Diary of a Fourth-Year Vet Student: Let's Get It On

During my anesthesia rotation, I got the opportunity to put catheters into veins and arteries of dogs, cats, horses, and a sheep who did something stupid (oxymoron) and needed surgery to fix it.

As in any profession, anesthesia has its own set of entertaining "old wive's tales" that often have a tiny grain of truth in them. For example, here's one: little white dogs bleed more than other dogs. That's not actually true--little white dogs bleed no more or less than any other animal. You can be super careful but collecting blood for analysis and inserting catheters is a messy activity, and blood is going to get somewhere awkward or inconvenient. Even a tiny, stray drop or smear of blood on the fur of a little white dog shows up like it was painted in neon.


Another interesting one is "pitbull skin." This is in fact a real thing. Pit bulls (and bulldogs and related breeds) often have skin issues, with dry scales, bumps, and thickened skin that is not elastic like normal skin. When you push a catheter into them, their skin drags on the plastic catheter and bunches up around it. The drag makes it really hard to tell where you are, and whether you have hit the vein or not (if you have a good touch, you can feel a small change in resistance when the needle tip enters a vein but that is almost impossible to detect when you are pushing through pit bull skin). When you get a bunched up roll of skin in front of the needle, it makes it all that much harder to even advance the catheter. The thickened skin also makes it hard to see the veins which do not pop up like they do in normal skin. I poked the front leg of a pit bull completely blind--conceptually, I knew where the vein should be, but I could not see it at all. Even pit bull puppies, who shouldn't have had time to develop such bad skin, have pit bull skin.

In addition to placing venous catheters to use for fluids and drugs, vet students also place arterial catheters for use in a specific type of blood pressure monitoring setup. You've probably seen blood pressure cuffs. They are not very sensitive but are easy to use, and are not invasive. But if you place a catheter in an artery and run a line filled with fluid from the artery to an electronic sensor, you can measure blood pressure directly. Large animals (horses, ruminants) always get arterial lines because cuffs don't work well on them. But sometimes small animals got arterial lines too when it was critical that we monitored their blood pressure very accurately during a procedure.

During my three weeks of anesthesia rotation, I placed lots of catheters, and I didn't miss a single one. Only two or three required more than a single poke. I had some particular successes amongst all the successes. I placed an arterial line in the lingual facial artery of a horse in a dark surgical suite when the surgeons needed the lights off to see their monitors for the laparoscopic procedure. I could only feel the artery, not see it at all. It's a miracle that I didn't poke myself in the dark. While placing a catheter in the front leg of a cat, the cat twitched as I was preparing to tape, and the plastic catheter bent and blood began spurting out. Sure that I had just buggered that up, I pushed it back in, and looked up at the tech helping me. She said, was the blood coming from the catheter or from around the catheter? I said, um, from around it. Okay, she said, tape that sucker in there. That catheter remained patent for over 24 hours--it got the cat through surgery and a day of aftercare in ICU.

I am also proud of the catheter pictured below. Sometimes, for various reasons, we have to use rear legs or the jugular vein to place catheters. This particular dog had already had many procedures done and the veins in his front legs were total shit--collapsed, full of clots and hematomas. He was a mess. On top of that, he was a pit bull and had the aforementioned shitty skin! I had to push that long, long catheter into his lateral saphenous vein with that crummy thick skin dragging all the way. He was having surgery done on both of his elbows, but the surgeon wanted to take a look at his knees for grins and giggles. When the radiographs were made and I saw my handiwork, I immediately snapped a picture of it. Beautiful!

I got much better with my taping too. Taping catheters is its own arcane art, and everyone has their preferred way. The best way is the way that keeps the catheter in the vein as long as you need it to be in there. At the teaching hospital, the first piece of tape is not supposed to be pretty or perfect--it is supposed to hold the darned thing in place while you put the pretty and perfect tape pieces on. The anesthesia techs encourage us to be less tentative with that first piece and to just get it taped on there by singing Marvin Gaye's "Let's Get It On" to us while we work. It is effective because we all end up humming it by the end of the first couple of days.

Diary of a Fourth-Year Vet Student: Life and Death

Death is ever present in veterinary medicine. Both GPs and specialists have to address death on a daily basis. As part of our training, vet med students are introduced to it in many different ways.

I was on call one night during my anesthesia rotation, and got called in around 9pm for an emergency colic surgery on a mare. Students aren't left on their own for this sort of thing--an anesthesia technician is called in too. It was evident minutes into the procedure that the prognosis for this horse was going to be extremely poor, but the surgeons do their best to make absolutely sure that they have considered all possible solutions, so I had to monitor the anesthesia and keep this poor horse alive for almost an hour even though everyone in the room knew what the outcome was going to be.

The mare had a strangulating lipoma wrapped around her small intestines. Her large intestines were so distended with gas that they literally popped out of the initial incision. The lipoma was large, about the size of a cantaloupe, and was wrapped around a part of the gut called the ileo-cecal junction. In a horse, this is a pretty critical section of gut plumbing. Upstream of this junction is the part of the small intestine called the ileum. The entire ileum in this mare was black and necrotic. It smelled terrible. It smelled like death. When dealing with sections of dead gut, it is theoretically possible to cut out the bad part and rejoin good (i.e., living) tissue to good tissue, but the extent of the necrosis and the location of the strangulation combined to make an extremely poor prognosis for this horse.

I will spare you the photos of the horse's guts but I will share this with you. It is a picture of a toxic line in the horse's gums (lower jaw). I had only read about this particular clinical sign and never had the opportunity to see it before.

Notice how her gums are very pale above a sharply defined, dark red line. This is a sign of impending septic shock. There were a lot of really bad chemicals coming out of all those dead intestinal cells that were now in her blood stream, wreaking havoc with her vessels and immune system. Even if the surgeons could have successfully resected her gut, when she was revived from surgery, her body would have been flooded with the bad chemicals. She likely would not have survived that.

Anesthesia lets us straddle the line between life and death. Alone, it is not a cure for anything. It is just one of the many tools we use to make our animals better if we can.

Diary of a Fourth-Year Vet Student: You Are Getting Very Sleepy

Anesthesiology is one of the more arcane aspects of human and animal medicine. When you do surgery, the animal is reduced to the square of tissue in your operating field. When you do anesthesia, the animal becomes patterns of breathing, heart rate, blood pressure, blood oxygenation…a bunch of numbers collected by machines and sensing devices, and sometimes the old fashioned way with your fingers on a big artery to count pulses or checking for eyelid reflexes or mucous membrane color (should be pink always!). By altering the amount of inhaled anesthetic gas, changing fluid rates, and starting and stopping drugs from the dozens we have available to us, we can affect all of these parameters. 

For me, being in charge of anesthesia for a procedure is super stressful—you are keeping the animal alive despite the terrible things being done to its body, and not just alive but keeping certain physical parameters within specific limits. Your attention cannot waiver. You have to keep one ear open to the chatter coming from the surgical team--they may initiate procedures that will have a dramatic effect on the status of the patient but they might forget to alert you in advance. You may have half a dozen different screens to monitor. And you are constantly recording things--physical parameters, when you give drugs and how much you give and where you give it...complicated but also very interesting from a physiological perspective.

I have been thinking pretty deeply about anesthesia for the past week as I completed the first week of my three-week anesthesia rotation. In one short week, I managed to rack up my "big four"--a cardio case (I ended up with two big ones), a cat, a horse, and giving an epidural injection to any species (I gave one to a dog).

Students are also responsible for placing IV catheters. I was pretty worried about that since I haven't had much success with small animals, but I have to say that I was rather successful this past week. I placed IV catheters in every one of my patients, and with the exception of one dog, I got the catheter placed correctly in a single needle stick (in that particular dog, I got it placed correctly with the second stick in the same leg). My tally includes a 12-year-old cat with chronic renal disease, a French bulldog, and an elderly long-haired doxie. Those particular dogs are difficult because they have short, deformed legs and veins with strange anatomical placements. Weird anatomy trivia: veins often vary from the ideal, arteries rarely do. The cat--well, it's a cat. You have a limited amount of time before any cat decides it is done with all of your nonsense. They have thin skin, fragile veins, and with renal disease they can also have low blood pressure. So my successes are a bit more meaningful because they include these difficult patients.

I also had to place a temporary venous catheter in a horse during a procedure so that we could give it some antibiotics. Horses are always trying to die so they nearly always require a dobutamine CRI (continuous rate infusion) added to their IV fluid line to keep their blood pressure up. All of that was going into the catheter placed in the horse's jugular vein so I had to use another location for the antibiotics (some drugs do not play well with others). The horse was in dorsal recumbancy (on his back) and the room lights were off since the procedure was laparoscopic and the surgeons needed to see their monitors. The anesthesiologist told me to palpate a particular vein on the bottom of the horse's jaw (which was fully exposed). I couldn't see the vein in the dark, and only vaguely recalled its position from first-year gross anatomy class, but I could feel it. And by golly, I put that catheter in the vein in one poke. In the dark. It was amazing and empowering to me for the anesthesiologist to act as if he was completely confident of my ability to do this, no matter what he may have been thinking.

I did not have the best experience with anesthesia during my junior small animal surgery lab although things got quite a bit better during my junior large animal surgery lab. And now I find that I am really enjoying a rotation that I was initially dreading. 

CircusK9 Update, Long Overdue

During September, I will be traveling for two back-to-back, poultry-related preceptorships. I hope to be able to write more about them later, but for now, I wanted to put up a brief post about the dogs.  I've been so focused on vet school recently that I haven't written much about the general mental and physical state of the pack.

In the past couple of months, I've interviewed 8 or 9 people to see how they would work out for pet-sitting. And as I introduce the dogs to these new people, I am reminded of origin stories that I have sort of forgotten, that have become buried in my other quotidian concerns.

Azza will be 8 years old at the end of this year (she was born near the end of December, 2010). Azza still acts like a puppy for the most part: playful and joyful. In large part, I credit this to the fact that she lives with fox terriers. She is so much more resilient at facing the random events that life throws at her. Not quite a normal dog, but I worry about her much less than I used to.

Mimi is rounding the corner on 13 years, and has lost most of her upper teeth, yet will play fetch with a tennis ball until she drops. She is going deaf, and has started vocalizing nearly continuously, a sort of low moaning sound. Her Parkinsonian-like tremors have become quite extreme, present even when she is at rest, and often while she is sleeping (they only disappear when she is in REM sleep). Despite my advanced training, I can't explain what is wrong with her. She is not ataxic, she knows exactly where her body is in space, she has no muscle weakness, and she has no pain from this disease. She does have two lumps that I plan to have my vet poke (technically, collect a fine-needle aspirate from them). I am fairly sure they are lipomas, but it is better to be sure. They have nothing at all to do with her tremors.

From the day that I brought Archie home, Azza has been convinced that I did so for her. Whenever I go looking for them inside or outside the house, I invariably find them together, touching paws or laying side by side. They are true partners in crime, always looking for trouble.

Archie is a spoiled little monster, and I love every second of it. It was a bittersweet email that I got from AKC telling me he was ranked the #11 smooth fox terrier in AKC agility this year. He doesn't even have a single double-Q to his name! And this entire year will be a holiday from both training and trialing. A fourth-year vet student has some downtime, but not that much. It was clear from our last few trials that he needed a bit more maturing, so this "gap year" may not be the worst thing that could happen to his agility career. I am focusing instead on building my relationship with him. I must admit that I ignored some basic training in favor of driving him forward in agility. Time for re-collection.

More Musings on Vermin

I ended up trapping four black rats, one male the first night, and three females over two more nights. They were identical to the male in appearance but slightly smaller. Then the trap remained empty for about a week even though I baited it each night with delicious, fresh vegan offerings. The depredations on Beast's sprouting grass seeds and my compost bin seem to be at an end for now.

I have recently tackled a new vermin problem: yellow jackets. The bastards are out in force in the PNW during this very dry summer. Archie is normally a fearless little fox terrier, but he is absolutely turned to jelly by yellow jackets ever since he was attacked by a swarm of them. They are so numerous that they are covering my hummingbird feeder ports and driving the birds away too. Time to reduce their numbers, at least locally.

Here is a picture of one of my traps taken this morning. I put this trap out, freshly baited, about 24 hours before this photo was taken.

Here is a picture of the trap taken just a few minutes ago. The blurry bits in the pic are more soon-to-be victims. The bodies mount up and it is so satisfying. Not quite the same level of satisfying as climbing into a freshly made bed, but very, very close.

Diary of A Fourth-Year Vet Student: Doing The Things!

Some rotations are significantly better than others with respect to doing actual vet things to real animals. In this photo, I am opening up an abscess on the left front leg of a piglet, probably caused by a bite wound from his pen mates as piglets are bitey little things with needle-sharp teeth. A nice pus fountain ensued. This little piglet was lucky--the abscess was outside the joint capsule so he got to keep the leg. I flushed the wound with saline and dilute iodine and we sent him on his way.

This pig is owned by the university. I have been somewhat reluctant to post photos of animals owned by clients. Issues of confidentiality come into play. Lots of clients are quite happy to have us take, and use, photos of their animals. But there is always that one person who will raise a stink.

During that same therio (reproduction) rotation, we had a very interesting surgery earlier in the week on another piglet. He had been castrated at the university swine center, but they could only find one testicle. So they carted him up to the hospital a few days later to see if we could find the other testicle. Everyone suspected it was still inside his belly, as it is fairly common for one or both testicles to not fully descend. Usually they are lurking near a structure called the inguinal ring. Surgery with general anesthesia is required to remove these testicles but it is a standard procedure. We ultrasounded his belly first but could not find a structure that we were sure was a testicle. We opened him up anyway, fully expecting to be in and out in 30-40 minutes tops.

Only one problem: we couldn't find the other testicle. We couldn't find anything that even looked testicle-ish.

After diligent searching for over an hour, all we could find was the structure in the picture below.

This tiny bifurcating structure is a uterus! The large red loops to the lower left are his small intestine, which we had to exteriorize so we could see inside better. They are red because they are getting dehydrated and a bit angry. They were stuffed back into the piglet a few minutes after this photos was taken.

The piglet had retained Müllerian tissues. This is a simplification, but the default state of developing mammalian embryos is female. For male gonads to develop, cascades of several key hormones have to be produced that suppress further development of the female (Müllerian) tissues, cause regression of those tissues, and begin development of male (Wolffian) tissues. The timing of these multiple hormonal cascades is pretty important too. If one of those cascades begins too early or too late, there can be some unusual developmental consequences. In this case, the result was a piglet with a single testicle and a tiny uterus. The piglet lacked the rest of the Müllerian duct (cervix and vagina) and if he had ovaries, they were really tiny. So these tissues weren't ever going to be functional in the sense that they could be used for reproduction. But these kinds of tissues are tricky--they can begin to produce hormones later in the life of the mammal that can lead to metabolic disorders and cancer. So we removed everything we could find.

Biology and physiology are certainly amazing.