Wednesday, August 26, 2015

Are We There Yet?

Ever since my vet school decision was made, I've been asked dozens of times if I am "excited" about starting classes this fall. For many months, my reply was "I'm too busy with finishing my masters thesis to worry about that." Then it became "I'm too busy with the emergency vet clinic job this summer to have any energy left to think about vet school."

But reality intrudes, as is its wont. In early August, the first-year students (officially, the OSU CVM Class of 2019) received from an admin person at the vet school an email with 15 attachments. First, that is just insane. The attachments refer to half a dozen different issues and the email is in clear violation of the first rule of emailing: keep the damned thing short and confined to one subject only. Second, why are they clogging up our inboxes with that nonsense? What about Dropbox? Why not link all that info to a web page and send us the address? And third, whoa--reality.

I think the excitement switch flipped when, triggered by that email, I registered for my fall classes then set up my calendar.

A week in the life of a first-year vet student. More about the French class later.

I reviewed the list of required and optional textbooks then did the requisite online price comparisons. I also emailed my "Big Sib" to ask her how optional was optional. The Big Sib is usually a second- or third-year student. They select their "Little Sib" based on a silly survey (example question: if you were stranded on a tropical island, what three things would you want with you? I answered: an eight-inch long fixed-blade knife, the complete works of Shakespeare, and dental floss). I've already purchased the three textbooks I'll be using this fall, and two of them are sitting on the worktable next to me.

One of the things I've learned from my work in the vet clinic this summer is the importance of the heart and the blood. When we monitor patients, the minimum data we collect includes heart rate, temperature, respiration rate, and capillary refill rate. Because I only see critical care patients, blood pressure monitoring is often included too. All of those things are directly linked to the heart and blood. We also collect blood, lots and lots of blood, and analyze it for an array of cell types, protein and ion concentrations, clotting rates, and so forth. While I've learned how to collect the blood and physical data and run the machines that do the analyses, I've not learned much about what it all means. I can see patterns and trends but I haven't had any physical context for them.

So, I picked up my physiology textbook and began to leaf through it. NINE chapters on the heart and circulation. Yep, that emphasis is consistent with what I'm seeing in the clinic. I've now read the first four heart/circulation chapters, taking notes, redrawing and re-annotating graphs. And even with those small steps, I'm already building a framework from which I can hang the patterns that I observe in the emergency patients. The physiology constrains cause and effect. It allows prediction and treatment. Wow. Science.

I'm closing this post with a picture of a blood sample from a dog with hyperlipidemia. Hyper means excess, lipid means fat, and -emia refers to blood. A 1 mL venous blood sample was placed in this small tube. The tube went into a centrifuge which spun the cells down to the bottom of the tube (the dark layer) and plasma up to the top (plasma is usually yellowish and clear). We extracted most of the plasma for a chemical analysis so it is missing from this picture. But what's cool about this picture is the layer of bacon fat at the top of the cells. Yes, bacon fat. Fats are lipids that are solid at room temperature. There is so much fat in this dog's blood that it forms its own layer in the tube. The dog was morbidly obese and rather revolting to handle, sort of like holding a balloon filled with cake batter. He also had pancreatitis. Acute? Chronic? Hard to say. 

A discussion of the connection between hyperlipidemia and pancreatitis and obesity is not where I want to go with this blog, ever. I only want to emphasize that blood and the heart are pretty important things to understand if we want to treat disease in humans or animals.

Eight-inch long fixed-blade knife, the complete works of Shakespeare, and dental floss. Plus I'm sure that I will get through two more chapters on blood and the heart before classes start. Yeah, now I'm excited.

Wednesday, August 19, 2015

Reaching Goals, Bananas, and the IV Catheter

As I posted a bit ago, I wanted to try my hand at setting an IV catheter. Realistically, the best choice would be a largish, calm dog that wasn't in a critical condition. I've been biding my time, carefully watching my fellow nurses set and tape IV catheters in an array of animals, and continuing to practice taping a catheter using bananas: cheap, leg-shaped, and entirely sacrificial.

An opportunity finally presented itself. I'll be ending my job with the clinic in a couple of weeks and decided to take advantage of my enormous employee discount while I've still got it and get a dental cleaning done on Mimi.

Ah, the perfect dog at last. She's in excellent health with great veins (I stare at her and Azza's veins all the time). Plus, although the goal is to stick the animal only one time (less pain, less anxiety, more professional all around), if I had to poke her more than once, I would have no guilt about it. You might find that odd but I would feel really bad practicing on someone's sick animal. Mimi? No problem poking her with needles!

I scheduled her dental for 8am Tuesday, immediately after I ended my work shift. I brought her into work with me at 1am and she got to spend the night barking in a kennel and running around the treatment office when I wasn't too busy with other tasks.

And thankfully, the nurse assigned to Tuesday morning surgeries was one that I like and trust. I told her my plan: I wanted to do the blood draws on Mimi for the pre-anesthetic blood tests and I wanted to place her IV catheter. I told the nurse that I would not keep poking Mimi indefinitely but that I wanted to try. She was quite supportive of my plan.

We started with the blood draw. I needed about 1.5 ml for the two tests. Mimi was very wiggly and I ended up poking her four times, two in each leg, before I got barely enough. Unfortunately, one of the tubes clotted too soon and we needed more. I let the other nurse do this since I figured I had already used up all my tries on blood draws on Mimi.

Now, the IV catheter.

I got out alcohol-soaked and chlorhex-soaked cotton balls, clippers, a T-port, my four pieces of carefully measured and torn tape, a catheter, some gauze.

I could see Mimi's accessory vein really well. A lot of the nurses I work with insert the tip of the catheter at the point that the accessory vein and cephalic vein join. You have to get the tip of the catheter past a valve that lies in the cephalic vein just up from this Y; inserting at the Y positions you well for this. I couldn't see her cephalic vein at first but suddenly it was like her skin went clear and I could see everything. The noise in the clinic disappeared. The entire world had telescoped down to Mimi's left front leg and the quiet murmur of the nurse holding her. The nurse had an excellent hold on Mimi, so critical when you are drawing blood or placing catheters. I slowly inserted the needle...suddenly there was a flash of blood so I pushed the catheter (a small hollow plastic tube) off the needle and into the vein. This was followed by half a dozen drops of blood flowing out of the catheter. I rushed to cap it off, and realized two things. One, I needed to remember to breathe. Two, I successfully put that IV catheter in Mimi's leg on the very first try.

I taped it up, slowly to be sure, but after my banana practice, rather neatly all things considered. The other nurse kept coaching me along, offering advice when I needed it and encouragement too.

When I finished, I carried Mimi around to show everyone. I don't care one bit if they thought I was ridiculous. It was my first IV catheter ever and it went really well. One of the doctors, a bit of a curmudgeon, high-fived me! I was so excited.

Of course an e-collar was necessary for a dog like Mimi. You can see the green vet wrap on her hind legs where I had to keep poking her for blood.

I hope that the nurses I've worked with are proud too. I have watched them, learned from them, and hopefully can execute some things with accuracy and confidence. They deserve a big, big thanks for their patience in putting up with me this summer. I will be a better vet because I worked with them.

Saturday, August 15, 2015

Playing at Agility

All summer, I've tried to set up some agility equipment for the dogs at least once a week. I know that doesn't seem like much but Mimi is too old to trial and Azza is, well, Azza is what she is. We just play at agility. But it's fun to test ourselves.

My work in the house with the cone and a jump bar during the winter really paid off. Azza has been embracing jumping, although she will only tackle jumps set to 8"; any taller and she will go around the jump. That's okay because I'd rather test her ability to learn and read my handling. She's been doing up to four jumps in sequence, she can read front crosses, serpentines, wraps, and sends to backsides, she will recall over a series of jumps, she loves loves loves the tunnel and my little table, and while she's not flying through the 2x2 weaves, she will eagerly trot through four poles that are nearly in line. She's in fact ready to have the third 2x2 added in. She seems much less worried about touching the metal base. However, she will never have lightening-fast weaves since that requires her to touch the poles, something she is careful not to do. She seems willing to play this strange game and have a bit of fun while she's at it.

A couple of weeks ago I introduced Azza to the joy of the bunny fur tug-n-treat. I play agility with Mimi with the bunny fur tug and Azza's been observing this for weeks. Using the clicker at first, then graduating to using the fur pouch itself and its delicious treats inside, Azza has learned to chase the thrown toy then return it to me for a treat, both rewarding behaviors for her. Sometimes I run with her to the toy so she gets the treat in place--as a result, she's decided the fur pouch is a rather interesting object.

I have also started working with Mimi on flipping away from me. I'm relying more on body motion signals than verbals, in particular the hand motions I use to have her spin in place in front of me. I used a flip away quite a bit with Iz but I never taught that to Mimi. She's picking it up very quickly.

My yard is small and my equipment is limited. I decide in advance what skill I'd like to work on then either find a bit of a published course or exercise that will do or I create my own. Most of the summer we've been working on going to backsides of jumps and weave entries. Even though there is a large skill gap between Mimi and Azza, if I put some thought and effort in it, I can come up with one setup that will work for both.

I generally work both dogs quite hard. Each dog gets three five-minute sessions and I alternate them so they get a chance to rest in between.

Here's the course's we've worked on in the past three weeks. I called the two shown below "Less is More." Yep, that's right, for one week, I worked the dogs for half an hour on only two jumps! Lots of practice with backsides and wraps. In the course on the left, you can barely see the two 2x2 weaves I put at the bottom of the course for Azza. Mimi did the six poles at the top of the course. That week we focused on weave entries.

I took the course section shown below out of a Clean Run article analysing the 2015 AKC International Team Tryouts Jumpers course. I only set up the part in the orange box and I added my little table at the position of the orange star. We had great fun with this. Some tough challenges if you decide to have the dog take the backside of every jump. I plan to set up the part at the top next week to work on funky tunnel entrances and exits.

You might be thinking, what's the point if we aren't competing? I would answer that agility challenges the dogs and keeps their little neurons whirring. It's good exercise for all of us. We get to run around the yard in the cool mornings. Treats and lots of praise and excitement are included, which we all like. And it's fun!

Thursday, August 06, 2015

Are You A Shruggie?

Shruggies is a term for health care providers, including doctors, nurses, and vets, who fail to challenge practitioners of SCAM (supplements and complementary and alternative "medicine"). Despite knowing there is no scientific basis, or even a chemical or physical basis, for many SCAM claims (e.g., homeopathy, acupuncture) and despite knowing that there is no clinical trial evidence for their efficacy (e.g., glucosamine), shruggies say, if the SCAM performs no better than placebo in well-designed clinical trials, then what's the harm? (More on placebo effects here.)

In the case of human doctors, the underlying deception involved in offering the patient a treatment that may make the patient feel subjectively better for a short period of time but fails to alter in any objectively measurable way their symptoms or condition is a matter of ethical debate. For example, is it ethical to not tell a patient they have a life-threatening illness so their final days will be happy and without stress? That's a deception that will certainly make them feel subjectively better for a short period of time, just like a SCAM. Most doctors would not accept the latter scenario as ethical. Then why would they accept as ethical the deception necessary for all SCAMs? And if they don't think that is ethical, then why are they willing to "shrug" it off?

In veterinary medicine, this deception that allows the owner feel better by "doing something" but leaves the animal to suffer cannot even be a matter of such debate: it is ethically wrong to that we permit this.

There is extensive peer-reviewed literature on the lack of efficacy of SCAMs. Pick any one of them that you like: detoxification, homeopathy, acupuncture, Chinese herbs, naturopathy, touch therapy, supplements. So many to choose from! Either they are described with feel-good woo words (natural, holistic, life force) or with laughably misused sciencey words (energy, quantum) or both. None of them stand up to objective, evidence-based clinical trials with a statistically significant number of participants and properly defined control groups. Some SCAMs are actively harmful, but most are simply no better than placebo. What's the harm? The SCAM of acupuncture is often offered as a pain treatment. It has been repeatedly shown in well designed clinical trials that acupuncture does not objectively and measurably reduce pain. It is ethically wrong for a SCAM practitioner to deceive a caregiver into believing their pet's pain is being reduced. It is just as ethically wrong for a shruggie to look at his colleague sticking needles into an animal and say, well, what's the harm? 

(Don't even get me started on the fact that human and veterinary acupuncturists are consistently photographed sticking needles into the skin of people and animals without wearing gloves. That is incredibly irresponsible and unprofessional.)

We humans do a very good job at finding quick justification for things that happen to us: I ate this berry then I got sick. Therefore that berry is bad. But is that the right conclusion? Does cause directly lead to effect? Perhaps the berry was not ripe--eat it two weeks later and it would not have made you sick. Perhaps you are allergic to that berry but someone else could eat it with no ill effect. Perhaps the berry had a mold or fungus on it that you could not see and that made you sick. Perhaps you ate something half an hour previously that in fact made you sick but you forgot about eating that other thing when you found the berry bush. Perhaps you were already sick with another illness and it was a coincidence that you began to show symptoms right after you ate the berry. We hate coincidences. We prefer the neat explanation, cause and effect tied up with a bow. We prefer explanations that mesh with our previously defined opinions.

Thinking through all the possibilities that could explain an event, that could sort out the cause and effect, is hard work and requires time and discipline. Setting aside our own logical fallacies and biases is even harder. Designing proper evidence-based tests with objective, quantitative measures of all the possibilities to determine which explanation was right is difficult and takes practice and time. (Correlation does not determine cause and effect, by the way. It only suggests two things are related.) Conducting the tests would take even more time. Isn't it simpler to jump to the easiest explanation: that berry is bad. 

What if you take that berry incident further? What if you now attach some sort of magical thinking to the berry or to your experience? For example, what if you concluded that a god didn't want you to eat that berry because the plant is sacred. Now not only is the berry bad for you, you've given it some additional properties. It's bad for you because it is magical.

Just imagine if your doctor or dentist or veterinarian treated your and your pet this way, using pre-scientific magical thinking instead of modern evidence-based medicine? Oops, that's exactly what SCAM practitioners do.

When it comes to SCAMs, ethical doctors and veterinarians should not shrug them off. We have the tools and the expertise to evaluate their claims of efficacy. Many studies have already been conducted and the evidence is clear. We need to speak up and educate our clients and our colleagues: belief in and use of SCAMs does cause harm (warning: this link goes to a PDF)

I've left untouched in this screed discussion of caregiver bias (see additional discussion here), one of the underlying sources of placebo effect in veterinary SCAMs; the reliance on anecdote in SCAMs in place of evidence-based inquiry; and the straw man argument that Big Pharma is only in it for the money (if your SCAM practitioner is selling you a treatment that does nothing and that is based completely and fundamentally on your acceptance of a deception, who's really in it for the money?). 

Monday, August 03, 2015

You Deserve a Cookie!

I will freely admit that I am bitterly cynical and despairing of seeing much good in most of mankind. But I am neither heartless nor hopeless. My night nurse job in the emergency vet clinic has shown me that again and again. 

With only two people awake most of the night (the vet is usually asleep upstairs), we two nurses keep constant track of each other. The clinic is a large one and just about any kind of random shit could happen, from something as trivial as needing help holding a cat to get a temperature to a 9-1-1 call to the police to deal with a belligerent and possibly drug-addled client threatening physical violence to us. In other words, I know far too much about my colleague's bathroom habits ("gotta pee, be right back"). Still, most of the time the silence and the darkened rooms can easily lead you to feel that you are completely alone.

As a result, I am often caught by my co-workers chirping silly nonsense to animals as I perform this or that procedure: "okay, little bit, let's get this catheter sorted so we can go out for a walk"; "sorry, honey bunny, I've got to poke you in the bum"; "hold still, you crazed beast, I've got to shove this down your throat". I keep telling them, tease me as much as you want, I'm not going to stop. So, not heartless. We do the best we can for the weakest amongst us. And if silly chatter gets me there, well, piss off with the teasing.

The night nurse supervisor is scheduled to leave an hour before I do, so I bridge the gap between the night and the day ICU staff. Once the night supervisor rounds the day ICU supervisor on current patients, which also happens about the same time that the vet comes back downstairs, I alternate my focus between the day ICU nurse and the doctor.

It's my personal practice to complete pre-assigned patient care tasks first, then ask the day nurse or doctor how I can help them. I explicitly say, what can I do for you? They never turn this offer down. There is always something that needs to be done, some changes in treatment plans that need to be recorded and implemented, new blood to be drawn, additional drugs to be given. So, not hopeless. I know that they are going to have the best interests of the animal and client in mind. We are a team trying to make our tiny corner of the world a little better. If there is something I can do, then I need to do it.

In short, despite my personal curmudgeonly perspective, I try my best to support my team and to care for the animals in equal measure.

The clinic I work for is large and has many employees. The management of the clinic provides these slips of papers called "cookies". You can fill them out for any employee, describing some special thing that they did that you want to call special attention to. I have done so several times for one nurse in particular that has spent a lot of time training me. I thought we were supposed to slip them into the locked box labeled "cookies", which is what I did. Turns out another common practice is to give the filled-out slips to that employee, who can choose to put them in the locked box or not. 

Here's a cookie recently given to me by a day ICU nurse whom I respect:

Okay, I have to admit, I'm a sucker for this. Of course more money in my paycheck would be better than a slip of paper. But to know directly from my co-worker that she finds me helpful certainly makes me feel invested and rewarded.

In other news, the other night I finally achieved my first successful hind-leg blood draw from the saphenous vein (scroll down for pics of the saphenous vein; the cephalic vein is usually where the IV catheter is placed). If you have a short-coated dog, you can see the saphenous vein crossing the outside of their hind leg just above their ankle (it's also there in cats, but harder to see unless you hold the vein off). Okay, it was a relatively calm Doberman bitch, so it wasn't like I could miss the damned thing. Still, I had tried this blood draw on three other dogs and failed. She was standing so the angle for the needle was a bit funky. Still, I got it in one poke! I was so pleased. Blood, beautiful venous blood!