Saturday, March 17, 2018

Diary of a Third-Year Vet Student: An Amazing Little Thing

Something wondrous happened during Large Animal Surgery lab on Wednesday. It was the last surgery of the term and the last surgery we will perform as third-year vet students. I've mentioned before that we are grouped into teams of three for our surgery labs and rotate through the positions of surgeon, assistant, and anesthesiologist for the big procedures. It's an excellent way to learn how to perform those roles and how to communicate effectively with each other. For this term, I was grouped with two guys that I'd not worked with before on other class projects. I've now spent a lot of time with them in close quarters in highly stressful conditions, and I'd have to say that I got really damned lucky to be their teammate. 

Speaking of close quarters, vet med usually involves teams of people working in sometimes less than ideal spaces. Forget the blood and poop and pus fountains. If you are sensitive about touching other people or being touched, vet med is not for you. It can get pretty cozy at times.

Anyway, for this last surgery, I was the surgeon, having picked this procedure at the beginning of the term thinking it would be relatively straightforward. Well, that happy delusion persisted until we got the notes from the instructor on the surgery protocol...and everyone who had unhappily chosen to be surgeon for this one started freaking out. Not just the usual grumbling, but freaking out. This was by far the most complex surgical procedure we had yet performed, involving incision and then closure of multiple layers of different tissues (I ended up going through 9 packs of suture material before we were done). The procedure itself was quite complex with some new techniques of tissue handling that we had not done before either. And on top of all of that, the instructor wanted us to close one of the organs using a suture pattern we had never even heard of, much less knew how to do. Yikes!

I scurried off to Dr. Google but couldn't find a good picture of this suture pattern. The instructor's notes included a written description of the pattern, but as you know, a picture is worth a thousand words. Plus the written description didn't make a lot of sense. I finally decided to sketch a couple of possibilities of how the pattern might look in Powerpoint and emailed the instructor. Close, but not quite right, she said. I tried again--and bingo! On the third try, I managed to draw a correct picture of the pattern. Once she said, yep, that's it, I emailed it to the class. We surgeons were all still freaking out but that was one less unknown going into the lab.

The procedure that we performed on our sheep is called a left paralumbar fossa exploratory celiotomy and rumenotomy. Not to worry, I am not going to go into all the details. The point of the exploratory celiotomy part is to be able to examine the abdomen of ruminants like our sheep for abnormalities; ceasarians and ovariectomies can also be done with this approach. With sterile sleeves over our sterile gowns and gloves, my assistant and I had our hands in our sheep nearly up to our armpits, identifying organs solely by feel. It was utterly amazing. The rumenotomy part involves opening the rumen of the animal to look for abscesses and metal bits that might be a source of disease. The rumen of ruminants like sheep and cows are enormous fermentation bags. Since these animals aren't terribly discriminating eaters, they sometimes swallow nails and wire. These sharp things can get lodged in a specific location and sometimes poke all the way through their guts, sometimes even to their hearts. A rumenotomy is the procedure one performs to get access to the inside of the rumen so you can feel around for sharp bits and get them out of there. Normally, one would not do this procedure unless you had verified using radiography or ultrasound that there was something in there, or if the labwork suggested the presence of abscesses. Once again, we had to stick our hands in there and feel around, this time inside the fermentation bag. 

Now all of that long-winded intro is to get us all up to the amazing thing that happened. The incision in the rumen was the one that had to be closed using the new pattern. It was an oversew, meaning I had to close the incision with the pattern then sew over my first closure with the same pattern again. Oversewing is a common method for closing hollow organs like the rumen. I placed my first knot then got sort of fuddled and had to talk the pattern through with my team (they were awesome). Lots of stressors were gathering at this point: new pattern to be placed in tissue I had never handled before, clinician and resident lurking behind my shoulder watching, the rumen is quite vascular so the surgical field was extremely bloody with 3 or 4 little vessels jetting blood into the air and adding to the chaos (I was told to ignore those, keep going), and pressure to keep up a steady pace (surgery is not a race but you shouldn't dawdle).

I placed the first layer of closure in the rumen and my assistant and I were cleaning up the surgical field in preparation for the next layer of closure (the little bleeders were now tucked inside the first closure). The resident drifted over and said, hey, that's a really nice closure. Then she drifted off to the next station. I looked up at my team with tears in my eyes and said, I have never before been told by any surgery lab instructor that I did anything right or good. 

Yeah, I know, that's really sad, isn't it? But suddenly, there it was, an amazing little thing that was actually an enormous thing for me.

And it was indeed a fabulous closure. I totally nailed that new pattern. My assistant and I went on to complete all of the required tissue closures and wrapped up that lab in good time and good spirits. The instructor later complimented our group in particular on our ability to think through problems and not just stand around waiting to be told what to do next. I credit my teammates. Both of them like to talk a lot during procedures which is precisely how we learn from each other.

Given the horror of my Small Animal Surgery labs, it's a miracle that I'd even want to do any surgery again. But I can think of no better ending than completing this difficult surgery on such a high note. It made me think that this vet thing might be happening after all. 

Thursday, March 15, 2018

I'm Watching You

Our beloved canine companions have a job that they perform with amazing dedication: they watch us every single minute of every hour of every day. My fox terriers are particularly adept at this task, and as I noted years ago, I haven't peed alone since my first fox terrier joined my house (Harry in 1998). Mimi insists on accompanying me to the bathroom each morning when I shower and get ready for the day, so I just gave in and keep a small dog bed and blanket permanently installed there for her use. 

Archie is a relatively independent little dog but he is in no way aloof. He loves affection and attention. Even so, I really didn't understand the extraordinary depth of his attention to me and my actions.  

A few weekends ago, I was getting ready on a Sunday morning to head to campus for my weekly peer tutoring session in physiology. Physiology is a first-year course, and a very difficult one. Every year, two or three students drop out or fail because of physiology. I've been providing these tutoring sessions to two years' worth of first-year students. The college pays me a pittance for my time, so it's not about money for me. I do it because I enjoy it, and because review of fundamental principles is always helpful, no matter how much you think you know about a subject. Anyway, I was getting dressed that morning, and without giving it much thought, pulled on a pair of comfortable cotton pants. Archie immediately began to run from me to the closet where his agility training bag is stored, back and forth, back and forth. It took me a while to figure out what was going on. The pants I had chosen to wear that day were pants that I normally only wear to agility trials in the winter and spring. They are loose enough so that I can wear thermal underwear and my knee brace underneath them without constriction, and black in color so they can get as gross as I need with dog slobber, treat bits wiped off fingers, and dirt, and still be reasonably presentable. 

I had to pick my jaw off the floor when I figured this out. Archie watches me so carefully that even my selection of clothing gives important information to him. 

Just in case you think this is a fluke, I have a second example. Yesterday, a Wednesday, was our last junior surgery lab for this term. It was a long day, but with finals looming next week, my study group wanted to meet and we decided to meet at my house. I got home and was bustling around the house trying to straighten it a little bit when I noticed Archie again running back and forth between me and the closet containing his agility training bag. 

I figured it out quickly--it was Wednesday, one of the nights he goes to agility class. Really? Really, does my dog know what day of the week it is? I think that he does. While he doesn't know minutes or hours or days as specific things, he is able to track the passage of days to the next class. He knew that we should be getting ready for class on that day at that time, and was letting me know, hey, I'm ready, let's go!

Of course he was quite distracted when the study group arrived and snacks were being passed around the room. But these two events have made me think more deeply about the information that I am giving my dogs. Frankly, the unanticipated association that I created for Archie of specific clothing or days of the week with the excitement of agility is one that I want to preserve, not dilute with false promises.

Friday, March 09, 2018

T3i: How Do I Love Thee? Let Me Count The Ways.

Two weekends ago, Archie earned his AKC Excellent Standard title, so I proudly enter the ring with Rosecountry's Bust A Move AX AXJ. Our focus is now on MACH points and double Qs.

But that's not what I came here to talk about. An update from the Terrier Toy Testing Institute (T3i) is long overdue. 

I stumbled across some large, flat, multiple-squeaker toys last year and on a whim, bought two. I called them "fishy" but they are actually frogs. Archie loves this style of toy. He loves them so much that he loved both "fishies" to death. When there was nothing left but bits of plastic rattling around in the squeakers and threads holding the covers on, all the plush long worn away, I knew I had to find replacements. 

I think the new toys meet all the necessary criteria. They are not from the same manufacturer but they are basically the same style. It took Archie a year to destroy the first two toys even with regular appearance in the daily toy rotation of a very active terrier, so T3i rates these a 10!

I've mentioned the odd way that Archie plays with his toys, how he rucks up dog beds and blankets to shove the toys underneath, only to root them out and do it all again. Here's a video of Archie in action!

source of the title of this post

Thursday, March 08, 2018

Diary of a Third-Year Vet Student: Boosting My Confidence

Yesterday we did our first sheep surgery. I was the assistant surgeon. My team for the Large Animal Surgery Lab class has been really great at communicating and dividing up tasks, and after a bit of discussion, we decided that I'd try to place the jugular catheter in the sheep.

With one of my teammates holding the sheep securely, I clipped his neck. Then I did a rough prep with betadine and alcohol and injected a line of lidocaine under his skin where the catheter was going to be placed. Then I put on sterile gloves and did a sterile prep. My other teammate opened the package so I could grab the catheter while remaining sterile and he helped me fill it with heparinized saline. I hit the jugular vein right away but passed the catheter all the way through the vein so we had to pull that one and give it a go with a second catheter. It's really important that these be placed in sterile conditions so you don't introduce bacteria into the skin or blood. I was successful with the second catheter and placed two stitches through his skin and tied them around the catheter port to hold it in place.

My arms were shaking from a combination of stress and excitement when I finished. It was a big boost to my confidence to get it done quickly, efficiently, and properly. Even better, that catheter remained patent for the two hours it took to do the surgery. I can't take all the credit, however, because successful catheter placement depends quite a lot on the person holding the animal. Our ram weighs 186 lb and was not sedated. I kept thinking about that as I was kneeling on the ground in front of him, poking him with sharp things, but my teammate did a fabulous job of keeping the ram steady and calm.

Next week is the last week of this winter term, then finals, then a week off. Our lecture and lab schedule drops off a lot in the spring term because we will be doing mini (week-long) clinical rotations to prepare us for the real things that start in June. Our cohort will break up then since the order of the clinical rotations is different for each of us. Plus their length depends on the track that we have chosen. Most vet schools offer tracks along the lines of small animal, large animal, non-traditional, and general. I went with the general track. With my interest in poultry medicine, none of the other tracks were suitable. Finishing my time in vet school with a well-rounded exposure to all facets of vet med seemed to be the most reasonable choice.

Since I can't put up a picture of the sheep, I will leave this here instead.

Freezing fog is typical for western Oregon winters. These ice feathers formed on my car windshield overnight. I took the photo sitting inside the car looking out towards the sun which is just below the horizon.

Wednesday, February 14, 2018

Diary of a Third-Year Vet Student: But How Is The Hemostasis?

It’s a rule of life that we develop rules of life as we go along. One of my rules is, “Never miss an opportunity to pee.” A new rule that I have added since starting my vet school is, “Whenever you encounter really stinky odors wafting out of Necropsy, make a beeline for the viewing gallery and start asking questions—you are bound to learn something.” Death is a constant and significant element of veterinary medicine. Oftentimes, doing a necropsy is the only way to collect a key tissue or fluid sample for analysis. In the case of some diseases in some species, it may be the only way to make a definitive diagnosis. In vet med, being able to perform a proper necropsy is a learned skill that is just as important as doing surgery. During our fourth year clinical rotations, each of us will do a one- or two-week stint in that part of the hospital. I'm looking forward to it.

Necropsy is not what I decided to write about today. I wanted to write about a related aspect of vet school: using cadavers to learn procedures. It's really great when we get live animals to do surgeries on, but for some invasive procedures and surgeries, it is prudent that we practice on cadavers first. 

Despite my interest in necropsy, I detest our cadaver labs. The animals, or their parts, are either still frozen or are melting into goo after being used for a couple of weeks in other labs. Cadaver labs don't have the alluring stink of necropy. They just smell bad. Sometimes I can hardly bring myself to touch the specimens--they are cold, slick with a film of bacteria and ooze, and the texture is so very wrong. 

But last week in our Large Animal Surgery lab, the instructors threw us an interesting twist. We were to perform two procedures that are commonly done on horses to correct growth abnormalities in their legs. Each team had a horse cadaver leg. Just the front leg from below the elbow to the hoof. Here's the twist: the two people in each team who were to perform the surgeries had to scrub in, gown up, do a sterile prep of the surgical sites, do sterile drapes of the surgical fields, and suture up the incisions as appropriate when we were done.

Having us treat the cadaver lab as if it were a surgery on a living animal completely changed the way we all approached it. I thought it was an excellent review of the sterile techniques we are required to learn and put into practice, and a good way to get us to focus on doing the surgery well and not just mess around in a horse cadaver leg. It felt like a real surgery.

We even had to write surgery reports. That's what the title of this post refers to. Hemostasis means controlling blood loss during surgery. Since cadavers don't bleed, there is no need to monitor and react to that but quite a few of us put the statement "Hemostasis was adequate" in our reports for a little dark vet med humor.

Of course, there was a bit of a disconnect when we began the lab by duct taping the legs to the surgical tables.

The magic was quite gone when the legs showed up again for this week's lab. We practiced the common nerve blocks and joint injections in horses that are used to diagnose and treat lameness, injecting saline mixed with a blue dye. After we completed all of the procedures, we had to dissect the legs to see how close we got to the target nerves and joint capsules. My team struggled mightily with one of the joint injections that should have been really easy. We found out on dissection that the horse had proliferative bony growth covering the joint. No wonder we couldn't get a needle in there! It was also likely the reason he was euthanized. It was a long afternoon with a decaying horse leg. But it was a necessary step along the way to becoming a veterinarian.

Wednesday, January 31, 2018

CircusK9: File Under "Never A Dull Moment"

Hijinks and hilarity are the rule, not the exception, at CircusK9. I have two stories to illustrate and amuse. 

The first story is about Archie. He loves to play--he plays with the cat, with Azza, with his toys, with me. When I am studying, he brings me toys one by one, hoping that maybe this one will entice me to play since the one he brought me five minutes earlier did not. I've written before about looking up from my books and notes and computer to find myself surrounded by a sea of dog toys, so many that I have to move them out of the way to move my chair. 

Often when he is super stimulated during toy play, he carries his toys into Azza's or Mimi's crate, or to the two dog beds by my study area. He proceeds to ruck up the bedding, vigorously pulling it up and back with his front paws, with the general aim of burying his treasure within. He can completely turn over all of the bedding in the process, and in the case of the dog beds, move them several feet across the room. He will also bury his antlers like this. So every morning, while the dogs are eating breakfast, I go around to all the crates and dog beds to straighten out the bedding and remove all of Archie's stashed toys and antlers. 

The other morning while I was straightening up the dog things, I was completely taken aback to find this:

That is a picture of an antler and a plush toy carefully placed on the cat's scratching box. In case you are thinking, "pfft, carefully placed--that was just an accident", I will tell you that I removed them and a different antler and two different toys were on the scratching box the next morning. Archie deliberately stashed his treasure there.

There are several levels of silliness here. I have no idea why Archie gets so much pleasure out of burying his toys--he never retrieves them so I think it is the act of moving everything around that he likes. He never puts toys in his own crate. The terriers regularly take snoozes in any available crate or bed, but they absolutely know which crate is theirs. While the cat doesn't use a crate, Archie sees him use the scratch box every day. I can only assume that Archie logically translated this as "cat's special place, good for stashing treasure." Makes perfect sense.

The second story is about Archie and the cat. I don't free-feed Beast--every meal is measured out. Thus he is convinced that he will starve and blow away like a bit of fluff, and he is constantly, and loudly, on the lookout for things he can eat. The compost bucket is a regular stop on his rounds although I've learned to put the lid on it when I put things like eggshells in there. He will come to the kitchen and beg just like the dogs when I am preparing dinner, although I have a low tolerance for that behavior and chase them all out after a few minutes. 

Last night, I carved out an hour to make some real food. I sliced up half a sweet onion, peeled and cubed an eggplant, and cleaned, trimmed, and cut up three chicken thighs into thumb-sized chunks (when you are in vet school, you learn that when you manage to find time to cook, you cook big, enough for several meals, because you don't know when you'll have time again). I put all of that deliciousness into a saucepan with olive oil, salt, black pepper, and basil, gave it a bit of a stir, and turned on the burner. Suddenly, and now I can't even remember exactly why, I had to run back to the bedroom for something. It seemed necessary at the time. I was only gone for a few seconds. 

I returned to the kitchen just in time to see the cat leaping off the stove with a piece of raw chicken dangling from his mouth. A piece of raw chicken he pulled directly from the heating saucepan. Little fucker. Archie was waiting below, jaws open like a crocodile--he is a very alert terrier and knows when the cat is up to something. The cat leaped over his head, hit the floor, and the chase was on. The cat was so frantic to take his treasure into the bedroom and under the bed, and Archie was so equally frantic to take the raw chicken from the cat's mouth, that they were bouncing off each other, off walls, off corners, off furniture, like pinballs. Archie was growling, the cat was growling, I was laughing so hard I could barely stand up. 

I grabbed a flashlight, ran to the bedroom (yo, a nod to earthquake preparedness here, I have flashlights stashed all over the place), and dropped to the floor to watch it all play out. I sleep on a platform bed so Archie was not as maneuverable in that low space as the cat was but he sure gave it his all. In the end, the cat managed to choke down the piece of raw chicken before Archie could take it from him. Archie had to console himself with licking up drool and juice from the floor.

Never, ever a dull moment.

Saturday, January 27, 2018

Diary of a Third-Year Vet Student: Back in the Saddle Again

Our pony, Thomas O'Malley, is shaping up nicely. He had a bath last Monday and is getting groomed daily. Nobody on my team is all that expert at daily horse care but we make an attempt at keeping him brushed. I've been trying different grooming tools on him. He seems to like a regular plastic hairbrush with knobs on the bristles the best. I can gently brush his face and forelock and he closes his eyes in what I think is pleasure.

My Large Animal Surgery team castrated Thomas on Wednesday. We do three big surgeries this term and each team got to decide who would be surgeon, assistant, and anesthesiologist for each one. I intentionally negotiated with my team members to do anesthesia for this first (and only) surgery on our ponies.

I had a really terrible experience at anesthesia for the third dog spay that my Small Animal Surgery team did last term. The dog survived, but she did all she could to make things difficult. She needed glycopyrrolate twice during surgery to get her heart rate up, she needed more injected pain meds (morphine) during the surgery (she had already received 3x what we had planned before that point), and most of my monitoring devices stopped working or weren't working. I only had a device to measure the oxygenation of her blood and her heart rate, and a crappy little inline device that we added during the procedure to measure how much CO2 she was blowing off. And that's basically it. I was manually breathing for her by squeezing the rebreathing bag 4 to 6 times a minute, every 10 to 15 seconds or so. I had to do that for 1 hour and 45 minutes. ONE HOUR AND 45 MINUTES. I'll leave it to you to figure out how many times I squeezed that bag, but it was a horror show. I stared at the clock for my mark then watched the manometer to make sure I didn't squeeze too hard (easy to do) then turned back to the clock. I was hardly breathing myself. I stopped just twice during that period to manually measure her blood pressure using a cuff and a squeeze bulb--inaccurate but it was the best I could do under those time constraints. She was hyperventilating so she was not inhaling as much inhalant anesthetic as she needed and I had to keep adjusting the rate of flow of that drug. Her belly was rapidly moving up and down for most of the entire procedure from the hyperventilation, making it very difficult for my teammate to place the three layers of suture required.

But she survived, and recovered smoothly and quickly despite being pumped full of all kinds of drugs. And I learned a lot about physiology and anesthesia in one afternoon. A crash course, really. Even so, I felt pretty traumatized by it and I didn't want that experience to hold me back when it was my turn to run anesthesia for my Large Animal teammates. So I decided I needed to tackle the anesthesia role as soon as possible--get right back into the saddle.

No matter what the procedure, the student anesthesiologist has to give peri-op antibiotics, pre-op analgesics, and pre-sedating drugs so we can place the IV catheter. Then we induce with more drugs, intubate, give more induction drugs because we tend to err on the low side, and get the patient hooked up to O2, inhalant anesthetic, and what seems like thousands of monitoring wires and leads. The drugs and doses vary with species but the basic tasks are more or less the same. I did all of those things for our pony without too much trouble or reference to my notes. And when all of the other ponies became hypotensive (blood pressure too low) and had to be put on special IV drips to address that, our pony's blood pressure remained nearly normal, as in waking and walking around normal. His heart rate--same thing. He was absolutely sedated, but he was just not having any problems with it! The only bit of trouble was that he wanted to stop breathing every so often. His average respiration was about 5 to 8 breaths per minute but they weren't evenly spaced and I sometimes had to remind him to breathe by manually giving him a breath. But given that I had spent most of the dog spay doing just that, I had no problem with it.

Besides the castration, which was basically more like a giant dog neuter than a pony castration, we did some additional procedures including hoof care. I had to continue to monitor anesthesia during that as well as help my team.

I am really pleased with how well it all came out. I felt like I had a much better idea of the balance between the drugs and what I was observing and monitoring. Rather than squawk out a panicked "help!", I was instead calmly calling over the clinician or resident and saying, "I see this combination of physical parameters that look great, holding steady for an hour, but this other parameter is trending a little off. I don't believe it is a problem but I wanted to verify that." Such a huge difference between panic and validation of my interpretation of the situation. I am so very glad that I chose to repeat the anesthesia experience right away. It wasn't a perfect walk in the park--I made a couple of rookie but correctable mistakes. I learned from those too. All of my classmates are taking similar tiny steps towards becoming a veterinarian.