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.

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