I Have A Curse

Maybe it's "beginner's luck," but my cases all turn into wacky, that-never-happens, no-one-has-seen-anything-like-it sagas. I'm not complaining, but it's uncanny. I've had to research things that the other vets have hardly seen a handful of times in thirty years of practice. I've had straightforward cases develop bizarre crazyland complications. Last year, my boss told me I'd seen more weird stuff in two months than he'd seen in two years.

Here's a selection of the weird and wonderfuls I've seen...

• Great Dane with Lyme disease who came back a week later with a severe immune-mediated vasculitis (his leg was a water balloon).
• The same week, a cat came in for a recent "swollen foot." Sounds like a cat bite abscess, right? Nope. Huge elbow mass full of joint fluid. Maybe a synovial sarcoma?
• Also that week, a young cat brought in because he was having trouble breathing. Turns out he had acute anuric renal failure, for absolutely no reason we could figure out, and didn't respond to treatment. Died that day, nothing to do with the breathing.
• My first month in practice I encountered a dog with megaoesophagus, which is a rare condition.
• My first month, I also prescribed routine ear drops for an ear infection--a situation that happens on an almost daily basis. But this dog went death in both ears immediately after starting the drops. The owners were so mad at me I could barely talk to them. Has never happened before in this practice with any ear medication for any of the other vets.
• My boss saw a cat for a cat bite abscess and I ended up with the recheck the next week on his day off. He assured me it would be routine. Turned out to be in massive acute liver failure and spent the day on oxygen support because it could barely breathe.
• My first blocked bladder cat was a female with five struvite stones at least the size of your thumbnail. My boss has never seen as many large stones in a cat in his whole career.
• I saw a cat with nice owners a few times for small issues, then he came in a month later, on death's door, with a stomach full of blood. He was an indoor, only cat with no medications and no access to anything unsavory that we knew of.
• I had an ongoing saga with a cat that wouldn't really eat for weeks to months for no discernable reason. The owner is a little batty, and wouldn't let us do the full nine yards with regard to treatment, but still cicled around with this cat for ages. Weekly rechecks, repeat blood work and imaging, no response to any medication--and we must have tried the whole pharmacy.

I'm sure many more are on the horizon. They especially like coming in when I'm by myself, like Saturdays or in the evening on my late day. There have been a lot of panic texts to my boss these past six months.

You Have A Cold? Time For GDV Dog To Come In When You're By Yourself.

Yesterday, when I left the house, I felt normal. By the time I got to work, I had one of those, "Oh, the air is a bit dry" sore throats. Then I proceeded to get sicker by the hour. Since I hadn't been sick in the morning, I wasn't prepared. At home I have a cornucopia of cold and flu remedies, but at work all I had was tea. Lots and lots of tea.

It figures this would happen on my late day, when the clinic closes at 8pm. Things went pretty well, considering. Most of my exams were new pets adopted from the shelter, getting their free exam. I speyed a shelter cat. Dental on a dog that didn't need any extractions. For the evening appointments, one showed up super early, one was just a booster with no exam, and we knocked it out of the park.

Yay, maybe I can get home somewhat early and then take some NyQuil and pass out!

Ten minutes to seven, phone call. Young dog that has been severely vomiting all day. May have eaten sewing fabric or needles. Hmm, doesn't really sound like something that I want to wait overnight.

I knew it was going to be a long haul as soon as they arrived, because this dog was a big labby thing that was going crazy. All over the place, jumping, panting, anxious, wouldn't sit still. There were only three of us in the whole clinic, and one of the technicians is recovering from broken ribs so can't handle any animals. So it was two tiny young women against big anxious dog. When we finally managed to get an xray... Oh shit, that looks like GDV.

I decided to call the emergency clinic to see what they recommended. I had the brilliant plan to email them the xrays. Turns out none of us knew how to actually log in to the email account.

Long story short, it wasn't actually GDV, gave it some meds, and the dog got better overnight. They canceled their recheck appointment today, along with the other... three or so appointments I had. So after the handful of morning appointments, everyone kind of shuffled me out the door to go home and rest.

My First Day On The Job Involved A Proptosed Eye

One of the reasons I took the job that I did was that they were interested in hiring a new grad, and willing to give me training wheels for my transition from vet student to actual vet. For my first month, I was never alone in the clinic, so no evenings or weekends, and I was paired with the most experienced senior vet techs. My appointments were all scheduled for 30 minutes instead of twenty, and I was given extra "block off" time for work-ins. My first few days, I didn't have any scheduled appointments at all. I was meant to observe, familiarise myself with where everything is, and maybe jump in on work-ins or walk-ins.

As life would have it, there was a work-in at 8am that first Monday. A dog that had gotten into a fight with its larger friend, and may have gotten a laceration above one eye. "Redness" above the eye, they said. Perfect first case for the new grad, they said.

So in I go and as soon as I lay eyes on the dog, I know exactly what happened, and that I have no idea what to do about it. It wasn't a laceration. It was a proptosed eye.

Small, buggy-eyed dogs like pugs and shih-tzus already have their eyes halfway out of their heads. Therefore, it's pretty easy to pop them the rest of the way out. A solid squeeze or bang on the head could do it. If you catch them straightaway, you can push them right back in. Naturally, this happened the previous afternoon, so the eye had been bulging out exposed to the world for more than 12 hours.

In typical new grad fashion, I gave an excuse to bring the dog out back ("have a look at it under the bright lamp in treatment"), found my boss, and promptly went, "What do I do, what do I do!"

Long story short, we admitted her to the hospital for mini surgery to put the eye back in and suture the eyelids together to hold it. All went well, and I saw her every week for a month or two. The eye retained some function to it and time will tell what happens to it in the long run.

It turns out this was a prelude to the theme of my career. Nothing normal happens to me. It's only the wacky, you-don't-see-that-every-day cases, time and time again.

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.

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."

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.

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!

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.

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.

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.

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!

My Patient, the Wuss/The Urine Sample Ordeal

I was supposed to do a spey today, but because my patient has a zillion problems, it was cancelled last night. However, when I arrived at school this morning, anaesthesia had already given my patient her pre-meds and was about to take her down to the surgery theatres. Two students told me the vets had decided she would definitely not have surgery, but the clinicians themselves were nowhere to be found. Que confusion, and anaesthesia becoming very unhappy.

The unfortunate thing about the morning is that the clinicians have this habit of all disappearing right when you have the most questions. Usually it's because they do rounds, and you can see them all standing there discussing the in-patients, but can't interrupt. But occasionally they all disappear for meetings, and it's always the worst timing possible. So today when I had no clue what was going on with my patient, it was very unhelpful that I couldn't find a free clinician to even tell me if the surgery was going ahead or not.

Eventually, I confirmed that she has other problems to worry about, behaviour issues not being the least of them, and we would investigate the UTI rather than doing the spey. She got transferred to a medicine student, but since I no longer had anything to do that morning, I followed her around and did all the stuff anyway. Since she was already sedated, the vet wanted to use a quick ultrasound to perform a cystocentesis (jab the bladder with a needle). I mentioned in my post yesterday that this dog is a giant wuss, but I completely underestimated that fact. Just putting the ultrasound probe against her belly caused a riot of screeching and whining and struggling. To an outside observer, it might have sounded like we were stabbing her to death. And just a reminder, this is a heavily sedated dog.

There was some confusion about when, exactly, she had been sedated, so vet #1 said we should give it another half hour for the meds to hit their peak effect. Vet #2 got around to it in about an hour, and as it turns out, the sedatives were given much earlier than either vet had realised, and now completely worn off. I went to get her out of her cage, only to be greeted by an alert, tail-waggy-but-whiny puppy.

They zonked her out again, and this time gave her an extra large dose, considering what happened last time. Vet #2 mentioned that it was twice what he would normally use.

Unfortunately, zonking them out relaxes all their muscles, so as soon as the nurse lifted the dog out of the cage so we could get a urine sample, the relaxed bladder emptied itself all over the blanket. Vet #3 made a frowny face as she felt the now-empty bladder. Crap.

Well, maybe there's enough still in there that the imaging people can get a cysto sample using the proper ultrasound.

We wheeled our patient down to imaging, where an actual ultrasonographer was waiting, and fortunately, this time the dog was out like a light. A tense couple of minutes followed, as the ultrasonographer poked his needle into the bladder over and over again to no avail. You could see on the image just how thick the bladder wall was. The needle was pushing against it, but not breaking through into the organ itself. He redirected, poked in quickly, pushed in slowly (even to the point that you could see the needle going through and pushing on the far wall), used a different needle--still nothing. Finally, by some miracle, on what may have been the last attempt, vet #3 pulled the plunger and urine! She handed me the syringe and said, "Guard this with your life."

We then typed up the forms for the lab, and I got sent on a Quest: bring these items to the pathology lab! 

That's pretty much the end of the story, but to tie things up I should mention that when we checked the results later, there was a lot of bacteria. We put her onto a course of antibiotics and sent her home.

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.