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.
A Ross vet student blog.
Tuesday, October 15, 2013
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.
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.
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.
Sunday, September 29, 2013
Amazeballs.
I'm sure at some point in vet school everyone has a case that just takes them on an emotional rollercoaster, makes them exhausted and grumpy at times, and elated and walking on clouds at others. I just had my first one.
On Tuesday at around 3:30pm we got a call that a 4-day-old downer calf was coming in. When he arrived he was "flat out" meaning on his side, unresponsive, kind of comatose but awake. The history I got from the owner was that the calf had been at the teat constantly, and crying through the night. It sounded like he wasn't getting enough to eat. My top differential was failure of passive transfer. Either mom wasn't producing enough milk or her teats were blocked or something was causing this calf to not get enough colostrum in his first day of life and he wound up immune compromised.
His serum total protein was 5.0g/dL, which was a good indicator of inadequate maternal immunity transfer. A value of 5.5 or above indicates adequate transfer. Normal serum total protein is around 7.0 with half being albumin and half being globulin (antibodies). 5.0 - 3.5 = 1.5. So he got something, just not enough. Unfortunately his blood glucose was 38 and he had a fever of 103.7. So that steered my differentials away from purely failure of passive transfer and into FPT and a secondary septicemia. He had an expiratory grunt and when I listened to his lung sounds they were harsh on expiration, leading me to believe he had a lung infection. We stuck an ultrasound probe on his chest and saw thickening of his pleural membranes and some consolidation.
So at that point my problem list was:
- Hypoproteinemia
- Hypoglycemia
- High lactate (4.9 yikes!)
- pleuritis
- dull mentation/weakness/ataxia
We gave him a fluid bolus of 1L of saline and then started him on an 8% dextrose drip to help with the lactate and hypoglycemia. We gave him some anti-inflammatories and antibiotics for the infection. And we gave him a unit of plasma for the low protein and lowered immunity.
Over the next two days he got a little bit better, started drinking from a bottle again. Then on Friday he crashed and burned. We'd corrected his lactate and his glucose, both were within normal range again. But his ataxia suddenly got worse, his mentation plummeted, and he started head pressing. So what had originally been our secondary neurological signs became suspected primary. We did a CSF tap and sent it to clinical pathology. I was sitting in the breakroom typing my SOAP when I saw the clin path people walking down the hallway toward the in house large animal ward and I thought, "Oh no..." Because clin path people don't belong down there. They stay in their offices and lab upstairs. If they came down for this, it's bad. I ran out the door to catch up with them.
Sure enough, Dr. Russell greeted me with a print out and he said, "This should make your skin crawl." The protein in his cerebrospinal fluid was 5.2g/dL. That's higher than in his blood. Normal CSF has a total protein of around 0.5g/dL. The total white cell count was 113,000/mL. Normal is 10-20/mL. Translation: Calf has an infection in his brain. The fluid was analyzed and showed high numbers of intracellular and free short, thick rods. So we added bacterial meningitis to the problem list.
We switched his antibiotic, since clearly the first one was not working, and over the next 48 hours changed his fluid rate, dextrose concentration, and fluid type half a dozen times based on seesawing blood work results. We added a nasogastric tube and feedings every 4 hours. And we also administered mannitol three times, which has to be given slowly over a period of hours and the patient has to be monitored the entire time for respiratory distress because if it's given too fast it can cause pulmonary edema. Basically, I lived at the clinic Friday and Saturday. And Saturday I was on call for ambulatory service and had to go on three farm calls as well as keeping up with his treatments. Thankfully another Rossie was on RAHMs with me who was helping me out with the calf when I was away on a call.
It was very touch and go, but then I got news that he had finally passed some feces. I came in and he was standing, alert, and hungry! He sucked down a bottle last night on his own and again three times for the overnight students. He ate very well this morning and is much more "with it" mentally. Things are looking very optimistic for him.
This is the first time I have personally been responsible for the care of a patient who has gone from completely unresponsive and mere hours from death, to making a full recovery (almost there, give it another couple of days). I did that. And it feels incredible. Pulling 12-14 hour days five days in a row, sitting in a stall with a comatose calf for hours at a time, not seeing sunlight because I'm there before it comes up and leave after it goes down.
When I was serving tables as a waitress, if I had a long night or a bad night, I hated the world. I was miserable. Even at my most exhausted and sore and disappointed this week, I was never in a foul mood. I guess that's how you know you're in the right field.
On Tuesday at around 3:30pm we got a call that a 4-day-old downer calf was coming in. When he arrived he was "flat out" meaning on his side, unresponsive, kind of comatose but awake. The history I got from the owner was that the calf had been at the teat constantly, and crying through the night. It sounded like he wasn't getting enough to eat. My top differential was failure of passive transfer. Either mom wasn't producing enough milk or her teats were blocked or something was causing this calf to not get enough colostrum in his first day of life and he wound up immune compromised.
His serum total protein was 5.0g/dL, which was a good indicator of inadequate maternal immunity transfer. A value of 5.5 or above indicates adequate transfer. Normal serum total protein is around 7.0 with half being albumin and half being globulin (antibodies). 5.0 - 3.5 = 1.5. So he got something, just not enough. Unfortunately his blood glucose was 38 and he had a fever of 103.7. So that steered my differentials away from purely failure of passive transfer and into FPT and a secondary septicemia. He had an expiratory grunt and when I listened to his lung sounds they were harsh on expiration, leading me to believe he had a lung infection. We stuck an ultrasound probe on his chest and saw thickening of his pleural membranes and some consolidation.
So at that point my problem list was:
- Hypoproteinemia
- Hypoglycemia
- High lactate (4.9 yikes!)
- pleuritis
- dull mentation/weakness/ataxia
We gave him a fluid bolus of 1L of saline and then started him on an 8% dextrose drip to help with the lactate and hypoglycemia. We gave him some anti-inflammatories and antibiotics for the infection. And we gave him a unit of plasma for the low protein and lowered immunity.
Over the next two days he got a little bit better, started drinking from a bottle again. Then on Friday he crashed and burned. We'd corrected his lactate and his glucose, both were within normal range again. But his ataxia suddenly got worse, his mentation plummeted, and he started head pressing. So what had originally been our secondary neurological signs became suspected primary. We did a CSF tap and sent it to clinical pathology. I was sitting in the breakroom typing my SOAP when I saw the clin path people walking down the hallway toward the in house large animal ward and I thought, "Oh no..." Because clin path people don't belong down there. They stay in their offices and lab upstairs. If they came down for this, it's bad. I ran out the door to catch up with them.
Sure enough, Dr. Russell greeted me with a print out and he said, "This should make your skin crawl." The protein in his cerebrospinal fluid was 5.2g/dL. That's higher than in his blood. Normal CSF has a total protein of around 0.5g/dL. The total white cell count was 113,000/mL. Normal is 10-20/mL. Translation: Calf has an infection in his brain. The fluid was analyzed and showed high numbers of intracellular and free short, thick rods. So we added bacterial meningitis to the problem list.
We switched his antibiotic, since clearly the first one was not working, and over the next 48 hours changed his fluid rate, dextrose concentration, and fluid type half a dozen times based on seesawing blood work results. We added a nasogastric tube and feedings every 4 hours. And we also administered mannitol three times, which has to be given slowly over a period of hours and the patient has to be monitored the entire time for respiratory distress because if it's given too fast it can cause pulmonary edema. Basically, I lived at the clinic Friday and Saturday. And Saturday I was on call for ambulatory service and had to go on three farm calls as well as keeping up with his treatments. Thankfully another Rossie was on RAHMs with me who was helping me out with the calf when I was away on a call.
It was very touch and go, but then I got news that he had finally passed some feces. I came in and he was standing, alert, and hungry! He sucked down a bottle last night on his own and again three times for the overnight students. He ate very well this morning and is much more "with it" mentally. Things are looking very optimistic for him.
This is the first time I have personally been responsible for the care of a patient who has gone from completely unresponsive and mere hours from death, to making a full recovery (almost there, give it another couple of days). I did that. And it feels incredible. Pulling 12-14 hour days five days in a row, sitting in a stall with a comatose calf for hours at a time, not seeing sunlight because I'm there before it comes up and leave after it goes down.
When I was serving tables as a waitress, if I had a long night or a bad night, I hated the world. I was miserable. Even at my most exhausted and sore and disappointed this week, I was never in a foul mood. I guess that's how you know you're in the right field.
Tuesday, September 24, 2013
NAVLE.
My exam is scheduled. Tuesday, December 10th at 8am I'll be taking my veterinary licensing exam. I pretty much want to vomit.
Saturday, September 21, 2013
Making a decision.
These past two weeks I've been on lab animal rotation. And I have to admit, I was bored stiff most of the time. The sad part is, I was following around an actual, board-certified vet the entire time, so it's not as though my experience wasn't an accurate reflection of what her day to day is like. And her day to day is spending most of her time behind a desk, or in meetings. Clinically, there was very little going on.
I think this has solidified in my mind what path I want my career to take. And it kind of breaks my heart a little. For the last four years, I've had my mind set on a career in lab animal medicine. And the primary drive for that was because I care deeply about rodents used in lab animal medicine, and want to make beneficial changes in their housing and care. And let's face it, there just aren't that many people who deeply, genuinely care about mice and rats. Being one of those people, I feel a responsibility to go into LAM.
Unfortunately, I no longer think it would make me very happy. I love the hands on stuff. Surgery, especially. And you just don't get to do that much surgery as a lab animal vet. Or many treatments, for that matter. The researcher does most of their own surgeries, and the technicians do most of the treatments. I would hate being stuck behind a mountain of paperwork, and in meetings, all day, every day, with very little practical work with the animals.
The thing that sucks is that while a boarded lab animal vet can hope to make anywhere from $90-120K, an average small animal vet makes about half of that. The hit in salary is a hard pill to swallow. Also, the knowledge that my professional life will be harder in private practice. Clients will get angry at me, they'll be heartbroken when I can't save their pet, I'll be heartbroken when I can't save their pet. Emotionally, the toll private practice will take on me will be much, much worse. The hours will be longer and less predictable. All in all, private practice is a less cushy, comfortable job than lab animal, any way you slice it.
But I can't ignore my gut. And these last two weeks my gut has been telling me, "This is awful. You'd be bored, frustrated, and miserable. You're itching to get your hands on an animal after two WEEKS. Imagine two years. Or twenty."
So I think I'm going to pursue small animal private practice. Which terrifies me, to be honest. Changing my plans in such a huge way, the financial hit, the unpredictability and drama of private practice. It scares me to be leaving my comfy lab animal bubble. And there's a part of me that feels like I'm betraying and turning my back on the rodents that need me to be their advocate, and that hurts a lot. But I think I'll be happier in the end.
I think this has solidified in my mind what path I want my career to take. And it kind of breaks my heart a little. For the last four years, I've had my mind set on a career in lab animal medicine. And the primary drive for that was because I care deeply about rodents used in lab animal medicine, and want to make beneficial changes in their housing and care. And let's face it, there just aren't that many people who deeply, genuinely care about mice and rats. Being one of those people, I feel a responsibility to go into LAM.
Unfortunately, I no longer think it would make me very happy. I love the hands on stuff. Surgery, especially. And you just don't get to do that much surgery as a lab animal vet. Or many treatments, for that matter. The researcher does most of their own surgeries, and the technicians do most of the treatments. I would hate being stuck behind a mountain of paperwork, and in meetings, all day, every day, with very little practical work with the animals.
The thing that sucks is that while a boarded lab animal vet can hope to make anywhere from $90-120K, an average small animal vet makes about half of that. The hit in salary is a hard pill to swallow. Also, the knowledge that my professional life will be harder in private practice. Clients will get angry at me, they'll be heartbroken when I can't save their pet, I'll be heartbroken when I can't save their pet. Emotionally, the toll private practice will take on me will be much, much worse. The hours will be longer and less predictable. All in all, private practice is a less cushy, comfortable job than lab animal, any way you slice it.
But I can't ignore my gut. And these last two weeks my gut has been telling me, "This is awful. You'd be bored, frustrated, and miserable. You're itching to get your hands on an animal after two WEEKS. Imagine two years. Or twenty."
So I think I'm going to pursue small animal private practice. Which terrifies me, to be honest. Changing my plans in such a huge way, the financial hit, the unpredictability and drama of private practice. It scares me to be leaving my comfy lab animal bubble. And there's a part of me that feels like I'm betraying and turning my back on the rodents that need me to be their advocate, and that hurts a lot. But I think I'll be happier in the end.
Monday, September 16, 2013
Left my heart...
Lately I feel more and more like a child of two worlds.
The weather is getting cooler here in Illinois. Fall is almost here and I'm loving it. I grew up in the midwest, and autumn is absolutely my favorite season. I can't describe the perfection of a beautiful fall day to someone who grew up somewhere without a true autumn season. The sun is warm, but the breeze is crisp and cold and makes your cheeks pink. The sunlight filtering through leaves so brightly jewel-colored red, orange and yellow makes you feel like you're standing in a kaleidoscope. The air smells like woodsmoke and baking spices. It's been my own personal Nirvana since I was a kid.
Then I moved to St. Kitts. At first I hated the heat and humidity, but soon I grew accustomed to it. I fell in love with the coqui frogs at night, and the serenity I felt floating face down watching brightly colored fish darting around me. Now when someone still at Ross posts a photo of themselves on the beach, I feel a pang of longing to be there. I miss the ocean and eating barbecue chicken with my feet buried in the sand. I miss my friends. The island got under my skin in a big, bad way and I miss it so, so much at times.
The weather is getting cooler here in Illinois. Fall is almost here and I'm loving it. I grew up in the midwest, and autumn is absolutely my favorite season. I can't describe the perfection of a beautiful fall day to someone who grew up somewhere without a true autumn season. The sun is warm, but the breeze is crisp and cold and makes your cheeks pink. The sunlight filtering through leaves so brightly jewel-colored red, orange and yellow makes you feel like you're standing in a kaleidoscope. The air smells like woodsmoke and baking spices. It's been my own personal Nirvana since I was a kid.
Then I moved to St. Kitts. At first I hated the heat and humidity, but soon I grew accustomed to it. I fell in love with the coqui frogs at night, and the serenity I felt floating face down watching brightly colored fish darting around me. Now when someone still at Ross posts a photo of themselves on the beach, I feel a pang of longing to be there. I miss the ocean and eating barbecue chicken with my feet buried in the sand. I miss my friends. The island got under my skin in a big, bad way and I miss it so, so much at times.
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