...and my week off comes to a close. seven days of relaxation are behind me, seven days of hard work before me. my best friend and brother-in-law spent the last 2 days with us. i saw the rest of jim's siblings today at a post-baby shower dinner (his sister is due to have her baby in about a month). it was wonderful to see family. i miss everyone so much. i think that's part of my sad feelings at work - when i want to get away from work and it's stresses - i don't have the support system here that i had in the old hometown. it makes everything harder. the week after this, i'm going back to my hometown (3.5 hours away) to see my parents and brothers. i'm looking forward to that immensely.
saturday was utterly leisurely. we went out on the lake and river on a pontoon boat belonging to my husband's little sister's in-laws. we swam in the perfect temperature water and enjoyed the gorgeous late summer day. afterwards, we played ladderball, sat around the campfire, ate weenies and s'mores, and chewed the fat. it was a lovely summer day....
tomorrow, i return to work bright and early (8am). it's a holiday, so i expect that we'll be slammed with business...*sigh* hopefully everyone will stay home, grill weenies, and drink beer in anticipation of the first football game of our season tomorrow night. i'm stoked about it. unfortunately, it starts at 8pm - and i'm scheduled to get off at 8pm. we all know what that means on a holiday night. i'll probably be leaving work around 9 or 1opm... **sniff** breaks my heart even more than the fact that i'll be working christmas day this year.
Sunday, August 31, 2008
Saturday, August 30, 2008
gah
i am such a night person. i have switched to days and ack! i just don't like getting up at 7am. i never will. it's always going to be anathema to me. daytime work is so different. i shadow and work with 2 internal medicine specialists. one of them is a professor/clinician from my alma mater - which is great. i love her dearly. the other internist is also fantabulous, albeit very soft-spoken. sometimes i feel like i need a hearing aid to figure out what the heck he's saying - but otherwise, he's great. very good at what he does.
days are a bit on the dull side. my job is to 1) follow around the internist and learn about case management and 2) manage patients that presented to the ER service the previous night and need to say in the hospital. those 2 things in and of themselves are not dull...but...the days have been slow. the only patient i've had to manage on today and yesterday is a post-op gastric dilatation and volvulus (stomach bloat and rotation = cut off blood supply. another day, another post).
oh - i had a true lepto case. i mentioned back a couple of posts my renal failure dog - the only bright spot in a bad 2 days. when he came in, he was very very sick and his kidney values were crappy (acute renal failure). he also had elevated liver enzymes. at the time, i highly suspected lepto. leptospirosis is a bacteria that is water-borne (ponds, rivers, creeks, the like). it's hard to diagnose for a variety of reasons. you can't test for antibodies very well because most dogs in the southeast have been exposed and have antibodies. a good analogy: if you were to be tested for antibodies to chicken pox right now, you would probably have them. but you don't have chicken pox at the moment. it's indication of prior infection or exposure. further, vaccines cause production of antibodies - and around here, we routinely vaccinate for lepto. one way to get around this is to do paired titers. take a sample now. if you get a high value - great. but that's not necessarily diagnostic. you treat the dog, and then you test again in about 2 weeks. if that number is dropping - then you probably had true infection before. there are other tests for lepto - PCR (polymerase chain reaction) and the like. all fraught with their own errors and problems.
so what do we do? we combine our clinical suspicion (acute renal failure, very sick outdoor dog, very high positive antibody test to lepto) and make a diagnosis. treatment is antibiotics, so even if we don't know for sure that lepto is the cause of a dog's acute renal failure, we always start lepto antibiotic therapy.
every dog that is admitted to the hospital with acute renal failure is put on "lepto watch". lepto is contagious to people (zoonotic) through urine contamination. thus, you have to be very careful with workers if you have even the slightest suspicion that lepto may be the inciting cause of kidney failure.
when i saw this dog - incredibly sick, incredibly dehydrated, in renal failure with elevated liver values, i immediately suspected him to be a true lepto.
i received my antibody tests back yesterday - and he had VERY high titers to a specific strain (serovar) of lepto. he actually had lepto. i had a real lepto dog! i had a moment of clinical genius and warned my coworkers when he was admitted that i thought he was a true lepto, not a "fake" lepto. it was a nice validation. i have developed some clinical judgement. finally:)
it makes up for the 150 ways every HOUR of the day i feel dumb and ill-prepared to be a doctor and like i will never, ever be good enough!
days are a bit on the dull side. my job is to 1) follow around the internist and learn about case management and 2) manage patients that presented to the ER service the previous night and need to say in the hospital. those 2 things in and of themselves are not dull...but...the days have been slow. the only patient i've had to manage on today and yesterday is a post-op gastric dilatation and volvulus (stomach bloat and rotation = cut off blood supply. another day, another post).
oh - i had a true lepto case. i mentioned back a couple of posts my renal failure dog - the only bright spot in a bad 2 days. when he came in, he was very very sick and his kidney values were crappy (acute renal failure). he also had elevated liver enzymes. at the time, i highly suspected lepto. leptospirosis is a bacteria that is water-borne (ponds, rivers, creeks, the like). it's hard to diagnose for a variety of reasons. you can't test for antibodies very well because most dogs in the southeast have been exposed and have antibodies. a good analogy: if you were to be tested for antibodies to chicken pox right now, you would probably have them. but you don't have chicken pox at the moment. it's indication of prior infection or exposure. further, vaccines cause production of antibodies - and around here, we routinely vaccinate for lepto. one way to get around this is to do paired titers. take a sample now. if you get a high value - great. but that's not necessarily diagnostic. you treat the dog, and then you test again in about 2 weeks. if that number is dropping - then you probably had true infection before. there are other tests for lepto - PCR (polymerase chain reaction) and the like. all fraught with their own errors and problems.
so what do we do? we combine our clinical suspicion (acute renal failure, very sick outdoor dog, very high positive antibody test to lepto) and make a diagnosis. treatment is antibiotics, so even if we don't know for sure that lepto is the cause of a dog's acute renal failure, we always start lepto antibiotic therapy.
every dog that is admitted to the hospital with acute renal failure is put on "lepto watch". lepto is contagious to people (zoonotic) through urine contamination. thus, you have to be very careful with workers if you have even the slightest suspicion that lepto may be the inciting cause of kidney failure.
when i saw this dog - incredibly sick, incredibly dehydrated, in renal failure with elevated liver values, i immediately suspected him to be a true lepto.
i received my antibody tests back yesterday - and he had VERY high titers to a specific strain (serovar) of lepto. he actually had lepto. i had a real lepto dog! i had a moment of clinical genius and warned my coworkers when he was admitted that i thought he was a true lepto, not a "fake" lepto. it was a nice validation. i have developed some clinical judgement. finally:)
it makes up for the 150 ways every HOUR of the day i feel dumb and ill-prepared to be a doctor and like i will never, ever be good enough!
Friday, August 29, 2008
it's a heartache tonight...
i was standing around (yeah, right) on friday night when the techs came rushing back with a dog in severe respiratory distress. it was a 1.5 year old springer spaniel mix. she was open-mouthed breathing, gasping for air. the way she sounded, i suspected an upper respiratory obstruction. the owners knew of no recent traumatic injury.
my attending clinician was gloved in on a laceration repair, and the extern was busy suturing up something else, so the case was all mine. while the techs got a catheter in and administered intra-nasal oxygen, i pried the dog's jaws open and peered down her throat. nothing. na-da. zilch. i grabbed my stethoscope and placed the bell on the dog's left chest. nothing. no heart sounds, no lungs, nothing. (the heart should be loudest on the left). i listened on the right and nearly went deaf. the heart was banging so desperately hard on the right side, it felt like it was trying to escape the cage of the ribs.
i looked at the attending (working on the laceration nearby). "i think she has a diaphragmatic hernia" i told him matter-of-factly.
"tap her," was his reply.
while i grabbed clippers, the techs got me guaze and a butterfly catheter. i shaved a big spot on her right chest, sterilely prepped it, and tried to suck air out. i got blood. not enough to indicate blood in the chest, though. i tried again and again, but each time - the tap was negative. something was blocking the tip of my needle.
"lateral xray," i snapped - and the technicians rushed her to the table. sure enough, the diaphragm was blown - the liver and some of the stomach were in the chest, crushing the lungs and heart.
while they held the dog and gave oxygen, i went to tell the owner's the dire news. $1500-2000 for surgery, a 50/50 shot at success. the owner looked at me and informed me matter-of-factly that the dog belonged to her husband...with cancer. she had to try. after gaining her signature and talking to her briefly, i rushed back to get the dog prepped.
when we opened the abdomen, the hole in the diaphragm was enormous. through it, we could clearly see the beating heart and the poor, collapsed lungs. "bag her!" barked the senior clinician. it was amazing to watch the poor little teeny lungs become bright pink and fluffy as the technician vigorously pumped iso and oxygen into them.
as i retracted the liver, the clinician carefully sutured up the diaphragm. about halfway through, he commented to me, "what's that awful smell?" i didn't know, but i had noticed it as well. we continued on and finished closing the diaphragm. we then started removing all of the bowel from the abdomen and examining it. alas, the source of the smell was revealed. far down in the small intestine was a section of bowel perhaps 5 inches long that was dead. not only dead, but it had rotted enough that feces were spilling into the abdomen. great news.
the clinician didn't blink but examined the bowel, looking for areas that still had pulses. we discussed the viability of the sections above and below the dead area, and then we cut it out and anastamosed the ends together. in the meantime, a technician was using a 3 way stop cock and a 60 cc syringe to evacuate the air of the chest cavity. each time we achieved negative pressure, the chest would inevitably fill up with air again. it would take a few minutes, but the diaphragm was not holding negative pressure. the clinician returned to his sutures and added some more. yet the chest continued to leak somewhere.
after checking the diaphragm yet again, the senior decided that a lung lobe had been traumatized and was leaking air into the chest. the solution? a thoracotomy (open the chest) and lung lobectomy. i was advised to glove out and call the owners before entering the chest, as the likelihood of recovery kept declining (the dog had a septic abdomen from the ruptured bowel and now need for an open chest surgery). when i spoke to them...i had only grave news.
they elected (wisely in all likelihood) to stop. after all that work, we euthanized on the table.
my attending clinician was gloved in on a laceration repair, and the extern was busy suturing up something else, so the case was all mine. while the techs got a catheter in and administered intra-nasal oxygen, i pried the dog's jaws open and peered down her throat. nothing. na-da. zilch. i grabbed my stethoscope and placed the bell on the dog's left chest. nothing. no heart sounds, no lungs, nothing. (the heart should be loudest on the left). i listened on the right and nearly went deaf. the heart was banging so desperately hard on the right side, it felt like it was trying to escape the cage of the ribs.
i looked at the attending (working on the laceration nearby). "i think she has a diaphragmatic hernia" i told him matter-of-factly.
"tap her," was his reply.
while i grabbed clippers, the techs got me guaze and a butterfly catheter. i shaved a big spot on her right chest, sterilely prepped it, and tried to suck air out. i got blood. not enough to indicate blood in the chest, though. i tried again and again, but each time - the tap was negative. something was blocking the tip of my needle.
"lateral xray," i snapped - and the technicians rushed her to the table. sure enough, the diaphragm was blown - the liver and some of the stomach were in the chest, crushing the lungs and heart.
while they held the dog and gave oxygen, i went to tell the owner's the dire news. $1500-2000 for surgery, a 50/50 shot at success. the owner looked at me and informed me matter-of-factly that the dog belonged to her husband...with cancer. she had to try. after gaining her signature and talking to her briefly, i rushed back to get the dog prepped.
when we opened the abdomen, the hole in the diaphragm was enormous. through it, we could clearly see the beating heart and the poor, collapsed lungs. "bag her!" barked the senior clinician. it was amazing to watch the poor little teeny lungs become bright pink and fluffy as the technician vigorously pumped iso and oxygen into them.
as i retracted the liver, the clinician carefully sutured up the diaphragm. about halfway through, he commented to me, "what's that awful smell?" i didn't know, but i had noticed it as well. we continued on and finished closing the diaphragm. we then started removing all of the bowel from the abdomen and examining it. alas, the source of the smell was revealed. far down in the small intestine was a section of bowel perhaps 5 inches long that was dead. not only dead, but it had rotted enough that feces were spilling into the abdomen. great news.
the clinician didn't blink but examined the bowel, looking for areas that still had pulses. we discussed the viability of the sections above and below the dead area, and then we cut it out and anastamosed the ends together. in the meantime, a technician was using a 3 way stop cock and a 60 cc syringe to evacuate the air of the chest cavity. each time we achieved negative pressure, the chest would inevitably fill up with air again. it would take a few minutes, but the diaphragm was not holding negative pressure. the clinician returned to his sutures and added some more. yet the chest continued to leak somewhere.
after checking the diaphragm yet again, the senior decided that a lung lobe had been traumatized and was leaking air into the chest. the solution? a thoracotomy (open the chest) and lung lobectomy. i was advised to glove out and call the owners before entering the chest, as the likelihood of recovery kept declining (the dog had a septic abdomen from the ruptured bowel and now need for an open chest surgery). when i spoke to them...i had only grave news.
they elected (wisely in all likelihood) to stop. after all that work, we euthanized on the table.
not such a useless surgery?
on sunday night, i was presented with a 2 year old dog that had sudden onset of vomiting and diarrhea. she had incredibly bloody, watery diarrhea leaking out of her, as well as intractable vomiting. the owners reported that she had been vomiting all day and couldn't even hold down water.
on my physical exam, she was depressed and significantly dehydrated, as well as painful in her abdomen. i couldn't find anything else of note. i discussed with the owners the full panel of diagnostics that we usually recommend in these cases: bloodwork, xrays (to insure that no foreign body was ingested), and hospitalization for treatment. after giving them the V and D spiel, i told them that honestly, i expected her to be a simple case of gastroenteritis. i recommended running bloodwork and treating the symptoms. if she responded - great. if not, we could proceed with xrays.
the owners agreed to my estimate (for bloodwork and 1-2 nights hospitalization) of $600-800. i whisked the patient off to the back. bloodwork was pristine, other than mild signs of inflammation on the CBC. i started her on anti-emetics and high dose fluid therapy.
i monitored her all night, and she never really responded as i would have liked her to. she continued to be dehydrated, despite heavy rehydration efforts. she continued to be nauseated, despite injectable anti-emetic (Cerenia) and Reglan in her fluid bag.
when i left that morning, i told the day clinician that xrays were probably warranted to ensure that there was no obstruction.
i came back that evening to the dog being prepped for surgery. a barium study was done by my colleague, showing gastric obstruction. without questioning this, i gloved up and went to surgery, expecting to find a wad of plastic blocking the pylorus. no luck. there was no obstruction, in the stomach or elsewhere. i took biopsies of the stomach and the intestines (which were not moving and looked angry) and closed her back up - crossing my fingers as i did so. cutting a piece out of the intestines and suturing it back together always scares me...
and then the news came back to me. i glanced at the xrays. they had showed nothing significant, so a barium study was done. a barium study is conducted using a radio-opaque dye that is put is force fed to the animal. when xrays are taken, it shows up incredibly bright white. it takes the stomach about 4 hours (in a normal animal) to empty. for some reason, the study on this dog was done in 1 hour - and a gastric obstruction assumed because the barium didn't leave the stomach. but that was normal, i realized - far too late to stop from going to surgery, obviously.
when the owner realized where the bill was (on top of having an incorrectly done barium study, she was also GROSSLY underquoted for surgery) - she politely told me that she couldn't pay for it. i understood her frustration. obviously, i deducted the barium study, as it was done wrong. i messed around with other figures, and we eventually came to a settlement on what her bill was. still $500 more than she had expected.
and then i spent the next 2 days beating myself up for doing a needless surgery.
and then my biopsies came back. IBD (inflammatory bowel disease). IBD is an idiopathic (don't know what causes it) disease of cats and dogs in which the intestines become infiltrated with white blood cells like plasma cell and lymphocytes. these set up a nasty inflammatory reaction and lead to the clinical signs of abdominal discomfort, vomiting, and diarrhea. treatment is varied from dietary changes to a novel protein source like kangaroo or duck or rabbit (some people theorize that underlying food allergies cause this disease) to things like steroids and probiotics.
wow. my biopsies were actually useful. my patient was treated and placed on a new diet and sent home.
seems my surgery wasn't quite so useless (thankfully).
on my physical exam, she was depressed and significantly dehydrated, as well as painful in her abdomen. i couldn't find anything else of note. i discussed with the owners the full panel of diagnostics that we usually recommend in these cases: bloodwork, xrays (to insure that no foreign body was ingested), and hospitalization for treatment. after giving them the V and D spiel, i told them that honestly, i expected her to be a simple case of gastroenteritis. i recommended running bloodwork and treating the symptoms. if she responded - great. if not, we could proceed with xrays.
the owners agreed to my estimate (for bloodwork and 1-2 nights hospitalization) of $600-800. i whisked the patient off to the back. bloodwork was pristine, other than mild signs of inflammation on the CBC. i started her on anti-emetics and high dose fluid therapy.
i monitored her all night, and she never really responded as i would have liked her to. she continued to be dehydrated, despite heavy rehydration efforts. she continued to be nauseated, despite injectable anti-emetic (Cerenia) and Reglan in her fluid bag.
when i left that morning, i told the day clinician that xrays were probably warranted to ensure that there was no obstruction.
i came back that evening to the dog being prepped for surgery. a barium study was done by my colleague, showing gastric obstruction. without questioning this, i gloved up and went to surgery, expecting to find a wad of plastic blocking the pylorus. no luck. there was no obstruction, in the stomach or elsewhere. i took biopsies of the stomach and the intestines (which were not moving and looked angry) and closed her back up - crossing my fingers as i did so. cutting a piece out of the intestines and suturing it back together always scares me...
and then the news came back to me. i glanced at the xrays. they had showed nothing significant, so a barium study was done. a barium study is conducted using a radio-opaque dye that is put is force fed to the animal. when xrays are taken, it shows up incredibly bright white. it takes the stomach about 4 hours (in a normal animal) to empty. for some reason, the study on this dog was done in 1 hour - and a gastric obstruction assumed because the barium didn't leave the stomach. but that was normal, i realized - far too late to stop from going to surgery, obviously.
when the owner realized where the bill was (on top of having an incorrectly done barium study, she was also GROSSLY underquoted for surgery) - she politely told me that she couldn't pay for it. i understood her frustration. obviously, i deducted the barium study, as it was done wrong. i messed around with other figures, and we eventually came to a settlement on what her bill was. still $500 more than she had expected.
and then i spent the next 2 days beating myself up for doing a needless surgery.
and then my biopsies came back. IBD (inflammatory bowel disease). IBD is an idiopathic (don't know what causes it) disease of cats and dogs in which the intestines become infiltrated with white blood cells like plasma cell and lymphocytes. these set up a nasty inflammatory reaction and lead to the clinical signs of abdominal discomfort, vomiting, and diarrhea. treatment is varied from dietary changes to a novel protein source like kangaroo or duck or rabbit (some people theorize that underlying food allergies cause this disease) to things like steroids and probiotics.
wow. my biopsies were actually useful. my patient was treated and placed on a new diet and sent home.
seems my surgery wasn't quite so useless (thankfully).
Wednesday, August 27, 2008
i'll think about it tomorrow
in the words of one of my favorite heroines, scarlett o'hara.
work sucks. i had a long post about why - but - despite my anonymity - i elected to take it down. i'm old enough to know better, right? can't accuse others of stupid behavior if i make the same mistakes. anonymity be damned.
perhaps someday again i'll actually talk about all the cool cases i get to see - the surgeries i've either done or assisted...but right now, i'm bitter, i'm tired, and i don't want to think about veterinary medicine for another 5 days (till i have to go back).
work sucks. i had a long post about why - but - despite my anonymity - i elected to take it down. i'm old enough to know better, right? can't accuse others of stupid behavior if i make the same mistakes. anonymity be damned.
perhaps someday again i'll actually talk about all the cool cases i get to see - the surgeries i've either done or assisted...but right now, i'm bitter, i'm tired, and i don't want to think about veterinary medicine for another 5 days (till i have to go back).
Tuesday, August 26, 2008
an easy diagnosis
back a couple of weeks ago, i saw a case that taught me the value of selective medicine. i.e. medicine outside of the ivory tower of vet school.
my owners were an older couple in their 60s. they brought me their mixed breed, 7 year old pit-bullish dog for increased drinking. as they described her insatiable appetite for water, i was running through my head THE list for pu/pd (polyuria/polydipsia - increased urinating and drinking) which includes no less than 20 differentials. diabetes was a big concern of mine, as well as other considerations...until the owner stopped me by pointing out that the dog had a huge "knot" in her neck. a lightbulb lit up so bright it almost blinded my mind's eye as i stepped around the table and felt the dog's enormous lymph nodes. both mandibular (below the jaw) and one of the suprascapular (in front of the shoulder) lymph nodes were extremely large. the dog didn't have a fever and seemed to be feeling well otherwise. all very bad signs. they scream cancer! cancer! cancer! cancer!
what, you might wonder, about increased drinking and large lymph nodes made me think cancer right off the bat? when dogs have a type of cancer called lymphoma, the tumor cells produce a substance called PTH-rp. this is a mimic of parathyroid hormone (PTH), something the body already makes. it comes from the (surprise) parathyroid glands in the neck and is crucial in maintaining calcium balance in the body (it upregulates reabsorption of calcium from the intestines, bone, and kidney). when the cancer cells start making this mimic, the body cannot tell the difference between it and real PTH, so the body starts reabsorbing calcium in massive amounts. this hypercalcemia leads to dysfunction in the kidneys so that they can't do their job and properly reabsorb water. massive amounts of fluid are lost through the kidneys, and significant dehydration occurs. the animal will drink and drink and drink, but it cannot keep up with the needs of the body. if high enough, the hypercalcemia can be a life-threatening condition in itself. other diseases can cause hypercalcemia, including fungal infection (which we see a TON of here in the south). fungal can also cause enlarged lymph nodes. however, a recent study in JAVMA showed that the occurrence of elevated calcium with fungal disease is incredibly rare (much rarer than originally supposed). further, the dog was feeling good, had no fever, and no other signs besides lymphadenopathy and polydipsia.
i discussed with the owners my suspicion that their dog had lymphoma, a very common cancer of dogs. they were naturally taken aback by the news this seemingly benign problem (more drinking) could indicate such a potentially life-threatening disease. and money was a problem. i recommended complete staging - bloodwork, xrays, etc to see if the cancer had spread beyond the lymph nodes. they declined.
the treatment for lymphoma in dogs is chemotherapy (systemic treatment for systemic disease). this runs between $3000-4000 for the first course. unlike chemo in people, dogs don't usually get sick. the reason is that our treatment goals are different. in veterinary medicine we strive for quality of life, not quantity. dogs do not have a sense of the length of life (at least, not to our understanding). to prolong their lives through horrible suffering (vomiting, diarrhea, hair loss) to gain a few years is meaningless. instead of trying to give them more time, we try to give them remission time: life as a happy healthy dog. the doses used for chemotherapy are much smaller when compared with human doses. with chemotherapy, we can usually achieve remission and good quality of life for up to a year and a half post-diagnosis. some dogs don't respond, of course. this has to do with a variety of factors, including which kind of lymphoma they have (t-cell versus b-cell). but generally, dogs do well with chemo. several of my friends have dogs that have been through the gold standard chemo (UW-Madison protocol) and several rescue protocols (what are used once the dog stops responding to UW-Madison). as a sidenote: hypercalcemia is usually associated with t-cell lymphoma, which has a worse prognosis and a poorer response to chemotherapy.
i discussed this with the owners, and they were very frank with me. they didn't have health insurance for themselves and their myriad health problems, let alone four grand lying around to treat their dog. they wanted a diagnosis - and they wanted it cheap. then they wanted palliative care (steroids) that would carry their dog for perhaps another 3 months.
i had limited money and needed both a diagnosis and some steroids (which are cheap, thankfully). instead of getting to do my super-duper vet school ivory tower diagnostics, i had to pick very carefully what i wanted to spend my clients' money on. i suspected the calcium was high based on my physical exam, but i needed to be sure. thus, i elected to run an ionized calcium (which indicates the amount of free "usable" calcium in the body and is a better indicator of blood calcium than just a plain calcium on a chemistry panel) and do a fine needle aspirate of the lymph nodes (stick a needle in them and make slides for cytology).
i ran my iCa. it was 1.9. vet people who read this will be going HOLY HYPERCALCEMIA BATMAN! that's really high. my FNA revealed what i suspected. big fat abnormal lymphocytes (called lymphoblasts). and my diagnosis was complete.
i relayed the news to my owners, who elected to proceed with palliative (make them feel better till they die) care. steroids are great for beating lymphoma back into remission - but they are very temporary. eventually the cancer cells become resistant to steroids (thanks to the MDR gene) and the cancer comes roaring back. i explained this to them, and they understood. they took their dog home for her remaining days.
last i talked to them (about 5 days ago), my patient was doing well and her drinking had decreased somewhat (not totally but this is due to the steroids, which also cause increased drinking but for different reasons). i know that in some weeks time, i will be seeing her again - to perform the part of my job that i both appreciate and hate. until then...i hope she has quality time with her owners. i'm glad that i could give them peace of mind in knowing what they were dealing with and what their treatment options were.
my owners were an older couple in their 60s. they brought me their mixed breed, 7 year old pit-bullish dog for increased drinking. as they described her insatiable appetite for water, i was running through my head THE list for pu/pd (polyuria/polydipsia - increased urinating and drinking) which includes no less than 20 differentials. diabetes was a big concern of mine, as well as other considerations...until the owner stopped me by pointing out that the dog had a huge "knot" in her neck. a lightbulb lit up so bright it almost blinded my mind's eye as i stepped around the table and felt the dog's enormous lymph nodes. both mandibular (below the jaw) and one of the suprascapular (in front of the shoulder) lymph nodes were extremely large. the dog didn't have a fever and seemed to be feeling well otherwise. all very bad signs. they scream cancer! cancer! cancer! cancer!
what, you might wonder, about increased drinking and large lymph nodes made me think cancer right off the bat? when dogs have a type of cancer called lymphoma, the tumor cells produce a substance called PTH-rp. this is a mimic of parathyroid hormone (PTH), something the body already makes. it comes from the (surprise) parathyroid glands in the neck and is crucial in maintaining calcium balance in the body (it upregulates reabsorption of calcium from the intestines, bone, and kidney). when the cancer cells start making this mimic, the body cannot tell the difference between it and real PTH, so the body starts reabsorbing calcium in massive amounts. this hypercalcemia leads to dysfunction in the kidneys so that they can't do their job and properly reabsorb water. massive amounts of fluid are lost through the kidneys, and significant dehydration occurs. the animal will drink and drink and drink, but it cannot keep up with the needs of the body. if high enough, the hypercalcemia can be a life-threatening condition in itself. other diseases can cause hypercalcemia, including fungal infection (which we see a TON of here in the south). fungal can also cause enlarged lymph nodes. however, a recent study in JAVMA showed that the occurrence of elevated calcium with fungal disease is incredibly rare (much rarer than originally supposed). further, the dog was feeling good, had no fever, and no other signs besides lymphadenopathy and polydipsia.
i discussed with the owners my suspicion that their dog had lymphoma, a very common cancer of dogs. they were naturally taken aback by the news this seemingly benign problem (more drinking) could indicate such a potentially life-threatening disease. and money was a problem. i recommended complete staging - bloodwork, xrays, etc to see if the cancer had spread beyond the lymph nodes. they declined.
the treatment for lymphoma in dogs is chemotherapy (systemic treatment for systemic disease). this runs between $3000-4000 for the first course. unlike chemo in people, dogs don't usually get sick. the reason is that our treatment goals are different. in veterinary medicine we strive for quality of life, not quantity. dogs do not have a sense of the length of life (at least, not to our understanding). to prolong their lives through horrible suffering (vomiting, diarrhea, hair loss) to gain a few years is meaningless. instead of trying to give them more time, we try to give them remission time: life as a happy healthy dog. the doses used for chemotherapy are much smaller when compared with human doses. with chemotherapy, we can usually achieve remission and good quality of life for up to a year and a half post-diagnosis. some dogs don't respond, of course. this has to do with a variety of factors, including which kind of lymphoma they have (t-cell versus b-cell). but generally, dogs do well with chemo. several of my friends have dogs that have been through the gold standard chemo (UW-Madison protocol) and several rescue protocols (what are used once the dog stops responding to UW-Madison). as a sidenote: hypercalcemia is usually associated with t-cell lymphoma, which has a worse prognosis and a poorer response to chemotherapy.
i discussed this with the owners, and they were very frank with me. they didn't have health insurance for themselves and their myriad health problems, let alone four grand lying around to treat their dog. they wanted a diagnosis - and they wanted it cheap. then they wanted palliative care (steroids) that would carry their dog for perhaps another 3 months.
i had limited money and needed both a diagnosis and some steroids (which are cheap, thankfully). instead of getting to do my super-duper vet school ivory tower diagnostics, i had to pick very carefully what i wanted to spend my clients' money on. i suspected the calcium was high based on my physical exam, but i needed to be sure. thus, i elected to run an ionized calcium (which indicates the amount of free "usable" calcium in the body and is a better indicator of blood calcium than just a plain calcium on a chemistry panel) and do a fine needle aspirate of the lymph nodes (stick a needle in them and make slides for cytology).
i ran my iCa. it was 1.9. vet people who read this will be going HOLY HYPERCALCEMIA BATMAN! that's really high. my FNA revealed what i suspected. big fat abnormal lymphocytes (called lymphoblasts). and my diagnosis was complete.
i relayed the news to my owners, who elected to proceed with palliative (make them feel better till they die) care. steroids are great for beating lymphoma back into remission - but they are very temporary. eventually the cancer cells become resistant to steroids (thanks to the MDR gene) and the cancer comes roaring back. i explained this to them, and they understood. they took their dog home for her remaining days.
last i talked to them (about 5 days ago), my patient was doing well and her drinking had decreased somewhat (not totally but this is due to the steroids, which also cause increased drinking but for different reasons). i know that in some weeks time, i will be seeing her again - to perform the part of my job that i both appreciate and hate. until then...i hope she has quality time with her owners. i'm glad that i could give them peace of mind in knowing what they were dealing with and what their treatment options were.
Saturday, August 23, 2008
i would've posted sooner, but truthfully - i was a) too exhausted after a 21 hour shift on sunday/monday and b) too depressed to have it in me to write.
here's a brief litany of some of the cases i took in/treated on sunday/monday:
1) a 1lb yorkie puppy, stepped on by owner with pulmonary contusions and possible GI perforation: died when IV catheter was being placed
2) 1 lb tortoiseshell kitten eaten up by fleas, parasites, so dehydrated/anemic that we were unable to place an IV anywhere - even our intraosseous (bone marrow) catheters failed: euthanized via cardiac stick after heavy sedation
3) 15 year old schnauzer with a heart rate of 30 and every arrhythmia in the book - owned by a jerk sexist (80 year old man) who treated me like garbage because i was female: euthanized due to owner's refusal to work up underlying problem.
4) 16 year old cat with a 6/6 heart murmur, a thyroid slip (enlarged thyroid probably meaning hyperthyroidism), thin, weak in the rear limbs: euthanized.
5) 4 month old puppy, laterally recumbent, comatose, partially seizing, with blood pouring from his mouth but no identifiable cause or laceration. clotting times were normal, so rat poisoning seemed unlikely: euthanized after struggling to figure out what was wrong with him and failing (despite the help of a specialist and my intern-mate).
it was not a fun couple of days. the only case i had that was rewarding was a 30 lb mixed breed dog that came in vomiting for 4 days, hunched, painful, and extremely dehydrated and lethargic. he was in acute renal failure. i managed to reverse that with my treatment. it was something to be proud of, i have to say. renal failure can be a challenge to manage, but i was proud of him. he's going home today, after 5 days in the hospital.
i also had a heat stroke that became my patient when i came on the late night shift on saturday. he was managed by cooling and IV fluids initially. when i took over his case, he was still obtunded and having partial seizures. i requested a blood glucose - only to find it was 28 (normal is 75-100 or so). i gave him boluses of dextrose and started him on dextrose laced fluids, and he went from completely stuporous with partial seizures to sitting up, drinking, and looking like an almost normal (albeit weak) dog. i felt really good about identifying a problem that had initially been missed in him - treating it - and making a huge difference (perhaps between life and death).
it almost made up for the clusterf*ck surrounding my patient that needed an amputation but was refused by his referring veterinarian, the sexist schnauzer's owner that requested a male doctor (i'll probably tell the whole story some other time), and the 4 month old puppy that i nor anyone else could help.
it was a very long 110 hour week (i kid you not). yesterday - instead of sleeping - i went down to georgia to a clinic that's thinking about hiring me to do relief work. a classmate of mine works there and spoke highly of it. if i take the position, i'll be working 3 days of my off week. it might be a terrible idea, due to the fact that when i'm on, i work between 90-120 hour weeks. we'll see how it works out. the money will be nice.
here's a brief litany of some of the cases i took in/treated on sunday/monday:
1) a 1lb yorkie puppy, stepped on by owner with pulmonary contusions and possible GI perforation: died when IV catheter was being placed
2) 1 lb tortoiseshell kitten eaten up by fleas, parasites, so dehydrated/anemic that we were unable to place an IV anywhere - even our intraosseous (bone marrow) catheters failed: euthanized via cardiac stick after heavy sedation
3) 15 year old schnauzer with a heart rate of 30 and every arrhythmia in the book - owned by a jerk sexist (80 year old man) who treated me like garbage because i was female: euthanized due to owner's refusal to work up underlying problem.
4) 16 year old cat with a 6/6 heart murmur, a thyroid slip (enlarged thyroid probably meaning hyperthyroidism), thin, weak in the rear limbs: euthanized.
5) 4 month old puppy, laterally recumbent, comatose, partially seizing, with blood pouring from his mouth but no identifiable cause or laceration. clotting times were normal, so rat poisoning seemed unlikely: euthanized after struggling to figure out what was wrong with him and failing (despite the help of a specialist and my intern-mate).
it was not a fun couple of days. the only case i had that was rewarding was a 30 lb mixed breed dog that came in vomiting for 4 days, hunched, painful, and extremely dehydrated and lethargic. he was in acute renal failure. i managed to reverse that with my treatment. it was something to be proud of, i have to say. renal failure can be a challenge to manage, but i was proud of him. he's going home today, after 5 days in the hospital.
i also had a heat stroke that became my patient when i came on the late night shift on saturday. he was managed by cooling and IV fluids initially. when i took over his case, he was still obtunded and having partial seizures. i requested a blood glucose - only to find it was 28 (normal is 75-100 or so). i gave him boluses of dextrose and started him on dextrose laced fluids, and he went from completely stuporous with partial seizures to sitting up, drinking, and looking like an almost normal (albeit weak) dog. i felt really good about identifying a problem that had initially been missed in him - treating it - and making a huge difference (perhaps between life and death).
it almost made up for the clusterf*ck surrounding my patient that needed an amputation but was refused by his referring veterinarian, the sexist schnauzer's owner that requested a male doctor (i'll probably tell the whole story some other time), and the 4 month old puppy that i nor anyone else could help.
it was a very long 110 hour week (i kid you not). yesterday - instead of sleeping - i went down to georgia to a clinic that's thinking about hiring me to do relief work. a classmate of mine works there and spoke highly of it. if i take the position, i'll be working 3 days of my off week. it might be a terrible idea, due to the fact that when i'm on, i work between 90-120 hour weeks. we'll see how it works out. the money will be nice.
Thursday, August 21, 2008
small annoyances (but generally, all is well)
the person who so offended my delicate feelings apologized (rather sincerely, i thought). i have many flaws but holding grudges is not one of them, so that situation is finished. i opened my ears and shut my mouth and noted that all around me are coworkers, colleagues, and others dealing with difficult and multi-layered interpersonal relationships. i realized (yet again) that my tendency towards schizophrenic paranoia and self-isolation are a borderline disorder, and i found my feet again at work.
small (to medium sized) annoyances:
1) work has been deadly slow. the theory is that everyone is spending money now that kids are going back to school (new school clothes, etc). last night we saw a whopping 6 patients. none of the owners had money, so they were all sent home with recommendations for what might be causing their problems. i have never worked a wednesday night where we didn't see AT LEAST 15-20 patients. there is a mere 1 hospitalized patient (mine...very interesting/confusing case).
2) micromanagement of cases. i have a superior that is out of the state right now. yet, she is managing one of my cases over the phone. i'm an intern. i'm here to learn. i get that - i really really do. however, waking up after sleeping on overnight to be informed that we ARE adding this treatment and doing this diagnostic without even the courtesy of having it discussed with me so that i can add my reasons for electing NOT to do that therapy...a little on the infuriating side. i've been told repeatedly that i'm handling the case extremely well, and yet...
that's it. that's the list of grievances for today.
things i'm excited about:
1) my best friend and brother-in-law are coming to stay with us labor day weekend. i miss them terribly and can't wait to see them.
2) sunday night is my last day on for a full 7 days.
3) seeing my husband again. he's started back to school and will thus be commuting back to our hold stomping grounds (2 hours one way) on a rather frequent basis. i've been working, he's been working - i feel like strangers sometime.
4) going shopping for "new school clothes" (really - i just want to go shopping...i haven't in a very long time, and i need a new pair of shoes. just because).
probably other things, but at the moment, i can't remember what they are.
small (to medium sized) annoyances:
1) work has been deadly slow. the theory is that everyone is spending money now that kids are going back to school (new school clothes, etc). last night we saw a whopping 6 patients. none of the owners had money, so they were all sent home with recommendations for what might be causing their problems. i have never worked a wednesday night where we didn't see AT LEAST 15-20 patients. there is a mere 1 hospitalized patient (mine...very interesting/confusing case).
2) micromanagement of cases. i have a superior that is out of the state right now. yet, she is managing one of my cases over the phone. i'm an intern. i'm here to learn. i get that - i really really do. however, waking up after sleeping on overnight to be informed that we ARE adding this treatment and doing this diagnostic without even the courtesy of having it discussed with me so that i can add my reasons for electing NOT to do that therapy...a little on the infuriating side. i've been told repeatedly that i'm handling the case extremely well, and yet...
that's it. that's the list of grievances for today.
things i'm excited about:
1) my best friend and brother-in-law are coming to stay with us labor day weekend. i miss them terribly and can't wait to see them.
2) sunday night is my last day on for a full 7 days.
3) seeing my husband again. he's started back to school and will thus be commuting back to our hold stomping grounds (2 hours one way) on a rather frequent basis. i've been working, he's been working - i feel like strangers sometime.
4) going shopping for "new school clothes" (really - i just want to go shopping...i haven't in a very long time, and i need a new pair of shoes. just because).
probably other things, but at the moment, i can't remember what they are.
Saturday, August 16, 2008
and now for something entirely different...
i've given myself full permission to stop thinking about veterinary medicine when i'm off work. no studying, no fretting, no checking VIN for interesting rounds and articles and message board stuff. nope. when i'm off work, i'm not a vet.
in observance of this rule, i also called my would-be other employer and told them that after much careful consideration (and 8 days of hell at work) that i would be declining the part time position they offered me. i felt as if an enormous weight was lifted from my shoulders. i spent my 5 day hiatus from work (i go back tomorrow for 8 days of overnight shifts) enjoying time with my husband, cooking for my houseguests (an extern from my alma mater is staying with us, and her husband came to visit on thurs/fri/sat), going hiking and climbing yesterday, and going out for drinks and dancing at our local gay club last night. today, i have been utterly useless, sleeping, reading my frivolous fashion magazines, doing laundry, and shortly about to watch one of my netflix 80s classics (the goonies or the terminator). the husband is camping tonight. i would have joined him, but i have to work the 12p-12am shift tomorrow before starting true overnights on monday.
after that, i have 7 days off, 7 on...and then somewhere in that 2nd week of september, i have the weekend off for the first home football game of the season. i looooove me some football!!!
in observance of this rule, i also called my would-be other employer and told them that after much careful consideration (and 8 days of hell at work) that i would be declining the part time position they offered me. i felt as if an enormous weight was lifted from my shoulders. i spent my 5 day hiatus from work (i go back tomorrow for 8 days of overnight shifts) enjoying time with my husband, cooking for my houseguests (an extern from my alma mater is staying with us, and her husband came to visit on thurs/fri/sat), going hiking and climbing yesterday, and going out for drinks and dancing at our local gay club last night. today, i have been utterly useless, sleeping, reading my frivolous fashion magazines, doing laundry, and shortly about to watch one of my netflix 80s classics (the goonies or the terminator). the husband is camping tonight. i would have joined him, but i have to work the 12p-12am shift tomorrow before starting true overnights on monday.
after that, i have 7 days off, 7 on...and then somewhere in that 2nd week of september, i have the weekend off for the first home football game of the season. i looooove me some football!!!
Thursday, August 14, 2008
once more into the breach, dear friends...
i will bid you all a fond adieu until i return 7 days from hence (if you're so lucky). my 6 day hiatus has not been particularly relaxing - i entertained 3 nights out of the 6, worked at the shelter doing spay/neuters, and cleaned a great deal (today). it was an enjoyable six day break, however.
i will return when i can to post stories...
i will return when i can to post stories...
Wednesday, August 13, 2008
for now, we stand alone
you will notice that i have once again cloaked myself in anonymity. it seems best -for a variety of reasons. all of my old posts are tucked away, so that one day - when i write a book about my experiences - i'll already have it mostly finished (i have 300+ pages of old posts!)
so...i'm going to talk about work. not about some of the interesting and stressful cases i've had to deal with - but the other side of work. the interpersonal side.
i knew it would be difficult for me. i'm the eldest of 5 children - the other 4 being boys. i also come from a big, argumentative family. family holidays are organized chaos and involve a lot of shouting and friendly arguing. in short - i'm combative by nature. on top of that, i've just started working as a doctor, so i question EVERYTHING - everything i do, everything other doctors do. i'm constantly looking for the best way to diagnose and treat my patients. when confronted with something i don't recognize or understand, i look it up. i use VIN (veterinary inter-network) religiously. i'm a total and complete perfectionist. and medicine doesn't leave much room for perfectionism. in short, i'm high-strung and prone to being very stressed at work. not only am i dealing with the terrifying nature of being the one responsible for my patients, the one who must diagnose them, and treat them, and not accidentally kill them...i also have to deal with doctors above me, my intern-mates, technicians, and receptionists. it's a lot of people. and we're all women. there is 1 - read that - ONE - male working with us. that's a lot of estrogen in one place. a place already running at maximum stress level.
i am constantly cognizant of how i interact with people. i always, always try to say please and thank you. i always try to lend a hand and clean when the ICU is chaotic and stuff is strewn everywhere. if i'm walking my patient to the front and his drain leaks on the floor, i get the mop and clean it up. i try to make sure when i request help from the technicians that i do so with a pleasant manner, no matter how stressed or behind i am. i'm always thinking about these things - ALWAYS. even when i go home at night and when i'm off work for 5 days at a time.
and yet i think i'm the intern no one likes working with. how do i know? suffice to say that myspace isn't as private as some foolish, very young technicians think.
it wasn't so much the comment i accidentally stumbled on that made me feel so bad. i've been feeling bad for a while about work. i can tell that i am not loved. and i never, ever wanted to be the doctor that everyone dreads being on with and makes hearts sink when she walks through the door.
what amazes me is that my clients love me. i've received heartfelt thank you cards, a toaster oven big enough to roast a turkey, and tons of affirmation. one of my patient's owners (the kitty whose tail i amputated) asked me if their daughter could shadow me, because i so obviously love what i'm doing - and i'm good at it. how can i be so good with my owners and my patients - and not with the people that work underneath me? i have infinite - and i mean infinite - patience with animals. i never lose my temper, never get upset when they are aggressive or frightened or hard to handle.
but to do my job right - to serve my patients and my clients to the best of my ability - sometimes i have to be demanding. amazingly, the myspace comment was in regards to me filling my own prescriptions one particularly crazy sunday. i thought that getting my own (patient's) drugs would be helpful. apparently, i was sorely mistaken.
it's not important, really. it just adds another dimension to the already incredibly stressful job that i have taken. at the end of my 8 day stretches, all i want to do is curl up and sleep for 2 days - not talk to anyone other than jim, not leave the house, not do anything. at the end of that period, i hate veterinary medicine, i hate myself, i hate my job...it's not a good way to feel.
i went out to dinner with a couple of my intern-mates and one of the ER docs (who was herself an intern last year) - we went out for $2 pint night after that, and we had long heart-to-hearts. it made me feel a great deal better about things. but it's still gnawing at me.
oh well, i never thought an internship would be easy. i just didn't realize all the ways it would be so difficult.
so...i'm going to talk about work. not about some of the interesting and stressful cases i've had to deal with - but the other side of work. the interpersonal side.
i knew it would be difficult for me. i'm the eldest of 5 children - the other 4 being boys. i also come from a big, argumentative family. family holidays are organized chaos and involve a lot of shouting and friendly arguing. in short - i'm combative by nature. on top of that, i've just started working as a doctor, so i question EVERYTHING - everything i do, everything other doctors do. i'm constantly looking for the best way to diagnose and treat my patients. when confronted with something i don't recognize or understand, i look it up. i use VIN (veterinary inter-network) religiously. i'm a total and complete perfectionist. and medicine doesn't leave much room for perfectionism. in short, i'm high-strung and prone to being very stressed at work. not only am i dealing with the terrifying nature of being the one responsible for my patients, the one who must diagnose them, and treat them, and not accidentally kill them...i also have to deal with doctors above me, my intern-mates, technicians, and receptionists. it's a lot of people. and we're all women. there is 1 - read that - ONE - male working with us. that's a lot of estrogen in one place. a place already running at maximum stress level.
i am constantly cognizant of how i interact with people. i always, always try to say please and thank you. i always try to lend a hand and clean when the ICU is chaotic and stuff is strewn everywhere. if i'm walking my patient to the front and his drain leaks on the floor, i get the mop and clean it up. i try to make sure when i request help from the technicians that i do so with a pleasant manner, no matter how stressed or behind i am. i'm always thinking about these things - ALWAYS. even when i go home at night and when i'm off work for 5 days at a time.
and yet i think i'm the intern no one likes working with. how do i know? suffice to say that myspace isn't as private as some foolish, very young technicians think.
it wasn't so much the comment i accidentally stumbled on that made me feel so bad. i've been feeling bad for a while about work. i can tell that i am not loved. and i never, ever wanted to be the doctor that everyone dreads being on with and makes hearts sink when she walks through the door.
what amazes me is that my clients love me. i've received heartfelt thank you cards, a toaster oven big enough to roast a turkey, and tons of affirmation. one of my patient's owners (the kitty whose tail i amputated) asked me if their daughter could shadow me, because i so obviously love what i'm doing - and i'm good at it. how can i be so good with my owners and my patients - and not with the people that work underneath me? i have infinite - and i mean infinite - patience with animals. i never lose my temper, never get upset when they are aggressive or frightened or hard to handle.
but to do my job right - to serve my patients and my clients to the best of my ability - sometimes i have to be demanding. amazingly, the myspace comment was in regards to me filling my own prescriptions one particularly crazy sunday. i thought that getting my own (patient's) drugs would be helpful. apparently, i was sorely mistaken.
it's not important, really. it just adds another dimension to the already incredibly stressful job that i have taken. at the end of my 8 day stretches, all i want to do is curl up and sleep for 2 days - not talk to anyone other than jim, not leave the house, not do anything. at the end of that period, i hate veterinary medicine, i hate myself, i hate my job...it's not a good way to feel.
i went out to dinner with a couple of my intern-mates and one of the ER docs (who was herself an intern last year) - we went out for $2 pint night after that, and we had long heart-to-hearts. it made me feel a great deal better about things. but it's still gnawing at me.
oh well, i never thought an internship would be easy. i just didn't realize all the ways it would be so difficult.
the kids don't stand a chance
we had visitors again this weekend. our new spare bedroom is shaping up to see a high volume customer load. we'll have to rename this place the ashe B&B. my brother, his GF, and my niece lola b came to visit us for the night. i love having company. i love having a nice spare bedroom and making breakfast and extravagant meals. this morning's menu: french toast, scrambled eggs, bacon, and grits. this evening: rare roast beef, garlic mashed potatoes, corn on the cob, tomato salad, and devil's food cake for dessert. decadent...:)
and i got to spend time with my gorgeous and sweet niece. a nice way to spend a couple of days before going on for 7 nights in a row. i'll be disappearing for about a week, by the way.
and i got to spend time with my gorgeous and sweet niece. a nice way to spend a couple of days before going on for 7 nights in a row. i'll be disappearing for about a week, by the way.
Monday, August 11, 2008
it's the end of the world as we know it.
so i decided i'd like to earn some extra moolah and do a good deed simultaneously. it worked out well that the new animal shelter extraordinaire opened here about 11 days ago. they're desperately seeking vets from our area to come and spay/neuter the 300+ animals up for adoption. after the first 20 - you make $15 per animal. in 2 days of part-time work, i did 13. seven more and i can make it a paying gig. it's great practice for tissue handling, suturing, and the like. unfortunately, i'm not used to standing at a surgery table for 4 hours in a row. my neck and back are frozen in a rock hard, cramped position that tylenol and a heating pad cannot seem to loosen. ah well...i've done most of my good deed community service. now if i could just figure out how to rid myself of the bag o'rocks in my neck.
my intern-mate and classmate came over for dinner tonight. we went italian. she brought bruschetta and bagel chips, as well as a lovely cabernet sauvignon. i fixed chicken breasts stuffed with ricotta, parmesan, mozzarella, and spinach, as well as corn on the cob, and a nice spinach, tomato, and mozzarella salad. we had a lovely butter cream with chocolate icing cake and vanilla ice cream for dessert. afterwards, we sat on the back porch, in the dark of a pleasant southern summer night, swinging, and catching up - discussing our recent vet school experience, our relief in graduating, and our new job. all in all, a nice evening.
unrelated to that paragraph but directly relating to the first: i know how the world will end. it's not with a bang or a whimper - but a mew. everyone has been very worried about the hadron collider - or whatever it's called - forming a black hole on earth and swallowing everyone. in case you have no idea what i'm referring to: http://en.wikipedia.org/wiki/Large_Hadron_Collider.
point being that some people think the LHC heralds the beginning of the end of earth and the universe. however - i know differently. it is not the large hadron collider that will end all - it is the little known kitten vortex (or KV) that exists at the animal shelter at which i now pseudo-volunteer. if you enter the kitten ward, you are assaulted by literally 105 kittens of every ilk - size, shape, personality - all mewing for attention - paws hanging out of cages, batting at the air, in the desperate hopes of being petted and coddled. there is so much cuteness in that room that i maintain if but 2 more kittens are added and 1 more susceptible person, the room will collapse in on itself and form a micro black-hole - leading to the end of everything as we know it.
i'm thinking about contacting NASA.
my intern-mate and classmate came over for dinner tonight. we went italian. she brought bruschetta and bagel chips, as well as a lovely cabernet sauvignon. i fixed chicken breasts stuffed with ricotta, parmesan, mozzarella, and spinach, as well as corn on the cob, and a nice spinach, tomato, and mozzarella salad. we had a lovely butter cream with chocolate icing cake and vanilla ice cream for dessert. afterwards, we sat on the back porch, in the dark of a pleasant southern summer night, swinging, and catching up - discussing our recent vet school experience, our relief in graduating, and our new job. all in all, a nice evening.
unrelated to that paragraph but directly relating to the first: i know how the world will end. it's not with a bang or a whimper - but a mew. everyone has been very worried about the hadron collider - or whatever it's called - forming a black hole on earth and swallowing everyone. in case you have no idea what i'm referring to: http://en.wikipedia.org/wiki/Large_Hadron_Collider.
point being that some people think the LHC heralds the beginning of the end of earth and the universe. however - i know differently. it is not the large hadron collider that will end all - it is the little known kitten vortex (or KV) that exists at the animal shelter at which i now pseudo-volunteer. if you enter the kitten ward, you are assaulted by literally 105 kittens of every ilk - size, shape, personality - all mewing for attention - paws hanging out of cages, batting at the air, in the desperate hopes of being petted and coddled. there is so much cuteness in that room that i maintain if but 2 more kittens are added and 1 more susceptible person, the room will collapse in on itself and form a micro black-hole - leading to the end of everything as we know it.
i'm thinking about contacting NASA.
Saturday, August 9, 2008
there are no words
for what i endured as a new doctor this weekend. the 4th of july was total madness. the sunday after was on par with an episode of ER. every time i tried to come up for air, another dire emergency walked through the door. one after the other...bam bam bam bam. take an episode of ER, subtract the silly soap opera emotional theatrics and occasional gun-waving maniacs and bitchy catfights - and that is what this past weekend was like. i worked 70 hours in 4 days. i'll do the math for you - that's 17.5 hour days.
i saw a seizing ferret with a probable insulinoma (tumor of the pancreas) which i nursed for 2 days, including taking him home for the night in his little box with his syringe pump, a heat stroke (temperature of 109), a fever of unknown origin, a head trauma / hit by car chihuahua, a weimaraner with megaesophagus and pneumonia, a very bad snakebite, a cat mauled by a pit bull...and the list goes on and on and on.
my shifts officially ended at midnight, but i never left before 3AM - at the earliest - due to procedures waiting to be done, as well as paperwork. further - on monday night - the one night i got off at 1:30am, i came home to find my own cat with a fever of 106. i knew he was sick - a neighborhood tomcat attacked him and bit him. i knew he had two brewing abscesses - but when i took him to work to lance and drain them, i was so swamped, i never had the chance. one ruptured and drained on its own. the other never did. i finally got to lance it with a scalpel on sunday night. afterwards, bu stopped eating, drinking, and became lethargic. when i picked him up on monday morning, i was shocked at how hot he was. so instead of sleeping, i rushed back to work with him, plugged a catheter into him, and got him some IV antibiotics. he's doing better now, but he's still mildly feverish - so he's still at work - getting fluids and antibiotics.
i am exhausted. challenged. stuporous. excited. scared. constantly awakening to the art that is medicine - an art that i haven't mastered yet. it's terrifying and surreal. but also rewarding.
here are some pics of my handiwork. kitty's tail was degloved (in a car engine, i suspect). kitty required an amputation, unfortunately.
i saw a seizing ferret with a probable insulinoma (tumor of the pancreas) which i nursed for 2 days, including taking him home for the night in his little box with his syringe pump, a heat stroke (temperature of 109), a fever of unknown origin, a head trauma / hit by car chihuahua, a weimaraner with megaesophagus and pneumonia, a very bad snakebite, a cat mauled by a pit bull...and the list goes on and on and on.
my shifts officially ended at midnight, but i never left before 3AM - at the earliest - due to procedures waiting to be done, as well as paperwork. further - on monday night - the one night i got off at 1:30am, i came home to find my own cat with a fever of 106. i knew he was sick - a neighborhood tomcat attacked him and bit him. i knew he had two brewing abscesses - but when i took him to work to lance and drain them, i was so swamped, i never had the chance. one ruptured and drained on its own. the other never did. i finally got to lance it with a scalpel on sunday night. afterwards, bu stopped eating, drinking, and became lethargic. when i picked him up on monday morning, i was shocked at how hot he was. so instead of sleeping, i rushed back to work with him, plugged a catheter into him, and got him some IV antibiotics. he's doing better now, but he's still mildly feverish - so he's still at work - getting fluids and antibiotics.
i am exhausted. challenged. stuporous. excited. scared. constantly awakening to the art that is medicine - an art that i haven't mastered yet. it's terrifying and surreal. but also rewarding.
here are some pics of my handiwork. kitty's tail was degloved (in a car engine, i suspect). kitty required an amputation, unfortunately.
Friday, August 8, 2008
mark the day, folks
8/8/08 - the day i left work a mere 30 minutes AFTER my shift ended. hell has officially frozen over.
i had 4 cases hospitalized when i left, but i had finished paperwork, treatments, and checked on everyone before i left at 12:17am.
tonight, i stopped taking cases at 10pm. i did my paperwork as i went. i didn't follow the techs around helping with xrays and whatnot. i did my physical exam, i came up with a plan, i did my paperwork. it worked beautifully. of course - it was an uncharacteristically quiet friday night. that means tomorrow will be a living nightmare. but whatever.
i can handle it. (right??)
tonight i saw a kitty with pyrethrin toxicity (DO NOT USE HARTZ OR SARGENTS FLEA CONTROL ON CATS - DESPITE WHAT THE LABEL SAYS!!!!), an organophosphate toxicity, a snakebite, a hit by car, and a neurological dog. all in all, an interesting but doable night on the job (as evidenced by the fact that i'm coherent enough to post something).
i had 4 cases hospitalized when i left, but i had finished paperwork, treatments, and checked on everyone before i left at 12:17am.
tonight, i stopped taking cases at 10pm. i did my paperwork as i went. i didn't follow the techs around helping with xrays and whatnot. i did my physical exam, i came up with a plan, i did my paperwork. it worked beautifully. of course - it was an uncharacteristically quiet friday night. that means tomorrow will be a living nightmare. but whatever.
i can handle it. (right??)
tonight i saw a kitty with pyrethrin toxicity (DO NOT USE HARTZ OR SARGENTS FLEA CONTROL ON CATS - DESPITE WHAT THE LABEL SAYS!!!!), an organophosphate toxicity, a snakebite, a hit by car, and a neurological dog. all in all, an interesting but doable night on the job (as evidenced by the fact that i'm coherent enough to post something).
Thursday, August 7, 2008
guilty, guilty, guilty
those of you who know me at all in my real life know that i have a hopelessly self-righteous superiority complex when it comes to TV and video games. it's not because i think that there is anything inherently wrong with either thing. it's more because every time i see the crap that's on tv, my stomach churns. people actually watch this? i think to myself, disgusted and depressed at the state of our entertainment. i don't have cable. not even basic cable. i don't remember the last time i sat down and watched TV. i do love movies and some HBO shows that i own on dvd (sex and the city, sopranos)...but other than that...i hold TV in somewhat low regard. perhaps i have read ray bradbury's 'farenheit 451' too many times. but for whatever reason, i just plain don't like TV. the only time i want to have cable is during football season. same with video games. it seems like too many intelligent people i know play video games in lieu of reading a book or watching/reading the news or going outside and doing something athletic and challenging. again - it's not against video games themselves - just the amount of time some people i know spend doing it. to their own detriment, i contend. on the other hand - people have spare time - and they may do with it as they please. i'm not exactly judging others for indulging in too much TV or video games - we live in a free society. it just makes me sad how much time people spend immersed in utterly vapid "entertainment" - MTV being an excellent example.
so - stepping down from my soapbox (pedestal) - i am about to become a total hypocrite and wallow in the mud.
i .................................... am .................................... completely ................................ and ............................. totally addicted to guitar hero.
i played it at my brother-in-law's house on their PS3. and i haven't been able to stop thinking about it since. jim and i went out and bought it last night and now i'm totally and completely addicted.
on the one hand, it's kind of a good thing. after last week's mind-numbing work schedule and exhaustion, i need something to totally take my mind off veterinary medicine. i have to say, it's great for that. of course, i'm developing carpal tunnel syndrome in my left hand from playing on medium...but hey...who cares??
on that note, i start my 2nd job a week from today at the other animal hospital. i know, i know - bad idea, right? here's my thought process: jim and i have 1 credit card which we only use when cash flow is exceptionally tight. moving after graduation cost quite a bit, so some of that was put on the credit card. we owe about $1800 on it at the moment. that's all our debt (of course not including student loans). i can work 6 days at my new job and pay it off in entirety, then jim and i can save up for a house or a car for jim or whatever. it's a small amount of debt relative to most people i know, but it's something we would like to take care of first and foremost. after those 6 days, i will reassess. if i'm exhausted and burned out, then i won't work anymore. if i'm enjoying it - then we'll see.
alright, off to practice the mad guitar riff in 'crazy on you.'
so - stepping down from my soapbox (pedestal) - i am about to become a total hypocrite and wallow in the mud.
i .................................... am .................................... completely ................................ and ............................. totally addicted to guitar hero.
i played it at my brother-in-law's house on their PS3. and i haven't been able to stop thinking about it since. jim and i went out and bought it last night and now i'm totally and completely addicted.
on the one hand, it's kind of a good thing. after last week's mind-numbing work schedule and exhaustion, i need something to totally take my mind off veterinary medicine. i have to say, it's great for that. of course, i'm developing carpal tunnel syndrome in my left hand from playing on medium...but hey...who cares??
on that note, i start my 2nd job a week from today at the other animal hospital. i know, i know - bad idea, right? here's my thought process: jim and i have 1 credit card which we only use when cash flow is exceptionally tight. moving after graduation cost quite a bit, so some of that was put on the credit card. we owe about $1800 on it at the moment. that's all our debt (of course not including student loans). i can work 6 days at my new job and pay it off in entirety, then jim and i can save up for a house or a car for jim or whatever. it's a small amount of debt relative to most people i know, but it's something we would like to take care of first and foremost. after those 6 days, i will reassess. if i'm exhausted and burned out, then i won't work anymore. if i'm enjoying it - then we'll see.
alright, off to practice the mad guitar riff in 'crazy on you.'
Tuesday, August 5, 2008
my world is my work and my work is my world
at least - that's how it seems right now. in 8 days - 130+ hours. i've been told by my husband to set some limits. the problem is - what limits do i set? if i don't do my paperwork - who suffers? me - if i get sued and lack proper paperwork to back myself up. or if one of my intern-mates doesn't know how i treated a patient...my patient suffers. so no shortcuts on tedious and time-consuming paperwork. what about emergencies, then? if i cut off taking emergencies 2 hours before the end of my shift then i get dirty looks from the senior clinicians, although we've been told by the medical director (the highest authority) to stop taking appointments 2 hours prior to the end of our shift. even doing that on sunday night - i was at work an extra 8 hours - doing eye surgery, as well as a surgery dehiscence repair. a 19 hour shift. all of us interns are in the same boat. we (or the nature of our business) work ourselves to death. i recall a recent 20 hour-ish shift during which i didn't drink or eat the entire time. OSHA regulations require that we don't eat or drink in the ICU. we're only allowed drinks/food in the lounge. it's an infuriating rule that ensures that i am not properly hydrated or fed. OSHA wants to protect our health? they ought to prevent hypoglycemia-induced collapse secondary to starvation/dehydration. i should write a letter to someone.
i have 3 days off until i have to go back and work the (hellish, no doubt) weekend. during my last week on i dealt with an uncontrollably seizuring dog, an insane nurse practitioner owner that insulted me by insinuating i would not treat her dog because i disagreed with her assessment of my patient's status, a raccoon that was to be euthanized and have his head removed (NOT in my job contract), technicians disagreeing with my drug dosages (correct dosages but different from what they are used to administering) and running to my attending clinician with the news that i'd made a "mistake" before even asking me about the dose, euthanizing an otherwise happy, healthy 2 year old dachshund with a slipped disc, euthanizing a dozen other animals - some on death's doorstep - others with fixable (albeit expensively) problems...and the litany goes on and on.
i was bone-tired when i got home last night, easily prodded into tears.
today - the husband and i spent some time together. we finally saw the dark knight, which was excellent and far, far exceeded my expectations. it was also a bit heavy for my day off - as in SUPER DEPRESSING. we had bbq afterwards. it was a nice remove from my job.
i have 3 days off until i have to go back and work the (hellish, no doubt) weekend. during my last week on i dealt with an uncontrollably seizuring dog, an insane nurse practitioner owner that insulted me by insinuating i would not treat her dog because i disagreed with her assessment of my patient's status, a raccoon that was to be euthanized and have his head removed (NOT in my job contract), technicians disagreeing with my drug dosages (correct dosages but different from what they are used to administering) and running to my attending clinician with the news that i'd made a "mistake" before even asking me about the dose, euthanizing an otherwise happy, healthy 2 year old dachshund with a slipped disc, euthanizing a dozen other animals - some on death's doorstep - others with fixable (albeit expensively) problems...and the litany goes on and on.
i was bone-tired when i got home last night, easily prodded into tears.
today - the husband and i spent some time together. we finally saw the dark knight, which was excellent and far, far exceeded my expectations. it was also a bit heavy for my day off - as in SUPER DEPRESSING. we had bbq afterwards. it was a nice remove from my job.
Sunday, August 3, 2008
imperfections on the brain
i've been flipping through my patient cards and trying to decide which one would garner the most interest. i'm sure that after the july 4th weekend madness (i'm working friday through monday - "12" hour days...and by 12, i'm guessing 16-20) i will have lots of interesting stories to tell. but what i'm really doing is avoiding talking about something over which i've been fretting.
sunday 2 weeks ago - i was presented with a small dog that had been mauled by another, much larger dog. on cursory, hands-off exam - i saw 2 things that immediately worried me: schiff-sherrington posture and a very large abdominal hernia.
schiff-sherrington posture describes when the front limbs are rigidly extended and the back legs are flaccid or normal. with this posture - mentation is normal - the animal is alert and aware (unless there's concurrent head trauma). this represents a lesion in the spinal cord between the third thoracic vertebrae and third lumbar vertebrae (thoracolumbar area). in the case of trauma like this - the cause is almost 100% a spinal fracture.
coupled with that, the dog had a very large bulge running along his body wall and abdomen. i palpated carefully and was confident that i was feeling small intestines herniated. there were multiple puncture wounds along the flank and abdomen. the dog was in very poor shape. he was in excruciating pain and shock. i started fluids and heavy opioids and went to talk to his distraught owner.
she was not alone. her mother and daughters (both younger than 7) were present. they were well-behaved but naturally upset at the state of their 2 elders (mom and grandmom). i talked them through the condition of their dog. i told them that i suspected a spinal fracture. we discussed the cost of diagnosing this (radiographs for the spinal fracture) and other diagnostics. the owners were very strapped for money. they agreed to xrays, and then they went to apply for CareCredit (a line of credit that can be used for medical needs like plastic surgery, dentistry, and veterinary work). while they attended to that, we took our little patient to xrays. sure enough, L2 was badly damaged. the transverse process (the point on top of the vertebrae that you can feel if you run your finger along a dog's spine) was destroyed. the vertebral body was half the length of a normal one, having fragmented, and the spine was luxated. it was bad.
back i went to the owners with this news. i gave them a poor prognosis. they had failed to qualify for carecredit and money was a definite issue. we discussed stabilizing the dog and sending him to UT for spinal fracture repair (stabilization surgery). that coupled with the hernia would have cost $3000-5000. the owners couldn't afford the $350 that it cost for what we had already done. further, the dog would have most likely faced a life in a dog cart, with bladder expressions, and physical therapy.
so - what - you might wonder - has been bothering me exactly? i handled the case well. i gave good pain control, i managed the shock, i did diagnostics in the correct order so that i could give the owner's my best guess at how he would do and what he would need. we discussed everything at length - the dog's condition, their financial state, the likelihood that he would recover well. i gave them an accurate estimate...i did it all right. right?
except i forgot to check deep pain. deep pain sensation is the last thing to be lost in spinal injury. if it's gone - the prognosis for return to walking, bladder control function, and the like is extremely poor. if it's intact, the prognosis is much better. and i forgot to check it! it's a basic part of a neurological exam, something i've done a hundred times at school. and yet - in the craziness that is sunday afternoon - i forgot.
the owners elected euthanasia. it was terrible. it took them 4 hours to proceed with it. we had to wait until the husband came, then the grandfather. at the end, there were 6 people present, plus me, plus a technician. the dog was in terrible pain, despite my extremely heavy hand with the opioids. though i repeatedly warned them to not move him around (as they were saying good-bye), the owner and her mother both did - leading to the owner receiving a bite on her thumb. it was stressful and emotional. before it was over - the mother asked me 1) was i the REAL doctor? and 2) was i sure that the xrays belonged to their dog?
but don't get me wrong - they weren't bad people. just incredibly distraught at the horrible trauma that had befallen the smallest member of their family. in the end, he went peacefully.
they could only pay $320 of their bill and post-dated a check for the $30 difference. the dog was in terrible shape. he likely had other internal injuries along with his herniated intestines and spinal fracture. the chance that he would have survived and had quality of life was very small. i knew all of this. i know i handled it well. and yet, i beat myself up for forgetting to check deep pain sensation for a week. after talking to many experienced veterinarians, i have been able to let it go and focus on the fact
that nothing i did or didn't do affected the outcome of that case.
but it's this experience that makes me realize why vets have the 2nd highest suicide rate of all medical professions. don't get worried, i'm not considering suicide! but i realize how hard it is to let the little things go. i want to do the best i possibly can for all of my patients, all the time. i want to be absolutely perfect in my pursuit of correct diagnostics, absolutely vigilant in my physical exam and monitoring, and never forget or miss ANYTHING. EVER. and i'm realizing that it's not possible. that it would require a god-like perfection. and - cliched as it sounds - humans are far, far from perfect. unfortunately for me (and my fellow vets and human counter-parts) doctors are held to a different standard. understandably. we carry the weight of lives on our shoulders. some people scoff and say to me that i just treat animals. i challenge those who would laugh to spend one day with some of my owners - some of the people that view their animals as small, furry children. judge it if you will - but regardless of how you personally view animals and their place in the family dynamic - those people love their animals as they love their family members. sometimes they are the family. i'm not putting my job on par with that of an MD, but i take it as seriously - that i can assure you. and it hurts when i feel as if i missed something - no matter how small and insignificant in the long run.
sunday 2 weeks ago - i was presented with a small dog that had been mauled by another, much larger dog. on cursory, hands-off exam - i saw 2 things that immediately worried me: schiff-sherrington posture and a very large abdominal hernia.
schiff-sherrington posture describes when the front limbs are rigidly extended and the back legs are flaccid or normal. with this posture - mentation is normal - the animal is alert and aware (unless there's concurrent head trauma). this represents a lesion in the spinal cord between the third thoracic vertebrae and third lumbar vertebrae (thoracolumbar area). in the case of trauma like this - the cause is almost 100% a spinal fracture.
coupled with that, the dog had a very large bulge running along his body wall and abdomen. i palpated carefully and was confident that i was feeling small intestines herniated. there were multiple puncture wounds along the flank and abdomen. the dog was in very poor shape. he was in excruciating pain and shock. i started fluids and heavy opioids and went to talk to his distraught owner.
she was not alone. her mother and daughters (both younger than 7) were present. they were well-behaved but naturally upset at the state of their 2 elders (mom and grandmom). i talked them through the condition of their dog. i told them that i suspected a spinal fracture. we discussed the cost of diagnosing this (radiographs for the spinal fracture) and other diagnostics. the owners were very strapped for money. they agreed to xrays, and then they went to apply for CareCredit (a line of credit that can be used for medical needs like plastic surgery, dentistry, and veterinary work). while they attended to that, we took our little patient to xrays. sure enough, L2 was badly damaged. the transverse process (the point on top of the vertebrae that you can feel if you run your finger along a dog's spine) was destroyed. the vertebral body was half the length of a normal one, having fragmented, and the spine was luxated. it was bad.
back i went to the owners with this news. i gave them a poor prognosis. they had failed to qualify for carecredit and money was a definite issue. we discussed stabilizing the dog and sending him to UT for spinal fracture repair (stabilization surgery). that coupled with the hernia would have cost $3000-5000. the owners couldn't afford the $350 that it cost for what we had already done. further, the dog would have most likely faced a life in a dog cart, with bladder expressions, and physical therapy.
so - what - you might wonder - has been bothering me exactly? i handled the case well. i gave good pain control, i managed the shock, i did diagnostics in the correct order so that i could give the owner's my best guess at how he would do and what he would need. we discussed everything at length - the dog's condition, their financial state, the likelihood that he would recover well. i gave them an accurate estimate...i did it all right. right?
except i forgot to check deep pain. deep pain sensation is the last thing to be lost in spinal injury. if it's gone - the prognosis for return to walking, bladder control function, and the like is extremely poor. if it's intact, the prognosis is much better. and i forgot to check it! it's a basic part of a neurological exam, something i've done a hundred times at school. and yet - in the craziness that is sunday afternoon - i forgot.
the owners elected euthanasia. it was terrible. it took them 4 hours to proceed with it. we had to wait until the husband came, then the grandfather. at the end, there were 6 people present, plus me, plus a technician. the dog was in terrible pain, despite my extremely heavy hand with the opioids. though i repeatedly warned them to not move him around (as they were saying good-bye), the owner and her mother both did - leading to the owner receiving a bite on her thumb. it was stressful and emotional. before it was over - the mother asked me 1) was i the REAL doctor? and 2) was i sure that the xrays belonged to their dog?
but don't get me wrong - they weren't bad people. just incredibly distraught at the horrible trauma that had befallen the smallest member of their family. in the end, he went peacefully.
they could only pay $320 of their bill and post-dated a check for the $30 difference. the dog was in terrible shape. he likely had other internal injuries along with his herniated intestines and spinal fracture. the chance that he would have survived and had quality of life was very small. i knew all of this. i know i handled it well. and yet, i beat myself up for forgetting to check deep pain sensation for a week. after talking to many experienced veterinarians, i have been able to let it go and focus on the fact
that nothing i did or didn't do affected the outcome of that case.
but it's this experience that makes me realize why vets have the 2nd highest suicide rate of all medical professions. don't get worried, i'm not considering suicide! but i realize how hard it is to let the little things go. i want to do the best i possibly can for all of my patients, all the time. i want to be absolutely perfect in my pursuit of correct diagnostics, absolutely vigilant in my physical exam and monitoring, and never forget or miss ANYTHING. EVER. and i'm realizing that it's not possible. that it would require a god-like perfection. and - cliched as it sounds - humans are far, far from perfect. unfortunately for me (and my fellow vets and human counter-parts) doctors are held to a different standard. understandably. we carry the weight of lives on our shoulders. some people scoff and say to me that i just treat animals. i challenge those who would laugh to spend one day with some of my owners - some of the people that view their animals as small, furry children. judge it if you will - but regardless of how you personally view animals and their place in the family dynamic - those people love their animals as they love their family members. sometimes they are the family. i'm not putting my job on par with that of an MD, but i take it as seriously - that i can assure you. and it hurts when i feel as if i missed something - no matter how small and insignificant in the long run.
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