Diary of a Fourth-Year Vet Student: That'll Do, Pig, That'll Do

I have spent this week in a preceptorship that really put me on the spot in a lot of ways. I was constantly grilled with thought problems based on real-life scenarios that this person had experienced. I had to use a leg hook to catch feisty chickens--much harder than it looks, you have to be committed once you grab one. I had to get blood from many different types of chicken, and under time pressure. Sure, the basic anatomy is the same but some were so small I could barely tuck them under my arm (in this world, you hold your own bird to collect blood). Apparently I was only the second student in 10 years who had managed to bleed one particular strain, and even better, I pulled about 40% of the needed samples in that barn, which was not shabby at all.

And today, I got to do postings (the word used in the poultry world for field necropsies) on guinea fowl. They were not reaching target weight. Based on observation in the house and discussions with Clemente, the farm manager (who spoke only Spanish), we suspected coccidia, a type of intestinal parasite. It is such a problem in chickens that we vaccinate for coccidia, but guinea fowl do not get this vaccine. So the farm manager grabbed a transport crate and turned it on end, and we euthanized five birds who were not doing well. And I did the necropsies right there. I like to talk when I necropsy, probably annoying to some, but it is helpful if people who have never seen a necropsy before are watching you: "Hmm, the trachea and larynx are clean. Look, there is no feed in the crop. The liver looks great, smooth, no lesions. Oh, look at that gall bladder--a bit bigger than it should be, but then the bird hasn't been eating for a few days." And so on.

When I was done, the guy I am working with this week suggested a picture. There is only one commercial guinea fowl producer in the US and we were not only standing in one of his barns, we were doing field necropsies on the birds. Not many vet students get that opportunity. A picture! Great idea! Suddenly, the farm manager jumped over and put his arm around me.

And that photo is priceless to me. It says a lot that I could walk in and get the confidence of that guy in a couple of hours. Those are his birds in the sense that he takes care of them every single day. He wants to do what it takes to help them get better.

My mentor told me in the car afterwards that I had done an excellent job with the necropsies, and with Clemente.

Diary of a Fourth-Year Vet Student: A Weight Is Lifted

I passed the NAVLE, the national licensing exam for veterinarians. I took it back in mid-November. Everyone had to wait for their score until the testing period closed in late December.

There are some incredibly arcane statistics that go into calculating an individual score for the NAVLE. The specific questions are randomly selected for each test taker--I got around 8 questions on sensitivity and specificity while one of my classmates got none on that topic--and questions are assigned different weighting values based on how hard they are. The minimum number of points that are needed to pass varies a bit from year to year, but they usually equate to a 70-75% score.

You get an idea of how your performance compares to others who took the test during the same window as you (November to December, 2018) in specific categories such as dog, food animal (essentially sheep, goats, and cattle), pig, etc. Compared to my peers, I totally killed it in the pig and equine categories. My large animal medicine instructors will be very pleased. But I did well in all of the categories and passed the exam with plenty of points to spare above the minimum.

Everyone, every single person, leaves the exam feeling like they failed it. It is hours of grueling concentration and knowledge retrieval and application. And it is a huge weight lifted to know that it is now behind me.

Nutrition, Disease, and Mimi

For years, Mimi has exhibited symptoms of "generalized tremor syndrome." She has nearly continuous tremors of parts or all of her body. The tremors get worse when she is excited or stressed. They are also present when she is sitting quietly and thus relatively relaxed and continue even when she is falling asleep. They disappear only when she is fully in REM sleep. This particular tremor syndrome is usually observed in smaller dogs like the small terrier breeds. The tremors showed up when Mimi was just a few years old, and have been slowly progressive since then. They are not painful and they do not affect her ability to run, eat, play, defecate, or engage in any other normal dog activities. All of these are typical characteristics for this disease.

This tremor syndrome has been fairly well studied. It can't be linked to any infectious agent or toxin. Some dogs have a mild increase of white blood cells in their cerebrospinal fluid, but that isn't observed in all cases. Thus it isn't strictly speaking an inflammatory disease, although it has been described as a type of meningoencephalitis (the -itis is used to describe inflammatory diseases). Instead, the syndrome is thought to be immune-mediated. That means that the immune system got its signals crossed at some point and began to attack a specific part of the body because the immune system thinks it is foreign.

When most dogs with this syndrome are given immune-suppressive doses of corticosteroids, they begin to improve, often within a few days. The tremors may be completely eliminated in some dogs and they can taper off the steroids. Sometimes the tremors return and then the dog has to begin the course of steroids all over again.

Steroids like prednisone are a powerful component of the vet med pharmacopia. But when they are given at immune-suppressive doses, they can have some unpleasant side effects. Heck, they can have unpleasant side effects at the lower anti-inflammatory doses. They are not to be prescribed lightly. Suppressing the immune system is not to be done lightly.

For some months now, I have been reading up on this generalized tremor syndrome and wondering if I should put Mimi on an immunosuppressive course of prednisone. She is much older than the typical dog that is treated for this syndrome, mainly because the tremors don't affect her life and I chose not to treat it earlier. Not all dogs who take prednisone achieve resolution of the tremors. I've been on the fence about this since I can't predict Mimi's response to treatment.

And because Mimi is an old girl (13 years now), I have also been thinking about age-related cognitive decline. Harry experienced a significant cognitive decline during his last two years. So when I ran across Purina's new prescription diet aimed specifically at slowing this kind of cognitive decline in dogs, I was quite interested. To be clear, once neurological damage and cognitive decline are present, they are not reversible. Purina intends for this diet to be fed prophylactically to dogs before they begin to show clinical signs. The diet, called Purina Proplan Neurocare, is only available by prescription. Purina, like Hills and a couple of other food companies, does actual feeding trials for their diets. This makes their claims for their diets much more compelling. They have published some good papers on the diet and it certainly seems to work as they claim it should.

What makes their Neurocare diet different? They increase the levels of omega-3 fatty acids, the vitamin B complex, and the antioxidants Vitamin E and Vitamin C. They also include medium-chain fatty acids (vegetable sourced). These fatty acids are processed by the body using slightly different metabolic pathways than longer chain fatty acids. It's not that long-chain fatty acids are bad. Quite the contrary, the long-chain fatty acids in the omega-3 family are extremely useful and are valuable additions to any diet, including yours. But the normal human and dog diet doesn't include much in the way of medium-chain fatty acids and far too much saturated fatty acids.

Purina, like Hills and Royal Canin and other companies that made veterinary diets, also make similar diets that you can buy without a prescription. In the case of Purina, the grocery-store version of their Neurocare diet is called Purina One Vibrant Maturity. Of course, it is not quite the same formulation as the prescription diet. It lacks the extra omega-3 fatty acids. But it has extra zinc, selenium, and Vitamin E. All three of these are important players in anti-oxidant metabolic pathways. And Vibrant Maturity includes those same medium-chain fatty acids and most of the Vitamin B complex. So there is considerable overlap between the diets.

Since I started working towards this new vet med career, I have been interested in how diet can be used to decrease incidence or susceptibility to disease, to decrease the use of drugs, and to improve performance. These concepts apply to old fox terriers as much as they apply to poultry houses with 120,000 broiler chicks.

On a bit of a whim, I decided to feed Mimi the Purina One Vibrant Maturity kibble just to see what would happen. I have now been feeding it for four weeks, which is generally the length of time we know we have to feed a new diet before we can expect to see changes in whatever clinical sign we are monitoring. I made no other changes to her diet or activities.

With respect to her cognition, all I can say is that she is no worse than she was four weeks ago, although that is a really subjective interpretation that has a high risk of owner confirmation bias. She wasn't exhibiting signs of cognitive decline before I started feeding her Vibrant Maturity, and Purina's claim is that their diet will delay these kinds of changes. So this part of my little experiment is a bit moot at this time.

But here is the amazing part: after four weeks, Mimi's tremors are notably reduced. Her head tremors have almost completely disappeared. Her body tremors are still present, although they are somewhat positional now (her hind legs will tremor more if she stands just so, and will tremor less if she stands another way). To make sure I wasn't seeing changes that I wanted to see, I had two other people look at her who have seen her tremors in the past. They saw the same changes that I saw.

This is the take-home lesson: I was apparently able to alter the course of her tremor syndrome using diet alone. I suspect that Purina is not aware that their diet could have this effect since their focus has been on the cognitive benefits.

These kinds of serendipitous observations are what drive me as a scientist and as a soon-to-be newly minted veterinarian. My mind is swirling with ideas for project designs and funding sources. I'm not likely to follow through with any of them, but you never know what future opportunities might appear!

Diary of a Fourth-Year Vet Student: You Know You Are One If...

How do you know you are a fourth-year vet student?

1. You don't have time to eat the lunch you packed for the day, and after 15 hours on your feet in the hospital, you are too tired to eat it for dinner when you get home that night. You are in fact too tired to eat anything for dinner and choose to fall into bed instead. So you take that same lunch back to school the next day.

2. You are offered a half-sandwich by your clinician and your first thought is, there must be strings attached to this, it can't be free. Then your second thought is, don't be stupid, never turn down free food. You grab it, say thanks, and shove it under your white coat because you are in a treatment area and shouldn't have food in that space. Well, you will definitely get yelled at for having food there, the clinician won't. You scurry out into a hallway, find a quiet corner, and began to literally cram the sandwich into your mouth. A classmate walks by and sees you tucked into the corner and says, hey, how's it going. You slowly look over your shoulder, your mouth full of sweet, sweet calories, and you mumble, "...small animal surgery". She nods knowingly, and leaves you to your two minutes of peace and food.

3. You have 50 competing priorities and you are literally running to another part of the hospital to try to take care of at least one or two of them when you round a corner and bump into a crying classmate. You immediately stop--because at that moment, her problems are far, far larger than whatever your problems are, and because tomorrow that could very likely be you sobbing into a bowl of canned dog food--and you give her a hug and say, tell me what's up. You listen, you give advice if you can, you listen some more, you hug her again then look her in the eyes and say, you can do this thing. Then you rush off again.

My classmate was crying because she thought her patient wasn't getting appropriate pain medications and that he was painful, and the clinician and resident weren't listening to her suggestions. I told her to go back and keep advocating for her patient. I told her that she was a good vet and what she was suggesting seemed appropriate. She told me later that day that she did go back and make her argument again, and they listened and changed the dog's pain meds. She was so happy with her patient's changed demeanor now that he wasn't so painful.

4. You get fired by a client.

This is a fairly common thing across the board in vet med, but it is more surreal in this particular tertiary teaching hospital in which all of the small animal patients are referrals only. You can't just call and make an appointment. Your vet has to contact us. The firings I've witnessed have all involved students so it seems like somebody isn't thinking these things through very well. Here is my own story.

The woman brought in a pitbull mix who, like ever so many pitbulls and their cousins, had horrible joints and terrible skin. Elbows, wrists, knees, hips--all degenerating, all arthritic and painful. We had performed an operation on one of his knees earlier in the year and she was returning so we could perform the same operation on his other knee. The dog was obese and he was so painful that he could barely walk. The problem was that this dog also had horrible dermatitis. In his inguinal area (his crotch area) and the area of his belly in front of his prepuce, the skin had open, weeping sores. The skin between his toes was so darkly stained with saliva from licking that it was not the usual red-brown but nearly black. Overall his skin was thickened and scaly. Pretty much a normal Tuesday for a pitbull. She tried to blow smoke up our ass about how he just had a reaction to being bathed at PetsMart two days before (yep, she was trying to throw some minimum wage worker at PetsMart under the bus). It actually took much longer than that for his skin to get this bad. I called the regular veterinarian and discovered that the dog had a multi-year history of chronic bacterial dermatitis that would respond to a short course of antibiotics then come raging back again. (Don't get me started on how fucked up that is--they are creating drug-resistant bacteria by treating this problem in this manner.) This was most certainly not in his history. I relayed all this to the clinician, and showed her the dog's skin. She agreed with my assessment--doing surgery on an animal with an obvious skin infection greatly increases the risk of post-surgical infection, and doing joint surgery in that case could potentially lead to a septic joint and even loss of the limb. Joint infections are not to be trifled with. So we decided to send the dog back home to see if his dermatitis could be cleared up with our recommendation of chlorhex baths and a better diet. The clinician and I went over every line in the discharge instructions before she sent me into the room with the client to talk to her about this plan.

When I told the client that we weren't going to do surgery at this time, she got quite angry. She continued to trot out the PetsMart bath nonsense. I told her that the dog's skin had been that bad for days, even weeks, and she got even more angry. True, that was a mistake on my part because if my tone was even a little bit off, that would make it sound like it was her fault, and in fact that is how I think she was taking it, but jesus, the dog's skin was frighteningly nasty. She interrupted me and said, "I am tired of this middleman business. I am tired of this. I am tired of talking to students."

I paused and said, "You do know that this is a teaching hospital?" (I am already going to hell, so in for a penny, in for a pound, right?)

She looked at me and said, "I am tired of talking to students and I am tired of talking to YOU!"

I dropped the discharge instructions on the empty chair next to her and walked out of the room without another word. Honestly, I was a bit hurt in that brief moment but it quickly turned to hilarity when a teammate asked me what was wrong (my face must have had one of those priceless expressions), and I relayed what had happened. I contacted the clinician, told her that I was really sorry but that I made a mess that only she could sort out. NINETY MINUTES later she emerged from the exam room shaking her head. She looked at me and said, "That woman is insane. You did nothing wrong."

5. You get told by a client whose pet is a frequent flyer with multiple, inches-thick folders containing his medical history, that you are the best student she has ever worked with.

I have been told that by three different clients in the past two weeks.

6. You spend four weeks working with two other students on the same very difficult rotation. You become such a smoothly functioning team that, by the fourth week, clinicians and techs can't tell which student has which patient because the three of you begin to work like Borgs, speaking with one voice and one purpose. That might sound creepy but it actually results in excellent patient care.

Nothing gets overlooked when you reach this kind of teamwork. If I was scrubbed in for a surgery, I didn't even have to ask, I just knew that Lani would be setting up my ICU treatment sheets and Sushil would be in the OR taking notes for my surgery report. If they were in surgery, I would be doing the treatments for their other patients or trotting tissue samples down to the diagnostic lab. I was lucky to be part of such a strong team.

Blog Update

Blogger provides me with some simple stats on the blog, including the location of IP addresses that access it. For some reason, about 4 weeks ago, the number of page views jumped up into the hundreds per day--and the origin was all IP addresses in Russia. There is no logical reason that my blog would be of interest to Russian intel bots but I decided to take the blog offline for couple of weeks to see if that calmed things down. I'm sorry if that abrupt action worried any of the regular readers. All is otherwise well at CircusK9.