Thursday, August 21, 2014

My FeLV experience.

As if new grads don't have enough to deal with, I got the added bonus of very nearly euthanizing my healthy cat!

When my husband and I moved back in together in May, we combined our cats for the first time. I had Mama and Cas, and he had Roosevelt. He adopted Roosevelt from a shelter in Spokane, Washington in December 2012 and had kept him as an indoor only, single kitty in his apartment for a year and a half. In mid-August, my benefits kicked in and through Banfield as a part of my contract I get three of our Owner Wellness Plans. I brought Roosevelt in as the first of the three to booster his vaccines, run blood work, and do a dental cleaning. I received a nasty shock when he turned up weakly FeLV+ on an ELISA snap test. I thought it was probably a false positive, so I ran it again. Same result.

I panicked, raced home to grab my two cats, brought them in and tested them. Both tested negative, and I vaccinated them right away.

Don and I had a serious conversation that night about the risk Roosevelt posed to my cats, even with them vaccinated, and how very bad FeLV was. I told him that even vaccinated, I wasn't prepared to risk losing Mama or Cas to this disease. He was ready to euthanize Roosevelt right then, but I asked him to let me submit an IFA as a confirmatory test, because Roosevelt's history just didn't fit with this disease.

Feline leukemia virus stats are a bit all over the place, but the general gist is this: 30% of cats will obtain the virus, get sick with what is called the "primary viremia" stage of the disease, and mount a sufficient immune response so that they completely clear it and are immune for life. The rest of the 70% either die outright of infection (usually the kittens that are infected young before their immune systems are very good) or they become persistently infected with the "secondary viremia" stage of the disease because they didn't clear the virus. This stage occurs when the virus is present in the bone marrow and associated with white blood cells. These cats typically die within 1-3 years of suppressed immune system diseases like chronic respiratory infections, or lymphosarcoma.

Roosevelt's IFA was negative. This didn't fit with his history at all. There was no way Roosevelt could've been infected within the last year and a half as a single, indoor-only cat. The only way he could've been recently infected was if Cas or Mama had done so within the last couple of months, but both of them are negative. The reason this is odd is because a positive ELISA, which tests for the primary viremia stage, and a negative IFA, which tests for the secondary, white blood cell-associated stage, is only possible with recent infection. Which in Roosevelt's case was impossible.

With this confusing, discordant result, I submitted a PCR on whole blood. This test is the grand-daddy test that would determine if he had any circulating virus in his system at all. It was negative. That settled it; Roosevelt does not have FeLV. Curious, I took the second blood sample we drew for the PCR that I had saved part of, which was taken about a week later from the first sample I ran the first two ELISAs on, and ran a 3rd ELISA. It came back positive.

I've since spoken with two internal medicine specialists about this case - one of the phone consultant clinicians from Antech, the lab I submitted the tests to, and Dr. Gillespie who I externed with at IndyVet this past spring. Both feel that even with three positive ELISAs ran on two different blood samples taken on different days, this is a case of a false positive ELISA. Something in Roosevelt's blood is cross-reacting with the test as similar to the p27 protein FeLV antigen that the test screens for.

I submit this as a case for any of my vet school or fellow clinician readers. If you get a cat whose history does not fit with the clinical progression of FeLV, yet tests positive on ELISA, always submit a confirmatory test before euthanizing!

Sunday, July 27, 2014

Just vet stuff.

So if any of you are wondering what real life is like after vet school, here's my breakdown so far.

We all have our strengths and weaknesses. A common problem many new grads have is communicating with owners. It's intimidating telling someone you want their money, no matter how justified the reason is. Due to having been a tech for a number of years prior to vet school, and just my own shameless personality, I have zero problem talking to owners. Even difficult owners aren't really a big issue for me. My biggest hurdle right now is time managment.

Speaking of time management, here's the deal. You go from a teaching hospital with every drug known to man, the latest diagnostic tools like ultrasound, a CT, an MRI, the latest nutroceutical therapeutics like cold laser and hydrotherapy, to a tiny clinic with a limited pharmacy and if you're lucky digital radiology. Maybe not, if you're doing an internship or you happen to work at a really awesome clinic. But for most of you, it's going to take you forever to discharge your first few dozen or so appointments because you have to decide what you want to do (which you won't have your protocols down in your head yet for skin, eyes, cough, etc) then decide what you CAN do with what you have to work with, then okay it with the owner which will usually modify it further due to cost. It's gonna take awhile.

Also, my first few spays have taken me an hour. No one's there to hold your instruments for you, or follow your suture line by keeping your tag out of your way. I'm primarily spaying 4 lb chihuahuas and whatever-poo puppies, which by the time I've placed my clamps gives me no space to work in. Also, I freaking hate those needle drivers with the scissors in the handle. I've cut my suture line unintentionally THREE times! And then had to start over. Not to mention, the scissors are so far down the handle that it's next to impossible to clip your tags short enough without craning your neck so far you're practically resting your cheek on the patient. So. Much. HATE.

Other than that, things have been fairly decent. I'm an okay doctor, I can generally keep up with appointments with a good tech team keeping me on track. I'm frustrated sometimes that I'm not accomplishing things as quickly as the other doctors, which I recognize is silly and I need to stop being so hard on myself. I get frustrated when I don't have access to drugs I want and my boss won't buy them, or when techs who are used to the way the other doctors do things get a little passive aggressive with me when I want to do things another way. Just micro-struggles that you'll all deal with once you're out in practice.

So that's it. That's the reality of a new grad in practice. It's not very glamorous, but it isn't hellish, either. It's a lot like having a job, oddly enough. ;)

Sunday, June 29, 2014

I'm alive!

So if anyone is still reading this, hello! I am writing my first post as Julie Lada, DVM! I locked down my blog while applying for jobs. It's just a good idea to minimize your non-professional social media presence during that time.

Externships were a mixed bag for me. My first one, at the emergency/internal medicine specialty clinic was fantastic. I learned so, so much so quickly. I got to play with an endoscope, and take biopsies (bone core, and endoscopic). I saw a few splenectomies, one of which weighed 15.5 lbs! And a ton of pyometras, most of which were septic and required 3-4 days of 24 hour care. Spay your pets, people!

The second internship was very informative in many regards, and also very frustrating. The first thing I learned was that the avian specialist, a large part of the reason I chose that clinic, would be gone for 2/3 of the time I was there and I wasn't told this prior to scheduling. That was a huge let down, particularly since I really enjoyed working with him my first day. The second half of the problem was that I don't know if they aren't accustomed to hosting students so near the end of their schooling, but I was basically treated like a technician to a large degree. Instead of going into exotics appointments, I was being asked to scale and polish dog teeth, or even restrain for anal gland expressions. If I mentioned that I was already comfortable with my skills doing a routine scale & polish, but if they had any extractions to please let me know as I needed more experience with those, I was told that I was "there to learn" and to stop turning down opportunities I was given. I was also asked not to assist with taking a history in the room, just to stand against the wall until I was asked to do something. Compare this with at the previous externship, I was going into rooms on my own to take a history, do a physical, and report back to the internal medicine specialist with my differential list and plan. And at this clinic, I wasn't even allowed to ask a single question.

Like I said, frustrating. Probably the nail in the coffin was a neuter gone horribly wrong, where I was told, "It's all you, I'm just your assistant!" and then everything I wanted to do was second-guessed and micromanaged. Many of the things that the vet "assisting" me wanted me to do are outdated and now regarded as incorrect technique. For example, I was told to place eight throws on each spermatic cord. Eight! And I was also told that you cannot place a transfixing ligature in a neuter. I was really uncomfortable, and then told later that I made her feel uncomfortable. So both of us were unhappy with the way it went. (FYI, my new employer watched me do a dog neuter two days ago. I used a one clamp technique, two ligatures - one modified Millers and one transfixing. All of my ligatures held beautifully, and I was done inside of 20 minutes start to finish. She called me a "rock star" and said I didn't require any further instruction in routine surgeries. I'm just saying, surgery is one of my strong suits and it really, really bothered me to have my skills brought into question.)

So yeah, I ended that externship early and came home to take an in-house rotation at Illinois because we were just a horrible fit. For that reason, Rossies, I recommend not taking a 4 week externship unless you really know the clinic well. I could've been stuck there for another 2 weeks of misery.

In other news, I have a job! I interviewed at four clinics, and was offered 3 out of 4 of the positions. The one I was turned down for smarted a bit, as it was a great salary working with very talented people with lots of the latest diagnostic toys. But I made it from the initial 17 new grads interviewing to the final 5, so I can be proud of that, at least. And I'm happy with where I wound up. The team and I seem like a really great fit, we joke around a lot, and it's a comfortable atmosphere. I'm the newest addition at the Banfield clinic at Trader's Point in Indianapolis, going from a 3 to a 4 doctor clinic. So far I've been really impressed with the company; patient care, client satisfaction, diagnostics, employee benefits, etc. I think I can really be happy here. And my clinic just got a digital dental radiograph unit, so yaaaay! Now if I can just talk my boss into letting me get an ultrasound. ;)

So there you have it. I completed my goal of writing a Ross vet student blog from start to finish. Now you guys know it's possible to survive without failing out or being eaten alive by a giant centipede. Good luck, Rossies! And now and always, GO GREEN!

Tuesday, March 18, 2014

Sprint to the finish!

The end is in sight, I can see the blue ribbon waiting for me! I just finished up my last rotation at the University of Illinois on Friday. Now I head off on 8 weeks of externships, and then I'm done! This last rotation, soft tissue surgery, was hands down my favorite so far.

I never expected to love surgery. I just had an interview recently where I was asked to name a couple of my favorite rotations/fields within veterinary medicine. I told my interviewer that I think there are common experiences in vet school that everyone goes through; when you try something you were dreading/thought you'd be terrible at and find you actually love and excel at it, and when you stumble upon something that you're randomly great at. For me, surgery was the thing that I expected to be awful at. The reason why is that I used to get quite faint while working as a tech and watching surgeries. It happened again at Ross in 3rd semester while watching a necropsy. I was terrified that I'd be unable to complete my live animal surgeries in 7th semester, so I volunteered for the feral cat spay/neuter days to get as much table time as possible before I had to do it for a grade. Turns out, I just have to be the one holding the scalpel! Once my mind is focused on a task, I'm able to shut out the part that gets woozy (usually, sometimes I still get a little light-headed and have to yawn, dance around a bit, bite my cheek, and then I can power through it). But it turns out, the same quality that drew me to culinary arts and pushing myself to achieve more and more adeptness at cooking, also applies to surgery. The perfect chocolate hazelnut tarte vs. the perfect gastropexy. Both require attention to detail and a delicate touch.

The thing I stumbled upon and just happened to be good at is radiographic imaging interpretation. The first day of class our professor said that in order to become good at reading radiographs we'd have to "learn how to see." And that it could take years for clinicians to develop this skill. For some reason, I can just see things intuitively. Pathological changes in radiographic images can be incredibly subtle, but for some reason they stand out to me. I'm able to create a 3D map in my mind of how structures sit within the body and overlay that with what I'm seeing on the 2D image in front of me, keeping a visual reference image of what "normal" would look like in comparison. I don't know why I can do this, and it was certainly unexpected. But now I really enjoy diagnostic imaging and want to pursue a continuing education and certification in the use of ultrasound, since I feel that's a weak area for me at the moment but it's such a profoundly useful tool in private practice if you know how to use it.

Speaking of interviews, I have potentially exciting news that I have to sit on until I know for sure. However, things appear to be falling into place, for both myself and my husband. Right now the future looks bright and we're both cautiously ecstatic. After 3+ years of living apart, and the fear that we wouldn't find work in the same city right away after I graduate and we'd have to continue to live separately for some time, our lives finally seem to be moving in the right direction. I'll post as soon as I know more!

Thursday, March 13, 2014

"Rub their nose in it!" And other such myths.

Dog training is a hot button issue right now. Dozens of TV, magazine and book personalities are dying to tell you the best way to get your dog to stop jumping up on your guests or going through your trash. In some ways, that is a great thing. Traditionally, dog training consisted of a rolled up newspaper. Getting the issue of dog behavior and training into the public awareness is a huge step for behaviorists and people who are passionate about pet welfare. However, as usual, anytime a topic becomes popular and a profit can be made off of claiming to be an expert, you get bad ideas and bad information being promoted just as heavily as the good. Television shows in particular focus on which host is the most charismatic rather than the most knowledgeable or accurate.

Part of the challenge for me personally, being a vet student and passionate animal behavior geek as well as a firm believer in evidence-based medicine, is the pervasiveness of bad ideas in my field of study. Witnessing a colleague perform an "alpha roll" right in front of me, it's a struggle to balance my desire to address the issue with the need to still maintain good relationships and not become known as the token naysayer.

Dog training is one of those topics that must be handled with a delicate touch. A method isn't purely a method anymore when you're talking about its application toward an animal that a person feels a strong emotional connection with. The method becomes the person employing it, and its effectiveness becomes intrinsically tied to their value as a pet owner. Like it or not, as any trainer or behaviorist will tell you, the moment you say something like, "Dominance-based training is not as effective as we previously thought and can actually have detrimental effects on an animal" it becomes translated by the person you're talking to as, "You're a bad owner and you abuse your dog."

The problem with any topic in medicine is that bad arguments can be made to sound very persuasive and convincing by using the lingo. The argument behind dominance-based training methods is an excellent example of this (BARF diets are another good example). Advocates such as Cesar Millan point to wolf pack hierarchy models as an example of "natural" applications of dominance-based behavioral conditioning. They tell dog owners to be their dog's "alpha" by using techniques employed by wolves such as throat holds and alpha rolls. They also attempt to shame owners by telling them that disobedience is a form of dominance which proves that their dog doesn't respect their status as "pack leader." The appeal to nature fallacy is something we skeptics are well aware of but it is unfortunately remarkably persuasive with the general public.

A huge, glaring problem with the dominance hierarchy argument is that it makes the assumption that behavior models which we have obtained based on the study of captive wolf packs are reflective of natural behavior in the wild. This is patently false. Firstly, the dominance-based hierarchy suggested by Millan only occurs in captive wolf packs. Wolf packs in the wild consist of genetically related members with the breeding pair being the "alphas." The frequent displays of aggression and dominance seen in captivity do not occur in a natural setting. Secondly, feral dog "packs" - the aggregates formed by stray dogs - do not display this hierarchy model, so even if it were true of wolves in the wild this model does not appear applicable for domestic canines. (Mech, 1999; Taylor & Francis, 2004)

And then there's the problem with the word "dominance" itself. Common usage would lead most people to believe that dominance is a personality trait; something a dog just is. A common thing we hear from our clients is, "She's just so dominant!" Or claim that their dog is trying to be dominant over them. Dominance has a very specific meaning within the context of animal behavior and it isn't something an animal just is. This is a common misunderstanding and something I've even seen my colleagues use. Dr. Sophia Yin, a DVM with a Master's in animal behavior and a widely renowned expert in dog behavior does a pretty good job of summing it up here. She has written extensively on the topics of dominance, aggression and training and I highly encourage anyone with a dog to spend several hours reading her articles. The American Veterinary Society of Animal Behavior reinforces Dr. Yin's position with their official statement on dominance theory:

“Dominance is defined as a relationship between individual animals that is established by force/aggression and submission, to determine who has priority access to multiple resources such as food, preferred resting spots, and mates (Bernstein 1981; Drews 1993)... In our relationship with our pets, priority access to resources is not the major concern. The majority of behaviors owners want to modify, such as excessive vocalization, unruly greetings, and failure to come when called, are not related to valued resources and may not even involve aggression. Rather, these behaviors occur because they have been inadvertently rewarded and because alternate appropriate behaviors have not been trained instead.”

But beyond the implausibility of the theory behind the use of dominance and physically aversive stimuli in dog training, as well as the misuse of the term "dominance", there is the added factor that it just doesn't have a wide range of practical use. Meaning in the majority of cases, it doesn't work. Several recent studies have confirmed that dominance/positive punishment training methods have a number of negative effects on dogs (including physical injury and death in cases of choke chains and prong collars being used incorrectly) and can actually impair learning ability. These methods also cause fear and escalate aggression in terms of frequency, magnitude and situational aggression - meaning a dog that wasn't previously aggressive becomes aggressive, or a conditionally aggressive dog begins to display aggression in situations where it previously did not (Husson et al, 2009; Hiby et al, 2004; AVSAB, 2008). This is particularly worrisome for vets and shelter workers. An owner employing dominance-based techniques toward their dog who is aggressive toward other dogs can actually cause that dog to not only be more aggressive toward other dogs, due to the added negative association with pain and fear, but also cause the dog to redirect its aggression toward its owner. In which case the problem goes from being something that could possibly be solved via proper training to what is a probable euthanasia case.

Positive reinforcement techniques such as clicker training are gaining momentum, and it's got behaviorists cheering in the streets (or rather, their offices). These techniques avoid the negative associations with pain and fear seen with dominance-based techniques and thus the ramping-up effect on aggression.

Finally, I know that this is a contentious topic and I anticipate anecdotes from those who have used Cesar Millan's or other dominance-based techniques successfully. A few words on that.

First of all, there are always outliers. I saw something recently that I quite liked and determined to borrow that said that between 80-90% of smokers will develop lung cancer, which means that 10-20 out of every 100 smokers will not develop lung cancer. So you will often hear claims such as, "My father smoked two packs a day for forty years and died in his sleep at 85 years old!" And while true, it does not disprove the fact that overall smoking is highly associated with lung cancer.

Also consider that the effect of fear on the cessation of all forms of behavior is fairly well documented. Simply put, a fearful animal will stop doing anything, including what you wanted them to stop doing. A dog that is fearful of inviting a painful punishment can appear to an owner to be "cured" of the unwanted behavior. But in fact, the underlying issue of why this dog was exhibiting the unwanted behavior is still unaddressed. A dog that is fear aggressive toward strangers, for example, is still terrified of strangers but simply stops reacting. Don't confuse this with being a happy, healthy, well-adjusted dog. An animal that has stopping displaying observable fear signals is still fearful, and the use of punishment can contribute to a more unpredictable animal that will give no warning before attacking (AVSAB, 2007)

Wednesday, January 22, 2014

Sunday, January 19, 2014

Long overdue update.

I guess when someone other than my mom is nagging me to update, that's how I know it's been far too long. So I've got today off, and I'm warm in bed with lots of coffee and the kitties. I had just gotten back into town from a primary care rotation in Chicago and decided to stop in on a small gathering of friends. I walked up behind a friend I hadn't seen in months and gave her a hug, and she suddenly went completely limp. I wasn't expecting it, so I'm sorry to say I didn't control her fall as well as I should have, but I managed to prevent her from hitting her head. We're still not sure if it was the corset she was wearing, or locking her knees, or a combination of both, but she just passed out for a second. Her corset was really tightly laced. Luckily my handy instrument pack Ross gave us when we transitioned from 7th semester to clinics was in my purse, and I used my hemostats to get the laces undone. I checked her pulse rate and quality, and she was fine. Paramedics showed up and got a blood pressure and pulse ox reading. She declined to go to the hospital. Anyway... Interesting night, definitely. I never expected to undress a woman in public with medical instruments, but hey! Life is full of surprises.

So, yeah. My primary care rotation was at Furnetic. Great clinic, lots of awesome people. It definitely helped me realize what really gets me excited about general practice and what leaves me feeling a little bored. I really love surgery. The one day I spent all day in the OR with animals rotating on and off the table was my favorite. Diagnostics are also super fun. Putting together a puzzle and knowing how to help an animal is such a great feeling.

I got my first negative evaluation in clinics so far from orthopedic surgery. I passed, but it was pretty harsh. Part of that was earned, but part of it I feel really wasn't. But, oh well. Orthopedics is and always has been by far my least favorite subject. My heart wasn't really in the rotation from the get-go, and having it for three weeks instead of the usual two (hooray for the holidays!), as well as the timing right after I took the NAVLE and was experiencing a bit of a depression funk, pretty much ensured that I was miserable the entire time. I'm sure that influenced my usual level of participation.

Speaking of NAVLE, we've all heard that we're getting scores back this week. I'm impatient and just want to rip the bandaid off. I've never been very good at waiting for potentially bad news. Fingers crossed I won't be retaking it in April!