Sunday, August 26, 2012

Know When To Keep Your Mouth Shut

OK, I needed to write something irreverent to make up for all the deep thoughts I’ve been having lately.  This is a tale of the occupational hazards that accompany my profession…I have been limited as to how much information I can give when I’m at school because of client confidentiality issues.  Many of my patients have singular personalities and diseases, to where it would not be difficult for anyone loosely associated with the institution to pick out who I’m telling tales on, but this one is pretty generic, and names are withheld to protect the guilty. 

I was on necropsy duty recently. (For any naïve to the ways of veterinary medicine, this is like an autopsy for an animal.  We take apart the dead things and see what made them stop ticking.)  On the table was a horse that had colicked and died.  He hadn’t been dead long, but due to the nature of his illness he was bloated up like a giant, hairy balloon.  We wear a lot of gear on the necropsy floor; coveralls, rubber boots, long latex gloves, safety glasses, and thick cotton “cut” gloves to protect your non-knife-wielding hand is the minimum.  Things get more complicated when there is a potential zoonotic disease case, but colic is generally pretty safe for the bipeds in the room so we were in basic gear.  I made the first few cuts, then began the ticklish procedure of opening the abdomen.  Why is this the ticklish part, you ask?  Because when a horse is bloated, it is easier than ever to pierce a pressurized piece of gut, which results in rapid deflation accompanied by a projectile rush of fetid air, rank fluid, and partially fermented feed material.  I went at this horse like a bomb squad rookie, enduring mild ridicule from the duty clinician for taking so long to get the abdomen open.  I didn’t keep track of time, but I’d estimate I took around 20 minutes to carefully slice through the various abdominal muscle layers to reveal the shining, fragile peritoneal membrane.  Once there, I still had to make final landing, so I tried the old trick of “tenting” the peritoneum with a pair of forceps to lift it gently away from the pressurized intestines clamoring for exit just below the surface.  Tenting was a no go, the membrane was already stretched to the limit.  After making sure my safety glasses were in place and my mouth was closed, I tickled the peritoneum with my eight-inch necropsy blade as the rest of the crew stood at a safe distance, offering “encouragement.”  The membrane parted like an electronic gate and an unviolated loop of small intestine crowded out of the newly made opening.  Now, I could safety up and use the metal bar of my forceps as a stop as I finished removing the muscular wall.  Success!  I had opened the abdomen and I was not covered in intestinal schmoo! 

Once the abdomen has been laid open, the next step is to lift the back edge of the rib cage and stick a knife through the diaphragm, checking to make sure that the thoracic cavity was still at negative pressure and opening the way to come in with the long-handled rib crackers in order to remove the rib cage and allow full access to the lungs and heart.  The duty clinician stepped forward to make entry into the thoracic cavity as I stood nearby with the giant metal yard implement, ready to clip some ribs.  My mentor lifted the back of the rib cage and made a quick stab into the diaphragm.  Suddenly, I was hit with a rush of not-so-fresh air and a light baptism of green-flecked material.  The view from behind my safety glasses was…well, gritty.  Thankfully my mouth had been compulsively clamped shut as the knife made its arc.  The clinician looked at my shocked expression and said, “That was just the thoracic cavity.”  Ummm, well, ok.  I guess having green chunks in the thoracic cavity would help explain why this horse had died, but if the diaphragm had a hole in it, and the gut also had a hole allowing feed material to escape, wouldn’t that have released some of the pressure before we started opening cavities?  Upon closer inspection, we discovered a tiny, clean (read: made by a sharp blade and not by overwhelming pressure from inside) slit in a section of the large colon that was up by where the ribs connects to the spine, where it does not belong.  Welcome to veterinary medicine, where keeping your mouth shut is almost never a bad decision.

Wednesday, August 22, 2012

Sometimes, Death Pisses Me Off

I try to keep this blog on a positive note, even with the twisted nature of the profession I've chosen I can usually find at least some dark humor in things, but today has been a hard day.  We're coming up on exactly one year since Big Man died, we're at six months since losing my friend Brent to cancer, and working on the third month since another friend took his own life.  I've always had a temper, but I've been struggling with irrational rage over this suicide.  He and I had been friends since I was in high school.  He was actually my first boyfriend.  We only dated a few months, but we stayed in touch afterward, I was just young and didn't want to be tied to anyone.  I'm not the best about staying in touch, but we generally got together once or twice a year and talked on the phone once in a while in between, which is doing pretty good considering I've lived in a different time zone since I graduated from high school.  He was a hard-luck case, struggling through life, often due to poor choices and too much beer.  It could just as easily been me if I hadn't gotten a good college scholarship and had some other lucky breaks.  Rationally, I know that there isn't anything I could have done to save my friend...but the irrational part of my mind is unrelenting. 

One part of my mind is angry that I didn't stay in closer touch with him.  It had been nearly a year since we had talked.  Another friend actually talked to him the night of the suicide, though, and had no indication of what was coming.  I know that my opinion still held some sway on my friend, and if I had known the hell he must have been in, with alcohol and hopelessness, I could have pushed him on through the low parts.

Another part of my mind is absolutely furious with him for choosing this route.  I want to physically shake him and curse him for leaving us.  I want to tell him that he was acting like an emotional teenager.  I want to tell him to grow the hell up and be there for the people who need him in their lives.  Through the course of our friendship, we both did stupid things.  I thought he knew that I was always going to be a friend to him, whatever he had done or needed.  We lose enough good people too early due to accidents and illness, checking out the way he did was absolute bullshit.  I won't say there wasn't a time that I considered suicide, but my good friends got me to the other side and helped me see that I could survive anything if I just kept moving.

I guess if I were into pop psychology, I would say that I lack closure over my friend's death.  I received the news over the phone the morning after it happened and it was like a punch in the gut.  I never got a chance to say goodbye or tell him he was being stupid.  The other recent deaths I've dealt with aren't easy, but at least they both knew things were winding down.  They had done what they could to put it off, they were simply out of options.  Their family and friends were as prepared as you can ever be to have a piece of your life ripped out.  It's just the abject wastefulness of losing my friend to a self-inflicted gunshot that pisses me off. 

Tuesday, June 26, 2012

Extern-a-palooza 2012

Four more days until I get to shower in my own (well, my own rented) shower and sleep in my own (also rented) bed again.  I left home 3.5 weeks ago and have been on a wandering odyssey filled with horses, veterinarians, veterinary technicians, veterinary students, chiggers, baby racoons, a small hawk, a Mississippi Kite (the original Angry Bird), bucking horses (a different and vastly superior sort of equine), Mexican gangsters, clones, strippers, wanna-be bikers who think it's ok to hit on me, and assorted small mammals.  I have slept on eight different beds or bed-like surfaces during this time.  My truck is currently 500 miles overdue for an oil change and the state inspection expires in five days, though I believe there is technically an additional five day grace period after the actual expiration.  I am a nine-hour drive away from home and I will be making the return trip with 12 lbs of Miniature Australian Shepherd/hummingbird on crank mix dog.  I'm not sure anyone will survive, least of all, me.  Several articles of clothing have been lost to permanent green "recip mare on alfalfa diet" staining, and I am convinced that several gallons of panhandle dirt have worked their way deep into my pores and entered my bloodstream.  On the whole, it's been a fantastic road trip.

Saturday, May 5, 2012

The Final Finals, Part 2

Tuesday, D-Day #2, 0618—Have already been studying so long this morning I’m thinking it would be fun to theme a foal crop’s names based on random diseases…”Pelvic Pyelectasia” “Hydronephrosis” “Calcinosis Cutis” “Macrocantharynchus Hyarudinaceus” “Hydatid Cyst” “Lymphosarcoma” “Renal Adenocarcinoma”

0826—Just colored on my iPad screen with a Sharpie highlighter.  1 hour and 34 minutes until the ultimate radiology smackdown.  Fueled by a low carb Monster energy drink, smoked almonds, Skittles, and a cup of coffee.

1112—Find empty couch on 3rd floor of vet school and settle in to do reading/homework for my afternoon class. (“What?!” you ask, indignantly.  “Class AND homework DURING finals??”)  (“Yes,” I reply,  “because vet school blows.  And just when you think it can’t get any worse, it does.  That’s what vet school is.  Just one ‘Worst Day of Your Life’ after another.  For four years.  And then you owe the government a lot of money.”)  It wasn’t done earlier because it was sent to us yesterday, and I kinda had a few other things come up. 

1532—Came home, dispensed veterinary advice, cleaned the grey kitten’s eyes again, fed my horse, watched the kittens hiss and spit at the dog while he looked puzzled and wagged his tail, collapsed into bed.

1755—Microwave pizza and Golden Girls reruns.  Only one more final, and it is of the “take-home” variety.

2245—Stupid rebound insomnia.

Wednesday, 0832—Finals hang-over.  It’s like a drinking binge, without the good times.  Staying close to the couch and taking all the OTC cold medicine I have in the house.

1230—Feeling mildly improved, time to go to class.  Pick up last final exam, spend two hours talking about horse penises, and two hours talking about cattle who have eaten things they shouldn’t.  Highlight of the day is walking between classes, come upon a technician pushing a cart down the hallway with a bloody garbage bag on it.  After exchanging greetings, he quips “I’m the only school employee who actually gets a head.”  (Yep, read it again, you’ll get there…)  Ah, veterinary humor.

2129—Finally done with exams, just have to remember/manage to turn it in by 10 AM tomorrow.

Thursday, 0858—Turned in exam, turned in time sheet for work, back at home to play with kittens and get dressed up for make-believe time (aka, communication training).

1800—Made it through communication play-time, got a few hours at work, arrived at home feeling like I had been drug through a knothole backwards.  My throat is revolting, and the rest of my body is threatening to join the overthrow.  Begin self-induced Nyquil coma.

Saturday, 2146--Finally able to stand up without vertigo.  One more day before 4th year clinics start.  Have yet to start on the giant to-do list I had hoped to knock out, and have backed out of all plans for fun with friends.  Ugh.  "It will all be worth it someday," right?

The Final Finals, Part 1

Since this is my last set of real, classroom, lecture-style final exams, I decided it might be entertaining to keep a journal of the thoughts and events that carried me through this twisted week.  This semester was a fairly easy one in terms of final exams, with only two "real" exams.  I'll split it up into a couple of entries so it doesn't get prohibitively long.

Sunday, Finals Eve, 2350—Have begun “triage studying” after getting through all oncology learning objectives, approximately 1/3 of neurology notes, and absolutely nothing on feline respiratory diseases.  Neurology information was divided up by a “star” system by the professor, with * meaning just know the basics, ** meaning know “some” detail, and *** meaning know in depth.  Realize I will be doing good to know *** information at * level.  Crap.  The dog is wandering around the apartment snapping at flies with a crazed look in his eyes.  Decide to get through 10 more pages of neurology notes before bed.

Monday, D-Day #1, 0635—Got up, ate a protein bar, made coffee, let the dog out, fed the barn cat and cleaned the grey kitten’s eyes out.  Convince myself that this counts as studying feline respiratory diseases since I’m pretty sure the kittens have feline herpesvirus.  Congratulate self on multitasking skills.  Continue panic-driven flight through neurology notes.

0823—Finally done with first pass through neurology notes.  Unfortunately, my brain is like a liver with knowledge and there is significant first-pass metabolism of facts which are then lost until readministration.  Begin working on neurology review questions, with a heartfelt prayer that they will be repeated verbatim on the exam.

0942—Consuming mid-morning snack of a peanut butter sandwich and a cappuccino.  My stomach is threatening mutiny.  I believe the pancreas is behind this, not because it makes physiologic sense, but simply because the pancreas is not to be trusted.  Barenaked Ladies are singing “Who Needs Sleep?” on iTunes DJ.  Touché, iTunes, touché.

1103—Have finally gotten through all of the material for today’s exam one time.  Realize I haven’t paid my auto insurance this month and it’s due today.  Crap.  Find bill, write check.  Debate whether to mail it and let it get there a day late or try to make it to their office before exam time.  Decide it won’t be the first or last time I’ve paid a day late, and studying while driving is dangerous.  1 hour and 57 minutes until exam time.

1149—Took the dog outside, sat down near barn to go over neuro notes while he stretched his legs.  Now my notes have goat teeth marks on them.  Time to forage for food and top up my caffeine levels.  Cheez Its are awesome.

1153—Swearing at an apparently child-proof Lunchable package.

1156—The cheese in this Lunchable does. Not. Taste. Right.  Crackers and chopped formed turkey miscellanea it is, then.

1158—Hmmmm, yogurt does not taste right either, and is suspiciously runny.  Check fridge.  It is running but is an unexpectedly tepid environment.  Enter thoughts of foodborne pathogens multiplying logarithmically in my food supply.  Move this to bottom of current concerns list and return to last-ditch study effort.

1708—Went to school and completed small animal medicine final, then sat in computer lab for a couple of hours watching abdominal ultrasound videos.  Stopped by the store on the way home to restock on energy drinks and had the brilliant idea of getting the dog some dental chews so that he would not be staring me down and/or playing with his insanely loud squeaky football while I was studying.  Mentally patted myself of the back for my exceptional forethought and consideration for my pet.  Arrived home, fed the horse, retrieved the dog from his outdoor pen, fed the cat, cleaned the grey kitten’s eyes again, went into the house and triumphantly handed the dog a dental chew before sitting down to start studying for the comprehensive radiology final.  Dog smiles and settles into his dog bed to work on the chew.

1712—Dog stands up, gives me an alarmed look, and regurgitates partially digested dental chew all over the floor…and I mean ALL over, in a voluminous puddle of tan frothy sliminess.  Clean up vomit.  Reluctantly hand dog his loud squeaky football.  Remind myself that I love this dog and do not wish him harm.

2022—I have all the focus and clarity of a rabid squirrel in a washing machine that has just hit the spin cycle with an unbalanced load.

2215—I give up.  Must sleep.

Tuesday, March 27, 2012

Stock Tips from the Dark Side

Products I wish I’d bought stock in before starting vet school:

5 Hour Energy & Clif Builder’s Bars:  I hoard these in my backpack like a crazed squirrel.  According to my research, which, admittedly and in an ironic parallel to my life, lacked a control sample; a person can survive for at least three days with little else for sustenance.  Don’t worry, your gut will learn to handle hydrolyzed-iso-whey-soya protein after a while.  One note of caution, when the 5 Hour Energy label says “Do not consume more than 3 shots in 24 hours,” they mean that.  Overdose can cause that crazed squirrel comparison to apply to more than your packing tendencies.

Shout stain remover:  Removes donkey blood, diarrhea from pyometra cows, pyo from pyometra cows, clingy boyfriends, equine dental schmoo, and granuloma fallout.  I’m convinced that this stuff could cure herpes.  If I didn’t have a steady supply, my clothes would become disposable items.

Ibuprofen:  Well yeah, I used a lot of this before vet school.  There is some opportunity cost associated with working with horses and cattle.  Vet school has expanded my love for ibuprofen, as it now applies to stress cramps in my back brought on by 12-hour bulimic study marathons, stress headaches brought on by listening to small animal internists explain the intricacies of the endocrine system…again…and stress fractures brought on by the miles I need to run to make the pain in my head go away.

Omeprazole:  To prevent the NSAID-induced gastric ulcers caused by existing on a diet of Clif Bars, 5 Hour Energy, and ibuprofen in conjunction with having the endogenous cortisol levels of a geriatric Cushingoid lab rat in a shock therapy trial.

McDonald’s:  I really, really don’t care for their food, but it’s the fast food joint that is closest to my house.  Lack of time to cook and wash dishes lead me to the golden arches more times in a given week than I care to think about.  Compared to protein bars, it almost seems like real food.

Rawhide chews:  These have taken over for actually spending time with my dog.  They are like guilt balm.  If he’s busy alternating between trying to swallow one of these whole, and trying to hork it back up again, I don’t have to feel so bad about not playing fetch with him for two hours a night, right?

Well, there it is.  
**Disclaimer:  Taking stock tips from a crazed-squirrel-shock-therapy-rat who barely manages to maintain the life skills required to go out in public is probably not an ideal strategy.  I will, however, expect a commission on any gains you make.  I just got a new box of omeprazole and I'd like to be able to afford some super-size fries to go with it.

Friday, February 3, 2012

I Thought I Selected "LARGE" Animal

I'm going to try not to let this turn into a bitter late night rant, but I make no guarantees...

Almost three years ago, I was accepted into veterinary school.  This was the result of several years of planning and sacrifice on my part, some blind luck, and the support of some very good people.  I knew it was going to be a long road.  Now, as a 3rd year student, I am trying very hard not to become an angry burnout.  In my application and interview, I passionately stated the reasons why I wanted to be a large animal veterinarian.  I think that this may have helped garner my acceptance, as this was around the time that the great "large animal veterinarian shortage" controversy was in full swing.  More evidence has come to light since then, and I am in the camp that believes that the "shortage" is not due to a lack of qualified young veterinarians, but more a sign of the times in which we live.  Rural areas are being encroached on and hobby farmers are replacing true ranching businesses.  A rural large animal veterinarian has to work long and hard to survive.  Most of my classmates want an 8-5 job, weekends off, and minimal emergency duty.  Few of them are comfortable around livestock.  I've accepted the fact that I'm in the minority.  I've worked in the industry long enough to know that I can do the work and that this is where I want to make my life.

Going into vet school, I was aware that a significant amount of the curriculum would be oriented around small animal medicine.  I wasn't thrilled about it, but I figured I could suck it up and go along until I could finally declare my large animal track and spend the majority of my time focused on what interests me.  This semester, which is my last semester in the classroom, more than half of my courseload is still focused on small animals.  My small animal track classmates have no specified large animal courses that they have to take now.  Our fourth year schedules came out today and I snuck a peek at what some of my small animal focused classmates had...they have two rotations, that is, four weeks, of large animal rotations.  I have four rotations (eight weeks) of small animal specific clinic work, and two more rotations that will be more than half small animal focus.  My two weeks of mandatory emergency duty?  Entirely in the small animal clinic.  I realize that the vet school is not a customer service oriented organization, but I'm dropping over $15K every year for an education, and they refuse to teach me what I need to learn.  Additionally, our anemic amount of externship time will barely allow me to visit even just the clinics I'm considering applying for internship with, and this includes spending all my break and vacation time working.  The CVM is actually hindering my education and career options.  Why do they even have a large animal track option when it's really a mixed animal track?  It's no wonder that it's nearly impossible to keep a large animal veterinarian in a rural community.  Expanding class sizes and flooding the market with small and mixed animal veterinarians is not the solution.

Wednesday, January 25, 2012

Late Instruction

In usual vet school style, I had to attend "communications training" today.  This pattern of being put to the test, then receiving instruction has become the norm over the past few years.  Of course, the scenarios we went through today were different than most of what I have faced in real life.  The "clients" were actors, and the "patients" were stuffed dogs and cats.  Unless you've ever tried to interact with a live client and a stuffed patient, you don't realize how much we, as veterinarians, rely on the animal to connect to the person attached to it.  The first setup we worked on was with a client who had just obtained a new dog after the death of her father.  During our feedback session, one of the suggestions our instructor made was to ask about the father...his name, how he died, etc.  I know that this is just my personality talking, but I would have shut down anyone asking about Big Man that soon after he died.  Unless you knew him, you couldn't understand.  The only reason I told anyone at school what was going on was because I knew I was acting like a basket case and didn't want them to think I had gone around the bend for no reason.  I know different people react differently, and some people like to talk about their troubles, but I don't think I'll ever be the veterinarian who asks about your dead relatives unless I knew them too.

The day wasn't all annoyance, though.  Highlights included trying to keep a straight face while a teenaged actor played the role of an overweight client (with the help of a few extra stuffed animals under his jacket) with a heavy foreign accent, and hearing one of my classmates use the phrase, "Well we can try a behavior-modifying drug like Zantac..." when on the spot and trying to find the word "Xanax."  Yeah, vet student humor.  We find strange things hilarious.

Thursday, January 5, 2012

Client Communication...In the Trenches!

The past couple of weeks have been outstanding! I`ve been back at the equine clinic I worked for before I got into vet school doing my first "official" externship here. I know that I`m learning a lot in school, but I always feel like I absorb so much more from my mentors at the clinic. For one thing, it`s one-on-one (or sometimes three-on-one) interaction and I can`t hide behind somebody smart if I don`t know an answer. I`m expected to speak up and I`m mocked (somewhat gently) if I say something outlandish. After 10 minutes of intense grilling today...which included an "Explain your radiographic findings to this client and list the treatment options" with no notes to consult, a very vague history of the horse`s use and problems, a brief lameness exam in which I was jogging the horse so I could only estimate how he was moving by the sounds he made behind me, and an actual client that I had never spoken to sitting beside me looking at the radiographs...I have a better understanding of equine tarsal osteoarthritis than I did after months of classroom instruction and thousands of dollars in tuition money spent. I floundered for a while stammering through some doctor words that I`ve worked very hard to learn, only to be told "Now explain it in a way that he can understand exactly what is causing this horse to be sore and how we are going to fix it." I was stumped. I made some inadequate hand gestures, did some pointing at the x-rays, mumbled about joint spaces and bone spurs, and Dr. B finally took pity on the team roper client and summed things up with an analogy of twisting a stack of silver dollars. As long as the surface is smooth, they roll right over each other. If you whack the edge of one of them, creating a divot and a point, the point will grate on the dollar below it. Simple. Dr. B has been in equine practice since before I was born. He is a brilliant veterinarian and an excellent mentor, and most of his clients adore him. I`ve heard him explain things to clients before and have tried to learn from him, but I know that what I learned today will always stick with me. He is also a great teacher and lives to grill students. Even when I worked for him as a technician, he knew that I was working toward going to vet school and has done a lot to enhance my education. Now that I am a third-year, I am subject to full-force grilling and it is definitely effective! He is tough, and he will give me hell if I say something incorrect, but I know that he is doing it in hopes of making me a better, or at least adequate, veterinarian. I have somehow blindly managed to meet and work with some of the best equine veterinarians in the business. God`s hand has been guiding my career even when I am completely oblivious. I interviewed for a job with Dr. B when I barely knew what it took to become a veterinarian and was fortunate enough to make him believe that I could do it. Another tough client interaction scenario came up last week. I went out on an emergency farm call with one of the interns at the practice. The call was for a 2-year-old stallion that had fallen down in a pen and was unable to rise. When we got to the farm the horse had gotten up but one front leg hung useless. Further examination revealed all signs pointing to a fractured humerus, and likely a severed radial nerve. Fractured humeri are rare, especially for a young, healthy horse falling in a pen with relatively soft dirt, as this one had. The owners were distraught, but practical. We euthanized the horse. Our only other option would have been to try to stabilize the fracture, which was closed but already substantially displaced, and transport the horse to the clinic. The 45-minute trailer ride probably would have worsened the situation. Surgical fixation of the fracture would have been difficult, if not impossible, and recovery from anesthesia would have been dangerous. Even if surgery and recovery were successful, the road to healing would have been long and hard for this horse. I would never presume to judge someone`s decision in matters of euthanasia for their animals, but I definitely feel that these people made the right call in putting the horse down right away. A couple of days ago, I went with another veterinarian to where the owner works to do some routine health care of the horses he rides there. I found myself in a conversation with the owner about the horse we had put down. He wasn`t really questioning the decision, but he admitted that he was disheartened by the whole situation. I sympathized. Euthanasia is something I feel strongly about. I don`t think I would feel right doing it if it was something I took lightly. I believe in our role as caretakers for our animals we sometimes have to make the hard decision to end their suffering. I am proud that I can help to stop the pain, even if it is in essence admitting defeat. I don`t know if I was able to make this man feel any better about losing his horse, but I was able to honestly and wholeheartedly tell him that I agreed with his decision. I hope that meant something to him.