feet in the living room every night before bed. When Mr. Beagle had passed, the cardiology resident and client counselor escorted Mr. Beagle's owner and her son out of CCU while I stayed behind to escort Mr. Beagle's remains down to necropsy. It broke my heart.
Ever-talented and CCU-loving student that I am, I managed a feat that few cardiology students ever achieve: I had a CCU inpatient while on cardiology rotation. (Yeah, I'm that good.)
My patient, a 13-year-old Beagle, arrived as a referral from a local clinic for what the rDVM felt was a cardiac arrhythmia (3rd degree AV block), with the intent of having the dog evaluated by the vet school's cardiology department for the feasibility of placing a pacemaker.
However, upon arrival Mr. Beagle was laterally recumbent, breathing quickly and shallowly, and had bluish purple gums and tongue. So, good student that I am, I immediately brought Mr. Beagle back to the cardiology department for some wonderful oxygen, then headed up to take a history from his owner.
Mr. Beagle's mom was the aforementioned elderly woman, accompanied (and driven, thankfully) by her son (who doesn't live with her). Mr. Beagle had started coughing several months ago, was diagnosed with an enlarged heart a month prior by his rDVM, and was placed on a diuretic that hadn't improved the cough at all. The night before presenting to the vet school, Mr. Beagle had experienced an acute onset of respiratory distress, which improved slightly overnight but not much, so Mr. Beagle headed to his rDVM that next morning.
Long story short, Mr. Beagle ended up in CCU in an oxygen cage overnight, along with several other treatments, none of which did anything to help his breathing. It turns out that his cardiac disease, while present, was rather minor. His arrhythmia was actually atrial standstill, not AV block, and was most likely incidental. His real problem was very severe respiratory disease, and we couldn't figure out the cause. Mr. Beagle's chest x-rays looked horrendous; a variety of diagnostics failed to show why. The next step would have been general anesthesia with airway endoscopy and possibly a bronchoalveolar lavage, but Mr. Beagle was just too unstable and probably would have died under anesthesia.
So Mr. Beagle's owner elected to do the unselfish thing and euthanize him. Tears were shed by all involved, but Mr. Beagle went peacefully with his owner telling us stories about the time he brought a live rabbit into the house and chased it around, how he once scared off a raccoon in the backyard, how he sleeps by his owner's feet in the living room every night before bed. When Mr. Beagle had passed, the cardiology resident and client counselor escorted Mr. Beagle's owner and her son out of CCU while I stayed behind to escort Mr. Beagle's remains down to necropsy. It broke my heart.
Ai, Chihuahua!
I got to have my very own high-maintenance CCU inpatient during the second half of my week of CCU day shifts. (A little clarification: most of the patients in CCU are under the "primary care" of another service -- like surgery, medicine, or oncology -- meaning that the doctor in charge of that patient's care comes from one of those services, and the patient's "primary student" also comes from that specialty service. The primary student is responsible for all of the communication with the clients [or making sure the DVM is giving the client updates], doing a physical exam on the patient every morning, writing new CCU orders, obtaining all drugs needed for that patient while in CCU, and, most fun of all, writing a daily "SOAP" which is an assessment of the patient's current status and a discussion of all of the patient's medical problems. Occasionally, however, a patient in CCU is under the primary care of one of the CCU clinicians, so one of the CCU day students "gets" to be the primary student on the case, meaning you "get" to take over all of the above responsibilities in addition to your already "action-packed" and "fun-filled" day of menial CCU tasks. So no, I was not overly excited to have my own CCU patient.)
Aside from the bureaucratic nonsense and busywork, though, I really liked my sad little patient, a middle-aged Chihuahua who presented in acute oliguric renal failure.
"Renal failure" means your kidneys have stopped working, or are close to it. "Acute" means it happened all of a sudden, versus being a drawn out process over months or years. "Oliguric" means "small urine," in that the kidneys have lost their ability to produce a normal amount of urine, so it's extraordinarily difficult for the body to remove excess fluid and waste/byproducts that are normally peed out. (However, "oliguric" is better than "anuric," which means no urine production.)
After many diagnostics, we determined the most likely cause for Mr. Chihuahua's acute renal failure to be leptospirosis, a nasty bacterial infection usually spread through contact with urine or contaminated standing water.
In addition to his renal failure, Mr. Chihuahua also had ongoing liver disease (also possibly caused by leptospirosis), unhappy muscles, complete loss of appetite, nausea and occasional vomiting, intermittent seizures, and diarrhea.
Since leptospirosis can be spread to people Mr. Chihuahua got his very own "isolation" area requiring people handling him and his urine/stools to wear a plastic gown, latex gloves, a cloth face mask, and plastic goggles. He also got 2 IV catheters (since he was on so many IV medications that many of them could not be combined into the same IV line because they didn't mix well), a urinary catheter, and a nasoesophageal feeding tube (which we fed down his throat through one of his nostrils, then stapled to his face. With a staple gun. While he was awake.).
Anyhow, Mr. Chihuahua was a pathetic mess for the longest time (okay, only about 4 days, but it felt like forever). Finally, he started producing massive amounts of urine (thus transitioning from oliguric ["small urine"] to polyuric ["many urine"] renal failure). Seriously, normal urine production is about 1-2 milliliters of urine per kilogram of body weight per hour, and Mr. Chihuahua got up to 25 ml/kg/hr. Yeesh.
Finally, after 9 days in the hospital, Mr. Chihuahua went home with a tiny appetite, no recent seizures, only a handful of medications, daily subcutaneous fluids to be given at home, and normal kidney values on his bloodwork! It's a testament to what we all need to be reminded of periodically: though the odds may be small, some animals can pull through even the most severe disease conditions if given a chance (and 9 days in CCU, and about $7000).
Aside from the bureaucratic nonsense and busywork, though, I really liked my sad little patient, a middle-aged Chihuahua who presented in acute oliguric renal failure.
"Renal failure" means your kidneys have stopped working, or are close to it. "Acute" means it happened all of a sudden, versus being a drawn out process over months or years. "Oliguric" means "small urine," in that the kidneys have lost their ability to produce a normal amount of urine, so it's extraordinarily difficult for the body to remove excess fluid and waste/byproducts that are normally peed out. (However, "oliguric" is better than "anuric," which means no urine production.)
After many diagnostics, we determined the most likely cause for Mr. Chihuahua's acute renal failure to be leptospirosis, a nasty bacterial infection usually spread through contact with urine or contaminated standing water.
In addition to his renal failure, Mr. Chihuahua also had ongoing liver disease (also possibly caused by leptospirosis), unhappy muscles, complete loss of appetite, nausea and occasional vomiting, intermittent seizures, and diarrhea.
Since leptospirosis can be spread to people Mr. Chihuahua got his very own "isolation" area requiring people handling him and his urine/stools to wear a plastic gown, latex gloves, a cloth face mask, and plastic goggles. He also got 2 IV catheters (since he was on so many IV medications that many of them could not be combined into the same IV line because they didn't mix well), a urinary catheter, and a nasoesophageal feeding tube (which we fed down his throat through one of his nostrils, then stapled to his face. With a staple gun. While he was awake.).
Anyhow, Mr. Chihuahua was a pathetic mess for the longest time (okay, only about 4 days, but it felt like forever). Finally, he started producing massive amounts of urine (thus transitioning from oliguric ["small urine"] to polyuric ["many urine"] renal failure). Seriously, normal urine production is about 1-2 milliliters of urine per kilogram of body weight per hour, and Mr. Chihuahua got up to 25 ml/kg/hr. Yeesh.
Finally, after 9 days in the hospital, Mr. Chihuahua went home with a tiny appetite, no recent seizures, only a handful of medications, daily subcutaneous fluids to be given at home, and normal kidney values on his bloodwork! It's a testament to what we all need to be reminded of periodically: though the odds may be small, some animals can pull through even the most severe disease conditions if given a chance (and 9 days in CCU, and about $7000).
I survived the marathon!
I'm greatly enjoying my first weekend after successfully completing my fantastical 19-days-in-a-row school/work marathon.
My second week of this most recent CCU rotation was the CCU "days" shift, requiring me to arrive at 6 am every day (Monday through Sunday) and stay till, on average, 6 pm. Yes, I kept track of my hours, and yes, it was a total of 85 hours in 7 days.
That week was definitely my most physically and emotionally challenging week of senior year (at least so far). For one thing, though I usually do quite well with being awake in the morning, I don't actually enjoy the act of getting up in the morning (at least not at an early time), and hearing the alarm go off at 5:15 am was, not unsurprisingly, even worse than getting up at 6 or 6:30.
There was the fact that I had multiple days in a row where it was pitch black when I left the house (my, how many stars you can see at 5:45 am!) and dusk when I got home. There was the way my days started with an hour of frantically running around CCU trying to catch up on all the 7 am treatments that the overnight students hadn't gotten done. There was the unpleasant habit of other students of walking hospitalized dogs on the nearest patch of grass outside the building and not taking the extra 1.5 seconds to grab a poop bag on their way out the door, or taking the extra 30 seconds to run back into the building and grab a poop sack. Which led to me stepping in a giant pile of dog crap and getting it all over my sneakers and scrub pants a mere 15 minutes into my 7th day shift. (Fortunately, it was a slow morning, so the night nurse sent me home to change into other pants, but it was oh-so-tempting just not to come back after that. Ask me how the rest of that day went. About the same as the first 15 minutes.)
The "fun" part about CCU is that they let you do a lot of procedures. As long as the patient isn't actively trying to die, you get to put in IV catheters, urinary catheters, arterial lines, jugular catheters, etc. However, that's not the case if you're working with an intern who also wants to practice those procedures.
The other "fun" part about the CCU day shift is teaching rounds in the afternoon. You work your butt off all day until 3 pm, then you have case rounds till about 3:30, then take a half hour or so to check on your patients and make sure all the 3 pm treatments were done, then you reconvene with the after-hours students and one of the residents for discussion on whatever topic you want to talk about from 4-5 pm.
Well, at least that's the idea. On Monday, our first day of the day shift, we finished case rounds at 3:30 pm then headed out to check on patients. By "we," I mean the students. The doctors and nurses all made a beeline for the brand new ultrasound machine so they could play with it and figure out how it worked. Which they did for an hour and a half. Until it was 5 o'clock and it was too late for teaching rounds and we students had wasted 90 minutes waiting for someone to teach us something. I confess, I had a little bit of a breakdown. Remember, I worked from 3-11 pm on Sunday night and had to be back at 6 am the next morning to start the day shift. For myriad other reasons, it was such a crummy Monday that the thought of having teaching rounds (which I honestly enjoy) was really all that had gotten me through the day. All I wanted to do was learn something then go home and sleep, and instead I worked my butt off then waited around doing nothing for 90 minutes then went home. There may have been some under-my-breath ranting about not getting my money's worth from the ~$1000/week in tuition I'm paying for senior year. It was not only the wasted time and the lack of teaching rounds, but the fact that 90% of a senior student's time in CCU is spent walking dogs, cleaning cages, feeding animals, giving pills, reconnecting tangled EKG leads, and trying to get the %&#*!@ IV catheters to draw so you don't have to stick the animal for the blood sample. I don't learn anything any time I do one of those things.
Anyhow, though it's only been a week since my last day in CCU, it feels like it was months ago -- which is great. And on the positive side, I've now completed all 3 of my weeks in CCU, so I never have a rotation there again!
I've moved on to cardiology, and thankfully I'm halfway through that. Well, kind of thankfully. On the one hand, the schedule is wonderful. We have morning rounds at 8:30, followed by one appointment every hour for 2-6 hours depending on the day (Tuesdays are "procedure days" so no appointments). There are no afternoon rounds; if it's slow, we talk about a cardiology topic like radiograph or EKG interpretation. We have time to eat lunch (at actual lunch time -- novel idea!) and as long as nothing's happening, we get to head home between 4 and 5.
However, cardiology is one of my least favorite subjects. I do feel like I've learned it better by working with some actual cardiology patients than by listening to lectures, but it's still a huge challenge for me. And one of the cardiology residents is not the nicest person in the world. Additionally, my single rotation-mate is probably my least favorite person in the entire senior class.
Oh well. You can do anything for 2 weeks, right? Only one more week to go for me, and then it's on to a fun-filled month of anesthesia. Yahoo!
My second week of this most recent CCU rotation was the CCU "days" shift, requiring me to arrive at 6 am every day (Monday through Sunday) and stay till, on average, 6 pm. Yes, I kept track of my hours, and yes, it was a total of 85 hours in 7 days.
That week was definitely my most physically and emotionally challenging week of senior year (at least so far). For one thing, though I usually do quite well with being awake in the morning, I don't actually enjoy the act of getting up in the morning (at least not at an early time), and hearing the alarm go off at 5:15 am was, not unsurprisingly, even worse than getting up at 6 or 6:30.
There was the fact that I had multiple days in a row where it was pitch black when I left the house (my, how many stars you can see at 5:45 am!) and dusk when I got home. There was the way my days started with an hour of frantically running around CCU trying to catch up on all the 7 am treatments that the overnight students hadn't gotten done. There was the unpleasant habit of other students of walking hospitalized dogs on the nearest patch of grass outside the building and not taking the extra 1.5 seconds to grab a poop bag on their way out the door, or taking the extra 30 seconds to run back into the building and grab a poop sack. Which led to me stepping in a giant pile of dog crap and getting it all over my sneakers and scrub pants a mere 15 minutes into my 7th day shift. (Fortunately, it was a slow morning, so the night nurse sent me home to change into other pants, but it was oh-so-tempting just not to come back after that. Ask me how the rest of that day went. About the same as the first 15 minutes.)
The "fun" part about CCU is that they let you do a lot of procedures. As long as the patient isn't actively trying to die, you get to put in IV catheters, urinary catheters, arterial lines, jugular catheters, etc. However, that's not the case if you're working with an intern who also wants to practice those procedures.
The other "fun" part about the CCU day shift is teaching rounds in the afternoon. You work your butt off all day until 3 pm, then you have case rounds till about 3:30, then take a half hour or so to check on your patients and make sure all the 3 pm treatments were done, then you reconvene with the after-hours students and one of the residents for discussion on whatever topic you want to talk about from 4-5 pm.
Well, at least that's the idea. On Monday, our first day of the day shift, we finished case rounds at 3:30 pm then headed out to check on patients. By "we," I mean the students. The doctors and nurses all made a beeline for the brand new ultrasound machine so they could play with it and figure out how it worked. Which they did for an hour and a half. Until it was 5 o'clock and it was too late for teaching rounds and we students had wasted 90 minutes waiting for someone to teach us something. I confess, I had a little bit of a breakdown. Remember, I worked from 3-11 pm on Sunday night and had to be back at 6 am the next morning to start the day shift. For myriad other reasons, it was such a crummy Monday that the thought of having teaching rounds (which I honestly enjoy) was really all that had gotten me through the day. All I wanted to do was learn something then go home and sleep, and instead I worked my butt off then waited around doing nothing for 90 minutes then went home. There may have been some under-my-breath ranting about not getting my money's worth from the ~$1000/week in tuition I'm paying for senior year. It was not only the wasted time and the lack of teaching rounds, but the fact that 90% of a senior student's time in CCU is spent walking dogs, cleaning cages, feeding animals, giving pills, reconnecting tangled EKG leads, and trying to get the %&#*!@ IV catheters to draw so you don't have to stick the animal for the blood sample. I don't learn anything any time I do one of those things.
Anyhow, though it's only been a week since my last day in CCU, it feels like it was months ago -- which is great. And on the positive side, I've now completed all 3 of my weeks in CCU, so I never have a rotation there again!
I've moved on to cardiology, and thankfully I'm halfway through that. Well, kind of thankfully. On the one hand, the schedule is wonderful. We have morning rounds at 8:30, followed by one appointment every hour for 2-6 hours depending on the day (Tuesdays are "procedure days" so no appointments). There are no afternoon rounds; if it's slow, we talk about a cardiology topic like radiograph or EKG interpretation. We have time to eat lunch (at actual lunch time -- novel idea!) and as long as nothing's happening, we get to head home between 4 and 5.
However, cardiology is one of my least favorite subjects. I do feel like I've learned it better by working with some actual cardiology patients than by listening to lectures, but it's still a huge challenge for me. And one of the cardiology residents is not the nicest person in the world. Additionally, my single rotation-mate is probably my least favorite person in the entire senior class.
Oh well. You can do anything for 2 weeks, right? Only one more week to go for me, and then it's on to a fun-filled month of anesthesia. Yahoo!
Thursday, October 13, 2011
The marathon continues
I'm halfway through my epic 19-full-work/school-days-in-a-row-with-no-breaks marathon.
It started with 7 days of the CCU swing shift (roughly 2:45-10:45 pm).
I'm now 3 days into my 7 days of the CCU day shift, and I've worked 38 hours in the last 3 days, with 4 more days to go at this pace. Ask me how that's going. (There have been tears.) PS: this shift starts at 6 am every day.
The last 5 days of the marathon will be my first week of cardiology, which I'm hoping (praying, begging, pleading) will be as laidback as I've heard. I could really use some days of showing up at 8:30 and leaving by 5 or 6. Plus, the odds of an inpatient are fairly low, so if all goes as planned, I'll actually have the weekend off once my 19-day marathon is done.
Would love to blog about what I've been doing on CCU (good and bad) but too tired. Stay tuned...
It started with 7 days of the CCU swing shift (roughly 2:45-10:45 pm).
I'm now 3 days into my 7 days of the CCU day shift, and I've worked 38 hours in the last 3 days, with 4 more days to go at this pace. Ask me how that's going. (There have been tears.) PS: this shift starts at 6 am every day.
The last 5 days of the marathon will be my first week of cardiology, which I'm hoping (praying, begging, pleading) will be as laidback as I've heard. I could really use some days of showing up at 8:30 and leaving by 5 or 6. Plus, the odds of an inpatient are fairly low, so if all goes as planned, I'll actually have the weekend off once my 19-day marathon is done.
Would love to blog about what I've been doing on CCU (good and bad) but too tired. Stay tuned...
Saturday, October 1, 2011
Necropsy: meh
That pretty much sums up my second week on necropsy. I've become somewhat accustomed to the gore, though I don't think I'd ever get to the point of enjoying hacking up people's pets and companions. However, it was easier to head to the necropsy floor during this second week knowing that I was nearing the end.
This week we necropsied lots of dogs, some cats, a few adult horses, several sheep, a couple chickens, a chameleon, a hedgehog, and a hamster. I stayed as far away as possible from anything but dogs and cats, though I did end up with one of the chickens. (Turns out chickens look all weird on the inside.)
My coolest case of the rotation was a 6 month old kitten who presented for an acute onset of respiratory difficulty. His owners didn't have any money so their rDVM took thoracic radiographs for free and diagnosed a diaphragmatic hernia. That's a hole in the diaphragm, which normally provides a complete separation between the chest cavity and abdominal cavity. With a hernia present, abdominal organs can sometimes migrate up into the thoracic cavity where, obviously, they can cause some difficulty breathing.
And it was no surprise that this kitten had been in so much respiratory distress. His entire intestinal tract, including all of his duodenum, jejunum, ileum, and most of his colon, were up in his chest, along with 2 of the 6 lobes of his liver, and his right kidney.
Most of the "ooooh!" moments came when we first opened up his abdomen and noticed how empty it was, then opened up his chest and observed that it looked like a second abdomen, then kept pulling organs back through the hernia and discovering more and more things that had displaced up there.
After taking "courtesy" (i.e. free) radiographs, the rDVM referred the kitten to the vet school for possible surgery. Why, I don't know, because if they couldn't even afford the $$ for radiographs, there's no way they could afford surgery. Had the kitten been a little more stable, and had finances allowed, surgery would probably have been curative. However, he was so distressed by the time he arrived that even putting him in an oxygen cage didn't really help. He might have died during surgery, even being on 100% oxygen and a ventilator. On necropsy his lungs were totally collapsed, so I can see why he couldn't breathe.
Other than that, my personal cases (we all help on most of the cases but one person has primary responsibility for each case and writing the necropsy report) were an old golden retriever with some kind of weird disseminated abdominal cancer, an old golden retriever with probable GI lymphoma, and an adult chicken with respiratory disease and conjunctivitis. (Here's a tip: turns out that deciding on your own to medicate the sick birds in your backyard flock with random antibiotics you have "left over" from your own illnesses generally does not do the birds any good, as evidenced by their presentation to necropsy.)
Anyhoo, I only had to go in for a couple hours this morning, which was nice, and I'm going to be optimistic and just head to church tomorrow morning in hopes that I won't get called in for a fun and exciting horse or cow necropsy. Fingers crossed I'm done with this unpleasant rotation!
Next week I start my second CCU rotation. The first week is the "after hours" shift, requiring me to arrive every day (Monday through Sunday) at 3 pm and hopefully finish between 10-11 pm, though it's possible I'll have to stay later sometimes. The second week is the "days" shift, where I'm scheduled for 7 days in a row (Monday through Sunday) from 6 am to 5:30 pm. Yes, that's right, 11.5 hours x 7 days = an 80.5 hour workweek (and note that those are the hours I'm scheduled for -- it doesn't include any time I have to stay late to do paperwork or finish up patient care, or any time I spend at home reviewing topics or studying for rounds -- hooray?). Suffice it to say, blogging may be intermittent or nonexistent for the next few weeks. Oh well, weekends, sleep, and sanity are overrated, right?
This week we necropsied lots of dogs, some cats, a few adult horses, several sheep, a couple chickens, a chameleon, a hedgehog, and a hamster. I stayed as far away as possible from anything but dogs and cats, though I did end up with one of the chickens. (Turns out chickens look all weird on the inside.)
My coolest case of the rotation was a 6 month old kitten who presented for an acute onset of respiratory difficulty. His owners didn't have any money so their rDVM took thoracic radiographs for free and diagnosed a diaphragmatic hernia. That's a hole in the diaphragm, which normally provides a complete separation between the chest cavity and abdominal cavity. With a hernia present, abdominal organs can sometimes migrate up into the thoracic cavity where, obviously, they can cause some difficulty breathing.
And it was no surprise that this kitten had been in so much respiratory distress. His entire intestinal tract, including all of his duodenum, jejunum, ileum, and most of his colon, were up in his chest, along with 2 of the 6 lobes of his liver, and his right kidney.
Most of the "ooooh!" moments came when we first opened up his abdomen and noticed how empty it was, then opened up his chest and observed that it looked like a second abdomen, then kept pulling organs back through the hernia and discovering more and more things that had displaced up there.
After taking "courtesy" (i.e. free) radiographs, the rDVM referred the kitten to the vet school for possible surgery. Why, I don't know, because if they couldn't even afford the $$ for radiographs, there's no way they could afford surgery. Had the kitten been a little more stable, and had finances allowed, surgery would probably have been curative. However, he was so distressed by the time he arrived that even putting him in an oxygen cage didn't really help. He might have died during surgery, even being on 100% oxygen and a ventilator. On necropsy his lungs were totally collapsed, so I can see why he couldn't breathe.
Other than that, my personal cases (we all help on most of the cases but one person has primary responsibility for each case and writing the necropsy report) were an old golden retriever with some kind of weird disseminated abdominal cancer, an old golden retriever with probable GI lymphoma, and an adult chicken with respiratory disease and conjunctivitis. (Here's a tip: turns out that deciding on your own to medicate the sick birds in your backyard flock with random antibiotics you have "left over" from your own illnesses generally does not do the birds any good, as evidenced by their presentation to necropsy.)
Anyhoo, I only had to go in for a couple hours this morning, which was nice, and I'm going to be optimistic and just head to church tomorrow morning in hopes that I won't get called in for a fun and exciting horse or cow necropsy. Fingers crossed I'm done with this unpleasant rotation!
Next week I start my second CCU rotation. The first week is the "after hours" shift, requiring me to arrive every day (Monday through Sunday) at 3 pm and hopefully finish between 10-11 pm, though it's possible I'll have to stay later sometimes. The second week is the "days" shift, where I'm scheduled for 7 days in a row (Monday through Sunday) from 6 am to 5:30 pm. Yes, that's right, 11.5 hours x 7 days = an 80.5 hour workweek (and note that those are the hours I'm scheduled for -- it doesn't include any time I have to stay late to do paperwork or finish up patient care, or any time I spend at home reviewing topics or studying for rounds -- hooray?). Suffice it to say, blogging may be intermittent or nonexistent for the next few weeks. Oh well, weekends, sleep, and sanity are overrated, right?
Saturday, September 24, 2011
Dead kittens and koi and bulls -- oh my!
I'm halfway through my necropsy rotation. I've not blogged about it yet not because I'm terribly busy (I'm not) but mostly because it's just depressing.
A necropsy is an autopsy or "post-mortem examination" on a deceased animal. Why they call it a necropsy, I have no idea.
And what we do during a necropsy is basically what they do during human autopsies: namely, cut out and examine all of the organs.
Over the last 5 days, I've necropsied dogs (young and old), cats (kittens and adults), cattle (beef and dairy, bulls/cows/aborted fetuses), horses (adults), and a koi (16 years old).
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Warning: the following information is not for the faint of heart. You've been duly advised.
Here's a sample of how we do a necropsy.
1. External examination of the animal, noting any bruising, swelling, masses, etc.
2. Lay the animal on its back (or on its side, in the case of large animals). Use a giant knife to make an incision through the skin on the underside of the animal, extending from the point of the chin down across the chest, across the abdomen, and down to the anus. Use the knife to cut the skin away from the subcutaneous tissues along either side. Cut through the muscles that bind the scapula to the thorax, so the forelimbs can be splayed flat out to the sides. Cut through the hip joints so the hindlimbs can be splayed out as well.
3. Poke a hole into the abdominal cavity. Cut the musculature along either side of the abdomen to expose the cavity. Look for any free abdominal fluid.
4. Pull back the liver so you can see the diaphragm and look for any holes. Poke a hole in the diaphragm and make sure air rushes into the chest cavity.
5. Use a knife to cut through the muscles along the ribs on either side of the chest. Then use giant garden shears to cut through each of the ribs so you can eventually pull off the underside of the rib cage to expose the thoracic cavity.
6. Use a scalpel to cut along the inside of the mandibles on either side under the jaw, so you can cut out the tongue. Disarticulate the hyoid apparatus (the tiny bones that suspend the tongue muscle). Peel the tongue back, down the neck, cutting connective tissue to free the trachea and esophagus as you go. Cut the esophagus, vena cava, and aorta where they enter the diaphragm. Remove the "pluck" in its entirety (includes the tongue, tonsils, thyroid, trachea, esophagus, thymus, heart, and lungs).
7. Flop the liver up into the now-empty thoracic cavity to get it out of your way. Cut out the omentum with the spleen attached.
8. Push the feces out of the rectum. Cut through the rectum, then cut through the connective tissue that suspends the intestines within the abdominal cavity until the intestines can be entirely removed, along with the pancreas and stomach.
9. Cut out the liver, gallbladder, and diaphragm as one unit.
10. Cut out the adrenal glands.
11. Cut out the kidneys (with ureters attached).
12. Cut into and examine the lining of the urinary bladder.
13. Examine each organ (tongue, tonsils, thyroid, trachea, esophagus, heart, lungs, lower airways, pulmonary vessels, thymus, spleen, omentum, mesentery, rectum, cecum, ileum, jejunum, duodenum, pancreas, liver, gallbaldder, diaphragm, adrenals, kidneys, urinary bladder) in detail. Take samples of most of those organs to submit for histopathology.
14. Cut out a femur or humerus and have it sliced in half so you can look at the marrow.
15. Cut open some or all of the joints (hocks, stifles, hips, elbows, carpi) to look for arthritis.
16. Cut off the head. Hack open the skull with a meat cleaver so you can remove and examine the brain.
17. Clean up.
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See why I'm not having very good dreams this week? The 'highlight' of Friday morning was cutting off a 3 week old kitten's head. The 'highlight' of Thursday morning was watching a live cow being shot then exsanguinated in the parking lot so we could necropsy it. Who knew, but it turns out that not all animals that arrive at necropsy are dead yet. Well, we fixed that.
It's heartbreaking when you let yourself realize that all of the animals (at least the small animals) were someone's pet with a name and a history and relationships. It's easy (and often helpful) to forget about that and just hack out the organs in a routine fashion, but sometimes it strikes you that this dog was only 2 years old, or look how cute this kitten was, or you think about how much pain one of the animals must have been in before it died, based on what you find on necropsy.
So, yeah, I'm ready to be done. If I'm to look on the positive side, at least I've gotten a good review of basic gross anatomy. And I'll undoubtedly need to do at least a few necropsies during my career. And I've learned an efficient way to decapitate a pet for the times when I need to submit a specimen to the public health department for rabies testing.
But that's about as positive as I can be after 5 days of eviscerating, dismembering, and decapitating dead animals, with another 5-7 days (depending on how many cases arrive next weekend) to go.
A necropsy is an autopsy or "post-mortem examination" on a deceased animal. Why they call it a necropsy, I have no idea.
And what we do during a necropsy is basically what they do during human autopsies: namely, cut out and examine all of the organs.
Over the last 5 days, I've necropsied dogs (young and old), cats (kittens and adults), cattle (beef and dairy, bulls/cows/aborted fetuses), horses (adults), and a koi (16 years old).
------------------
Warning: the following information is not for the faint of heart. You've been duly advised.
Here's a sample of how we do a necropsy.
1. External examination of the animal, noting any bruising, swelling, masses, etc.
2. Lay the animal on its back (or on its side, in the case of large animals). Use a giant knife to make an incision through the skin on the underside of the animal, extending from the point of the chin down across the chest, across the abdomen, and down to the anus. Use the knife to cut the skin away from the subcutaneous tissues along either side. Cut through the muscles that bind the scapula to the thorax, so the forelimbs can be splayed flat out to the sides. Cut through the hip joints so the hindlimbs can be splayed out as well.
3. Poke a hole into the abdominal cavity. Cut the musculature along either side of the abdomen to expose the cavity. Look for any free abdominal fluid.
4. Pull back the liver so you can see the diaphragm and look for any holes. Poke a hole in the diaphragm and make sure air rushes into the chest cavity.
5. Use a knife to cut through the muscles along the ribs on either side of the chest. Then use giant garden shears to cut through each of the ribs so you can eventually pull off the underside of the rib cage to expose the thoracic cavity.
6. Use a scalpel to cut along the inside of the mandibles on either side under the jaw, so you can cut out the tongue. Disarticulate the hyoid apparatus (the tiny bones that suspend the tongue muscle). Peel the tongue back, down the neck, cutting connective tissue to free the trachea and esophagus as you go. Cut the esophagus, vena cava, and aorta where they enter the diaphragm. Remove the "pluck" in its entirety (includes the tongue, tonsils, thyroid, trachea, esophagus, thymus, heart, and lungs).
7. Flop the liver up into the now-empty thoracic cavity to get it out of your way. Cut out the omentum with the spleen attached.
8. Push the feces out of the rectum. Cut through the rectum, then cut through the connective tissue that suspends the intestines within the abdominal cavity until the intestines can be entirely removed, along with the pancreas and stomach.
9. Cut out the liver, gallbladder, and diaphragm as one unit.
10. Cut out the adrenal glands.
11. Cut out the kidneys (with ureters attached).
12. Cut into and examine the lining of the urinary bladder.
13. Examine each organ (tongue, tonsils, thyroid, trachea, esophagus, heart, lungs, lower airways, pulmonary vessels, thymus, spleen, omentum, mesentery, rectum, cecum, ileum, jejunum, duodenum, pancreas, liver, gallbaldder, diaphragm, adrenals, kidneys, urinary bladder) in detail. Take samples of most of those organs to submit for histopathology.
14. Cut out a femur or humerus and have it sliced in half so you can look at the marrow.
15. Cut open some or all of the joints (hocks, stifles, hips, elbows, carpi) to look for arthritis.
16. Cut off the head. Hack open the skull with a meat cleaver so you can remove and examine the brain.
17. Clean up.
------------------
See why I'm not having very good dreams this week? The 'highlight' of Friday morning was cutting off a 3 week old kitten's head. The 'highlight' of Thursday morning was watching a live cow being shot then exsanguinated in the parking lot so we could necropsy it. Who knew, but it turns out that not all animals that arrive at necropsy are dead yet. Well, we fixed that.
It's heartbreaking when you let yourself realize that all of the animals (at least the small animals) were someone's pet with a name and a history and relationships. It's easy (and often helpful) to forget about that and just hack out the organs in a routine fashion, but sometimes it strikes you that this dog was only 2 years old, or look how cute this kitten was, or you think about how much pain one of the animals must have been in before it died, based on what you find on necropsy.
So, yeah, I'm ready to be done. If I'm to look on the positive side, at least I've gotten a good review of basic gross anatomy. And I'll undoubtedly need to do at least a few necropsies during my career. And I've learned an efficient way to decapitate a pet for the times when I need to submit a specimen to the public health department for rabies testing.
But that's about as positive as I can be after 5 days of eviscerating, dismembering, and decapitating dead animals, with another 5-7 days (depending on how many cases arrive next weekend) to go.
Grand Rounds: no fun, but done
Last Friday was my day to present for Grand Rounds, and my case was, as planned, the "comedy of errors" case I wrote about previously.
As you might guess, my presentation did not include mention of any of the errors made during this case. Hope none of you were worrying about that (Dad).
The "exciting" part of that week leading up to Friday was completing my 40-slide PowerPoint presentation on Tuesday evening, and my laptop (containing my sole copy of said PowerPoint presentation) experiencing hard drive issues on Wednesday afternoon that left my laptop unable to start up completely.
No, I have not gotten it fixed yet. Yes, that did mean that I got to re-write my entire Grand Rounds presentation. Sigh.
After several hours of struggle on Wednesday evening, trying to get the laptop to work, I resigned myself to the fact that I lacked the technological savvy to fix the computer, as well as the fact that I was slated to give my presentation in less than 36 hours. Thus, I started a re-write about 9 pm on Wednesday.
Which was continued and concluded between 5:30 and 7:30 am on Thursday morning.
The re-writing of the presentation went (thankfully) much faster than the initial research and formatting. And, since I used the older desktop computer's elderly version of PowerPoint (which I actually prefer to the 2007 version), I found a format I liked better.
But I'm not going to lie -- it was no fun and made for a rough end of the week.
By the time Friday morning rolled around, though, I wasn't all that nervous. I ran through my slides once with my advisor (the surgeon for my case) on Thursday night, then made CLH listen to me talk through the presentation when I got home. I did get up a little earlier than usual on Friday morning so I could run through it about 3 times under my breath.
I was scheduled to go last out of the three presenters that morning. The first two cases were about horses (a case of nephrosplenic entrapment and a case of Neorickettsia risticii infection). When it was finally my turn, everything went very well. There were no computer or microphone malfunctions. I really didn't feel nervous and was even able to make a few jokes as I went along. It was over in about 12 minutes (we are allotted 15 minutes and are supposed to leave a little time for questions from the audience), and nobody among the roughly 100 clinicians and students in attendence asked me any questions (the part I most feared -- it's really uncomfortable to watch classmates standing in front of their peers and instructors and being asked questions they don't know how to answer).
The rest of Friday breezed by after that. One of my oncology rotation-mates brought a chocolate cake with "Congrats" written on the top to celebrate (which was really sweet of him). I ended up with just 3 radiation patients (who all left by the end of the day) and an outpatient mammary mass removal. The mammary mass was an interesting case. The mass was subcutaneous and only about an inch in diameter. The surgeon (who I'd not worked with prior to that week) basically told me what to do and then left the surgery suite. Which was admittedly terrifying, but also pretty cool.
Overall it feels great to have Grand Rounds over with. I attended Grand Rounds yesterday morning, and felt much more relaxed and at ease, and more able to enjoy the presentations than before I'd done my own. And I never have to do it again!
As you might guess, my presentation did not include mention of any of the errors made during this case. Hope none of you were worrying about that (Dad).
The "exciting" part of that week leading up to Friday was completing my 40-slide PowerPoint presentation on Tuesday evening, and my laptop (containing my sole copy of said PowerPoint presentation) experiencing hard drive issues on Wednesday afternoon that left my laptop unable to start up completely.
No, I have not gotten it fixed yet. Yes, that did mean that I got to re-write my entire Grand Rounds presentation. Sigh.
After several hours of struggle on Wednesday evening, trying to get the laptop to work, I resigned myself to the fact that I lacked the technological savvy to fix the computer, as well as the fact that I was slated to give my presentation in less than 36 hours. Thus, I started a re-write about 9 pm on Wednesday.
Which was continued and concluded between 5:30 and 7:30 am on Thursday morning.
The re-writing of the presentation went (thankfully) much faster than the initial research and formatting. And, since I used the older desktop computer's elderly version of PowerPoint (which I actually prefer to the 2007 version), I found a format I liked better.
But I'm not going to lie -- it was no fun and made for a rough end of the week.
By the time Friday morning rolled around, though, I wasn't all that nervous. I ran through my slides once with my advisor (the surgeon for my case) on Thursday night, then made CLH listen to me talk through the presentation when I got home. I did get up a little earlier than usual on Friday morning so I could run through it about 3 times under my breath.
I was scheduled to go last out of the three presenters that morning. The first two cases were about horses (a case of nephrosplenic entrapment and a case of Neorickettsia risticii infection). When it was finally my turn, everything went very well. There were no computer or microphone malfunctions. I really didn't feel nervous and was even able to make a few jokes as I went along. It was over in about 12 minutes (we are allotted 15 minutes and are supposed to leave a little time for questions from the audience), and nobody among the roughly 100 clinicians and students in attendence asked me any questions (the part I most feared -- it's really uncomfortable to watch classmates standing in front of their peers and instructors and being asked questions they don't know how to answer).
The rest of Friday breezed by after that. One of my oncology rotation-mates brought a chocolate cake with "Congrats" written on the top to celebrate (which was really sweet of him). I ended up with just 3 radiation patients (who all left by the end of the day) and an outpatient mammary mass removal. The mammary mass was an interesting case. The mass was subcutaneous and only about an inch in diameter. The surgeon (who I'd not worked with prior to that week) basically told me what to do and then left the surgery suite. Which was admittedly terrifying, but also pretty cool.
Overall it feels great to have Grand Rounds over with. I attended Grand Rounds yesterday morning, and felt much more relaxed and at ease, and more able to enjoy the presentations than before I'd done my own. And I never have to do it again!
Sunday, September 11, 2011
Bring on the juniors!
The new juniors (I call them "new" juniors because it still seems a little weird to me that we are no longer the juniors) started their morning clinical rotations 3 weeks ago.
However, since I was on CCU overnights and Urgent Care days for the first 2 weeks of the semester (and there are no juniors on those rotations), I did not get a chance to work with any of the juniors until this past week on Oncology.
And they're so cute! It almost makes me a little nostalgic for the terror of starting junior year, the wild-eyed barely-restrained panic you can see in their faces when you ask them to do something, the mostly inaudible mumbling when they give (usually correct) answers to questions during morning rounds, the silent apology in their eyes when they know something that all of us seniors have failed to remember.
The 2 juniors we had on Oncology with us this week were very enthusiastic and willing to conquer their fears and tackle appointments -- which was quite fortunate, because they didn't really have a choice. Oncology schedules a certain number of new cases every morning based on how many seniors are on the rotation that week, so that each senior has one new appointment every morning. Somehow, the schedulers got word that there were 6 seniors last week and next week, so they scheduled 6 appointments every morning. However, there are really only 3 seniors from my vet school, plus 2 students from other vet schools who are basically the equivalent of us (so we are making them take cases) -- which leaves 1 appointment every morning for the juniors to handle!
I'm having a really good time helping them out, teaching them how to fill out forms, where to drop off prescriptions, how to navigate the medical records department. It's early enough in their semester that they really don't know much about hospital procedures, and are very grateful for assistance. And it's not like they don't know enough medicine at this point in their curriculum to be able to do a physical exam and take a history from a client (though they probably doubt their abilities) -- it's more the annoying logistical stuff they need help figuring out.
And I remember being a junior myself, when so many of the seniors would rush off to their appointments without pausing to ask if you wanted to tag along. They'd hurry through online forms and completing medical records without talking you through them, or look at you like you were an idiot if you politely informed them that you didn't know how to enter a radiology request yet. It was often frustrating to feel like you were getting in their way, or interrupting them while they were busy doing important things and you had some lowly question with an easy answer (albeit one you couldn't figure out without asking).
So I'm trying not to be one of "those" seniors. I figure that investing a little extra effort in the juniors this early in the year will help them be more confident and competent as the year progresses. It'll allow them to get more out of their own junior year since they will be able to do more things for themselves, and they will be able to help us out more and more as the year progresses. And I hope that, come this time next year, they'll remember some of the nicer seniors who didn't mind showing them around and answering questions, and they'll be prepared to pass that positive attitude along to the next class. Lord knows you need all the help you can get sometimes in this fast-paced, whirlwind adventure we call vet school.
However, since I was on CCU overnights and Urgent Care days for the first 2 weeks of the semester (and there are no juniors on those rotations), I did not get a chance to work with any of the juniors until this past week on Oncology.
And they're so cute! It almost makes me a little nostalgic for the terror of starting junior year, the wild-eyed barely-restrained panic you can see in their faces when you ask them to do something, the mostly inaudible mumbling when they give (usually correct) answers to questions during morning rounds, the silent apology in their eyes when they know something that all of us seniors have failed to remember.
The 2 juniors we had on Oncology with us this week were very enthusiastic and willing to conquer their fears and tackle appointments -- which was quite fortunate, because they didn't really have a choice. Oncology schedules a certain number of new cases every morning based on how many seniors are on the rotation that week, so that each senior has one new appointment every morning. Somehow, the schedulers got word that there were 6 seniors last week and next week, so they scheduled 6 appointments every morning. However, there are really only 3 seniors from my vet school, plus 2 students from other vet schools who are basically the equivalent of us (so we are making them take cases) -- which leaves 1 appointment every morning for the juniors to handle!
I'm having a really good time helping them out, teaching them how to fill out forms, where to drop off prescriptions, how to navigate the medical records department. It's early enough in their semester that they really don't know much about hospital procedures, and are very grateful for assistance. And it's not like they don't know enough medicine at this point in their curriculum to be able to do a physical exam and take a history from a client (though they probably doubt their abilities) -- it's more the annoying logistical stuff they need help figuring out.
And I remember being a junior myself, when so many of the seniors would rush off to their appointments without pausing to ask if you wanted to tag along. They'd hurry through online forms and completing medical records without talking you through them, or look at you like you were an idiot if you politely informed them that you didn't know how to enter a radiology request yet. It was often frustrating to feel like you were getting in their way, or interrupting them while they were busy doing important things and you had some lowly question with an easy answer (albeit one you couldn't figure out without asking).
So I'm trying not to be one of "those" seniors. I figure that investing a little extra effort in the juniors this early in the year will help them be more confident and competent as the year progresses. It'll allow them to get more out of their own junior year since they will be able to do more things for themselves, and they will be able to help us out more and more as the year progresses. And I hope that, come this time next year, they'll remember some of the nicer seniors who didn't mind showing them around and answering questions, and they'll be prepared to pass that positive attitude along to the next class. Lord knows you need all the help you can get sometimes in this fast-paced, whirlwind adventure we call vet school.
Saturday, September 10, 2011
My case for Grand Rounds: a comedy of errors
I've been on Oncology this week, which has been an exhausted but informative and often fun rotation.
One storm cloud looming over my head, however, is the fact that I have my requisite Grand Rounds presentation this coming Friday.
Grand Rounds is a cruel vet school tradition wherein every senior student selects a case they've seen on clinics to present on a Friday morning sometime during the year. We are assigned a general topic for our presentation, typically the rotation that we have been on 2-4 weeks prior to our Grand Rounds date. This means that my topic is Oncology.
For Grand Rounds, you put together a 15-minute PowerPoint presentation discussing a case of interest to you. Then you get up in front of the junior lecture hall in the VTH, which is filled with other senior and junior vet students, nurses, and (most terrifyingly) clinicians.
Yes, that means that you have to give a presentation to basically the entire rest of the hospital, including the doctors who have been teaching you for the last 3+ years and working with you on clinics all year.
Okay, now that I'm done throwing up, I can finish typing.
The case I've selected for next week's Grand Rounds is a 13-year-old female Lab/Chow mix named Vega.
Vega has very dedicated, well-informed, responsible, and caring owners (no, I didn't say "obsessed," but maybe you get my drift...) who refer to her as their daughter. They have no human children or other pets, so Vega really is their only child.
On routine pre-anesthetic bloodwork prior to a dental cleaning 5 years ago, Vega's rDVM noted elevated liver enzymes. Vega had a battery of tests, including bile acids and liver biopsies, to try to discover the underlying cause of her elevated liver values, but everything came back normal. Vega's rDVM has managed her liver enzymes in the intervening period with a regimen of liver support drugs (ursodiol, SAMe, vitamin E) and a liver diet (Hill's l/d).
And Vega's done fine. She's had bloodwork monitored twice yearly, and her rDVM has noted elevations in a couple of Vega's liver values that sometimes fluctuate but have never gone back down to the normal range. Vega has never acted sick or shown any clinical signs of liver disease.
About 6 weeks ago, though, Vega went in for her 6-month geriatric wellness exam, and Vega's rDVM palpated a mass in the front part of Vega's abdomen. She repeated Vega's usual bloodwork, which was unchanged from her previous values, and recommended an abdominal ultrasound.
The ultrasound confirmed the abdominal mass and determined it to be about the size of a large orange, arising from a lobe of Vega's liver, and appearing to be solitary. Vega was referred to the vet school for an Oncology consultation and possible surgery.
Now, a lot of owners would hesitate at the thought of dropping $2-3K on anesthesia and abdominal surgery to remove a liver mass that might very well be an incidental finding in a 13 year old dog. However, Vega doesn't act her age -- if I hadn't known her age prior to meeting her, I'd have thought she was maybe 8 instead of 13. She's very fit and active, and otherwise totally healthy except for some arthritis which is under control. And though it's possible that Vega's liver tumor could be something benign that would never cause her a problem, there's also a possibility that it could be a vascular malignancy that could rupture suddenly and cause internal hemorrhaging, or some other type of malignancy that could spread elsewhere and make her sick if not excised. So, given the fact that Vega's owners didn't have much in the way of financial concerns, I can absolutely see their rationale for wanting to go to surgery.
Vega stayed in the hospital for a few hours with us on Thursday so we could repeat bloodwork and urinalysis (unchanged from her rDVM's labs a month earlier), run coagulation times (normal), check her blood type in case a transfusion was needed during or after surgery, and take chest x-rays (normal).
Vega went home on Thursday night and came back bright and early on Friday morning for surgery. She was anesthetized around 11:30 am and I was called to come shave her around noon. Given the fact that she has about 25 variably sized SQ and skin masses all over her body, and particularly on her abdomen, it was a remarkable challenge to have to try and clip her hair over and around the masses adequately to make her abdomen ready for surgery. She rolled into the OR around 12:15 pm.
Upon making our abdominal incision (difficult to find her midline due to her lumpiness!) we removed her falciform. The falciform is a very thick, fatty, gelatinous ligament that sits on the belly of the abdominal cavity and is often excised during abdominal surgery, simply because it isn't necessary to leave it in the dog and it gets in the way during surgery.
Immediately under Vega's falciform was her enormous tumor, popping right out at us. It was more grapefruit than orange-sized, and very ugly and vascular. Fortunately, it appeared to be growing on a stalk out of one of the 6 liver lobes, and the remaining liver did not appear to be involved.
Here comes Error #1: The surgeon elected to use a surgical stapler to cut off the tumor from its stalk. The way it works is that the stalk of the tumor is placed in the mouth of the stapler, the stapler is clamped down, and a double row of staggered small staples is automatically fired into the intervening tissue, effectively ligating the blood supply.
It works great.
Usually.
Unfortunately, it wasn't apparent that the stapler had misfired until the surgeon cut the tumor off of the stalk, released the stapler from the remaining stalk, and hemorrhage ensued.
In retrospect, the bleeding wasn't that bad. It certainly wasn't as bad as it would have been had none of the staples been placed as intended. But there was a heck of a lot of bleeding nonetheless, and significantly more than we'd have expected had the stapler functioned correctly.
Luckily, the surgeon remained very calm, and directed me to retract the abdominal wall and apply pressure to the hemorrhage while she obtained some additional materials to help start clotting and clamp off the bleeding vessels. There were about 10 minutes of panic, though, when multiple surgery nurses rushed in to assist us, and a flood of about 6 anesthesia personnel ran in to help the student anesthetist monitor blood pressure and heart rate, administer additional fluids, and get ready to send someone to the pharmacy to pick up some blood for a transfusion.
In the end, no transfusion was needed, and Vega'a anesthesia actually remained quite uneventful. The thing is, the liver is a very vascular organ, since its job is to filter toxins out of the blood. Tumors anywhere in the body tend to be very vascular, since they can produce factors that stimulate the growth of extra blood vessels to feed themselves; liver tumors are exceptionally vascular. Though this complication ended well, it could have been much worse and might even have led to Vega bleeding out.
Okay. Bleeding under control. Surgeons' and my heart rates were dropping back down to some semblance of normal.
Here comes Error #2: An important part of an abdominal surgery (other than something elective, like a spay) is to perform an explore of all of the abdominal organs, whether you expect them to be abnormal or not. As part of Vega's abdominal explore, we noted that one of her remaining liver lobes had a slightly abnormal appearance. The surgeon collected a biopsy sample, and placed it on a small piece of sterile paper on the instrument table. Unfortunately, she did not immediately hand the biopsy sample off to a surgery nurse to place in a formalin container, as is usually done with tissue samples, and we all forgot about the sample. It was presumably thrown away with all of the wrappers and packaging from everything needed for Vega's surgery -- but when I "got" to go hunting for it in the trash about an hour later, it was nowhere to be found. Oops.
Anyway, the rest of Vega's abdominal explore was fine. We closed her up, then transported her to CCU where she woke up slowly but normally, and proceeded to return to her usual neurotic behavior -- panting, pacing, barking, and generally trying to destroy everything in her kennel. The poor CCU staff were apparently rather irritated by this (and understandably so), since she received 5 doses of IV sedatives during the night (which reportedly did nothing to alter her behavior), and she was eventually shut up in an oxygen cage on room air, which did nothing to stop her barking but did at least dull the sound so it was almost inaudible in the room.
Vega's owners received a surgery and hospitalization estimate that included a second night's stay in the hospital if needed, since arrhythmias and pain are not uncommon complications of a surgery like this and are best dealt with in a hospitalized setting. However, Vega experienced no arrhythmias, seemed nonpainful, and clearly expressed to us that she was ready to be discharged, so we arranged a dismissal time for 9 am on Saturday.
I met with Vega's owners at 9 am and went through her dismissal instructions -- her pain medications and their side effects, how to care for and monitor her surgical incision, activity restrictions, etc. It all went well, and I advised them it would be a few minutes while I went to CCU to unplug Vega from all of her lines and monitoring, remove her IV catheters, and remove the bandage that had been placed over her incision so it would stay clean in the hospital.
Well, it turns out that the surgery nurses have gotten some new brand of extra-mega-super adhesive to get the bandages to stick onto the skin around the incisions, because Vega threw a tantrum when we tried to remove her bandage. It was really an all-out drama-queen hissy-fit, complete with howling, moaning, and thrashing, even when we were just gently restraining her and not even touching her bandage.
I should explain what the bandage looks like. It's a long, thin, flat strip of what looks like cotton padding, about 2 inches wide, laid down along the length of her abdominal incision (which goes from her sternum to her pelvis). A piece of clear plastic (which looks like plastic wrap) is placed over the cotton layer, and extends about an inch and a half onto the skin on either side of the bandage. An adhesive is sprayed onto the skin around the incision as well as onto the outside of the cotton bandage, to affix the clear plastic to the skin around the incision as well as to the outside of the bandage.
Since we couldn't easily peel or pull the plastic layer off Vega's skin (even with the help of adhesive remover wipes), the surgeon decided to very carefully cut into the cotton layer in the center of the bandage, overlying the incision. Her goal was to cut out the cotton layer (which was not affixed to the skin) and just leave the plastic layer around the edges to fall off on its own.
Error #3: Unfortunately, while cutting into the middle of the cotton layer, the surgeon accidentally cut some of the skin sutures from Vega's abdominal incision.
Luckily, not many of the sutures were lost, and we only had to replace 2 or 3 stitches in order to re-secure the suture line. But, it still meant a lot more drama from Vega, as well as more time that her poor anxious owners spent up front waiting for us to bring her out, and there's the pesky little fact that the skin likes to bleed a lot when poked with a needle, so there was still a little blood that appeared to be coming from Vega's incision (though it wasn't) by the time her owners saw her.
All in all, none of the "oops"es were major or complicated Vega's recovery. Her liver mass shows every sign of being consistent with a hepatocellular carcinoma, a tumor type for which complete surgical excision is essentially curative. We won't have biopsy results until Monday or Tuesday, but we're hopeful that it won't be something worse than that.
Now what's left for me is to put together my Grand Rounds presentation. I have some really cool pictures that were taken of Vega's abdomen and tumor during surgery. Once we have the histopath back and have confirmed that it's hepatocellular carcinoma, I'll do a little more research, but until then I'm ready to sleep for awhile!
One storm cloud looming over my head, however, is the fact that I have my requisite Grand Rounds presentation this coming Friday.
Grand Rounds is a cruel vet school tradition wherein every senior student selects a case they've seen on clinics to present on a Friday morning sometime during the year. We are assigned a general topic for our presentation, typically the rotation that we have been on 2-4 weeks prior to our Grand Rounds date. This means that my topic is Oncology.
For Grand Rounds, you put together a 15-minute PowerPoint presentation discussing a case of interest to you. Then you get up in front of the junior lecture hall in the VTH, which is filled with other senior and junior vet students, nurses, and (most terrifyingly) clinicians.
Yes, that means that you have to give a presentation to basically the entire rest of the hospital, including the doctors who have been teaching you for the last 3+ years and working with you on clinics all year.
Okay, now that I'm done throwing up, I can finish typing.
The case I've selected for next week's Grand Rounds is a 13-year-old female Lab/Chow mix named Vega.
Vega has very dedicated, well-informed, responsible, and caring owners (no, I didn't say "obsessed," but maybe you get my drift...) who refer to her as their daughter. They have no human children or other pets, so Vega really is their only child.
On routine pre-anesthetic bloodwork prior to a dental cleaning 5 years ago, Vega's rDVM noted elevated liver enzymes. Vega had a battery of tests, including bile acids and liver biopsies, to try to discover the underlying cause of her elevated liver values, but everything came back normal. Vega's rDVM has managed her liver enzymes in the intervening period with a regimen of liver support drugs (ursodiol, SAMe, vitamin E) and a liver diet (Hill's l/d).
And Vega's done fine. She's had bloodwork monitored twice yearly, and her rDVM has noted elevations in a couple of Vega's liver values that sometimes fluctuate but have never gone back down to the normal range. Vega has never acted sick or shown any clinical signs of liver disease.
About 6 weeks ago, though, Vega went in for her 6-month geriatric wellness exam, and Vega's rDVM palpated a mass in the front part of Vega's abdomen. She repeated Vega's usual bloodwork, which was unchanged from her previous values, and recommended an abdominal ultrasound.
The ultrasound confirmed the abdominal mass and determined it to be about the size of a large orange, arising from a lobe of Vega's liver, and appearing to be solitary. Vega was referred to the vet school for an Oncology consultation and possible surgery.
Now, a lot of owners would hesitate at the thought of dropping $2-3K on anesthesia and abdominal surgery to remove a liver mass that might very well be an incidental finding in a 13 year old dog. However, Vega doesn't act her age -- if I hadn't known her age prior to meeting her, I'd have thought she was maybe 8 instead of 13. She's very fit and active, and otherwise totally healthy except for some arthritis which is under control. And though it's possible that Vega's liver tumor could be something benign that would never cause her a problem, there's also a possibility that it could be a vascular malignancy that could rupture suddenly and cause internal hemorrhaging, or some other type of malignancy that could spread elsewhere and make her sick if not excised. So, given the fact that Vega's owners didn't have much in the way of financial concerns, I can absolutely see their rationale for wanting to go to surgery.
Vega stayed in the hospital for a few hours with us on Thursday so we could repeat bloodwork and urinalysis (unchanged from her rDVM's labs a month earlier), run coagulation times (normal), check her blood type in case a transfusion was needed during or after surgery, and take chest x-rays (normal).
Vega went home on Thursday night and came back bright and early on Friday morning for surgery. She was anesthetized around 11:30 am and I was called to come shave her around noon. Given the fact that she has about 25 variably sized SQ and skin masses all over her body, and particularly on her abdomen, it was a remarkable challenge to have to try and clip her hair over and around the masses adequately to make her abdomen ready for surgery. She rolled into the OR around 12:15 pm.
Upon making our abdominal incision (difficult to find her midline due to her lumpiness!) we removed her falciform. The falciform is a very thick, fatty, gelatinous ligament that sits on the belly of the abdominal cavity and is often excised during abdominal surgery, simply because it isn't necessary to leave it in the dog and it gets in the way during surgery.
Immediately under Vega's falciform was her enormous tumor, popping right out at us. It was more grapefruit than orange-sized, and very ugly and vascular. Fortunately, it appeared to be growing on a stalk out of one of the 6 liver lobes, and the remaining liver did not appear to be involved.
Here comes Error #1: The surgeon elected to use a surgical stapler to cut off the tumor from its stalk. The way it works is that the stalk of the tumor is placed in the mouth of the stapler, the stapler is clamped down, and a double row of staggered small staples is automatically fired into the intervening tissue, effectively ligating the blood supply.
It works great.
Usually.
Unfortunately, it wasn't apparent that the stapler had misfired until the surgeon cut the tumor off of the stalk, released the stapler from the remaining stalk, and hemorrhage ensued.
In retrospect, the bleeding wasn't that bad. It certainly wasn't as bad as it would have been had none of the staples been placed as intended. But there was a heck of a lot of bleeding nonetheless, and significantly more than we'd have expected had the stapler functioned correctly.
Luckily, the surgeon remained very calm, and directed me to retract the abdominal wall and apply pressure to the hemorrhage while she obtained some additional materials to help start clotting and clamp off the bleeding vessels. There were about 10 minutes of panic, though, when multiple surgery nurses rushed in to assist us, and a flood of about 6 anesthesia personnel ran in to help the student anesthetist monitor blood pressure and heart rate, administer additional fluids, and get ready to send someone to the pharmacy to pick up some blood for a transfusion.
In the end, no transfusion was needed, and Vega'a anesthesia actually remained quite uneventful. The thing is, the liver is a very vascular organ, since its job is to filter toxins out of the blood. Tumors anywhere in the body tend to be very vascular, since they can produce factors that stimulate the growth of extra blood vessels to feed themselves; liver tumors are exceptionally vascular. Though this complication ended well, it could have been much worse and might even have led to Vega bleeding out.
Okay. Bleeding under control. Surgeons' and my heart rates were dropping back down to some semblance of normal.
Here comes Error #2: An important part of an abdominal surgery (other than something elective, like a spay) is to perform an explore of all of the abdominal organs, whether you expect them to be abnormal or not. As part of Vega's abdominal explore, we noted that one of her remaining liver lobes had a slightly abnormal appearance. The surgeon collected a biopsy sample, and placed it on a small piece of sterile paper on the instrument table. Unfortunately, she did not immediately hand the biopsy sample off to a surgery nurse to place in a formalin container, as is usually done with tissue samples, and we all forgot about the sample. It was presumably thrown away with all of the wrappers and packaging from everything needed for Vega's surgery -- but when I "got" to go hunting for it in the trash about an hour later, it was nowhere to be found. Oops.
Anyway, the rest of Vega's abdominal explore was fine. We closed her up, then transported her to CCU where she woke up slowly but normally, and proceeded to return to her usual neurotic behavior -- panting, pacing, barking, and generally trying to destroy everything in her kennel. The poor CCU staff were apparently rather irritated by this (and understandably so), since she received 5 doses of IV sedatives during the night (which reportedly did nothing to alter her behavior), and she was eventually shut up in an oxygen cage on room air, which did nothing to stop her barking but did at least dull the sound so it was almost inaudible in the room.
Vega's owners received a surgery and hospitalization estimate that included a second night's stay in the hospital if needed, since arrhythmias and pain are not uncommon complications of a surgery like this and are best dealt with in a hospitalized setting. However, Vega experienced no arrhythmias, seemed nonpainful, and clearly expressed to us that she was ready to be discharged, so we arranged a dismissal time for 9 am on Saturday.
I met with Vega's owners at 9 am and went through her dismissal instructions -- her pain medications and their side effects, how to care for and monitor her surgical incision, activity restrictions, etc. It all went well, and I advised them it would be a few minutes while I went to CCU to unplug Vega from all of her lines and monitoring, remove her IV catheters, and remove the bandage that had been placed over her incision so it would stay clean in the hospital.
Well, it turns out that the surgery nurses have gotten some new brand of extra-mega-super adhesive to get the bandages to stick onto the skin around the incisions, because Vega threw a tantrum when we tried to remove her bandage. It was really an all-out drama-queen hissy-fit, complete with howling, moaning, and thrashing, even when we were just gently restraining her and not even touching her bandage.
I should explain what the bandage looks like. It's a long, thin, flat strip of what looks like cotton padding, about 2 inches wide, laid down along the length of her abdominal incision (which goes from her sternum to her pelvis). A piece of clear plastic (which looks like plastic wrap) is placed over the cotton layer, and extends about an inch and a half onto the skin on either side of the bandage. An adhesive is sprayed onto the skin around the incision as well as onto the outside of the cotton bandage, to affix the clear plastic to the skin around the incision as well as to the outside of the bandage.
Since we couldn't easily peel or pull the plastic layer off Vega's skin (even with the help of adhesive remover wipes), the surgeon decided to very carefully cut into the cotton layer in the center of the bandage, overlying the incision. Her goal was to cut out the cotton layer (which was not affixed to the skin) and just leave the plastic layer around the edges to fall off on its own.
Error #3: Unfortunately, while cutting into the middle of the cotton layer, the surgeon accidentally cut some of the skin sutures from Vega's abdominal incision.
Luckily, not many of the sutures were lost, and we only had to replace 2 or 3 stitches in order to re-secure the suture line. But, it still meant a lot more drama from Vega, as well as more time that her poor anxious owners spent up front waiting for us to bring her out, and there's the pesky little fact that the skin likes to bleed a lot when poked with a needle, so there was still a little blood that appeared to be coming from Vega's incision (though it wasn't) by the time her owners saw her.
All in all, none of the "oops"es were major or complicated Vega's recovery. Her liver mass shows every sign of being consistent with a hepatocellular carcinoma, a tumor type for which complete surgical excision is essentially curative. We won't have biopsy results until Monday or Tuesday, but we're hopeful that it won't be something worse than that.
Now what's left for me is to put together my Grand Rounds presentation. I have some really cool pictures that were taken of Vega's abdomen and tumor during surgery. Once we have the histopath back and have confirmed that it's hepatocellular carcinoma, I'll do a little more research, but until then I'm ready to sleep for awhile!
Saturday, September 3, 2011
Helpful advice for CPR
I wanted to add to my last post -- during CPR rounds, the critical care clinician told us something that I think was extremely helpful in allowing me to stay calm and not panic during last night's CPR:
"When a patient presents for CPR, they are already dead. Whatever you do, you can't make it any worse. So don't worry!"
Good point!
"When a patient presents for CPR, they are already dead. Whatever you do, you can't make it any worse. So don't worry!"
Good point!
Euthanasia #2, CPR #1
My daytime Urgent Care rotation ended with a bang. We were far busier on Friday than any other day last week. We saw probably 15 patients in the first 4 hours of the day -- which is probably more patients than we saw total during any 10 hour shift on any of the other days. It was crazy -- about every 10-15 minutes we'd get a page that a new patient was here, along with pages about phone calls from clients or rDVMs every 5-10 minutes. It was kind of a lot of fun, in a strange way -- it's more exciting and invigorating to be busy like that than to be sitting around all day waiting for patients to show up, and it gave us students a real chance to learn how to triage patients. We also got practice explaining to owners that they are here to see an Urgent Care service, which means that some of the stable patients will be sitting around and waiting for awhile while we stabilize the more critical patients.
I primarily ended up with 2 patients, after most of my other ones were transferred to different services (neurology and internal medicine). My saddest patient was Joey, a middle-aged Labrador retriever who presented as a transfer from his rDVM with a complete urinary obstruction.
Joey was neutered only 1 month ago, when his owners noticed he was intermittently straining to urinate and his rDVM diagnosed an enlarged prostate (very common in intact adult male dogs). Testosterone causes the prostate to grow in size, consequently compressing the urethra and sometimes the rectum, resulting in difficulty urinating and/or defecating. The treatment is generally castration, and although the body's testosterone levels subside fairly quickly after the testicles are removed, it can take several weeks or months for the prostate to shrink back down to a more manageable size.
Since his castration, Joey had been able to urinate and defecate, but had still had some intermittent straining, which Joey's owners were told to expect. However, two days ago Joey became completely unable to urinate. His owners brought him to their rDVM, who felt that Joey's prostate was still somewhat enlarged but not enough to be causing his inability to urinate. Joey's rDVM took radiographs, which showed small stones in Joey's bladder, and a stone lodged in his urethra. The rDVM tried several times to place a urinary catheter (we are unsure if this was successful or not, or if the rDVM drained Joey's bladder by placing a needle through his abdominal wall), and eventually recommended that Joey head to the teaching hospital for treatment.
Upon arrival, Joey was happy and wagging his tail, but was clearly experiencing quite a bit of discomfort from his by-now distended bladder. Joey's owners were quite conflicted about how to proceed with his treatment. Our initial stabilization (about $500) would include the Urgent Care exam fee, pain meds, ensuring the rDVM's IV catheter was patent, starting IV fluids, running some bloodwork and a urinalysis, and attempting to place an indwelling urinary catheter. Long-term, Joey's owners would be looking at anesthesia and surgery for stone removal from Joey's bladder, as well as possible surgery to remove the stone from Joey's urethra if it could not be moved, and maybe even a perineal urethrostomy (crudely, a surgery that would make Joey pee like a girl) if Joey's urethra had been too badly damaged from the stone sitting in it and the repeated attempts to pass a urinary catheter.
As you can imagine, the financial estimate for these surgeries was pretty staggering, especially given the fact that, not knowing why Joey's urinary stones had formed in the first place, we could give no 100% guarantee that we would be able to prevent them from ever returning in the future. Sure, depending on the type of stones, there are medical things that could be done to decrease the likelihood of recurrence, but we couldn't say that they would never return. And Joey's owners knew that although they might be able to scrape together the funds for his initial surgery, it really wasn't in their budget, much less a second surgery.
In the end, Joey's owners permitted his initial stabilization to allow themselves time to make a decision about how to proceed with Joey's care. With sedation and multiple attempts, we managed to place a small-bore urinary catheter to drain Joey's bladder and keep him comfortable. However, the fact that his penis was dripping frank blood on presentation and throughout the day was a sign that his urinary tract was very unhappy.
Toward the end of the day, Joey's owners made the decision to euthanize him. They wanted to spend a few minutes with him outside the hospital in the garden area, then to put him to sleep out there. The intern on duty and I brought Joey to his mom and dad, and they said tearful goodbyes. Once we had Joey settled on some nice cushy blankets in the grass, his owners decided they couldn't stay until the very end, so the intern and I talked to Joey and rubbed his belly as he watched his owners walk away for the last time. Then we anesthetized and euthanized him. He went peacefully, with lots of petting and us telling him how much his owners loved him, the sun shining down through the tree above and a breeze in the air, but it broke my heart a little bit.
We made a clay paw print for Joey's owners to have, and clipped some of his fur for them to keep along with his collar and tags. His owners consented to a necropsy, so we'll be able to find out how severely damaged his urinary tract really was. (His owners didn't want to know the results of his necropsy, and I wouldn't have either.)
It was about 6 pm by the time I had prepared those mementos for Joey's owners, delivered his body to necropsy, and started a sympathy card to send to his mom and dad. After 7 nights in a row last week of 10-12 hour overnight shifts, followed by 4 days this week of 12-14 hour Urgent Care daytime shifts, and almost 12 hours into my 5th day on Urgent Care, I was emotionally and physically exhausted.
However, about 10 minutes after sitting down to complete the day's paperwork, I got quite the adrenaline boost when another student rushed down the hall toward the Urgent Care room yelling, "Get ready, we need CPR!"
The patient was a small elderly mixed breed dog, whose owners had rushed him in after he had developed acute respiratory distress as they were driving out of town for a Labor Day weekend camping trip. The dog appeared not to be breathing on presentation at the VTH, so he was immediately rushed back for CPR.
Other than walking into a patient undergoing CPR during one of my last overnight shifts (the CPR in that case was well underway by the time I arrived, and all I did was write down the drugs that were given as the rest of the team did compressions, etc.), yesterday's CPR situation was the first in which I've really been involved.
Fortunately, we had "CPR rounds" two days prior, in which a critical care clinician reviewed with us in detail the steps to perform CPR. I'm so very glad we had those rounds, because it allowed me to stay somewhat calmer in this situation.
One of the nurses immediately started chest compressions on the little dog (which is the most important thing to do), and another nurse and doctor got to work intubating the dog. A student and another doctor started placing an IV catheter, while another nurse placed an intraosseous catheter (directly into the cavity within one of the dog's bones) then hooked up an EKG. A second student went to get more help; a third student started recording what we were doing; and I headed to the crash cart to start pulling up doses of atropine and epinephrine.
We performed chest compressions, mechanical ventilation, monitored EKG, and gave 3 rounds of drugs within about 10 minutes, but with no change in the dog's condition, he was pronounced dead shortly thereafter. It was a sad situation for the family, who'd been told previously the little guy had a heart murmur but that there was nothing they could do about it (which may not have been true). Given the vast amount of fluid coming up from his lungs, it's possible he had acutely gone into heart failure. The family was shocked at his sudden death.
However, it was oddly rewarding to see how well everyone worked as a team. The goal of CPR rounds and "practice" CPR situations is to remind everybody how things are done so that nobody panics and everyone can play a useful role when a CPR situation arises. As you might expect, studies have shown that medical and veterinary teams that practice CPR regularly are more likely to have a successful outcome (although the reality is that, in CPR situations overall, there's only about a 5% chance of getting an animal 'back').
As the clinicians ever-so-helpfully remind us, in a matter of months we students will be the ones to whom the rest of the veterinary care teams look to as leaders in a time of crisis, and we'll need to be able to stay calm, give directions, and make decisions about things like CPR. That's a really scary thought, but CPR rounds and CPR practice make me feel the tiniest bit like I might actually be ready someday.
I primarily ended up with 2 patients, after most of my other ones were transferred to different services (neurology and internal medicine). My saddest patient was Joey, a middle-aged Labrador retriever who presented as a transfer from his rDVM with a complete urinary obstruction.
Joey was neutered only 1 month ago, when his owners noticed he was intermittently straining to urinate and his rDVM diagnosed an enlarged prostate (very common in intact adult male dogs). Testosterone causes the prostate to grow in size, consequently compressing the urethra and sometimes the rectum, resulting in difficulty urinating and/or defecating. The treatment is generally castration, and although the body's testosterone levels subside fairly quickly after the testicles are removed, it can take several weeks or months for the prostate to shrink back down to a more manageable size.
Since his castration, Joey had been able to urinate and defecate, but had still had some intermittent straining, which Joey's owners were told to expect. However, two days ago Joey became completely unable to urinate. His owners brought him to their rDVM, who felt that Joey's prostate was still somewhat enlarged but not enough to be causing his inability to urinate. Joey's rDVM took radiographs, which showed small stones in Joey's bladder, and a stone lodged in his urethra. The rDVM tried several times to place a urinary catheter (we are unsure if this was successful or not, or if the rDVM drained Joey's bladder by placing a needle through his abdominal wall), and eventually recommended that Joey head to the teaching hospital for treatment.
Upon arrival, Joey was happy and wagging his tail, but was clearly experiencing quite a bit of discomfort from his by-now distended bladder. Joey's owners were quite conflicted about how to proceed with his treatment. Our initial stabilization (about $500) would include the Urgent Care exam fee, pain meds, ensuring the rDVM's IV catheter was patent, starting IV fluids, running some bloodwork and a urinalysis, and attempting to place an indwelling urinary catheter. Long-term, Joey's owners would be looking at anesthesia and surgery for stone removal from Joey's bladder, as well as possible surgery to remove the stone from Joey's urethra if it could not be moved, and maybe even a perineal urethrostomy (crudely, a surgery that would make Joey pee like a girl) if Joey's urethra had been too badly damaged from the stone sitting in it and the repeated attempts to pass a urinary catheter.
As you can imagine, the financial estimate for these surgeries was pretty staggering, especially given the fact that, not knowing why Joey's urinary stones had formed in the first place, we could give no 100% guarantee that we would be able to prevent them from ever returning in the future. Sure, depending on the type of stones, there are medical things that could be done to decrease the likelihood of recurrence, but we couldn't say that they would never return. And Joey's owners knew that although they might be able to scrape together the funds for his initial surgery, it really wasn't in their budget, much less a second surgery.
In the end, Joey's owners permitted his initial stabilization to allow themselves time to make a decision about how to proceed with Joey's care. With sedation and multiple attempts, we managed to place a small-bore urinary catheter to drain Joey's bladder and keep him comfortable. However, the fact that his penis was dripping frank blood on presentation and throughout the day was a sign that his urinary tract was very unhappy.
Toward the end of the day, Joey's owners made the decision to euthanize him. They wanted to spend a few minutes with him outside the hospital in the garden area, then to put him to sleep out there. The intern on duty and I brought Joey to his mom and dad, and they said tearful goodbyes. Once we had Joey settled on some nice cushy blankets in the grass, his owners decided they couldn't stay until the very end, so the intern and I talked to Joey and rubbed his belly as he watched his owners walk away for the last time. Then we anesthetized and euthanized him. He went peacefully, with lots of petting and us telling him how much his owners loved him, the sun shining down through the tree above and a breeze in the air, but it broke my heart a little bit.
We made a clay paw print for Joey's owners to have, and clipped some of his fur for them to keep along with his collar and tags. His owners consented to a necropsy, so we'll be able to find out how severely damaged his urinary tract really was. (His owners didn't want to know the results of his necropsy, and I wouldn't have either.)
It was about 6 pm by the time I had prepared those mementos for Joey's owners, delivered his body to necropsy, and started a sympathy card to send to his mom and dad. After 7 nights in a row last week of 10-12 hour overnight shifts, followed by 4 days this week of 12-14 hour Urgent Care daytime shifts, and almost 12 hours into my 5th day on Urgent Care, I was emotionally and physically exhausted.
However, about 10 minutes after sitting down to complete the day's paperwork, I got quite the adrenaline boost when another student rushed down the hall toward the Urgent Care room yelling, "Get ready, we need CPR!"
The patient was a small elderly mixed breed dog, whose owners had rushed him in after he had developed acute respiratory distress as they were driving out of town for a Labor Day weekend camping trip. The dog appeared not to be breathing on presentation at the VTH, so he was immediately rushed back for CPR.
Other than walking into a patient undergoing CPR during one of my last overnight shifts (the CPR in that case was well underway by the time I arrived, and all I did was write down the drugs that were given as the rest of the team did compressions, etc.), yesterday's CPR situation was the first in which I've really been involved.
Fortunately, we had "CPR rounds" two days prior, in which a critical care clinician reviewed with us in detail the steps to perform CPR. I'm so very glad we had those rounds, because it allowed me to stay somewhat calmer in this situation.
One of the nurses immediately started chest compressions on the little dog (which is the most important thing to do), and another nurse and doctor got to work intubating the dog. A student and another doctor started placing an IV catheter, while another nurse placed an intraosseous catheter (directly into the cavity within one of the dog's bones) then hooked up an EKG. A second student went to get more help; a third student started recording what we were doing; and I headed to the crash cart to start pulling up doses of atropine and epinephrine.
We performed chest compressions, mechanical ventilation, monitored EKG, and gave 3 rounds of drugs within about 10 minutes, but with no change in the dog's condition, he was pronounced dead shortly thereafter. It was a sad situation for the family, who'd been told previously the little guy had a heart murmur but that there was nothing they could do about it (which may not have been true). Given the vast amount of fluid coming up from his lungs, it's possible he had acutely gone into heart failure. The family was shocked at his sudden death.
However, it was oddly rewarding to see how well everyone worked as a team. The goal of CPR rounds and "practice" CPR situations is to remind everybody how things are done so that nobody panics and everyone can play a useful role when a CPR situation arises. As you might expect, studies have shown that medical and veterinary teams that practice CPR regularly are more likely to have a successful outcome (although the reality is that, in CPR situations overall, there's only about a 5% chance of getting an animal 'back').
As the clinicians ever-so-helpfully remind us, in a matter of months we students will be the ones to whom the rest of the veterinary care teams look to as leaders in a time of crisis, and we'll need to be able to stay calm, give directions, and make decisions about things like CPR. That's a really scary thought, but CPR rounds and CPR practice make me feel the tiniest bit like I might actually be ready someday.
Thursday, September 1, 2011
Urgently Caring, one day at a time
My current CCU rotation is comprised of 2 pretty different weeks. Last week was the overnight shifts, and this week is a daytime Urgent Care shift.
Urgent Care (UC) sees patients from 7 am till 10 pm on weekdays, and more limited hours on weekends. (Emergencies during other hours go straight to CCU.)
On UC we see any patient who enters the building as a walk-in appointment, any patient who requires a same-day appointment but can't get in through the specialty service they hope to see, and any daytime emergencies like snakebites or hit-by-car cases.
It's kind of neat not to know what to expect when you get there for the day -- about 60% of the clients we see call ahead by a few minutes or hours to let us know when and why they are coming, and the other 40% just show up out of the blue. It definitely requires you to think on your feet.
I've ended up with an odd mix of patients this week. They are as follows:
1. A 6-month-old Lab puppy, presented on Monday morning for acute-onset (12-24 hour duration) vomiting and diarrhea. We hospitalized her overnight for IV fluids and supportive care. She was negative for parvo but did have coccidia and Campylobacter in her feces, which we are treating.
2. A middle-aged hound mix, presented on Monday afternoon for skin problems. He'd had an acute onset of severe generalized itching, lethargy, and inappetance 10 days prior, with some degree of improvement since then. We suspected an autoimmune dermatologic disease, so he came back on Tuesday for a dermatology consultation.
3. An older Australian shepherd, presented on Tuesday morning for a worsening head tilt and improving falling/abnormal gait of 2-3 weeks duration. She also had a 2 month history of recurrent vaginitis, and several skin masses. We worked up her vaginitis and she came back for an MRI and neurology consultation on Wednesday, which showed an inner ear inflammation.
4. A young Chihuahua, presented on Wednesday morning for neck and back pain, as well as a palmigrade stance (walking down on her wrists). Her rDVM suspected neurologic disease. We agreed but thought there may be an orthopedic component. The orthopods examined her and recommended a neuro consult. The neurologists examined her and recommended an internal medicine consult for immune-mediated polyarthritis. She had a fever, so stayed in CCU on fluids overnight and transferred to internal medicine on Thursday morning for joint taps.
5. My first euthanasia patient, presented on Thursday for euthanasia due to abject misery.
6. An elderly Doberman, presented on Thursday morning for an acute onset of steadily worsening neck pain and abnormal gait, suspected by his rDVM to be due to cervical disc disease. After seeing his bloodwork showing a lymphocyte count of 75K (normal is 1-4K) and collecting lymph node aspirates with severely abnormal cells, we diagnosed him with Stage Vb lymphoma.
The Doberman was definitely my saddest case of the week so far. He is such a nice dog with an equally nice owner, very willing to spend the money needed for an MRI and vertebral surgery (which is what his rDVM had prepared him for).
Lymphoma is a cancer of the lymphatic system, including the lymph nodes, which help drain infection and inflammation from the surrounding tissues. It's "staged" based on clinical presentation, from Stage I through Stage V. Stage I means the cancer is limited to a single lymph node or organ. Stage II means that nearby lymph nodes are involved. Stage III means that all of the lymph nodes around the body are involved. Stage IV means it has spread to the liver and/or spleen. And Stage V means that it has spread to the blood, the bone marrow, or other sites such as the brain or spinal cord.
Lymphoma is also given a "substage" of 'a' or 'b.' These are based somewhat crudely on how well the dog is doing: a substage 'a' dog is one who feels pretty good; a substage 'b' dog is one who feels poorly.
Negative prognostic factors (things that are associated with a bad outcome) for lymphoma are:
1. Stages III/IV/V are worse than Stages I/II
2. Substage 'b' is worse than 'a'
3. T-cell is worse than B-cell (Mr. Doberman is suspected to have T-cell)
4. Leukemia (cancerous cells in the blood) and spread to "protected sites" such as the spinal cord and brain are worse than lack of these factors
So poor Mr. Doberman has all of these things against him.
He became more and more painful throughout the day, eventually whining and moaning in pain even when lying in the most comfortable position he could find, and even after a whopping dose of oral pain meds. We started him on heavy doses of IV pain meds, which seemed to help somewhat, but pain meds alone would not be enough to control his discomfort, so he was anesthetized for a dose of palliative radiation in the area where his spinal cord is being disturbed, and he started on chemo.
It's so odd, because without doing bloodwork on this dog and seeing his enormously elevated lymphocyte count (which really can only be caused by leukemia or lymphoma), he probably would have headed for an MRI to see what was going on. He had otherwise been feeling well (normal appetite, energy level, etc.) and did not have any of the characteristic lymph node enlargement that is typically seen in lymphoma cases. That goes to show you why doing a step-wise work-up in these neurologic-type cases is always a good idea, starting with bloodwork/urinalysis and progressing to more advanced diagnostics one at a time.
I'm hoping for the best possible outcome for Mr. Doberman, but even that won't be all that great. If he responds well to palliative radiation, he may have 2-3 months of quality time left. However, it's possible that we will not be able to get his extreme pain under control, in which case he'll most likely end up in Doggie Heaven. The one consolation is that at least he hasn't spent a long, chronic period of time feeling miserable up to this diagnosis -- just a few days. I know his dad would love to see him get home for a few more weeks of loving.
Urgent Care (UC) sees patients from 7 am till 10 pm on weekdays, and more limited hours on weekends. (Emergencies during other hours go straight to CCU.)
On UC we see any patient who enters the building as a walk-in appointment, any patient who requires a same-day appointment but can't get in through the specialty service they hope to see, and any daytime emergencies like snakebites or hit-by-car cases.
It's kind of neat not to know what to expect when you get there for the day -- about 60% of the clients we see call ahead by a few minutes or hours to let us know when and why they are coming, and the other 40% just show up out of the blue. It definitely requires you to think on your feet.
I've ended up with an odd mix of patients this week. They are as follows:
1. A 6-month-old Lab puppy, presented on Monday morning for acute-onset (12-24 hour duration) vomiting and diarrhea. We hospitalized her overnight for IV fluids and supportive care. She was negative for parvo but did have coccidia and Campylobacter in her feces, which we are treating.
2. A middle-aged hound mix, presented on Monday afternoon for skin problems. He'd had an acute onset of severe generalized itching, lethargy, and inappetance 10 days prior, with some degree of improvement since then. We suspected an autoimmune dermatologic disease, so he came back on Tuesday for a dermatology consultation.
3. An older Australian shepherd, presented on Tuesday morning for a worsening head tilt and improving falling/abnormal gait of 2-3 weeks duration. She also had a 2 month history of recurrent vaginitis, and several skin masses. We worked up her vaginitis and she came back for an MRI and neurology consultation on Wednesday, which showed an inner ear inflammation.
4. A young Chihuahua, presented on Wednesday morning for neck and back pain, as well as a palmigrade stance (walking down on her wrists). Her rDVM suspected neurologic disease. We agreed but thought there may be an orthopedic component. The orthopods examined her and recommended a neuro consult. The neurologists examined her and recommended an internal medicine consult for immune-mediated polyarthritis. She had a fever, so stayed in CCU on fluids overnight and transferred to internal medicine on Thursday morning for joint taps.
5. My first euthanasia patient, presented on Thursday for euthanasia due to abject misery.
6. An elderly Doberman, presented on Thursday morning for an acute onset of steadily worsening neck pain and abnormal gait, suspected by his rDVM to be due to cervical disc disease. After seeing his bloodwork showing a lymphocyte count of 75K (normal is 1-4K) and collecting lymph node aspirates with severely abnormal cells, we diagnosed him with Stage Vb lymphoma.
The Doberman was definitely my saddest case of the week so far. He is such a nice dog with an equally nice owner, very willing to spend the money needed for an MRI and vertebral surgery (which is what his rDVM had prepared him for).
Lymphoma is a cancer of the lymphatic system, including the lymph nodes, which help drain infection and inflammation from the surrounding tissues. It's "staged" based on clinical presentation, from Stage I through Stage V. Stage I means the cancer is limited to a single lymph node or organ. Stage II means that nearby lymph nodes are involved. Stage III means that all of the lymph nodes around the body are involved. Stage IV means it has spread to the liver and/or spleen. And Stage V means that it has spread to the blood, the bone marrow, or other sites such as the brain or spinal cord.
Lymphoma is also given a "substage" of 'a' or 'b.' These are based somewhat crudely on how well the dog is doing: a substage 'a' dog is one who feels pretty good; a substage 'b' dog is one who feels poorly.
Negative prognostic factors (things that are associated with a bad outcome) for lymphoma are:
1. Stages III/IV/V are worse than Stages I/II
2. Substage 'b' is worse than 'a'
3. T-cell is worse than B-cell (Mr. Doberman is suspected to have T-cell)
4. Leukemia (cancerous cells in the blood) and spread to "protected sites" such as the spinal cord and brain are worse than lack of these factors
So poor Mr. Doberman has all of these things against him.
He became more and more painful throughout the day, eventually whining and moaning in pain even when lying in the most comfortable position he could find, and even after a whopping dose of oral pain meds. We started him on heavy doses of IV pain meds, which seemed to help somewhat, but pain meds alone would not be enough to control his discomfort, so he was anesthetized for a dose of palliative radiation in the area where his spinal cord is being disturbed, and he started on chemo.
It's so odd, because without doing bloodwork on this dog and seeing his enormously elevated lymphocyte count (which really can only be caused by leukemia or lymphoma), he probably would have headed for an MRI to see what was going on. He had otherwise been feeling well (normal appetite, energy level, etc.) and did not have any of the characteristic lymph node enlargement that is typically seen in lymphoma cases. That goes to show you why doing a step-wise work-up in these neurologic-type cases is always a good idea, starting with bloodwork/urinalysis and progressing to more advanced diagnostics one at a time.
I'm hoping for the best possible outcome for Mr. Doberman, but even that won't be all that great. If he responds well to palliative radiation, he may have 2-3 months of quality time left. However, it's possible that we will not be able to get his extreme pain under control, in which case he'll most likely end up in Doggie Heaven. The one consolation is that at least he hasn't spent a long, chronic period of time feeling miserable up to this diagnosis -- just a few days. I know his dad would love to see him get home for a few more weeks of loving.
My first euthanasia
I had my first euthanasia case on Urgent Care today.
Oliver was an elderly long-haired terrier who had never been to the VTH before. His presenting complaint was "mass in mouth/possible euthanasia."
On presentation, he looked to be a definite euthanasia. His long tan-and-silver hair was badly matted over his entire body. His eyes were cloudy with sticky green discharge. He smelled like a sewer. He was recumbent and unwilling to move.
And, most notably, he did indeed have a mass in his mouth -- a mass that had spread from his mouth to engulf and deform his entire palate, nose, and muzzle. He was bleeding from his mouth, kept coughing and gagging, and seemed to be having a lot of trouble breathing.
Oh, and maggots were crawling in and out of his nostrils.
Oliver's owner conveyed to me that they had noticed a small oral mass about 6 months ago, and it had just kept growing since then. Over the last 3-4 days, Oliver had stopped eating, seemed to be in respiratory distress, and started to smell really bad. Her husband wasn't sure it was "time" yet, but she was pretty convinced.
Oliver's owner said, "Do you think it might be cancer?" which gave me some idea that poor Oliver had never seen a vet since developing this tumor. My reply was, "Yes, these types of things are usually cancer." I was stupefied enough not to know what else to say.
After some brief discussion, Oliver's owner elected not to be present for his euthanasia, and requested that we bring him to the back for the procedure. We obliged after she signed the consent forms to permit the euthanasia, as well as an "educational post-mortem examination" (aka necropsy). She did not want his body or ashes back, but thought a clay paw print would be nice.
We carried little Oliver to the Urgent Care treatment room, where I struggled for about 5 minutes to get the clippers through the thickly matted hair on his front leg, then placed an IV cathether (on my first try!). Oliver immediately received a heavy sedative injection IV, followed by euthanasia solution. All in all, it went quickly and peacefully. After his death, we discovered that Oliver had many other large masses over his entire body, and toenails about 2 inches long (on a 15 pound dog).
I had been quite nervous about my first euthanasia, since I know what a difficult thing it can be for owners (and for the veterinary team). I guess it turned out well that (a) Oliver's need for euthanasia was not at all ambiguous, and (b) Oliver's owner did not wish to be present when he was euthanized. That meant that I got to skip the whole part about "When Oliver's body relaxes as his heart stops, you may see some muscle twitching. He may vocalize. His eyes may not close. He may leak stool or urine," etc.
But I can't bring myself to even begin to think about what Oliver went through for the last few months, and especially the last few days. I mean, who among us can say what it feels like to have maggots crawling around inside your nose, eating bits and pieces of you? How about a huge tumor in your mouth so large that you can't even close your jaws? Spending several days gagging on the blood that is constantly running down your throat?
In the end, I feel that you can't be too hard on anyone who eventually seeks veterinary care for their pet. I don't think Oliver's owners had any idea how badly he must have been suffering. Their ignorance probably led to a lot of pain on Oliver's part, but at least they brought him to us for a peaceful ending instead of letting him die a miserable death from dehydration, suffocation, and sepsis at home. Did they wait too long? Yes. Should they have sought veterinary care long ago? Of course. But will it do Oliver or his owners any good for us to scold and shame them? Probably not. I think once they hear the results of Oliver's necropsy (which they requested we tell them), they will have a better understanding of what he went through at the end.
The power of euthanasia is one of the greatest gifts we have as veterinarians, which is lacking in human medicine. It's hard to describe the feeling I get when participating in a euthanasia that is well done and appropriately timed -- emotionally satisfying, gratifying, relieving, comforting... (I still haven't found the right words). It's a good feeling to help a well-loved pet die peacefully and painlessly when you know you've done all you can and that ending the pet's suffering is the best thing to do. My feelings are a little more mixed than that in Oliver's case. All in all, it made for an introspective, pensive sort of day.
Oliver was an elderly long-haired terrier who had never been to the VTH before. His presenting complaint was "mass in mouth/possible euthanasia."
On presentation, he looked to be a definite euthanasia. His long tan-and-silver hair was badly matted over his entire body. His eyes were cloudy with sticky green discharge. He smelled like a sewer. He was recumbent and unwilling to move.
And, most notably, he did indeed have a mass in his mouth -- a mass that had spread from his mouth to engulf and deform his entire palate, nose, and muzzle. He was bleeding from his mouth, kept coughing and gagging, and seemed to be having a lot of trouble breathing.
Oh, and maggots were crawling in and out of his nostrils.
Oliver's owner conveyed to me that they had noticed a small oral mass about 6 months ago, and it had just kept growing since then. Over the last 3-4 days, Oliver had stopped eating, seemed to be in respiratory distress, and started to smell really bad. Her husband wasn't sure it was "time" yet, but she was pretty convinced.
Oliver's owner said, "Do you think it might be cancer?" which gave me some idea that poor Oliver had never seen a vet since developing this tumor. My reply was, "Yes, these types of things are usually cancer." I was stupefied enough not to know what else to say.
After some brief discussion, Oliver's owner elected not to be present for his euthanasia, and requested that we bring him to the back for the procedure. We obliged after she signed the consent forms to permit the euthanasia, as well as an "educational post-mortem examination" (aka necropsy). She did not want his body or ashes back, but thought a clay paw print would be nice.
We carried little Oliver to the Urgent Care treatment room, where I struggled for about 5 minutes to get the clippers through the thickly matted hair on his front leg, then placed an IV cathether (on my first try!). Oliver immediately received a heavy sedative injection IV, followed by euthanasia solution. All in all, it went quickly and peacefully. After his death, we discovered that Oliver had many other large masses over his entire body, and toenails about 2 inches long (on a 15 pound dog).
I had been quite nervous about my first euthanasia, since I know what a difficult thing it can be for owners (and for the veterinary team). I guess it turned out well that (a) Oliver's need for euthanasia was not at all ambiguous, and (b) Oliver's owner did not wish to be present when he was euthanized. That meant that I got to skip the whole part about "When Oliver's body relaxes as his heart stops, you may see some muscle twitching. He may vocalize. His eyes may not close. He may leak stool or urine," etc.
But I can't bring myself to even begin to think about what Oliver went through for the last few months, and especially the last few days. I mean, who among us can say what it feels like to have maggots crawling around inside your nose, eating bits and pieces of you? How about a huge tumor in your mouth so large that you can't even close your jaws? Spending several days gagging on the blood that is constantly running down your throat?
In the end, I feel that you can't be too hard on anyone who eventually seeks veterinary care for their pet. I don't think Oliver's owners had any idea how badly he must have been suffering. Their ignorance probably led to a lot of pain on Oliver's part, but at least they brought him to us for a peaceful ending instead of letting him die a miserable death from dehydration, suffocation, and sepsis at home. Did they wait too long? Yes. Should they have sought veterinary care long ago? Of course. But will it do Oliver or his owners any good for us to scold and shame them? Probably not. I think once they hear the results of Oliver's necropsy (which they requested we tell them), they will have a better understanding of what he went through at the end.
The power of euthanasia is one of the greatest gifts we have as veterinarians, which is lacking in human medicine. It's hard to describe the feeling I get when participating in a euthanasia that is well done and appropriately timed -- emotionally satisfying, gratifying, relieving, comforting... (I still haven't found the right words). It's a good feeling to help a well-loved pet die peacefully and painlessly when you know you've done all you can and that ending the pet's suffering is the best thing to do. My feelings are a little more mixed than that in Oliver's case. All in all, it made for an introspective, pensive sort of day.
Monday, August 29, 2011
My poor circadian rhythms
I'm officially back to a daytime schedule now, following Saturday night's final overnight shift.
I arrived at 9:50 pm for my 10 pm shift start, and walked into CPR. One of the patients who'd had GI surgery several days prior had suddenly arrested. I assisted for about 10 minutes, at which time they called it off and pronounced the poor guy deceased. It was a surprising turn, since this particular patient had seemed to be improving quite steadily since his surgery. Everyone was, understandably, upset. Losing a patient really sets a gloomy tone for the rest of the night.
Other than the CPR, my shift was an uneventful one, with a mere 3 inpatients and no outpatients for which I was responsible. My 3 were familiar ones:
1. Mr. Presa Canario post-op Wobbler's surgery, here since Tuesday (Wobbler's patients typically stay 5-7 days in the hospital because they have a hugely extensive surgery on the vertebrae in their neck, and must be kept totally quiet for at least that period of time, which means we dope them up pretty heavily with IV pain meds and don't let them leave their cage for anything until at least 3-4 days post-op). Mr. Presa Canario is in need of an attitude adjustment (or maybe a breed adjustment) -- since he's started feeling better, he's become much grumpier and consequently more terrifying -- so his urinary catheter and IV lines were removed so we don't have to deal with those, and we pretty much do nothing with him other than feed him. He will have gone home yesterday or today.
2. Mr. Dachshund post-op hemilaminectomy, here since Tuesday. Poor Mr. Dachshund. Hemilaminectomy patients typically stay in the hospital about 2-3 nights after surgery -- 2 nights if they do exceptionally well after surgery, and 3+ nights if they are a little slower to recover. Most of them are still partially paralyzed when they are discharged (it can take up to 6 months to make a full recovery), but that's manageable for owners at home as long as the dog can urinate and defecate on its own. The problem with Mr. Dachshund is that he's had ongoing bladder issues since his surgery. Immediately post-op with all of these patients, we place a urinary catheter because we don't want to have to take them outside and we don't want them peeing all over themselves. Then a day or two post-op, we remove the u-cath and see if they can urinate on their own. If they can't, we see if their bladder can be easily expressed manually by placing pressure on their abdomen. If the dog is peeing on his own or can be easily expressed, he can go home. Unfortunately, neither is the case for Mr. Dachshund, requiring us to place a temporary urinary catheter several times a day to help him empty his bladder. I'm really hoping he improves in this area soon because he's going nuts in the hospital from boredom, and consequently driving everybody else insane with his whining and barking!
3. The older German Shepherd post-op hemoabdomen and splenectomy (patient #4 from Friday night). He's been doing somewhat poorly. His lidocaine infusion, meant to help control his cardiac arrhythmias, was making him terribly nauseated so we had to stop it. That meant that for the first 6 hours of my shift, his heart was all over the place -- his heart rate would rapidly jump from a resting rate of 55 beats per minute up to 150-200, all while he was sleeping -- and he had almost entirely ventricular-origin beats, meaning the electrical current controlling his heart was originating from the ventricles (bottom chambers) instead of near the atria (top chambers). At about 4 am, we started him on magnesium chloride, which seemed to help somewhat to increase the number of normal beats he had. Unfortunately, his arterial blood gas analysis in the morning showed that he was oxygenating more poorly in the morning than he had the night before, suggesting incipient pneumonia or something else happening in his lungs. He's such a sweet guy; I hope he improves soon.
We had a couple outpatients come in, but my rotation-mate happened to deal with both of them: a rat with a probable brain tumor that we ended up euthanizing, and a cat post-declaw whose owner felt she was very painful.
It appears that the weekend is the time for a lot of phone calls, which makes sense if you think about it -- on a Thursday night, people are probably more likely to decide on their own that something can wait till their regular vet opens at 7 or 8 am the next day, whereas an ill pet on Saturday night may not be able to see its regular vet until Monday morning.
My favorite call was a hoarse woman who sounded like a 60-year-old lady who'd smoked for 50 years. She called around 5 am to say that her toy breed dog had seemed fine on Saturday, then had bloody diarrhea late on Saturday evening, tried to drink some water afterward and vomited it right back up, and seemed lethargic when she went to bed. When she awoke on Sunday morning, she observed him having a seizure-type episode, and at the time she called, the dog couldn't really walk, was "breathin' pretty hard," and had blood coming out of his mouth.
My response was, "It sounds like your dog may be very sick and we'd recommend that you bring him in right away." (Note: for anything that may not be emergent, I get the caller's name and number, check with the intern on duty, and give them a call back with advice [which is pretty much always "Bring your pet in"]. This was one case where I felt pretty darn sure what the intern's advice would be!)
The caller's response was, "Well, I got some things ta do this mornin' but I'll try an' bringim in in a coupla hours." I reiterated that it sounded like it shouldn't wait, and she said she'd be in when she had time. (The little dog arrived just as I was walking out at the end of my shift, and fortunately looked to be in decent shape, just based on my cursory glance.)
My challenge yesterday was to figure out how to get from a daytime sleeping schedule to a nighttime sleeping schedule in the course of 24 hours. What I ended up doing was heading to church in the morning, then coming home and napping from about noon till 4 (though I'd set my alarms for 2 pm, but don't remember hearing them or turning them off, which I apparently did). Several hours of wakeful grogginess ensued, then I headed to bed for the night around 9:15 pm -- only to awake at 4:30 am feeling quite well-rested and ready to start my day, so here I am!
I can imagine getting used to a regular schedule of working overnight hours, as long as you didn't have to do much switching back to daytime shifts. By the end of the week, when I had gotten into a routine (you all know I love my routine!), I felt pretty human for most of the day. I'm fortunate that I can sleep easily during the day, so that helped me adjust more quickly at the beginning of the week. However, I have a feeling that today is going to be a long day, and that it'll take me a couple more days to fully switch back to regular hours. Luckily, I may get all of Labor Day weekend off, so I anticipate some serious sleeping in and napping to fill up the Sleep Bank before I head into what may be an exhausting 2-week oncology rotation.
Urgent Care (7 am-6 pmish?) starts today. Hope I like it!
I arrived at 9:50 pm for my 10 pm shift start, and walked into CPR. One of the patients who'd had GI surgery several days prior had suddenly arrested. I assisted for about 10 minutes, at which time they called it off and pronounced the poor guy deceased. It was a surprising turn, since this particular patient had seemed to be improving quite steadily since his surgery. Everyone was, understandably, upset. Losing a patient really sets a gloomy tone for the rest of the night.
Other than the CPR, my shift was an uneventful one, with a mere 3 inpatients and no outpatients for which I was responsible. My 3 were familiar ones:
1. Mr. Presa Canario post-op Wobbler's surgery, here since Tuesday (Wobbler's patients typically stay 5-7 days in the hospital because they have a hugely extensive surgery on the vertebrae in their neck, and must be kept totally quiet for at least that period of time, which means we dope them up pretty heavily with IV pain meds and don't let them leave their cage for anything until at least 3-4 days post-op). Mr. Presa Canario is in need of an attitude adjustment (or maybe a breed adjustment) -- since he's started feeling better, he's become much grumpier and consequently more terrifying -- so his urinary catheter and IV lines were removed so we don't have to deal with those, and we pretty much do nothing with him other than feed him. He will have gone home yesterday or today.
2. Mr. Dachshund post-op hemilaminectomy, here since Tuesday. Poor Mr. Dachshund. Hemilaminectomy patients typically stay in the hospital about 2-3 nights after surgery -- 2 nights if they do exceptionally well after surgery, and 3+ nights if they are a little slower to recover. Most of them are still partially paralyzed when they are discharged (it can take up to 6 months to make a full recovery), but that's manageable for owners at home as long as the dog can urinate and defecate on its own. The problem with Mr. Dachshund is that he's had ongoing bladder issues since his surgery. Immediately post-op with all of these patients, we place a urinary catheter because we don't want to have to take them outside and we don't want them peeing all over themselves. Then a day or two post-op, we remove the u-cath and see if they can urinate on their own. If they can't, we see if their bladder can be easily expressed manually by placing pressure on their abdomen. If the dog is peeing on his own or can be easily expressed, he can go home. Unfortunately, neither is the case for Mr. Dachshund, requiring us to place a temporary urinary catheter several times a day to help him empty his bladder. I'm really hoping he improves in this area soon because he's going nuts in the hospital from boredom, and consequently driving everybody else insane with his whining and barking!
3. The older German Shepherd post-op hemoabdomen and splenectomy (patient #4 from Friday night). He's been doing somewhat poorly. His lidocaine infusion, meant to help control his cardiac arrhythmias, was making him terribly nauseated so we had to stop it. That meant that for the first 6 hours of my shift, his heart was all over the place -- his heart rate would rapidly jump from a resting rate of 55 beats per minute up to 150-200, all while he was sleeping -- and he had almost entirely ventricular-origin beats, meaning the electrical current controlling his heart was originating from the ventricles (bottom chambers) instead of near the atria (top chambers). At about 4 am, we started him on magnesium chloride, which seemed to help somewhat to increase the number of normal beats he had. Unfortunately, his arterial blood gas analysis in the morning showed that he was oxygenating more poorly in the morning than he had the night before, suggesting incipient pneumonia or something else happening in his lungs. He's such a sweet guy; I hope he improves soon.
We had a couple outpatients come in, but my rotation-mate happened to deal with both of them: a rat with a probable brain tumor that we ended up euthanizing, and a cat post-declaw whose owner felt she was very painful.
It appears that the weekend is the time for a lot of phone calls, which makes sense if you think about it -- on a Thursday night, people are probably more likely to decide on their own that something can wait till their regular vet opens at 7 or 8 am the next day, whereas an ill pet on Saturday night may not be able to see its regular vet until Monday morning.
My favorite call was a hoarse woman who sounded like a 60-year-old lady who'd smoked for 50 years. She called around 5 am to say that her toy breed dog had seemed fine on Saturday, then had bloody diarrhea late on Saturday evening, tried to drink some water afterward and vomited it right back up, and seemed lethargic when she went to bed. When she awoke on Sunday morning, she observed him having a seizure-type episode, and at the time she called, the dog couldn't really walk, was "breathin' pretty hard," and had blood coming out of his mouth.
My response was, "It sounds like your dog may be very sick and we'd recommend that you bring him in right away." (Note: for anything that may not be emergent, I get the caller's name and number, check with the intern on duty, and give them a call back with advice [which is pretty much always "Bring your pet in"]. This was one case where I felt pretty darn sure what the intern's advice would be!)
The caller's response was, "Well, I got some things ta do this mornin' but I'll try an' bringim in in a coupla hours." I reiterated that it sounded like it shouldn't wait, and she said she'd be in when she had time. (The little dog arrived just as I was walking out at the end of my shift, and fortunately looked to be in decent shape, just based on my cursory glance.)
My challenge yesterday was to figure out how to get from a daytime sleeping schedule to a nighttime sleeping schedule in the course of 24 hours. What I ended up doing was heading to church in the morning, then coming home and napping from about noon till 4 (though I'd set my alarms for 2 pm, but don't remember hearing them or turning them off, which I apparently did). Several hours of wakeful grogginess ensued, then I headed to bed for the night around 9:15 pm -- only to awake at 4:30 am feeling quite well-rested and ready to start my day, so here I am!
I can imagine getting used to a regular schedule of working overnight hours, as long as you didn't have to do much switching back to daytime shifts. By the end of the week, when I had gotten into a routine (you all know I love my routine!), I felt pretty human for most of the day. I'm fortunate that I can sleep easily during the day, so that helped me adjust more quickly at the beginning of the week. However, I have a feeling that today is going to be a long day, and that it'll take me a couple more days to fully switch back to regular hours. Luckily, I may get all of Labor Day weekend off, so I anticipate some serious sleeping in and napping to fill up the Sleep Bank before I head into what may be an exhausting 2-week oncology rotation.
Urgent Care (7 am-6 pmish?) starts today. Hope I like it!
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