Tuesday, October 15, 2013

Go to sleep, little kitty!

I'm on anesthesia rotation right now. Ax scares the crap out of me. The drugs we use to induce and maintain anesthesia have some profound systemic effects. They slow the heart, drop blood pressure, make them stop breathing... It's scary. When you think about the fact that the Illinois teaching hospital is a referral hospital, and we don't get average, every day, healthy pets for the most part, but difficult, involved cases, often with multiple combined illnesses, it's terrifying.

Usually, an Ax protocol goes like this:

Premedication: This is to make the animal sedate and relieve anxiety before placing an IV catheter and and inducing anesthesia. Usually a combination of an alpha-2 agonist or benzodiazepine with an opioid.

Induction: After you've placed an IV catheter, you induce anesthesia with propofol, thiopental, alfaxalone, etc. These agents usually induce apnea (no breathing). You've got about a minute from the time you induce until you need to have an endotracheal tube in that animal so you can hook them up to oxygen and ventilate them if necessary. It can be very scary. Cats in particular are difficult to intubate, because their largyngeal muscles spasm with stimulation and can cause a dry choke where their airway closes and then you cannot get a tube in. We often use a lidocaine splash block on the arytenoids to desensitize them and then use a thin wire stylet to guide the ET tube to avoid that.

Maintenance: You can use a TIVA (total intravenous anesthesia) of a combination of drugs to maintain sedation, but more often we use inhalants. Inhalants like isofluorane are extremely cardiovascular depressive. They cause hypotension and bradycardia.

That's all pretty intense, in and of itself. If you also have a bunch of complications that make you have to be very selective in your choice of drugs, and have to add CRIs (constant rate infusions) intra-op to correct the things that the anesthetic causes (dopamine to improve blood pressure, diuretics to improve blood flow to the kidneys in renal failure patients, dextrose for hypoglycemic patients)... Shit gets complicated and intimidating.

Two of my anesthesias wound up being cancelled because it wasn't safe to anesthetize them. Both were very involved, with bad systemic illnesses, and I was scared. I'm glad they were cancelled, not just because it was very unsafe for them and likely could've killed them, but also because it was a relief that I didn't have to go through with it. I am very happy, though, that I spent a long time researching for each case, carefully putting together what I thought was the safest anesthetic protocol uniquely crafted to that patient, and each time the faculty or resident anesthesiologist barely altered it at all. And my protocols were REALLY involved. Each of them involved 2-4 premeds, a co-induction with propofol and fentanyl, and at least two intra-op CRIs. Both had hypotension concerns, so I needed to keep my inhalant down as low as possible while still keeping them under.

It's nice when a board-certified specialist looks at your work and says, "I'm happy with this. Tweak this a bit, lower the dose of that, and we're good to go." And those changes were based on experience with those drugs in the specific conditions my patients had that I don't possess yet. So I'm pretty pleased with my performance so far.

Saturday, October 5, 2013

Long distance vet.

Recently a friend of mine in Australia messaged me about a lump on his cat's jaw. He had an appointment with his regular vet in a few days, but he wanted my take on it. The cat was older, and a few differentials popped into my mind, some of them not very good. I asked a few questions that would help me narrow it down:

Where exactly is it located?
Is it hard or soft?
Can you move it around in the tissue, or is it fairly fixed in place?
Is there pain associated with it?

The answers did narrow down the possibilities, unfortunately not in a direction I liked. I had to tell my friend that I was highly suspicious that this was an aggressive form of cancer seen in older cats, particularly in the location he was describing on the mandible, called squamous cell carcinoma. I told him I really hoped I was wrong, as I had not seen the cat myself, but given the description that if I were to work up this case SCC would be at the top of the list.

It's really, really hard delivering that kind of news. Particularly when someone isn't expecting it. I knew my friend well enough to know that he wouldn't want me to bullshit him. He'd want the facts, no matter how hard they were to hear. So I warned him that this does not have a good prognosis, as even with the most aggressive treatment (surgery to remove part of the jaw, chemotherapy, radiation therapy), most of the time the cancer has already metastasized by the time it's detected and the cat will die within a few months.

Turns out that SCC was confirmed with more tests. My friend opted for palliative therapy with pain killers and soft foods to make her comfortable for as long as possible, until the other day when he had her humanely euthanized at home. He's since written me a couple of times thanking me for my help and support. I was kind of taken away by his gratitude, because from my perspective I hadn't done much other than deliver some really bad news. His vet was the one deciding course of treatment and administering those treatments to make his old girl feel better.

It's a reminder that in this career your bedside manner, empathy, and a shoulder to cry on are equally if not more important as your skills as a diagnostician and clinician.

Thursday, October 3, 2013

Graduation date.

For the last 3 years, we've all been looking forward to graduating in New York City. It seemed so glamorous, so romantic, so thrilling! We'd wear fancy clothes and pretend we're fancy New Yorkers for an evening. It made it more special somehow, for a lot of us.

Well, screw all that, because we're graduating in Florida. Hot, sweaty, sticky Florida. Graduation has been announced. We'll be graduating at the Bank United Center in Coral Gables, Florida on June 13th, 2014. No one in my class is happy, except perhaps the people who already live in Florida. The rest of us are bitching about frizzy hair, melting makeup, sweaty clothes, and the decidedly less glamorous location taking away from our romantic, multi-year-long fantasy of New York.

I'm happy to be graduating. I'm not happy about looking shiny in all of my graduation photos.