My First Avian Clients Were A Piece Of Work

I decided I want to be an avian vet. In vet school, this idea was something like, "I want to be able to see a bird and not be afraid of it." So many vets out there refuse to see them, I figured, hey! There's a niche here waiting to be filled. So I studied our avian lectures very closely, I took avian electives, I got some experience at an aviary. When I realised how big a deal avian medicine can be, it hit home that I couldn't half-ass it--I had to know about birds, which is why vets who don't see a lot of birds often won't see any--so I also got my butt down to ExoticsCon, bought some textbooks, and started some focused studying.

The only thing left to do was, well, to actually start seeing birds. It's the only way to learn, really, especially skills like handling, physical exams, and blood draws. And answering the strange questions I never expected anyone to ask.

My sparkly exciting future full of our feathered friends dimmed a little bit when I encountered my first bird clients. Okay, they're technically the second--the first was a necropsy on an endangered duck, which I will definitely write about one of these days. But they were my first companion bird clients, and companion birds is really what I do. And boy oh boy, I definitely had a moment of, "Is this what bird people are like? I don't want fifty clients like this."

They found me by searching the AAV website, of which I am a member. This was before the newspaper article for our clinic announcing I was seeing birds, and maybe even before we got it onto the clinic website. These people managed to get onto a website mainly used by vets and look up where I work. This was slightly alarming because they kept referring to me as being "boarded" by the AAV. Er, I paid the association a membership fee and they send me a journal. Being boarded is a huge, huge ordeal involving giant scary exams, after which you are a specialist.

Anyway, they have a whole bunch of birds. The first one they brought me was a macaw. Like, pretty much the biggest companion bird there is. For my very first avian exam in real life, ever. EVER. And with technicians who hadn't handled a bird in over a decade. To top it off, these are pushy, anxious people, so their birds are pushy, anxious birds, and there's nothing as much fun as having a huge macaw lunge at you any time you get close. The owners were not impressed that I seemed "intimidated" by the birds. I wasn't, but when you've only been in practice for about 5 minutes, you don't have the hardened steel to not flinch backwards when a beak the size of your hand is snapping at you.

Once we got past the introductions, one of the very first things these people said to me is how Harrison's bird seed is actually really bad for birds and vets shouldn't be recommending it. They read it online. Luckily, they said this about two seconds before I was about to tell them to try Harrison's bird seed, so I avoided that argument. They are very proud of how rich and varied their birds' diets are--lots of fresh fruit and veggies, and seeds, and rice, and quinoa, and pasta, and... wait what? I tried to explain that a likely reason the feathers are ratty, and the stool is loose, and the beaks are flaky, is because they have (wait for it) an imbalanced diet, and I firmly suggested they at least increase the percent of formulated pellets. This lasted for all of two seconds of course, because they've been in a second time, and again proudly explained their home-made diet to me, which has zero pellets now.

Okay, so I'll never convince them to change the diet. I won't bother arguing. They also wanted me to check the loose stools, like I mentioned. I did a full faecal exam and actually came up with a diagnosis. Put up some meds for them to try. Turns out they went home and researched the drug on the internet, decided it's too dangerous, and it was far riskier to give the really-good-for-diarrhoea antibiotic than to let the birds keep having diarrhoea forever.

I spent at least an hour with these people, maybe even an hour and a half. I gave the birds tons of time to get used to my presence, the sight of the towel, me patting them, before I even started the exam. I talked with the owners about all their crazy "I read such and such online" questions. I explained everything about diet, and gave them handouts with information from trusted veterinary sources, as well as a ton of free samples of pellets and diet conversion products. Then they bitched about the bill, saying that for someone so inexperienced it should have been a lot less. Maybe, oh, $30.

They said they'd go back to their other vet. Whose history, by the way, was two, two-word lines: "[Date] Sexed - male." and "[Date] Nail trim." I was secretly relieved, because I knew it would be a headache to ever get these clients to comply with any veterinary advice.

Alas, it didn't stick. They came back a month or so later, with some more birds. This time around, they wanted me to examine a new bird, so they wouldn't have to keep it in quarantine/isolation for the full 30 days. They didn't want to do any of the bloodwork or viral testing that is recommended, and balked at the price of a hundred or two hundred dollars. They wanted to know why I couldn't just give it a "clean bill of health." I explained about asymptomatic carriers of disease, but they decided that chlamydiosis is a severe illness (one of them had caught it from a bird before), so if the bird had it, they'd be super sick by now.

That bird was strikingly sweet, and had excellent feathering and body condition. Even the owners commented on how much more quiet and docile she was compared to all their other birds. Turns out they'd only had it a week. Sigh. Can't wait to watch it slowly get more aggressive and poorly every time I see it...

"I Was Worried, So I Threw Out The Meds"

"I'm so worried about my dog. She's just wasting away and not herself at all anymore. Hasn't changed at all since 2 weeks ago."

"Did you give the meds?"

"No. I didn't like them so I threw them out."

To paraphrase the rest of our conversation:

"She's got diarrhoea."
"Do you want a probiotic?"
"No, she doesn't have diarrhoea. She's really painful."
"Do you want pain meds?"
"No. Her skin is so bad."
"Do you want to try some oil supplements?"
"She's just wasting away and I'm so worried."
"That's what the pred is for."
"I really don't want to use the pred."

And around and around we went.

Freedom!

A client made an appointment to be seen because her cat is "emancipated."

Sure, I'm Sure

I need to be more careful about what I say. I've always known this, but I had a reminder today.

I saw a 9 week old puppy, who had been in a week ago for a UTI. This appointment doubled as her originally scheduled puppy exam and first shots, as well as a recheck for the UTI. I had already made a poor impression on these people, because last week, I was about to send her home on Baytril, when I remembered--whoops, we don't want to give that to a puppy of that age. So I quickly caught them, said, "Wait, I changed my mind, take this antibiotic instead," and tried to explain the brain fart with a tangle of poorly articulated blabbering. Turns out this totally confused them (big surprise), and they'd been giving the cephalexin once a day instead of twice a day.

So anyway, he comes in today, and I had a hard time getting history out of him. I asked how the UTI is going, and if she's having any of the same symptoms. For some reason, this completely baffles him. "Any of the same symptoms???" I could practically see the question marks floating around his head. Since she's a puppy, she's still being housebroken, but eventually I figured out that she stopped squatting repeatedly outside and was now passing normal amounts of urine at a time. He asked about the antibiotics, and I told him to finish it up, at the twice daily dose. He asked me the first time while I was still trying to figure out what was going on--I couldn't tell if we needed to re-treat, or if she was better, or what. He then asked me again after we were finished talking about it, and again after the tech had joined us and helped me give her vaccines.

Afterwards, he complained to the front desk:

Him: Is she new?
Them: Since May.
Him: I asked if I should finish the antibiotics, and she said "Sure." She must be new.

He also added that he usually sees "a man." (My boss)

I actually have no idea what I said the first time. I was too busy trying to get the history out of him. I may have said "Sure," but I don't think I did--then again, I wasn't listening to myself. I do have a habit of agreeing to things when I'm not listening. (I'll be writing in a chart, someone asks me something, I say yes... A minute later think, wait, what? Tell me again, I wasn't listening). But I know FOR SURE, I told him all three times to finish the antibiotic and give it twice daily. The tech told me I definitely, definitively, for surely said "YES FINISH THE ANTIBIOTICS."

I know in my heart of hearts that he will forever remember only the "Sure." I'm now terribly paranoid about what other slip-ups have escaped my mouth. 

Double Trouble

Client brought her cat in to be seen. When she got to the clinic, she realised the other cat had been sleeping inside the carrier when she stuffed cat #1 in. "I thought it seemed awfully heavy!"

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.

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.

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.

A Client Liked Me

Today saw the end of surgery and the beginning of medicine. Hoorah! I like medicine.

Well, except for the part where we sat around for an hour before anyone came up with anything for us to do. We're on "drop-off medicine" this week, which are day patients that come in for treatments or diagnostics. This translates to us sitting in the treatment room until an animal arrives, the four of us crowding around to find that it just needs a vaccination and microchip, someone doing the vaccination and microchip, then we go back to sitting and waiting again.

My patient was a border collie in for some skin stuff, lumps and itchiness. The obvious step was to stick a needle into the lumps and do cytology, but since the poor attending clinician was the only vet on for three rosters (drop-off and consult medicine, and first-opinion surgery), my day involved a lot of chasing after him and waiting as nurses, students, interns, and vets snatched him this way and that. First I had to wait for him to check over my patient and confirm what we were going to do, then we had to get set up, do it, and talk to the client. In between every step was a lot of "Let me do this one thing," and then him disappearing.

And I mean disappearing. He steps through a door and then he's gone. As in literally nowhere to be found in the hospital. I suspect this has to do with going around in circles and entering rooms just as he leaves them, but I can't be sure. Sometimes he goes off in one direction, only to appear in a consult room on the other side of the hospital. I don't really know how he does it. I'm not even annoyed by the continual "I'll be right back this time for real, I promise" because I don't understand how it's even physically possible for him to be in so many places at once and do so many things at the same time.

After six hours of this, we finally got around to doing the fine needle aspirate, which involved both pokey-pokey and suckey-suckey maneuvers. We sent some off to the lab, and I stained the others. I didn't see anything on the slides and when I was describing them to the clinician, the best I could come up with was, "I couldn't see any cells. There's a bunch of... blobs." I got my classmate to look, and she confirmed my diagnosis of "blobs." He laughed at me, saying something like "is that your morphological diagnosis, blobs?" and then went on to observe, "oh yeah, there's your blobs." There really wasn't anything else on the slide to see.

The client was actually someone who works in the same building, which was very convenient because all I had to do was walk down the hallway to give her an update on her dog or ask her a question. The clinician also went down to talk to her a few times about treatments and diagnostics, so she got a pretty steady stream of information about her dog. I did up the discharge form, grabbed the meds, and went over everything with her before she took her dog home. When I asked her if she had any questions she said both I and the clinician had been very thorough and she felt very up-to-date and like she could easily come ask us any questions if they came up in the future. She thanked me for being so clear with everything and taking good care of her dog; she felt very well taken care of. To be fair, I mostly parroted everything the clinician told me to tell her, but I still consider it a success! She's my favourite kind of client: friendly, pleasant, and wants the best possible for her animal.

I can count my client interactions on one hand just about. So here it is, for the record: my first client to express that they liked my care of their animal!

She's perfectly healthy. Well, except...

This week we spey and neuter live, non-sheep animals, by ourselves, for the first time. At the beginning of the week we allocated patients to every student in an effort to have one spey and one castrate per person. The surgeries are on wednesday and friday, so the patients get admitted the day before.

My patient is a mixed-breed retriever/labrador-y thing with a ridiculous three-word name. She was scheduled to get dropped off at 10am, so from 8 to 10 I sat around with pretty much nothing to do. Now, there is a mandatory practical session for us to review suture techniques before we are allowed to do surgery tomorrow. My understanding is that the person running the prac suggested we all head on over to the wetlab if we weren't busy. At 10am. My roster-mates happily agreed and jaunted off to the prac without me, just as my patient arrived. This stressed me out as, so far, I've consistently missed all our scheduled tutorials because of other obligations. Roster-mates are unconcerned as they say "Oh well, we'll just tell her you'll be late."

So I cross my fingers that this will be a quick, routine admittance that shouldn't take more than 10 minutes. After all, my classmate admitted her castrate a half hour earlier without a hitch. Alas, I was out of luck.

The owner was not concerned at all, but this dog has pretty much every problem there is. It's standard procedure to ask after coughing, itching, or vomiting and diarrhoea. Normally the answer is "Oh no, no no, perfectly fine." This time, the answer to every one was "Oh yeah, every day." This dog coughs regularly, is itchier than their other dog, and has diarrhoea on a daily basis. Regarding that last one, I learned that she is fed fruit all the time--like, an apple or banana every day--so that made me roll my eyes, but less worried about the dog. And as for the coughing, at least the lungs were perfectly clear sounding. But then the owner mentions that the dog seems to have a UTI, has had one before and was on meds for it, and seems to be having another episode. Alarm bells go off that this could be a problem, and I need to talk to a clinician before I admit this patient.

To add insult to injury, I tried to finish my physical exam with the temperature, and this dog just would not have it. She whined and screamed and writhed. I asked the owner to hold her, and I still couldn't get the thermometer to stay in. What's worse, the owner's three young children were all there watching, and started complaining that it was hurting her. So I explained that it doesn't hurt, she's just a wuss, and we'd try to get a temperature later. Then I bolted for the exit and tried to find a clinician.

Naturally, there was only one clinician around, and because of it, he was completely swamped. The medicine students were pulling him left and right for the medicine consults and day patients, and I had to camp outside a consult room to try and catch him. He was too busy to really think about it, and just gave some hurried instructions as he walked around the hospital.

I ended up admitting the patient as if we would go ahead with the desexing, but prepared for the eventuality that we may need to change the plan if we find a problem. The owner was okay with this so I bring the dog into the hospital, at which point a nurse asks me to do the urine tests, and I am just like "I need to be at a tutorial 45 minutes ago, bye."

I did make it to the suture prac, where my roster-mates were sewing up disembodied dog legs, and had to get all the instructions repeated to me. I ended up rather rushed, but I'm a lot more comfortable with suturing than my classmates seem to be, so it didn't put me off too much. I got some good advice on subtleties about pulling the knots and what to do with your hands, but I'm already comfortable with the suture patterns, fortunately.

In the evening, my friend on after-hours treatments texted me to tell me my patient's spey is cancelled. She has too many other problems; apparently the word "vaginitis" was thrown around. So after all that, I don't even get to do my surgery.

Keeping Clients "In the Dark"

Today I did my first consult ever. It was kind of awkward and confusing because there is a form on the computer system that we're supposed to fill out, with boxes to tick off or fill in as we take the history and perform the physical exam. I had never used it before, and it's also more designed for medicine (and I am on referral surgery). History taking for referral surgery is kind of like "Dog jumped out of car window, broke leg. Vet sent us here for surgery." The form, however, has a thousand spaces for every detail of diet and lifestyle and what have you, and some of them seem redundant. Combine that with fumbling my questions because I'd never actually spoken to a client alone before, and you can imagine how awkward it was.

On top of that, it was pretty light out and I don't have a very high light requirement threshold, so I didn't even notice that the lights were off. I left the client in the room and went to go get the surgeon, who is very elusive and it took me like twenty minutes to find him, and the entire time she was sitting in this room in the dark. It wasn't until one of the interns was talking to me and mentioned "Oh is that the client sitting in the dark in consult room one?" that I figured it out. To be fair, she could have turned the light on pretty easily.

The other awkward thing about it was that there was some difficulty finding the xrays, and I hadn't thought to ask about them. So once I finally find the surgeon, he wants to know if the client brought the xrays with her, and sends me to ask. She says no, the referring vet promised they would be here this morning. I go back to the surgeon and report this, and he asks if they were digital or film. I don't know, because I didn't ask, so I get sent back to find out. So imagine you're this client, sitting in the dark, and this vet student keeps popping her head in every five minutes to ask details about these obviously missing xrays. It turns out the films got couriered to radiology rather than surgery, and the surgeon eventually found them and the consult proceeded as normal.

How Not to Give Insulin

When we were learning about insulin treatment, our professor shared this story.

One of her diabetic patients was very poorly controlled. They had tried adjusting the dose, the timing, and nothing was working. The insulin was stored in the correct place and not out of date, and the owners described their procedure of drawing it up correctly.

With nothing left to try, the vet asked them to bring everything in and show her how they were injecting.

It turns out, in the initial consult, they had been taught how to inject the insulin using an orange to practice on. So the owners had gone home and were injecting the insulin into an orange, and feeding the orange to their dog.