This morning was rather stressful because apparently all the instructions for today were given at afternoon rounds yesterday, which I missed because I was in surgery. All the cases for today had been divvied up, leaving me with no options.
The nurse put my name down for a lame labrador. It seemed fairly interesting, so I didn't mind too much. About five minutes later, another student approaches me and tells me he'd actually claimed that case last night, but didn't put his name into the system. I find out later that this student was supposed to find me after rounds yesterday and talk about the remaining cases, find out which one I wanted and sort out what was going to happen this morning. He didn't do that. He picked a case and went home.
At first, I put up a defense. "I haven't had a chance to do an orthopaedic exam yet," I explained, basically thinking you should have put your damn name on it, it's mine now. He agreed he would just come in on the consult and we would share the case. I go off and read all the patient notes, and eventually learn that he's started studying up on a completely different case and I may have successfully stolen this case for myself. I was a bit relieved, because it's unfair that my day would have been entirely screwed up and it was all his fault for not finding me yesterday afternoon while I was in theatre.
Then, as I'm reading the patient notes, a popup says one of my classmates is looking at that file on another computer. He's not on surgery this week, so I go ask him what's up, and he says it's a medicine case. We scratch our heads over this until we figure out the consult is scheduled under both medicine and surgery. I investigate, and long story short, it's a medicine case. No more case for me.
Just as I was about to get stressed out again, a new, urgent case pops up. A puppy fractured its femur. A case! Turns out it was not really the best case to have on a friday.
I did the consult when they arrived, and was pleased to find that I'm slightly less bumbly than I was in the first one. I was also pleased to find that the clients were willing to pay for the expensive fancy surgery. Thus the patient came under my care and dominated my entire day. Mostly that meant setting up a cage for him and then doing tons of paperwork.
In the afternoon, we went into surgery. It was interesting, but the hip area is challenging and the surgeon had a difficult time pinning the fracture back together and making sure he got all the pieces in the correct position. I became very glad that I was with the chillax surgeon, because eats-students-for-breakfast tends to get frustrated quickly and start throwing instruments around the room (not even joking). This guy was basically like "Aw, damn it," in a completely relaxed manner as he casually mentions he can't see anything and has no idea if his pins are in the correct place. After three hours of digging around in the hip joint trying to reduce the fracture and hold it together, he sews up a bazillion muscles, closes the wound, and we're off to radiology. However, if the pins aren't in the correct place, we have to come back in, take everything out, and do the alternate procedure where we just remove the femoral head rather than trying to hold it together with pins.
Guess what we found on xrays?
The sad thing is that the femoral neck, our goal during surgery, was very nicely aligned. He had fixed that part of the fracture perfectly. It just turns out that there was another fragment that must have come from somewhere else. Therefore, we had to go back in, re-scrub, undo all the skin staples and all the sutured muscles, and dive back down to the joint. At this point it's 6pm and we're looking at probably 2-4 more hours.
Before committing to the femoral head osteotomy, he tried to find that extra fragment, but couldn't. As far as he could tell, the joint surface was undamaged, though it was possible the fragment was too deep for us to reach. He called in the other surgeon, because once you take out the femoral head there's no going back--there's no chance of future improvements if the patient doesn't do well, like you can't do a total hip replacement when the puppy gets older. So we wait around for the other surgeon to arrive, and then they peer at it and poke at it for a good twenty minutes, discussing the pros and cons and what they think about what they see. The entire time, I'm thinking leave it, leave it, leave it. As much as I would like to see an FHO performed, I really didn't want to be there until 10pm on a friday. Finally, after much deliberation, they decided the best standard of care would be to leave the repair in place, and come back for a second operation if an FHO becomes necessary in the future. Phew!
I still had to write a surgery report, sort out some extra post-op meds, and do all the puppy's paperwork for the weekend, but at least I got home while it was still light out.
Friday, 10 January 2014
Thursday, 9 January 2014
Wrist Day
Since all my other patients have gone home, today was predominated by wrist-cat. This sweet little girl was found limping and it turns out she destroyed the ligaments in one of her wrists, probably from jumping down a big height and landing too hard on it. This is the same cat I admitted yesterday and we took more x-rays yesterday afternoon, confirming the need for surgery today.
The surgery is a salvage procedure where we fuse the carpal joints together so they don't end up becoming all degenerated and painful due to the instability from the ligaments. It was pretty much the coolest surgery I've seen. We opened up the wrist, destroyed all the cartilage with a burr, harvested bone from the shoulder and put a bone graft into the wrist, and then put on this absolutely tiny plate with even tinier screws. The idea is that the joints all heal into a big solid stretch of bone that is no longer flexible (fused into a normal standing position so she can still walk normally). There was lots of drilling and gadgets and metal implants and it was all very exciting. It was also my first time working with the really chillax surgeon. You see, there are two surgeons, one who eats students for breakfast, and one who jokes around and is very pleasant.
Unfortunately I missed afternoon rounds, because the surgery was long and started about they same time they did. This was slightly defeating because on monday, eats-students-for-breakfast gave us homework to present on thursday rounds, and all week I'd struggled to fit in my research and make notes. Turns out it didn't matter at all.
While I was waiting for the afternoon surgery, I adopted a fun patient that came in for an emergency Caesarian last night, and now had three brand new puppies. I watched over her, we did a bit of bloodwork, then I did the discharge with the client. She was a sweet little white fluffy dog, and her puppies were so tiny and silly and adorable.
In other news, we had a communications tutorial yesterday afternoon, talking about why clients leave practises and some common mistakes vets and vet students make. The lady shared some funny stories with us about students calling up the wrong client, and giving them a wonderful update about an animal that isn't theirs. She says there are mistakes every year: every year, animals get overdosed because of decimal places being in the wrong place, subcutaneous injections get given IV, forms get messed up and things don't go through. One time, a form didn't go through for an animal to get cremated, and this vet had seriously debated whether they should give the client some random ashes and pretend. They didn't actually do that, and she was very glad they admitted their mistake, because the first thing the client said was "I'm so glad you didn't try to pass off some other animal's ashes!" The vet said she was glad that conversation happened over the phone, because her face went bright red.
The surgery is a salvage procedure where we fuse the carpal joints together so they don't end up becoming all degenerated and painful due to the instability from the ligaments. It was pretty much the coolest surgery I've seen. We opened up the wrist, destroyed all the cartilage with a burr, harvested bone from the shoulder and put a bone graft into the wrist, and then put on this absolutely tiny plate with even tinier screws. The idea is that the joints all heal into a big solid stretch of bone that is no longer flexible (fused into a normal standing position so she can still walk normally). There was lots of drilling and gadgets and metal implants and it was all very exciting. It was also my first time working with the really chillax surgeon. You see, there are two surgeons, one who eats students for breakfast, and one who jokes around and is very pleasant.
Unfortunately I missed afternoon rounds, because the surgery was long and started about they same time they did. This was slightly defeating because on monday, eats-students-for-breakfast gave us homework to present on thursday rounds, and all week I'd struggled to fit in my research and make notes. Turns out it didn't matter at all.
While I was waiting for the afternoon surgery, I adopted a fun patient that came in for an emergency Caesarian last night, and now had three brand new puppies. I watched over her, we did a bit of bloodwork, then I did the discharge with the client. She was a sweet little white fluffy dog, and her puppies were so tiny and silly and adorable.
In other news, we had a communications tutorial yesterday afternoon, talking about why clients leave practises and some common mistakes vets and vet students make. The lady shared some funny stories with us about students calling up the wrong client, and giving them a wonderful update about an animal that isn't theirs. She says there are mistakes every year: every year, animals get overdosed because of decimal places being in the wrong place, subcutaneous injections get given IV, forms get messed up and things don't go through. One time, a form didn't go through for an animal to get cremated, and this vet had seriously debated whether they should give the client some random ashes and pretend. They didn't actually do that, and she was very glad they admitted their mistake, because the first thing the client said was "I'm so glad you didn't try to pass off some other animal's ashes!" The vet said she was glad that conversation happened over the phone, because her face went bright red.
Wednesday, 8 January 2014
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.
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.
Tuesday, 7 January 2014
Second Day of Surgery Was Also Butt
Apparently I get all the butt-dogs, and it's pretty much my own fault for signing up for those cases. Today's butt-dog was actually a vag-dog, but that's close enough.
I don't know why, but I was on top of it today. Man, I was getting everything done, immediately, which is totally not how yesterday went. It's also not how today went for my classmates on my roster, but I think that has to do with the timing of the various surgeries. Instead of describing my day like a story, I'm going to try a different approach.
My Patients
- Butt-dog: Yesterday's surgery (they stay the night in hospital), this guy was a huge sweetie. He was always friendly and cheerful, wagged his tail and sat down when I approached with a leash, and never tried to eat any of the other patients.
- Vag-dog: Came in for emergency (same-day) surgery due to a vaginal prolapse. Ouchie. Despite her situation, surprisingly also a sweetie. She was pregnant with puppies worth $10,000 each, so even though they usually get speyed to help prevent recurrence of the prolapse, that was not going to happen here. We had to confirm that was the case, so we did a quick ultrasound, and found at least two live puppies by their heartbeat. We only checked one side, so there are likely several more puppies.
- Fluff-ball spinal-dog 1: There are actually two small fluffy dogs that are spinal patients (both have paralysed hind limbs), and one of them is mine. I actually confused them when I signed up so got the less-cute one, but she's still very silly. I have to walk her with a sling under her hind end, like a wheelbarrow. It's kind of bizarre walking a spinal dog and then a normal dog right after, because you get used to managing the spinal dog's disability.
Responsibilities
(1. Do the consult - I haven't done any yet)
2. Perform physical exam and write up paperwork for findings
3. Fill in "patient management sheet," which is basically setting out a plan of what needs to be done when, like walking, feeding, meds, etc, for that day and the next day
4. Scrub in on the surgery
5. Decide and calculate post-op analgesia
6. Call owners
7. Write a surgery report explaining the procedure
8. Write a discharge sheet for the client, explaining what happened in hospital, what/how to give meds, and home care
9. Take care of walking, feeding, meds, physiotherapy etc during the day, as well as the next morning (surgery patients stay overnight)
10. Meet with client by yourself, go over everything and send animal home
In Between
- Rounds every morning and every afternoon, where we meet as a group and tell each other about our patients, and usually discuss aspects of those diseases
- Homework - we're supposed to present some topics on thursday
- Explain things to other roster students that you've figured out, like how to work the computer system
- Get assigned new patients
Apparently some of the other rosters, like the non-referral medicine, don't have much to do and just sit on their thumbs all day. I had absolutely no idea that the rest of my classmates are not nearly as busy as the four of us on referral surgery.
I don't know why, but I was on top of it today. Man, I was getting everything done, immediately, which is totally not how yesterday went. It's also not how today went for my classmates on my roster, but I think that has to do with the timing of the various surgeries. Instead of describing my day like a story, I'm going to try a different approach.
My Patients
- Butt-dog: Yesterday's surgery (they stay the night in hospital), this guy was a huge sweetie. He was always friendly and cheerful, wagged his tail and sat down when I approached with a leash, and never tried to eat any of the other patients.
- Vag-dog: Came in for emergency (same-day) surgery due to a vaginal prolapse. Ouchie. Despite her situation, surprisingly also a sweetie. She was pregnant with puppies worth $10,000 each, so even though they usually get speyed to help prevent recurrence of the prolapse, that was not going to happen here. We had to confirm that was the case, so we did a quick ultrasound, and found at least two live puppies by their heartbeat. We only checked one side, so there are likely several more puppies.
- Fluff-ball spinal-dog 1: There are actually two small fluffy dogs that are spinal patients (both have paralysed hind limbs), and one of them is mine. I actually confused them when I signed up so got the less-cute one, but she's still very silly. I have to walk her with a sling under her hind end, like a wheelbarrow. It's kind of bizarre walking a spinal dog and then a normal dog right after, because you get used to managing the spinal dog's disability.
Responsibilities
(1. Do the consult - I haven't done any yet)
2. Perform physical exam and write up paperwork for findings
3. Fill in "patient management sheet," which is basically setting out a plan of what needs to be done when, like walking, feeding, meds, etc, for that day and the next day
4. Scrub in on the surgery
5. Decide and calculate post-op analgesia
6. Call owners
7. Write a surgery report explaining the procedure
8. Write a discharge sheet for the client, explaining what happened in hospital, what/how to give meds, and home care
9. Take care of walking, feeding, meds, physiotherapy etc during the day, as well as the next morning (surgery patients stay overnight)
10. Meet with client by yourself, go over everything and send animal home
In Between
- Rounds every morning and every afternoon, where we meet as a group and tell each other about our patients, and usually discuss aspects of those diseases
- Homework - we're supposed to present some topics on thursday
- Explain things to other roster students that you've figured out, like how to work the computer system
- Get assigned new patients
Apparently some of the other rosters, like the non-referral medicine, don't have much to do and just sit on their thumbs all day. I had absolutely no idea that the rest of my classmates are not nearly as busy as the four of us on referral surgery.
Monday, 6 January 2014
First Day of Surgery Was Butt
I wish I could tell you that my first day of referral surgery involved the emergency splenectomy of the dog with a cancerous spleen that had ruptured and was bleeding into its abdomen.
It didn't. It involved butt.
After the orientation, in which they casually mentioned that we would be in charge of doing all our own consults (full history and physical exam, alone with the client), we were assigned cases. I got no-show and butt-dog.
No-show turned out to be a relief. Since this is referral surgery, the reason we have the case at the hospital is that some vet out in practice sent it to us. I read the referral letter, and it was a horribly complicated orthopaedic case with a number of problems on x-ray and CT scan, but no consistent pain response or localising signs to indicate a specific disease. So my first consult ever (ever) was going to be a confusing mess of me having to do a complete neurological and orthopaedic assessment, to come up with a list of differentials and treatment plan, for a case that had a real life vet scratching their head. Mind you, we're still at the stage where we have to think for five minutes to remember the basic questions, like "how long has he had this problem." Understandably, I was quite happy to find out that they had not turned up. I was especially happy because if they had turned up, I would have gotten no lunch today.
My other case was butt-dog. Some poor labrador whose anal sacs have been irritated for 3 frickin' months. He wasn't responding to medical treatment, so off to surgery to have said anal sacs removed. Incidentally, they were removed by the surgeon who is well reputed to feast on students' tears, which made day 1 slightly more stressful than it needed to be. I survived mostly unscathed, after about an hour or two of him saying "Swab" and me trying to get my hand in to swab the blood before too many seconds passed and he got annoyed.
Despite a surprisingly slow morning, after surgery, the day really did feel like butt. I had to sort out all the post-op meds, including pain relief and antibiotics, and get them from the pharmacy and set up all the forms, and like a thousand other things. Only, I had to do that with minimal help. It's sensible enough, we need to be able to do that, but on day 1, picking your own drugs, dose rates, and the other hairy details is a bit overwhelming. Between trying to get people to explain what on earth to put in the forms, double check my choices, and getting sent from one nurse to another to another to answer simple questions, it took me 2 hours to do something that should have taken 10 minutes.
Actually, allow me to backtrack. After surgery, I started to figure out the meds, had all those problems, but only 15 minutes before rounds started. In the middle of scratching out and re-writing and re-scratching out my calculations, my pager (yes, pager) goes off and we get sucked away to get grilled by the head surgeon on what we learned today. I didn't get to finish my post-op duties until afterwards, and then I got reprimanded for not having the form in to the pharmacy before 5pm. Surgery ended at 4:15, rounds started at 4:30.
Well, after my 12 hour day, I have about two hours to live my life before going to bed, because I have to get up ridiculously early to get all my in-hospital patients walked, fed, and examined before morning rounds start at eight. And by "live my life" I actually mean "do the research homework for the presentation on thursday."
It didn't. It involved butt.
After the orientation, in which they casually mentioned that we would be in charge of doing all our own consults (full history and physical exam, alone with the client), we were assigned cases. I got no-show and butt-dog.
No-show turned out to be a relief. Since this is referral surgery, the reason we have the case at the hospital is that some vet out in practice sent it to us. I read the referral letter, and it was a horribly complicated orthopaedic case with a number of problems on x-ray and CT scan, but no consistent pain response or localising signs to indicate a specific disease. So my first consult ever (ever) was going to be a confusing mess of me having to do a complete neurological and orthopaedic assessment, to come up with a list of differentials and treatment plan, for a case that had a real life vet scratching their head. Mind you, we're still at the stage where we have to think for five minutes to remember the basic questions, like "how long has he had this problem." Understandably, I was quite happy to find out that they had not turned up. I was especially happy because if they had turned up, I would have gotten no lunch today.
My other case was butt-dog. Some poor labrador whose anal sacs have been irritated for 3 frickin' months. He wasn't responding to medical treatment, so off to surgery to have said anal sacs removed. Incidentally, they were removed by the surgeon who is well reputed to feast on students' tears, which made day 1 slightly more stressful than it needed to be. I survived mostly unscathed, after about an hour or two of him saying "Swab" and me trying to get my hand in to swab the blood before too many seconds passed and he got annoyed.
Despite a surprisingly slow morning, after surgery, the day really did feel like butt. I had to sort out all the post-op meds, including pain relief and antibiotics, and get them from the pharmacy and set up all the forms, and like a thousand other things. Only, I had to do that with minimal help. It's sensible enough, we need to be able to do that, but on day 1, picking your own drugs, dose rates, and the other hairy details is a bit overwhelming. Between trying to get people to explain what on earth to put in the forms, double check my choices, and getting sent from one nurse to another to another to answer simple questions, it took me 2 hours to do something that should have taken 10 minutes.
Actually, allow me to backtrack. After surgery, I started to figure out the meds, had all those problems, but only 15 minutes before rounds started. In the middle of scratching out and re-writing and re-scratching out my calculations, my pager (yes, pager) goes off and we get sucked away to get grilled by the head surgeon on what we learned today. I didn't get to finish my post-op duties until afterwards, and then I got reprimanded for not having the form in to the pharmacy before 5pm. Surgery ended at 4:15, rounds started at 4:30.
Well, after my 12 hour day, I have about two hours to live my life before going to bed, because I have to get up ridiculously early to get all my in-hospital patients walked, fed, and examined before morning rounds start at eight. And by "live my life" I actually mean "do the research homework for the presentation on thursday."
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