I Finished Vet School Today

At 3:30pm, I walked out of my final exam of vet school, and left the small animal hospital for the last time (because I handed in my access card immediately afterwards)!

Here's what I said on facebook:

 THAT'S IT LAST EXAM VET SCHOOL DONE.

Vet school has become such a state of being it's hard to imagine actually being finished. No more lectures, treatments, missing lunch and dinner at the small animal hospital, falling asleep in rounds, running back and forth between radiology/surgery/ICU, getting cold and wet in a paddock, trying to make sense of the insides of a cow, pretending to know something about horses, hesitantly checking ESS feedback, endless hours at the large animal teaching unit, dressing up for all the costume parties, writing presentations practically every week, ten thousand assignments, walking 3-legged dogs in circles, yelling at Cornerstone while trying to do paperwork, struggling to get red book signatures, cluelessly palpating muddy sheep, oral exams, and a hundred other things.

I can actually sleep and have meals and hobbies for a change. No more sitting around studying every night, or feeling guilty about not studying every night (for a few days at least...) Phew, I can't believe it's actually over!

Now that I have time, I promise to update the blog and fill you in on exams and rosters and everything exciting that's been happening. I may sneakily add posts into the "past" so they fit chronologically. I have so many notes and experiences to catalogue!

It's been a full MONTH of studying for me, and it's not over yet. I still have to hardcore study for the next two weeks, then drive to Auckland for the seven hour computer based North American Licensing Exam. But then at long last I can breathe a sigh of relief, visit the South Island, and fly home and see my dogs and family!

And, let's not forget the most important part:

After five years, I am now a veterinarian.

Just Another Day on Necropsy

Warning: Posts relating to necropsy week are generally not for the faint of heart.

When we do a post-mortem examination, naturally we have to record what we found, which involves making notes on a blue sheet with boxes for each body system. My classmates tend to do this afterwards, over lunch, which is probably pretty sensible, as you'll see. I'm too paranoid that I'm going to completely forget something important, so I have to write things down as I think of them.

Today, once we removed a section of ribs, we set them down to one side and got to work removing the heart and lungs. As an aside, we had a really fascinating case. The dog had suffered from a bloody nose for about a month, which had gotten worse until the owners decided to euthanise. The abdomen was looking a bit "pot bellied" as well, but the dog was perfectly bright, happy, and eating well. However, when we opened the abdomen, a massive liver tumour practically jumped out at us. When we checked the nasal cavity (by sawing the face in half through the nose, by the way), it turned out to have, as suspected, and totally unrelated, a nasal tumour as well. Unlucky dog, eh?

So while we were busy getting excited about all the pathology, it turns out we had set the slab of ribs and muscles and fat right on top of our blue sheet. Whoops. Eventually, we noticed this, and when we picked the ribs up, the sheet went with it. I tried to pull the sheet off, but it wouldn't come. The fat was stuck fast. Pull pull pull, yank yank yank. Ummm, there's a giant mass of flesh stuck to half our paper.

Somehow, I managed to free our sheet without tearing it, leaving a large wet area around one quadrant. Blood and goop is a pretty normal part of a pathologist's life, so it probably doesn't matter apart from me feeling self-conscious. I proceeded to make the sheet worse and worse through the course of the lab by writing down notes and measurements with increasingly bloody gloves.

My partner and I looked at each other at the end of the morning and debated whether we should rewrite it, but there wasn't much time before the afternoon tutorial, so we figured, "Nahh, it probably doesn't matter." It planted the seed of doubt, however, and after the tutorial had finished, we both started thinking, "Well, maaaaaybeee we should rewrite it. Everyone else's PM reports are all pristine and neat." However, after a brief search, we discovered the clinician had already taken our pile of papers. Oh well.

Psychological Effects of the Small Animal Hospital

Hand touches faucet when washing hands - Crap, have to start over!

Barking dogs - What noise?

Strange ticking noise following me around all day - Oh right, I wear a watch now.

7:30am start - Wow, what a nice sleep-in.

End of the day - How many spots of dog drool got on my pants today? I don't have enough black pants if I can't wear this one again tomorrow.

Any repetetive motion such as grating cheese - Started counting by accident

Can't remember how to give directions - Go to the uh... the more distal part of the road...

Cell phone or tablet vibrates - I'm getting paged!

Dinner time - I have lettuce in the fridge. I guess I'll have lettuce for dinner. (Credit to my friend for that one).

Weekend - I have all this extra time today. Don't I have hobbies for days like this? I can't remember what they are.

Eating finger food - I washed my hands a thousand times today so no need to worry about contracting something.

Unusual animal comes into hospital - I want a pet parrot.

Introducing someone - Amber is a 23 year old female entire vet student with a history of lethargy and exercise intolerance.

Faced with life problem such as computer dying - Time to form a problem list and differential diagnoses.

There'a A Guinea Pig In Hospital

There's a guinea pig in hospital that's been a regular visitor. Apparently her owner loves her too much, and continues to feed her a mountain of fruit and vegetables despite repeated emphasis on the fact that guinea pigs require a large amount of roughage in their diet, a fact supported by the multiple nearly $1000 hospital bills. So once again, the guinea pig has been hospitalised, diagnosed, and put on meds. The upside to this is there's a guinea pig in hospital.

My reaction went something like this: Walks through ICU doors. "...going for ultrasound later todaaaaoooooohhh guinea pig!"

My excitement resulted in the intern handing me the guinea pig to hold for a while, which I was quite happy to do. She's a brown, smooth-coated piggie with an adorable Spanish name. The intern immediately walked away to do something, and other people entered the ICU and had a similar reaction to myself (including a clinician). Unfortunately, since I was holding the guinea pig, I started getting asked questions about the history and treatments. Of course, I had no clue, so I quickly found the intern and gave the guinea pig back.

That night I was on evening treatments, so I made a beeline to the ICU so I could be the one to do the guinea pig. It involved basically the same thing as any other animal, but tiny version. The heart rate was a bazillion beats per minute and their little bums are teeny tiny for trying to take a temperature. The other thing I had to do, since she was admitted for gastrointestinal hypomotility (I think), was count all the poops to make sure she was producing an adequate number per hour. So I stood there gathering all the guinea pig poops out of the cage and then counting them one by one. There were fifty, in case you were wondering.

Fifth Year In A Nutshell

Yesterday I got to sleep in and get home early. I didn't get up until 6:45am and I got home at 5:30pm.

I still fell asleep on the couch. At 7:30pm.

This Is What We're Reduced To

"Is there anything in your sandwich besides cheese?"
"Oh, no."
"So it's a slice of cheese and bread?"
"I was too tired to go shopping, so I just used what I had left."

-The small animal hospital strikes again.

I Had Hobbies Once

Assignment Checklist:

Poisonous plants project turned in.
4 person group project about handling a disaster turned in (we picked earthquake).
2 person group assignment about practice management turned in.
Last case report finished. (4 production, 2 equine)
Small animal disease client information handout finished.
Veterinary code of conduct assignment done.
Personality test assignment done (yes, they really made us do that).
4 person meatworks assignment out of the way.
Peer review of other groups' meatworks assignment finished.
Small animal surgical report, discharge instructions, anaesthetic record, and SOAP all signed off.
Red book skills 95% signed off.
Grand Rounds case presented to the department and done forever.

To do:
Public health case report.
Study for boards.

There is light at the end of the tunnel!

Refergency Friday and the Horse With Haemorrhagic Colitis

Warning: Blood is involved.

I once heard an internal medicine resident call Fridays "Refergency Friday," because it always seems that everyone waits until then to send over all the critical, complicated, or difficult cases. Today supported this trend, when the only emergency in all of equine roster rocked up at 9am. Not only was it an emergency, it was a potentially infectious (and potentially zoonotic) disease and the horse had to go straight into isolation.

Isolation is this little barn separated from the main equine barn. To go in, you have to put on special overalls and special boots, walk through disinfectants, and it's not a bad idea to put on two pairs of gloves. There are certain criteria for whether or not to put a horse in isolation:

2/3 of the following:
1. Fever
2. Diarrhoea
3. Low white blood cells

In our particular instance, we didn't find out that the horse had those things until it actually showed up. This was a prelude to the recurring theme of the fact that the history changed pretty much every single time someone talked to the client. However, the more immediate problem is that there are no supplies in isolation already; you have to bring everything down ahead of time, once you get the call. This makes sense because if the whole point is preventing spread of disease, you don't want to be using anything left over from the last patient that was in isolation.

So this nearly dead horse shows up and goes into isolation, and everyone starts moving at a frenetic pace. Unfortunately, about half the time when someone would ask me for something, I'd look around for it and find nothing. They wanted to put in an IV catheter, but the horse had terrible blood pressure, making it super difficult. Add this to the fact that I didn't have any of the things they actually needed and other students had to keep running back to the main barn to get them, tension got pretty high. Also, since we're students and not only didn't know our way around isolation (since we'd never been there before), the other student and I are totally not horse people and don't even know the basics. If someone asked for a certain object, we wouldn't know what it looked like, or which of several options they wanted. To top everything off, the horse was quite anxious, and it became dangerous on top of difficult to get anything done.

After a tense half an hour to an hour, the horse was finally sedated, catheterised, fluids were running, and things were more under control. Blood and abdominal fluid were sent off to the lab, and there was some time to catch our breath. After some teaching/learning about the physical exam findings and differential diagnoses, I got the lovely job of standing at the rear end with a pottle, waiting to catch what came out so someone could run diagnostics. This poor horse was literally crapping blood. Pure blood.

Things were looking pretty grim. Lab results kept making the picture worse and worse. The horse most likely had dead colon, allowing bacteria to translocate into the bloodstream and cause septicaemia, as well as fluid to collect in the abdomen. Blood was just pouring out the back end. Bloodwork showed that the kidney was showing signs of dysfunction, too. And though it was never confirmed, it was pretty likely that the horse was in disseminated intravascular coagulation (DIC).

They gave the horse some blood plasma, since when you're in a state like that, fluids aren't going to be enough. However, he had some sort of reaction (maybe anaphylaxis, or maybe he was just circling the drain and it was his time), and started getting wobbly, anxious, and then thrashing around. I wasn't there when this happened, but he came this close to killing someone. It was a downhill spiral from there, and he was euthanised.

He was sent over to post-mortem immediately, and we went down to have a look. His entire small and large colon was dead, dark and necrotic and haemorrhagic. The gut contents were mostly blood. It must have been a horrible, painful way to die. From the history, we suspected untreated intestinal parasites as a cause, though some other options include Salmonella, Clostridia, idiopathic colitis, or drug-induced. It's amazing to think that those things could cause such a horrific colitis.

I Volunteered For A Complicated Case On The First Day Of Equine

I have mentioned before that I'm not the biggest fan of horses. I am so not a fan of horses, in fact, that I've spent the entire year dreading the two weeks of equine. You hear more gossip about it every few weeks, about students who had to do hourly checks all night and then were not allowed to go home the next morning. People who brought sleeping bags and camped out in the equine barn, or who got stuck with the 2-4am shift on a colicking horse. It's not just the dreaded "on call," it's the fact that it's also freaking horses. They can kill you, you know. They have killed vet students.

I arrived nice and early on the first day of equine, at the brand new equine barn up on the hill--it was only completed a few months ago and I'd never, ever been up there. I had no idea how to get in since the door was locked and not a single person was around, but fortunately my roster-mate showed up and we found a side door. Eventually, everyone else showed up, but it didn't really breathe life into the place. We got given a tour of the barn: a cold, high-ceilinged, mostly gray building (inside and out) with a lot of empty space.

After the tour we had rounds, where the previous weeks' students handed the cases over and the clinicians told us what new cases would be coming in. There were two that day, one of which was a horse coming in for laryngeal tie-back surgery.

The thoughts that went through my head went something like this: The larynx is interesting. Dogs get laryngeal paralysis, too, and it's also treated by laryngeal tie-back. If I wait, I may end up with a really unpleasant case, like a lameness. I should jump on it now since I'm kind of interested in it.

That's how I ended up volunteering to be the primary student on what turned out to be the most involved case of equine roster.

The horse was actually coming in for a second surgery, as the first one had failed. This one was going to be similar with a few tweaks to hopefully give it a better chance of success. Long story short, the second surgery failed, too. Very bad news for the owner, who was training this horse to be a racehorse. I had to learn all about the first surgery, the complications and chances of failure, the second surgery and it's complications and chances of failure, and the options--which included a third surgery, and it's complications and chances of failure. I had the pleasure of getting grilled about these things at every morning and evening rounds for an entire week.

It didn't help that the horse was a nightmare half the time. As far as horses go, I can imagine much worse, and I was at least able to get things done most of the time. However, there was a lot of head tossing and leg stomping and general uncooperativeness. She needed eye medication for a few days, and that was pretty much impossible. You would not believe how tightly they can clamp their eyelids together.

Probably the event that most showcased just how much that horse did not respect me was one time when I was trying to clean out a back hoof, and she simply would not lift it up. I pulled, I pushed, I yanked, I tried every trick in the book and had two people helping me, but she wouldn't budge. I finally gave up and switched with my more horse-inclined classmate, and two seconds later the job was done.

She finally went home after a week, without getting the third surgery. I managed to knock out a whole bunch of skills with the one case alone: physical exam, rebreathing exam, PCV/TP, faecal egg count, ophthalmic exam, general horse handling and grooming, sedation and IV injections, IV catheter placement, oral medication, intramuscular injections, scrubbing into surgery, and probably more than that. And since I had been up to my ears in research all week, I managed to write a pretty good case report on it.

Horse Dancing is a Thing

I had a vague understanding that dressage is a thing, but I never realised that they sometimes do it to music.

This interview by Stephen Colbert basically sums up the conversation we had this afternoon during some downtime on equine roster.

Horse Anaesthetic Equipment Is Giant-Sized

The title says it all. I scrubbed in on the surgery for my equine case, and as much as I don't like equine surgery, I have to admit, the stuff is pretty cool.

The surgery room itself is big and white and clean feeling, with windows for people outside to look in. It's attached to the recovery box, which is a big black room, and once the horse is induced, they lift it up using a stretcher thingy with giant chains attached to the really high ceiling. The whole wall of the recovery box opens up into surgery, and there's an invisible boundary between the two since surgery is sterile, so a sterile team waits on the other side to take over from the non-sterile team in the recovery box. The horse gets hoisted up, floated around a corner, and set down on the giant surgery table.

The anaesthetic circuit is basically the same as any other circuit, but it's giant-sized. The tubes are as big around as your arm. The ventilator is this giant cylinder. The rebreathing bag is as big as a pillow.

As you might imagine, the fact that horses are so big works against them. If they're on their back, all their organs press against their diaphragm and make it hard to breathe. Their own weight squashes their nerves and muscles and can ruin them if you don't take proper precautions. And that's just the tip of the iceberg of the headache that is equine anaesthesia and surgery.

Turtle Lamp

There was a turtle surgery the other day.

You might be wondering how surgeons get inside the turtle. It turns out that one of the methods is to make an incision in the soft area in front of their back legs (or front, depending on what you want to do). Then they can stick an endoscope in, with a light source and a camera on it, and use tiny instruments with long handles. The best part is that the light makes the internal cavity of the turtle glow, and you can see it through the shell on their belly!

I can't find any good photos on google, so I'm going to show you the ones I took. I'm not sure if we're allowed to do that, so uh, don't tell the school on me please.

 

Intubated and with an IV catheter in her jugular.

 The reason the turtle looks so yellow is because there's a sticky sterile covering with iodine in it, called Ioban.

If you look carefully, you can see how bright the pink inside of the turtle is because of the light from the endoscope.

The screen showing the instruments and tissues on the endoscope.

Why was this turtle having surgery? The short and simple version is that it had egg impaction. And how did they definitively diagnose that? A CT scan. In case you were wondering, here's a picture from google of a turtle CT scan:

We Killed A Dinosaur

Wildlife medicine in New Zealand is somewhat unique. There are a lot of critters here that don't exist anywhere else, and, conversely, things that aren't here that are everywhere else. During my time on wildbase, I sadly never got to see a snake or ferret. But I did get to see lots of super endangered native creatures, such as takahe. There's like 260 of them left.

And tuatara, which are basically dinosaurs, and the star of today's blog post.

They're basically prehistoric. They're so primitive, they're their own order. I know they look like lizards, but they're closer to dinosaurs. According to wikipedia, "The two species of tuatara are the only surviving members of their order, which flourished around 200 million years ago."

One of them came to the hospital with a diseased eye. It had probably been traumatised (eg poked it into a stick or something) and was now blind, or at least that's my understanding. All their heroic efforts to treat it medically had failed, so it came down to surgery. The first eye enucleation surgery to ever be performed in a tuatara.

The interesting thing about wildlife and exotic medicine is that there isn't a whole mountain of literature for every single species. You might be the second person ever to anaesthetise a giraffe with that combination of drugs, so all you have to go on is one twenty-year old case report and extrapolation from other species. Unfortunately that's not as easy as it sounds, because drugs can have dramatically different effects as species have small differences in enzymes or receptors or whatever. For instance, cats are massively different to dogs in some areas, and we have lots of research about those species. You can imagine how often we diagnose and treat the same disease in, say, a tiger. Now imagine how likely you are to find anything published about a species that numbers in the thousands.

The other fun thing about tuatara surgery is that reptiles are ridiculous animals. The way it was explained to me is that everything in birds happens super fast, they can turn on a dime, and everything that happens in reptiles happens super slow. If a reptile emergency comes in, the first thing you should do is put on the kettle, so you can have a think about it over your tea. Any changes in their health tend to take a long time to manifest. That is important information for this story.

We went ahead with the surgery, which was all quite exciting. It was especially exciting for anaesthesia, who were very stressed out. I don't remember the details because I wasn't on anaesthesia then, but things like heart rate and respiratory rate were apparently quite distressing. So while anaesthesia was freaking out, the wildlife clinician was calmly shrugging it off, with the explanation that some crocodillians can have heart rates as low as one beat per minute. Turtle hearts can keep beating for 24 hours after death (as in, when you open them up at necropsy, you can find their heart beating in front of you... even if you take it out, apparently). Basically, it's impossible to tell if they're dead or alive while under anaesthesia, so he decided not to worry about it. (It fits the theme of not being able to tell if animals are alive while on wildlife roster).

The surgery went along just fine. They packed the empty eye socket with some mini absorbable sponge thingies and sutured it all up. They made it a little bandage that made it look like a pirate. I have an adorable picture, but I doubt I'm supposed to share it on the internet (it might get picked up by google images or something and be stuck there forever when people search about tuatara, and then I think the university might get a teeny bit mad at me).

Details aside, things were fine and dandy that night and into the next morning. During the day, however, the tuatara slowed down, and in grand reptile fashion, we began to question whether it was alive or not. The clinicians broke out more heroics and it went under intensive care for most of the afternoon. Interestingly, since tuatara are in their own order, you need another tuatara if you want to do a blood transfusion... and there's not too many of them around, as you can imagine.

We had the little guy on oxygen, breathing for him, and all sorts of monitoring. He got drugs and fluids and blood products and heating pads and everything we could think of. Unfortunately the monitoring equipment isn't exactly built for tuatara, so the accuracy was questionable, making it even harder to tell anything about the heart or whatever. The heart rate went down and he wouldn't breathe for himself. We did what we could, and gave it a few hours for good measure. He had gone very pale. Surprisingly, we still couldn't figure out if he was actually dead, so we stopped breathing for him and let the chips fall as they may. We put him back in the incubator for the night, just to be sure. The next morinng he hadn't moved any, so we were getting pretty confident we'd lost him.

Too bad for the world's first enucleation on a tuatara. The upside of taking two days to die is that we'd all kind of... accepted it. By the time we gave up on him, I had plenty of time to prepare myself emotionally so I wasn't particularly upset. If he'd given up the ghost in the middle of surgery or something, that would have been more difficult to deal with.

Phew, He's Breathing / Classic Vet Student Moment

A very sick little blue penguin was brought to the hospital. It wasn't doing well, so it went straight into what's basically the ICU "tank" in the wildlife ward, a clear incubator/oxygen cage thingy.

When I came back from lunch, the poor guy looked awfully still. I watched him for a moment, then had a mini panic attack when I couldn't see him breathing.

Deeply concerned, I peered into the tank and watched him for a good minute. Uh oh, did he stop breathing? Do we need to start CPR? Then, much to my relief, I thought I saw some chest movement. Phew! He's breathing.

The clinician came out of the ward a moment later and said, "The little blue penguin died while you were at lunch, by the way."

My Disappearing Patient

This morning, my patient disappeared from under my nose. We're supposed to show up before 8am to make sure our patients are checked, walked, given meds, etc before morning rounds. I was in the middle of taking this puppy's vital signs, when my classmate needed a hand to get a temperature on a wiggly dog. I put my patient back in her cage, we take the temperature, and when I turn around... she's gone.

A nurse had passed through, so we suspected she'd taken the puppy outside. My classmate took his dog out, and when he returned, I asked if he saw my patient out there. No. He hadn't.

It turns out anaesthesia had come and taken her. In the middle of treatments. One of the nurses flew in, snatched her away, and by the time I found her on the other side of the hospital, she'd been pre-medded and was half asleep. So much for her morning walk.

I Promise I Work in a Real Hospital

A sick rabbit came in today for not eating. We took some radiographs and figured out that it had intestines full of hair balls (trichobezoars). It got sent home with instructions to feed it pineapple juice.

PS: This may be an oversimplification for dramatic effect. We gave it metoclopramide and critical care diet mix, too.

PPS: The reason this is tagged for "neat facts" is that this is a common problem in rabbits and pineapple juice is a commonly suggested aspect of treatment. Apparently it's best if you blend the whole pineapple, since there's a lot of fibre in the core.

Maybe I CAN Actually Be A Doctor

I totally nailed a diagnosis yesterday.

Final year so far has involved a lot of struggling to remember details from the bazillions of lectures we had in the previous years, combined with the sudden need to actually apply these in a real world situation. Then you also add in all the hands on skills that you're kind of expected to know how to do, since they talked about them in lectures. You can guess how well that turns out.

One of these skills is abdominal palpation. The abdomen is this mysterious place full of soft squishy organs that seem rather indistinguishable from one another when you're trying to smoosh them between your hands. No amount of reading "palpably enlarged liver" will make you actually able to feel a liver, unfortunately. However, after most of a year of "yep, she has intestines," I finally had a patient where I made a diagnosis by feeling something. I felt a big hard mass near the front of the abdomen, and it was confirmed on xrays and ultrasound!

Another of these skills is the ability to hear a heart murmur. Anyone can figure out that a heart that sounds like a washing machine isn't normal, but anything less than that is starting to tax my vet student prowess. I spent a day with a cardiologist once, and every patient went something like me thinking, "That sounds normal," followed by him saying, "He has a murmur." Then the next day went something like me thinking, "Totally has a murmur," followed by him saying, "The heart sounds normal." And yet, I heard one all by myself yesterday. That's right, same patient!

A cat came in for losing her appetite gradually, and the two big things I found on physical exam (all by myself!) were an abdominal mass and a heart murmur. The intern, attending, radiologist, and anaesthetist all found the same things! Yay I got something right for a change. Take that, baffling world of abdomens.

Overseas Adventures

You might have noticed a lack of posts in May and June, and attributed it to the fact that I tend not to post for large periods of time. That actually wasn't the case, and in my defense, I never forget to post, I just get too busy or too tired. This time, I was overseas doing some externships at clinics in the northeastern US.

The first clinic I was at is a small animal general practice, so you'd think it would be pretty similar to my other weeks at local small animal practices. It wasn't.

I don't know how common this is in the states since I haven't been to as many practices there, but this place was doing high-end medicine. They don't just have digital xrays and ultrasound, they have chemotherapy, phsyical therapy (including a water treadmill), nutrition specialists, behaviour experts, endoscopy, and more. They do complex surgeries, not quite up to the level of a referral surgery service, but do perform many procedures that other practices would refer. The vets there are all extremely knowledgable. The practice also places a lot of emphasis on client communication and building client relationships, so they had lots of tips to share with me in the "soft skills" department as well. They even called up the Humane Society and had them send over a bunch of speys and neuters for me and my classmate! Our university doesn't even do that.

The other clinic I visited was a specialist clinic. They had multiple internal medicine specialists and boarded surgeons, as well as a regular oncologist, cardiologist, and a few other bits and bobs. That was a step away from the world of general practice, and delving into "What life is like as a specialist." I decided I probably don't want to be a specialist, but they do see some seriously cool stuff. The most memorable was a pair of 20-something-year-old Capuchin monkies that are trained to help blind people (and they do a LOT of neat things for them). It was interesting seeing the different personality types in the different specialties, and to go more in depth in the cases.

It's hard to form a post for a six week period. I did so many things its hard to remember them all, let alone pick some to write about. It was a mix of busy days and sightseeing. I reinforced a ton of my pharmacology and medicine, and got to do quite a few routine surgeries. One thing I noticed (I'm not sure if this is a regional difference, or just luck of the draw with cases), was the large number of pets on the same anti-anxiety meds as people, like Prozac and Xanax. There are different diseases and disease prevalences there, which was an interesting challenge. New Zealand doesn't have rabies, heartworms, ticks, or tick-borne diseases, which are all important in the US and part of standard medicine (eg annual vaccinations and testing). Also, the drugs they have are different, which is tough to remember sometimes.

The best thing about getting away and doing some externships was regaining joy and enthusiasm for veterinary medicine. Hospitals are run very differently to private practices, especially university hospitals. At school, we students are used as free labour for a lot of menial tasks that take away from our time and energy to focus on the medicine itself, things like doing redundant paperwork for the computer system or nursing care for all of our patients (which would be fine if I were at vet nursing school). The clinicians are so used to students, we're just "another one" to them, and they probably get tired of the same mistakes over and over. We have skills books that they need to sign, and we have to chase them down the halls on Friday afternoons before they'll finally, grudgingly give up a signature.

At a private clinic that doesn't see many students, they cared a lot more about my individual learning. They had the approach of, "What can we get you to do? What skills do you need signed off? Let's see if we can organise something for you." My spare time consisted of reading and discussing cases, instead of picking up poop and ice-packing surgical wounds. The biggest difference was that the vets treated me and my classmate like colleagues, rather than students. They asked our opinions on things and never talked down to us. It was a positive, collaborative atmosphere, and the things I did were a lot closer to "real" veterinary medicine than my rosters at uni. It was a great boost halfway through the year, because I'd been beginning to doubt my interest or commitment to the profession. Now I believe that's simply due to the warped perspective we get from spending all our time in a teaching hospital.

I feel like I'm not giving my trip decent justice, boiling down six weeks into those two paragraphs! I suppose most of the interesting stuff was case-related, which would involve getting more technical than the blog is intended to be, so I'll leave it at that.

Second Years Move In Slow Motion

This week I'm at one of the local practices in town. I think it's Easter break for people who have normal semesters (I had the option to have time off, but needed to schedule a week here). Apparently, as part of the new curriculum, the fledgling vet students start doing some clinic practical work in second year, where the school makes arrangements for them to spend two weeks with a private practice somewhere.

Instead of spending time with the vets, they actually shadow the vet nurses, learning things like IV catheters, bandages, monitoring and recovery from anaesthesia, and just what clinics are like and where things are. I think it's a fantastic idea. However, I'm totally not envious of them, because while I get to stand in on consults and surgery, they have to putter around the back, cleaning.

Interestingly, the second years are super slow. I know students are always slow, but it's fascinating to watch their brains go. For instance, they get asked to draw up a drug. It's one of the first times in their lives they've ever done that. What would take me somewhere between 10-30 seconds, and would take a vet nurse like 2-5 seconds, for them takes 2-3 minutes. I'll see one with a bottle, syringe, and needle one minute, turn away, and when I turn back the needle's made it onto the syringe and she's putting it in the bottle. Go do something else again, and when I look back, the drug is about 1/3 drawn up. Then 2/3. Then finally finished! Now... where does the bottle go?

Since they have so little clinical experience, they don't have the hang of where to look for things, or even what sort of cupboards and drawers there usually are. For me, I need to waste time poking around for the needles & syringe drawer on the Monday at a new clinic, but then I know where to go. For them, it's a mission to find anything, every single time.

They also stand around doe-eyed and lost-looking occasionally. The most fun part is that they'll look to me with questions, which makes me feel all knowledgeable and stuff. Unfortunately, since I've never been at this clinic before, I have no idea how things are done, either.

Specialists Are Very Important and Serious

Our local ophthalmologist is a friendly old guy that literally everyone knows, because he's pretty much the only ophthalmologist around (it's a small country). He's been at it so long he didn't actually have to do a residency, he just learned it all himself and sat the board exams just like that. So, that's cool.

Considering he drives a very expensive looking car and travels around the area doing all sorts of fancy I-didn't-know-you-could-even-do-that surgeries, you'd think he'd be a serious kinda guy, but he isn't. He wears a T-shirt during surgery, flirts with all the ladies, and makes bad jokes constantly, in between sewing up his suture pattern that's so tiny he's using a microscope to see his incision. I was holding something for him at one point as he cut away some excess tissue in a non-sterile procedure. He quite casually kept wiping bits off of his forceps onto my bare hand.

I don't know how he doesn't go cross-eyed doing those tiny surgeries every day, but he makes several thousand dollars for like fifteen minutes of work, soooo... some days, ophthalmology is pretty temping!

I Got to Go Out With the Coast Guard

Wildbase had a giant petrel in hospital for a few days, and with those giant seabirds it's quite important to get them back into the wild asap. More than a few days in hospital can end up causing a downhill turn. In this case the patient had been found on a beach, which means it must have been pretty sick, but as tends to happen in these cases, a particular cause wasn't identified. It was nursed and given lots to eat, and a big factor is restoring the waterproofing of their feathers.

After a few days, it was time for him to go home, which meant a trip out to the coast!

A forty minute drive to the coast later, with the petrel in a dog cage in the back, covered by a towel, we met the two guys at the little dock with their little boat. We climbed on in, and it was suggested to me that I not sit in the back, because I might "get a little wet." Instead, we stood in the cabin area, where there were back supports instead of seats. These made sense once we got going: after clearing the small bay, we took off.

It was super windy that day, and along with it came massive waves. And I mean several meters high. We'd go up one, fly off the crest into the air, freefall, and slam back down onto the water. Then up the next one, into the air, and down again. Fssssh-woooosh-POW. That's my impression of it.

Though somewhat terrifying, that part was pretty fun and not particularly nauseating. The difficult part was when we got far enough out (several kilometers, I forget the exact number), and came to a stop. The wildbase person I was with brought the bird out of his cage and put him over the side. Freedom! We waited to see what he did--would he paddle and drink and flap his wings like a normal bird? The answer was yes, he looked very happy and healthy! He quickly drifted away from us, exhibiting all the normal behaviours, and we watched him for a long time.

 

This turned out to be less fun than expected, because those waves were still massively high, and instead of rocketing over them, we were just sitting there, waving steeply back and forth. The wildbase lady described it later as, "I was telling myself, 'just focus on the bird, focus on the bird,' trying not to puke." Getting back to solid ground was quite a relief.

The Things You Go Through For Assignments

We have to write a few case reports this year, and one of the things that we're supposed to include is all the costs to the client. I had a case last week that was in hospital and got euthanised and necropsied on friday. It's been exactly one week since the farm visit, so I figured I could get my hands on the costings today. I never realised it would be such an ordeal.

Just like the other case report I did for a large animal, I went up to farm services and asked nicely for the costings. Last time, they looked up the case and printed it off. This time, they scratched their heads for a while trying to find the case, then scratched their heads for a while trying to find costings. One person asked another who asked another, and eventually they told me it hadn't been done yet.

So I went over to the vet, relayed what I'd been told, and asked for costings. She said the reception should have them. Reception said she should have them. We went out to reception to find them. Turns out they were on 2 different sheets on 2 different desks (one for the farm visit, one for the hospital stay). A nurse kindly offered to type them in right then and print them out for me. Phew! Finally. Thanks for doing that, sorry to bother you.

A few hiccups typing them in meant it took rather a while. The patient sheet was a huge mess because like half a dozen students had tried to write things on it, and of course no one put their notes in any of the correct places. Also someone had given a drug but not told me what exactly they'd drawn up, so I knew it was a vitamin B injection, but not which product it was. Nurse sighed about this, but took it in stride, without much more than a "They never help us" comment.

Then, just as she's about to finish, smack from the printer next to me. Or rather, from the cow vet standing at the printer next to me. He was trying to swipe his town library card instead of his university ID card, so it wouldn't read it or let him print. He got frustrated enough to punch the touch screen, which cracked it. Like, cracks radiating from the centre, covering the entire screen. And guess what--it's a touch screen. Even though the display didn't break, it wouldn't register the touches anymore, so the nurse wasn't able to actually select "print" for her document.

After a bit of a kerfuffel among the receptionists and some eye-rolling behind cow vet's back, the nurse and I headed for the vet tower. The vet tower is under a lot of construction, which means whenever you want to get through the hospital you have to re-route through some strange convoluted path. Eventually, we made it to a printer there, only to find someone in front of us trying to print. On a broken printer.

Fortunately, it turns out that printer only needed paper. Unfortunately, there wasn't any. The nurse went on a brief hunt, found a box, then no scissors with which to open the box. New hunt for scissors.

Finally, the printer was set to go. The other person printed her big pile of stuff. With bated breath, we waited while the printer charged up ours. And then at long last, I got my one little sheet with the list of costs for my calf.

Turtles and Geckos and Kiwis, Oh My

Day 1 on wildbase was a busy swarm of awesome. The wildlife ward is this tiny room tucked in between the treatment room and the dog kennels in the small animal hospital, which you walk by multiple times a day without ever really noticing. It turns out that just inside, there's a little mini clinic. There's one main room that includes a central surgery area (the whole place isn't much bigger than a dorm room), and then a doorway into the mini wards. There's a large room for a big animal, and another room packed with various sized cages. Five weeks in the smallies hospital, and I never realised there were a bazillion bird patients hanging out right there. Today, there were close to 20 inpatients.

The day started with a bang and never slowed down. On account of being a monday, after a brief tour, I got thrown into the whirlwind of getting food and meds to all 20-odd patients, with only the most basic experience to go on. After cutting up fruits, veggies, and almonds, my first animal-related task was to hold a kiwi while the vet tech force fed it. That's right, a kiwi.

One of the patients is a Kaka.

Mondays are apparently particularly hectic because they have rounds on mondays and thursdays. Treatments had to be finished by nine, and then all the wildlife staff (less than ten people) gathered around the tiny clinic to go over the history, diagnostic findings, and treatments for all the patients. There are a number of birds with wing or leg fractures that got surgery, with pins and external fixators and the whole kit and kaboodle. There are a few skinny birds that have been losing weight, a few odds and sods like strange skin lesions or neuro. One bird is in for diagnostics to confirm diabetes insipidus. At the other location, near the large animal teaching unit, there are purportedly three penguins and a few other big birds, but I didn't get out there today. One of the patients is an endangered New Zealand bird, and there are only around 400 left in the world.

After rounds, we had radiology booked for the morning, as we had three birds to radiograph. A harrier, a kingfisher, and some sort of pigeon. Wildbase is great because they have students every week and plunge you right into it. Almost right away, I was positioning the animals, holding, taking blood, making blood smears (badly), running PCV/TP, palpating lesions, all sorts of stuff.

 

A harrier.

After lunch, there were two consults. One was a sulfur crested cockatoo who we admitted for a whole slew of diagnostics, including bloodwork and skin scrapes. The other, however, made my day. It was a pet turtle with conjunctivitis, secondary to vitamin A deficiency (quite a common deficiency in exotic pets). So we did an ophthalmic exam on this turtle. I got to hold it while we examined and treated this turtle, and turtles are exactly as cute and awesome as you'd expect them to be (as long as you don't get bitten). Its little legs waggled around as I sandwiched it between my palms.

Ours was larger, but looked basically the same.

After the consults, it was time for the gecko surgery. Yeah, gecko surgery. It had a mass on its neck that was removed. Anaesthetists joined us to manage the anaesthesia, and the whole process of induction and intubation was quite an undertaking. The gecko was on a mask, and when it was asleep enough to lose its "righting reflex" when flipped over, they tried to get the endotracheal tube in. However, the gas anaesthetic diffuses out of the lungs pretty quickly, so there was a limited amount of time for each attempt. Because of the unusual anatomy, it took many attempts.

Despite all that, overall, the procedure wasn't much different than it would be for any other animal. The concerns about respiration and blood pressure are basically the same, it's just a tiny-sized animal. Surgical technique is the same. Suturing is the same, it's just scaly reptilian skin instead. Though, there are a lot of quirks to bear in mind as well. For instance, turtles' lungs are attached to the dorsal carapace, so if you need to ventilate them, you can flap their legs back and forth, and it actually works the lungs!

I also learned that the bottoms of geckos' feet are really, really cool. Not only do they look neat, they feel pretty neat, too.

 

More surgeries and radiographs and anaesthetics on the schedule for tomorrow, with all sorts of native New Zealand birds. Should be pretty exciting!

Yes, We'll Give Him Your Magic Water

A rabbit came in to the local clinic I've been at for a castrate (a surprisingly common occurrence). He came with a bag of goodies that included his hay to eat during recovery, and a little bottle of stuff to give him. The stuff was called Arnica 30, and the label very informatively said something to the effect of "Apply as required. Use to help reduce symptoms."

I think it's supposed to help their recovery and maybe provide pain relief or reduce inflammation or something. But it doesn't. I can promise you that. Why? Because it's homeopathy, which means it's water. It does absolutely nothing because it literally is just water.

The vet was all "We said we'd give it, so whatever," with a bit of eye rolling. She grabbed the spray bottle, puzzled over how you even use it, and squirted two or three puffs into the rabbits mouth--who, by the way, was rather "WTF?" about the whole ordeal. The vet wasn't sure if you actually give it in the mouth, but it was one of those "Shrug, it doesn't really matter" moments. The nurses kept laughing about the whole situation, but that rabbit got his Arnica just like he was promised, even if the only thing it accomplished was startling him a little bit.

The Two-Legged One's As Bad As The Four-Legged Ones

The general rule about how to deal with children in the consult room is: don't. Ignore them. Let the parents manage them and stay out of it. As a vet student I'm pretty good at this because while shadowing the vets, all I do is stand in a corner and stay silent, anyway (and subtly get my hands all over the animals doing a quiet physical exam, usually).

Today there was a four-year-old in our consult for a pair of Italian Greyhounds. These dogs were tiny, skinny, nervous, rat-like things that took some time for me to warm up to--even the client didn't like them. She was taking care of them for someone else, and one of the first things she said was "I'd never own dogs like these!" and I couldn't blame her. I ignored her little boy as I'm wont to do, but still enjoyed the progression of his behaviours through the consult.

Stage 1: I didn't notice him at all. I was half-listening to the vet talk about routine vaccination stuff.

Stage 2: I guess he got bored, too, because he decided to be Spiderman (I learned this after the fact). This involved him crawling around in circles on the floor, on four legs, making growly noises, and all of a sudden I found myself trying not to step on him in the same way I was trying not to step on the nervous dog. I wasn't looking at all, and felt some playfulness at the bottom of my pants leg, like a dog pulling on it or batting at it. Turns out it was actually the kid, mock attacking my leg. I still don't understand how this relates to Spiderman, but it was pretty much indistinguishable from what it's like in a puppy consult.

Stage 3: Mom told him not to do that to the lady, and that he can't play Spiderman right now. He stopped, pressed himself against the wall, and became completely still, silent, and sullen. Mom mentioned that he's hiding so we can't see him. At the sound of his name, he complains repeatedly to be left alone.

Stage 4: The vet produced a shiny toy that was as effective in entertaining vet students as little kids. It was a bright, highlighter-yellow, reflective band, of the sort that you smack against your wrist and they curl up. Then you have the pleasure of unfolding them, snapping them into a straight band again, and repeat. Reluctantly, I handed it off to the little kid, and he got as much pleasure out of this as I did. This kept him occupied for a long time, especially since he couldn't figure out how to snap it back straight, so it kept flying out of his hands and curling up again.

Stage 5: He climbed into the empty dog carrier and closed the lid over himself.

Brain Tally

On the whiteboard in the pathology museum:

A: 1/4 1
H: 1
L: 0
A: 0.2
G: 1/2 + 1
L: 1

You see, we're supposed to remove as many brains as possible over the week, and the prof is keeping score. For the record, my 1/4 was from a kitten brain, because the skull was so tiny it was basically snip-snip with the scissors, rather than a big ordeal with a saw.

My Life is A Horror Movie

Warning: I'm on necropsy this week. It's a little hard to tell, because we get so desensitised that we can easily eat our lunch while reviewing pictures of bloody, disemboweled animal corpses, but I'm pretty sure that talk of necropsy is disturbing imagery for the average person. Proceed with caution. The point of the post is, basically, blood and gore.

Here's how necropsy rotation works:

We show up in the morning (9am start! how unusual!) and have a little tutorial with the pathologist teaching the roster. We go over all the cases that have been submitted for the day and talk about our differential diagnoses and what we might expect to find on post-mortem. We divvy up the cases between the students, then head off to the PM room floor.

The PM room is designed with an elevated viewing area in front of the entrance, which includes things like the tutorial room and locker room doors, and a lower floor area that takes up most of the room. You have to go down some steps and wade through disinfectant to get there, and the floor is usually pretty wet. It's filled with drains, metal tables, and all the equipment you might want: tubs to carry organs around in, clamps to put heads in while you saw them open, tables of knives, a band saw in one corner, stuff like that.

Something slightly distressing to some is that the animals don't always arrive dead. The upshot is that means a very fresh PM, rather than something that's been in a freezer for a month, but the downside is we have to euthanise them ourselves. In the small animal world, it's a simple injection. But euthanising large animals is, I find, particularly unpleasant and not for the faint of heart--the larger the animal, the worse it is. They're rendered insensible (and probably dead) by a captive bolt into their skull, then to make extra super sure that they're dead, you slash open their throat so they exsanguinate (translation: ocean of blood on the floor).

Once they're not only merely dead, but really most sincerely dead, the students are unleashed. Basically, you go through everything, outside and inside, in a systematic way. While it's all very scientific and medical, to an outside observer, it's skinning, tearing out the heart and lungs, cutting through vessels and spilling blood everywhere, stuff like that. It's quite hack-and-slash feeling. When it's time to look at the abdomen, you've just got organs all over the place. And to check out the brain, you break out the saws and cut open the skull. The things you didn't realise you signed up for, eh?

One of the most disconcerting things is that the muscles keep twitching due to the nerves firing. I always find it startling, even when I know it's coming, that when you cut through a big nerve (like the sciatic), the leg jerks.

Something a little morbidly interesting is that the method of euthanasia dramatically impacts what the PM is like. I had a calf with a suspected central nervous system disease, so we didn't want to use a captive bolt and destroy the brain. I used the injection instead, which means the calf didn't exsanguinate like the others. Out of the three calves that were PM'd at the same time, guess whose table was drowned in blood?

At the end of the day, we have to write up everything we found and submit it for the pathologist to edit and finalise. We have these green sheets to take notes on, and by the end of the morning, both sheet and pen are saturated with essence of dead animal. Yet we just fold them up, take them home, and type it up on our computers like there's nothing unusual. I guess, to be honest, there isn't.

Necropsy, From the Tiny to the Giant

Warning: Descriptions of dead animals.

Pathology rounds are every friday afternoon, and for as long as we've been in vet school, we've been encouraged to attend. It requires nothing on your part, simply show up, stand around the post-mortem room, and watch. At first, it's practically incomprehensible, but as you progress through the years you start understanding more and more of what's being said and what you're looking at. Pathology rounds are a regular fixture in (some of) our lives, a weekly occurrence that's gone on as long as vet school has.

And finally, it becomes our turn to take the floor, our turn to stand on the other side of the room and hold up the cold entrails of dead animals for all to see.

You see, this week I'm on necropsy. On friday, we are the ones to present the cases that come in during the week. Some come in dead already, some arrive alive and get euthanised on the premises. We hack apart their bodies completely and utterly, send samples off to the lab, and save whatever is interesting for path rounds.

Today we had three animals: a kitten, an alpaca, and a cow. I got the kitten. Nine days old, it had been found dead underneath its mom, suspected crushed/smothered. Everything was so tiny, it was hard to do the PM steps like normal. Her teeny tiny mouth and tongue, and teeny tiny GIT and kidneys and spleen and everything, and super teeny tiny uterus--actually it was pretty cute. Or at least I thought so, and one other person, but the production trackers thought that was weird, and were all, "Psh, smallies people." But at any rate, I kept accidentally crushing and tearing things, and fur got all up in everything, and it was very difficult to cut organs open and get a good look at everything. I practically needed a microscope.

So here I am, with my animal that can fit in the palm of my hand, holding up its tiny heart and lungs between two fingers and poking at it with a pair of forceps, and at the table next to me is the team working on the cow: heart the size of my head, a mountain of rumen contents all over the floor, sawing and hacking with giant knives, cutting the ribs with massive bolt cutters, an ocean of blood leaking out of their animal. The liver alone was an entire armful. It amazes me how these two very different creatures are so similar in their composition. My kitten's little heart the size of a fingernail had all the same components as the massive cow heart, just miniature.

The alpaca was interesting, too, just by way of being an alpaca.

Snooze You Loose

Student: *Half falling asleep on desk* *Big yawn*

Prof: Warm afternoon on a sunny day, eh?

Student: Sorry! Post-prandial coma.

Prof: I fell asleep during my own tutorial once. A student was answering a question, and it must have been the soporific effect of her voice or something, put me right to sleep.

The Low Points of the Career

Some days being a vet isn't very glamorous. It's even worse for vet students, because you're at the bottom of the heirarchy. For instance...

Vet is pregnancy scanning cattle. Cows get lined up in the milking shed, vet goes down the line with the ultrasound. Vet students get remote screen so we can see the ultrasound as well, but it has a short range, so we have to delve into the pit to follow the vet.

Streams of urine and faeces pour out intermittently and unpredictably from both sides. You try to stand in the middle, but can't very well because all the milking cups are hanging there, in the way. Dodge forward, out of a splatter, into a spray. Dodge backward, out of a spray, into a splatter. Random cow gets a fright and kicks poo onto your arms/chest/face. Scurry forward to the end of the pit. After the vet is finished, time for the cows to go, and the next group to come in. Scurry back to the other side of the pit, get more poo kicked on you as cows hurry out of the shed.

Repeat.

A gradual, slow accumulation of cow poo. Slowly run out of clean spots on limb to scratch face, which is a bad combination with hundreds of flies in the shed. Poo lands on you. Flies land on poo. Poo lands on ultrasound screen, wipe it off... start running out of places to wipe it onto.

Long shower afterwards.

What Horse Vets Do

After a week of straight horseyness, here's my glimpse into the equine medicine world:

• Dentistry - mostly grinding off sharp points, and a few extractions.
• Scanning mares - rectal ultrasound for detecting heat, pregnancy, twins, etc. Pretty cool but very difficult to see the screen when it's so sunny.
• Castrations - everything involved in horse surgery is size massive. The endotracheal tube is as long as my arm and probably thicker around. The rebreathing bag is the size of my torso. Don't even get me started on the vaporiser and breathing circuit.
• Feet - horses are all legs. Lots of lameness exams. Abscesses, bruised feet, fractures, and more.
• Skin - poor itchy horse with a tick allergy. Ticks are horrid things.
• Eyes - saw a horse with uveitis (made the eye look all cloudy). My classmate got to see a squamous cell carcinoma (looked like white spots on the side of the eye).
• Pre-purchase exams - vets need special insurance to do these. Very thorough, including a general exam, lameness exam, scoping, and many radiographs. Possible to induce much trouble and lawsuits if done poorly.
• Laryngeal endoscopy - for various reasons including horses making noise when exercising. Very cool gadget and neat to be able to visualise the larynx of a live horse as it breathes.
• First aid sort of things - lacerations from kicks and whatnot.

Still not going to be a horse vet. But I wouldn't mind some riding lessons one day. There's something about the power and grace of horses--so big and beautiful and strong. As long as they don't try to kill me, that is. I'm sticking to my original opinion of "I appreciate horses at a distance."

As an aside, it's interesting and alien to see the horse world. Everyone seems to be born into it. The horsey people and horsey vets have all been riding and owning horses since they were children. The racing industry is unlike anything else, with all sorts of quirks and peculiar rules. It's a completely foreign world to me, so spending a week involved in it was something of an adventure.

Unbelieve-a-bull

The clinic that I'm with this week is in a town called Bulls. This unique town has embraced puns. You probably thought I was the one making some bad pun with this post title, but driving through Bulls is an eye-rolling, snicker-inducing experience.

When you first enter the town, the big sign says:
Ever herd of Bulls? A town like no udder!

Then as you pass through, pretty much every store has a cutesy name. The whole town is themed around bulls, with bull statues, bull logos, and bull artwork. A fence had been painted with cows dressed like Elvis and backup singers, holding farm tools, in front of a bunch of crops, with Las Vegies written on a sign behind them. The shops include such notable establishments as the Hungry Bull Restaurant, Collect-a-bulls Antiques, and Live-a-bull real estate. There's an ad for an agent that's great--no bull! The rubbish bins are shaped like milk canisters, have a Bulls logo on them (that direct you to the unforget-a-bull website), and are labeled "Respons-a-bull."

There are arrow signs all over the place directing you to local amenities and such. If you ever get lost, you could consult one to find the...

• Inform-a-bull (Information Centre)
• Const-a-bull (Police)
• Relieve-a-bull (Toilets)
• Delect-a-bull (A cafe)
• Soci-a-bull (Town Hall)
• Animal Hospit-a-bull
• Read-a-bull (Library)

And there's more. There's so many more.

On a big bull statue near the town hall, the plaque is dedicated to someone named James A. Bull.

I'm not making that up.

Still Not Going To Be An Equine Vet

I have to do an equine externship at a local practice, because apparently you can't avoid horses even when you track I-hate-horses. Er, I mean smallies.

Pros:
- Got given ice cream
- The vet has a new puppy, so I spent most of the day with said puppy in my lap or arms.
- Horses are gorgeous. Very pleasant to look at.
- Outside on nice days

Cons:
- Driving the whole damn day
- Unpack all your equipment, do your thing for 20 minutes, repack everything. Drive to next farm, unpack everything again, start over
- Outside on crappy days, too.
- Chain smoking client, impossible to avoid smoke cloud

Okay there are actually a zillion more reasons involving the medicine itself, the clients and client interaction, and the work/lifestyle on why I don't want to be an equine vet, and a lot of them overlap with why I decided not to do any production medicine, either. I could write a whole essay on it. In fact, I have, because we had to write an essay about why we wanted the track we chose (there are limited spots for each track). Maybe it will be the subject of a future blog post.

The Mysterious Myasthenic, and Acupuncture on Dogs

My week on referral medicine turned out to be as advertised: busy, complicated patients, extra reading, and lots of cool procedures. I alternated between "I am so gonna specialise in internal medicine" and "OMG I just want to be a GP this is too stressful."

Since other groups have purportedly had difficulties with people hogging cases and whatnot, my group learned from their mistakes and picked names randomly to form the order that we would take cases. My name got drawn first, so I took the patient that came in on monday: a four-year-old dog, J. The notes said regurgitation and evidence of megaoesophagus on radiographs - cool, I find oesophageal disease very interesting.

He did not come in with a presentation of oesophageal disease. He was, in fact, making a horrible inspiratory respiratory noise that sounded pretty much exactly like laryngeal paralysis. For some reason, the owner wasn't particularly concerned about this fact, and was a lot more worried about the ongoing "vomiting" the dog had been having since his stay in the kennel. This also happened to be my observed consult which made the whole scenario extra awkward. I proceeded with the consult as normal, but needless to say, we got the dog into the back and on oxygen pretty quickly.

So day 1 was all about stabilising him and figuring out what was going on. We got him into the O2 cage, got a catheter in (with difficulty), and gave him puffs from an inhaler just like people use. We planned to transfer him to surgery, and got him down to anaesthesia to have a laryngeal exam under sedation before they went ahead with the treatment (a laryngeal tie-back).

... He didn't have laryngeal paralysis. His larynx was fine.

Time for a new diagnosis, doctor. It's not like there are a thousand options on the differential diagnosis list... Also, we repeated the radiographs, and did indeed find megaoesophagus. Could it really be myasthenia gravis, the autoimmune disease that attacks the neuromuscular junction?

So J went for a neuro exam, with the boarded veterinary neurologist. She is very good at what she does. She can break down this really complicated subject into something very understandable and her methodical, logical approach to a diagnosis is mind-blowing. Unfortunately, the neuro exam ended up with a really long list of bizarre and subtle symptoms, like short steps, droopy eyes, uneven pupils, and difficulty swallowing. We went over every possible nerve involved and decided it must be a neuropathy or myopathy of some kind, and dysautonomia was a possibility (screwy autonomic nervous system). Putting everything together, myasthenia gravis was still at the top of the list.

There is a really cool test you can do for MG, where you inject a drug and, if they have the disease, they magically get better. Like, instantly. It wears off after a few minutes, but then you know they just need the longer-acting form of that drug and they're good to go. The downside is that an overdose of the drug causes a spectacular crisis. So we tried this--cautiously--even though J's presentation was really weird. And guess what! They decided that he did, indeed, improve--his gait got better and his swallowing improved. Thus he got put onto neostygmine.

All seemed to be going well. Then, when I arrived the next morning, it turns out he ended up having a cholinergic crisis a few hours prior--the whole works: excitement, urination, defaecation, salivation, and all that. Very spectacular and stressful, especially because he pulled out his IV catheter and that made it hard to get the emergency drugs into him. So we fiddled with his dose, and he kept having crises. We switched him from IV drugs to oral drugs (they're absorbed more slwoly), and he kept having crises. Long story short, he didn't respond well to the drugs. His disease symptoms would improve dramatically, but a few hours after the meds he would just have another crisis. He also kept regurgitating, more and more as time went on, and after a while it become yellow, opaque, pus-like gunk. Not good.

At one point, we wanted to use fluoroscopy to identify the best consistency of food for his megaoesophagus. Feeding is a big ordeal because you don't want them to regurgitate it immediately and then inhale it, leading to aspitation pneumonia. The radiology crew got all excited, brought out the fluoroscope, lots of vets, a mob of students, everyone in their lead-lined gowns and all the imaging equipment set up... and J was very stressed out. He got stressed out even with small amounts of handling, so between so many people, and having to put him up onto the imaging table, he went into considerable respiratory distress again. So... "Sorry guys." Everyone dis-gowned and filed out. The radiology crew were very much "Oh no it's perfectly okay!" but I think the students were disappointed, because the fluoroscope isn't used often (it's like real-time x-ray).

The neurologist suggested we try electroacupuncture. It doesn't perform miracles, but it's an effective adjunctive treatment with proven science. And it's awesome. She had just got the gadget so it was her second EAP ever (she does normal acupuncture as well, it's just the electro part that was new, I believe). Using anatomical landmarks such as counting vertebrae, she placed these very very tiny needles into the skin, and connected them to lightweight wires. Even the needles alone were enough to cause endorphin release, and our agitated, nervous dog zonked out completely. When she turned on the current, it was total nap-time for him. It was performed in a quiet consult room.

The way the EAP works is basically using a reflex arc. It stimulates the dermatomes that connect to the spinal cord segments of interest. The signals go in, excite the spinal cord, and in turn signals go out to other muscles. In this case, it was to the oesophagus. The increased electrical activity stimulates the muscles to contract, which they aren't doing normally because of the disease. Then, hopefully, the contraction stimulated by EAP allows the body to regain some of its own, natural tone. She had no idea how effective it would be. However, in her previous patient, an arthritic dog, the EAP proved to be an amazing analgesic, and that dog was able to get up and run and jump almost like normal for a while after the EAP had been performed.

On the thursday, poor J was still having all those troubles with his meds. He'd had 2 sessions of EAP, we'd fiddled with his dose a ton, and he'd still been having regular crises. Then we noticed he was coughing and regurgitating purulent material, took more radiographs, and discovered what we had feared all week: he had aspirated and now had pneumonia. It's possible it had been brewing before he even arrived. It's possible he aspirated some of his food or water while in the hospital, since it's so difficult to manage a patient with megaoesopahgus, and he'd been regurgitating so much. But either way, it became a serious, intensive care situation. Back into the O2 cage, regular monitoring, three or four different IV antibiotics, and a plethora of nursing care requirements. That day was a holiday and I was only scheduled to come in for morning treatments (usually an hour at most), but I ended up there for 5 hours, between taking xrays, writing up the new patient management sheet/requirements, drawing up drugs, monitoring, and administering everything.

This would quickly turn into an extremely expensive, long-term ordeal. We were fairly confident we could get him through this bout of pneumonia, but the problem was that he was very likely to simply aspirate again. The megaoesophagus was likely to be a lifelong management issue, and he was not tolerating his drugs even at low doses. So on the friday, the owners elected to euthanise him. He has been sent to post-mortem to confirm our diagnosis, but I don't know the results of that. It was very sad because he had a dedicated owner, and we had all worked so hard.

Because it was such an interesting, unique, and complex case, this will be my presentation for Grand Rounds this year. There was a great deal of learning for a great deal of students, I got the opportunity to be hugely involved in the patient care, and it was a rare opportunity to see the tests and procedures involved with this rare disease. All in all, it was a great case to have, and I think my week on referral medicine gave a great taste of the many facets of internal medicine.

Pretend They're a Fly on the Wall

To help us improve how we interact with clients, we had to do several "observed consults." Two of them were on consult week (and if you got the chance, you did more while on referral medicine). For comparison, the rest of the consults were us just grabbing the client, taking them into a room, taking a complete history and physical exam, and then locating an attending vet to talk about the case (including diagnoses and plan). They don't come in until you've finished with the client.

In the observed consult, on the other hand, they stay in the room with you. They explain to the client how it's going to work, and that they're going to be a bystander for the consult. They have a clipboard with a grading sheet--and the client gets one, too.

As you might expect, this throws things off. First of all, you're bound to be at least a little more self-conscious, talking in front of an actual vet. Secondly, both good and bad, sometimes the vet can't help themself and starts asking their own questions or redirecting the conversation. This becomes a nuisance if you're with a chatty vet, who strikes up conversation with their friend the client, all while you're still trying to get through the consult. And by far the most annoying thing that I noticed--and the vet agreed when she asked me what I thought about the experience--is that the clients behave very differently. They direct comments and questions at the clinician, even though the clinician is sitting in the corning not saying anything, and I am standing right smack in front of them with my hands on their dog. They're far less chatty with me the student, so it's hard to get into a flow. All in all it's not a very accurate representation of what it's like when the clinician isn't present.

There's a range of niceness when it comes to the grading. Some of the vets are real softies. One of the ones I got gave me tons of helpful advice, and said I did really well in a lot of regards, but still gave me low grades because he has high standards.

Some of the points that stood out were...
- Explain what's going to happen, so the client doesn't sit there wondering "why are they asking me all these unrelated questions?"
- Direct the conversation more; don't let the client run free and tell you everything on their mind. Easier said than done, especially when the client does not stop talking.
- Establish some rapport at the start--it's helpful to know the client's relationship to the animal and what they want out of the consult.

I got called out a lot on point #2. I was all "But... she was saying the answers to all the questions I was about to ask, so I didn't need to stop her," but I was still told I needed to give the consult some more direction. Thus came the question, "How on earth do you do that without being rude?" The best suggestion was to wait for them to take a breath.

Well, actually, what he said was to ask for clarification using a closed yes/no sort of question, so they can't keep going. Then you can redirect with an open question on a different angle. Or you could always outright stop them and politely say you want to focus on something else for the moment.

Another Day in the Smallies Hospital

Labrador comes in because it ate a rock. What's new?

And did I mention the cat that was dropped on its head as a kitten? He's a bit... strange... so whenever his owners go out of town, they board him with the hospital instead of a kennel. His skull is a bit odd shaped and he tends to circle around and stare strangely at things. He has seizures and comes with a massive bag full of all his medications. The medicine resident said, "If you're ever looking at him and concerned that he seems a bit strange, don't worry about it. That's just how he is."

Well That's Helpful

While planning an antibiotic course for a patient, I wanted to double-check the activity spectrum of cephalexin, to make sure it would work for what I wanted. I'm still learning the ropes when it comes to pharmacology.

The drug book told me that cephalexin has the same activity spectrum as tetracyclines.

Well, thanks.

I Know You Think It's Not, But The Problem Is Fleas.

In small animal medicine, especially in summer, a ridiculous proportion of your patients are dogs with skin allergies. There's a big spiel about how to figure out the problem step by step, doing food trials and what have you, but a shocking number of them stop after the first step.

For almost every skin patient I've seen recently, the issue was fleas.

Do you use flea medicine? Yes.

What do you use? Some obscure product made out of a chemical no one's heard of.

How do you apply it? On their backs. Right where they can lick it off. Also I take them for a swim in the river right afterwards.

How often do you use it? Oh, now and again. Maybe every other month.

Do you have other pets in the household? Yes. The cats have fleas. But I'm sure the dog doesn't.

I know you don't believe me, but let's try this flea treatment plan and see if the dog improves...

It does.

It's Actually A Walk-In Freezer

The air conditioning for the computer lab in the hospital is a source of some contention. The occasional person gets too hot and turns it on, and that transforms the room into an arctic survival training scenario. Even if you turn it back off, it inevitably gets turned back on again when you aren't looking.

One of the biggest culprits for the arctic warfare is a Canadian student. Someone printed out a Canadian flag and posted it above the rheostat, with text that reads: Welcome to Canada, where the temperature is always sub-optimal.

Medicine: A Sampler Platter of Patients

Patient 1: Vomiting dog.

Me: Does she have access to anything, something she might have gotten into?
Owner: We have fruit trees, but we thought we picked up all the plums. And we're renovating the fence, but we keep the dogs away from it.
Me: What about rubbish?
Owner: Just what drunk people throw over the fence. That's why we're renovating it.

Patient 2: Old dog in for a "health check."
Presenting problems:
- Going blind
- Sore "stomach" but actually sore around her entire hind end
- Drinking more lately
- Pants all the time
- Tires quickly after walks
- Limps on front leg
- There's a skin lump, but the owner can't find it again

Add onto this the fact that I pretty much couldn't examine her because she started getting mouthy as soon as I touched anywhere near her back end. Or anywhere, really. In fact, I started to wonder if it was more behavioural than pain.

Also the owner mentioned that her husband didn't want to take the dog to the vet after the motorbike accident, because "he's just bruised."

Because of cataracts and possible polydypsia (drinking too much), it became my job to follow owner + dog around outside with a soup ladle to try and catch a urine sample. Everyone was quite pleased to find that she is not, in fact, diabetic.

Not My Patient: Dog with bloodshot eyes.
On the schedule, a new appointment popped up with the note "bloodshot eyes after staying in the kennel."

"Bloodshot eyes?"

"Maybe it's just conjunctivitis, and they saw the reddened membranes and are just calling it bloodshot eyes."

Nope. The sclera (white part) was actually blood-red.

Top differentials:

1. Trauma - No signs of trauma. No history of trauma. Perfectly happy puppy.
2. Distemper - You may go your entire career without seeing this disease, depending on where you work. Comes with fever, snotty nose, eye discharge, etc - i.e., not perfectly happy puppy.
3. Rat bait poisoning - Tends to cause bleeding on the mucous membranes as well as other signs. Literally the only sign in this dog was the red eyes.

Though it was a long shot, they took blood to test for clotting times to see if it might be rat bait, and sent the dog home on some treatment. Results came back today: negative. Pretty sure the people on that case are still mystified. Their best guess right now is that he stuck his head through the bars at the kennel, got it stuck, and it's from the pressure when he was trying to yank his head back.

PS: These are just from today.

The Universe Doesn't Want Me To Have Patients

Every case I put my name on disappears.

Yesterday I signed up for a consult at 10:30 and 1:30. The 1:30 disappeared. Then the 10:30 didn't show, and reappeared on the schedule for 1:30. Then it turned out we had an ophthalmology practical that no one told us about at 1:00, so I didn't get to do the consult.

Today I put my name down for a 1:30 and a 3:00. The 1:30 disappeared. Again. A new one popped up at 3:30, so I signed up for that one instead. Then that one disappeared. Turns out it only moved to the 1:30 spot.

Whether I actually get to see any consults today remains to be seen.

It Matches Her Coat

Today I turned someone's dog orange.

Fortunately, it was a classmate, not a client, and it was during an ophthalmology practical lab. Which, by the way, no one told us we had until the ophthalmologist actually walked through the door into the hospital and we're like, "Uhhh, I guess we do have a prac this afternoon." It was finally confirmed that it was supposed to take place at 1pm (confirmed at 1pm), and as we all rush to arrive--including a number of students off on lunch--we suddenly realised we also had no idea where the prac was. Also it was very inconveniently timed and I had to miss my only consult for the day, rendering my day rather useless.

Anyway, back to the point--orangeness. Amongst other things, we were given a bunch of fluorescein dye to put in the dogs' eyes. It sticks to ulcers, glows under UV light, and just drains out through the tear ducts and into the nose. Usually you squirt it into the eye with a syringe or dropper or something, but for some reason we had a bazillion little strips with dye-coated tips. I used one of those. Why not?

There were only three dogs. One had some eye pathology so was constantly surrounded by a cloud of students and had lights shined into both eyes for pretty much the entire duration of the lab. One was teeny tiny and at that moment also being examined by others. So I selected the remaining dog, my classmate's, considering people were just sitting by her, talking. I should mention that this dog has white fur.

I went ahead and stuck the strip in like normal, but the dog squinted her eye shut around it really tightly, to the point that the eyelid rolled inward. After about 10 seconds, it became clear that orange was seeping out around her eye. I removed the strip and she opened the eye. She suddenly had a giant spot all around her eye, bright orange. It seemed to be an inordinately large spot considering the procedure, and it was contrasted nicely by the sheer whiteness of the fur around it.

To be fair, I did get the fluorescein into her eye. I don't think she has an ulcer.

(To add insult to injury, no one was paying much attention to the fluorescein strips, and I'm pretty sure some of my classmates thought something had gone horribly wrong with the syringe/dropper method.)

Vet School is a Constant Challenge

Before we were allowed to start in the small animal hospital, we had to take a quick online quiz about how the hospital operates and what we're expected to do. We have "purple books" which describe important info for all the rosters, and this was basically a quiz to check that we'd read it.

Would you pass vet school?

When an animal has been given a pre-med, any water in the cage should be:
Select one:
a. Removed.
b. drunk
c. poured over the animal
d. left so that the animal can slump into it and drown

After examining or handling an animal on a table I should
Select one:
a. clean up any obvious mess from the table top with chlorhexidine
b. lick the table clean
c. brush off any visible debris
d. leave the table for someone else to clean. What are the nurses paid for?
e. cover the table with 70% ethanol then light a match
f. clean and disinfect the table, even if there is no obvious mess.

When removing an animal from a cage you should
Select one:
a. Assume it is friendly, otherwise why would it be allowed in the clinic anyway?
b. Scruff it and drag it out?
c. Enlist classmates to help wrestle it into submission - bites and scratches are a badge of honour!
d. Assess it's behavior and response to your approach, and ask a staff member for assistance if the animal is potentially aggressive.

Do you need to fill out a SOAP form for every patient admitted to the hospital overnight?
Select one:
a. Yes
b. What’s a SOAP form?

Cell phones are not to be used in the clinic
Select one:
a. except when I need to phone my flat mates
b. unless there is nothing to do
c. except for texting
d. except when my boyfriend calls
e. except when my girlfriend calls
f. except when my boyfriend calls to tell me he has heard I have a girlfriend
g. Never!

The following items are dispensable, paid for by my fees, and I am therefore entitled to help myself and take from the clinic:
Select one:
a. thermometers
b. reflex hammers
c. surgical instruments
d. text books
e. ophthalmoscopes and otoscopes
f. lubricant
g. an education, and enough fond memories to last me a lifetime

Cornerstone history and physical examination notes should be
Select one:
a. written on a pieces of paper towel and left lying around the hospital.
b. Entered at the time of consultation, or immediately afterwards. 
c. entered some time in the day before I go home.
d. left blank, the clinician in charge of the case will do that if I forget.
e. left for later - there is a much more interesting case being admitted now.

When I walk a dog outside, I must
Select one:
a. hope that no one else sees the dog defaecating so I can blame it on another student
b. keep the dog on a lead and always take a plastic bag with me so as to capture and remove any faeces that the dog passes.
c. keep the dog on a lead but make sure that the dog defaecates behind a tree so that noone sees it.
d. let it wander around off its lead to do its business when and as it sees fit
e. allow it to eat the faeces strewn around, since that is normal for dogs

Then, of course, there are a handful of these thrown in there, and you need 100% correct, so I had to take the test twice.

What possible organisms implicated in infectious tracheobronchitis (Kennel Cough) can we vaccinate against?
Select one:
a. Bordetella bronchispetica and Strep. zooepidemicus.
b. Parainfluenza, CAV-2 and Bordetella Bronchiseptica.
c. Mycoplasma and CAV-2
d. Canine Herpes and parainfluenza.