Diary of a Third-Year Vet Student: Getting Closer

At our vet school, in the last term of their third year, vet students spend three weeks participating in "junior clinics." They are intended to prepare us for the real thing, our fourth-year clinical rotations that will begin in just a few short weeks. Not all schools arrange this, and it is an amazing feat of scheduling on the part of the faculty, but as I am finishing up the last of my three junior clinics, I have to say that I feel so much more prepared for what I will be facing in June.

The fourth year of all vet med programs is spent in clinical rotations: one- to four-week rotations in different parts of the hospital such as cardiology, large animal medicine, and anesthesia. I have chosen to pursue a "general" track (my other options were large animal, small animal, and non-traditional). None of the choices will directly help me pursue a career in poultry medicine, but the general track will give me the most well-rounded perspective. I will be getting my poulty-specific education during my preceptorships and internships (students have to arrange those on their own, and that's a whole 'nother blog post in itself).

Back to the junior clinics. I was assigned cardiology (mostly small animal), large animal medicine, and RVP (rural veterinary practice). The junior clinics only approximate the real thing. We only spend five mornings with each of our assigned areas. But if you get lucky, those five mornings can be jam-packed!

I am surprised to tell you that, despite my suburban upbringing, I am much more comfortable with cows and goats than I am with dogs and cats. On Monday, I helped perform physical exams on two 10-day old pygmy-Nubian cross goats and then supported one while it was sedated and debudded (the specialized cells that grow horn were removed from its head). They were the size of small cats, and just as cute as they could be.

I spent several hours yesterday doing pregnancy checks on dairy cows. Pregnancy checks are done via rectal palpation. You usually have to empty a fair bit of poop from the cow's colon first, and no matter how careful you are, you get poop all over you. And some of them like to pee on you as well. Preg checking is a messy undertaking. You always make sure to wear decent clothing under your coveralls because nobody will let you back in the vehicles covered with that much poop. When I was able to correctly diagnose not just a pregnancy but in which uterine horn the fetus was located, it felt like a major achievement. Our instructors always check our "work" via palpation or ultrasound, so no management decisions are made solely on the say-so of a student. It's an amazing learning opportunity.

Today I spent a couple of hours putting special ear tags onto dairy heifers who had been vaccinated against Brucella abortus, a bacterial disease that can cause abortion in cows and make people very sick as well as cause abortions in women. People usually get exposed by consuming unpasteurized milk or cheese. The vet, the fourth-year student, and I divided that task up--vaxxing 51 heifers--and made it into no work at all. The vet administered the vaccines (not that we students couldn't have done the poking but it was a bit of a safety issue--it is a modified live vaccine and an accidental needle stick could have made us very sick, plus annoyed lots of people because of the reams of paperwork that would have had to be completed), the fourth-year put in an ear tattoo, and I finished up with the bright orange metal tag (ear tags are great but can easily get pulled out and lost; tattoos are permanent but impossible to see from a distance; redundancy is the goal here). Oregon has a surveillance and eradication program for this particular pathogen, and keeps tight records on vaccinations and outbreaks. Our work today will end up in state and federal databases in a few days.

As we were working our way down the narrow aisle of heifers with their heads locked into stanchions, we had to climb over mounds of feed that were piled in front of them. The cows were constantly sniffing us, licking us, and nibbling at our coveralls. I was covered in cow slobber from waist down. They were very curious! 

I know that some of my classmates shudder at the thought of having to touch anything other than a dog or cat. But I think herd medicine is fascinating! The vaccine we were giving to the heifers protects both them and us from a really serious pathogen. It is a perfect combination of production animal medicine and public health. That's the kind of vet med I want to be involved in.

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

I recently got a chance to observe a very cool cardiac surgery. The pup came into the teaching hospital with a severe congenital defect in her heart. She had a grade 5 out of 6 murmur, which even inexperienced vet students could hear! Grade 5 murmurs also have something called a palpable thrill, which means you could feel the murmur by putting your hand on her chest. It felt like an electric buzzer was tucked in there.

This particular defect needs to be corrected. If it is not treated, animals die young of congestive heart failure. This pup had the severe murmur, extremely deranged blood flow patterns that we could see on echocardiography, and a greatly enlarged left heart that we could see on radiographs (x-rays). She didn’t have any obvious clinical signs of heart failure but it was only a matter of when, not if.

The defect was a persistent duct between her pulmonary artery and her aorta that should have closed a few days after birth. There are two common ways to correct this defect. The first method is to open up the chest and tie a suture around the persistent duct. Amazingly, this is the cheaper option!

The other method is to place a device called an Amplatz Occluder. This neat little device is specifically designed to resolve this particular defect in dogs, and placement of this device was the option that the owners of this pup chose. To place the occluder, a large catheter is first inserted into the dog’s femoral artery (in its thigh) and pushed all the way up to the aorta and then through the defect. The device is threaded into the catheter and pushed into the pulmonary artery. When it is deployed, it opens up like a mushroom-shaped umbrella. It is pushed up against one end of the duct by the pressure of the flowing blood. The device is made of a special metal mesh that encourages clots to form in and on it, and with time, fibrotic tissue forms around the device. All of this combines to close off that duct. The occluder becomes a permanent part of the dog’s body.

This surgery was a perfect combination of technology, medicine, and physics. Placing the catheters into the persistent duct requires a lot of real-time imaging and a steady hand on the part of the cardiac surgeon. Choosing the right size of occluder requires a lot of tests and imaging even before surgery begins. Here’s the cool physics part: the surgeon deployed the mushroom umbrella and in two heartbeats, the pup’s diastolic blood pressure increased from 30 (way too low) to 80 (in the normal range). In other words, the pattern and pressure of the blood flow through her heart became more normal in just two heartbeats. When she woke up from surgery, her murmur was completely gone. I listened to her new, normal heart rhythm myself. 

This is what makes vet med such a visceral experience. Students were involved in the entire procedure from the beginning. We could ask as many questions as we wanted. We helped obtain the physical exam and imaging data used to diagnose the problem. We watched the surgical procedure from just a couple of meters away. We were responsible for the aftercare of this pup (minimal, she woke up from anesthesia ravenous and ready to go home). And this was just another day in the cardiology unit at our vet school.

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. 

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.

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

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.

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.