Diary of a Fourth-Year Vet Student: Student Doctor, Student Surgeon

I'm on my first rotation of my fourth year of vet school, also called the clinical year. This particular rotation is unique to Oregon State University because of the many years-long relationship they have with Oregon Humane Society in Portland. Every vet med student spends three weeks at OHS sometime during their clinical year.

In some ways, this is a good rotation to begin with. We are treated like, and are expected to act like, doctors. We are expected to make diagnoses, suggest appropriate rule-out and monitoring tests, and suggest appropriate medications. We are also responsible for patient care for hospitalized patients--cats and dogs who are too sick to be housed with the other animals and too sick to be adopted. They might need surgery. They might need drugs to treat infections. They might just need some TLC and encouragement to eat. We see our patients three, four, five times a day for several days in a row. Sometimes they get better. Sometimes they don't, which is hard on everyone. Last week, I had a parvovirus-infected dog who had been placed in isolation. For every visit, I had to put on booties over my shoes, a disposable (one-time use) plastic gown, and gloves. One night, I woke up around 1:30am worried about my patient. I quietly left my room and went down to isolation and put on all that PPE. I opened the door to find my classmate Claudia already there before me. She woke up a few minutes before I did, also worried about my patient (she also had a patient in isolation who had pneumonia). Turns out that my pup was indeed having a bit of a crisis (spiking a fever associated with secondary pneumonia) and we spent about an hour sorting out some changes in her treatment. We were tired and not thinking clearly and not working all that quickly, but we made some choices that turned out to be good ones. In this rotation, I'm learning a lot about medicine and how to be a vet.

Because this is an enormous shelter that has a goal of finding a home for every adoptable dog and cat, we also get to do lots of spays and neuters during our rotation here. During the fall term of our third year, we each did one cat spay, one dog neuter, and one dog spay. I also did a bonus 1/2 cat neuter (I did one testicle, a classmate did the other). That is typical for most vet programs. But with the OHS rotation, we are getting considerably more experience than that. After the end of my second week, I've done 8 or 9 dog neuters, 6 or 7 kitten spays, one adult cat spay, one dog spay, and 10 or 11 cat neuters (the actual tally is on a sheet back at OHS). In fact, just yesterday afternoon, I did a puppy neuter, two kitten spays, and an adult dog neuter--and I completed all of these surgeries in less than 2 hours. I was also working 90% solo (I had a bit of a struggle with one of the kitten spays and needed help resolving that--one of her uterine horns had wrapped around her bladder and I didn't recognize that was the problem--easy to fix, just exteriorize the bladder, unwrap the uterine horn, poke the bladder back in, and continue on). To give you an idea how amazing it is for me to do those surgeries in 2 hours, our student surgeries last year on just a single animal were usually three or more hours long (partly because of our inexperience but also partly because of the incredibly fussy and complicated protocols we had to follow). Yesterday, it was just me (no assistant), the animal on the table, a vet tech floating around monitoring anesthesia (we had three student surgeons working at the same time), and a clinician gowned and gloved ready to help if we had questions, but perfectly content to stand back and let us do it on our own. An experienced vet can do a dog neuter in 10 minutes, and a kitten spay in 15 minutes. We student vets aren't quite there yet!

Surgery is a terrifying thing. You make an incision, look inside and see guts moving around, and it really hits home that there is a living, breathing animal underneath that surgical drape. It is also a very complicated thing, even for simple procedures like dog neuters. You've got a lot of tools that need to be held and manipulated in a certain way. You've got suture--how to hold the needle, which pattern to use for which tissue. You've got tissue that can bleed--subcutaneous tissue in particular can bleed a lot and it can make your surgical field look messy and scary but you have to totally ignore it and move on. You've got lots of tissue that you don't want to touch--but it's always right there in your way. You've got a time pressure on you to get that animal off the table as quickly as you can. You've got other surgeries going on around you and it cannot become a race. You don't win by finishing first, you win by doing it right.

Kitten spays are quite something. It's like doing dollhouse surgery. You almost need magnification. The incision is typically the width of your index finger--or less if you are really good. Their tissues are tiny and delicate. And as I learned earlier this week, it is very easy to tear that tissue by accident if you don't handle it gently. My rookie mistake could have killed the kitten if it wasn't corrected right away. I was terrified and totally freaked out (screaming inside, more or less hanging together on the outside), but the clinician very calmly walked me through how to fix the problem. She then told me, we've all made this mistake, and it's good that you did it here where you can learn how to fix it and learn how to prevent it. Even so, I had to go outside and have a cry when I finished up with that kitten. Later that evening, I confessed my fears and anxiety to Claudia, and she and I went down to the cattery to check on the kitten. Kitten was eating, purring, looked just fine. Yesterday, I had to take some super deep breaths when the techs laid another kitten on the surgery table in front of me. Was I ready for that? We are all gowned and gloved and masked so you get really good at reading eyes and other body language signals. My classmates, working on their own dogs and cats, looked up and sang out, you've got this kitten! You can totally do this! So I did. Then I did a second kitten. And while I was a bit tentative with my tissue handling, that probably reduced resulted in a better job overall.

So we are looking after each other, learning to make decisions for our patients, learning how to handle tissue and do surgeries efficiently and safely, learning how to diagnose problems, learning, learning, learning.

Diary of a Fourth-Year Vet Student: A Primer on Clinical Rotations

The most common questions that I get asked by friends who are not involved in vet med concern the fourth-year clinical rotations. Misconceptions abound, probably fostered in part by the many popular hospital dramas that over-simplify everything. This is definitely a blog-worthy topic!

What I'm going to describe applies to the great majority of vet schools that have teaching hospitals. Surprisingly, there are vet schools that do not have teaching hospitals attached to them. Their students still have to do fourth-year clinical rotations but they have to take them at another school. Sometimes there are formal arrangements between schools, and sometimes the students have to arrange these activities themselves. OSU has a large teaching hospital, so for the most part, OSU vet med students complete their core rotations here.

The fourth year of a vet med education consists of those core clinical rotations and a certain number of weeks of internships (e.g., taking a course at another university) or preceptorships (working with a vet in an environment such as a clinic or dairy farm). Most vet schools require students to declare a "track" in their third year. Large Animal, Small Animal, General, and something like Non-Traditional are typical tracks. The differences between the tracks are not huge and mainly take the form of more or fewer weeks available in the year's schedule to spend in internships/preceptorships.

Vet schools use the same clinical rotation scheduling software that nearly all human med schools use. It is clunky and fairly shitty but that's just the way of it. I've known my fourth-year schedule for some months now. Minor tweaks are possible but big changes are often not approved. 

Core clinical rotations consist of anywhere from 1 to 4 weeks spent in a particular service area of the teaching hospital. The "big four" rotations are small animal (SA) medicine, SA surgery, large animal (LA) medicine, and LA surgery. There are also rotations in imaging (mainly radiology but our school also has equipment for MRI and CT), anesthesia, cardiology, oncology, theriogenology (AKA reproduction), rural veterinary practice (farm calls), diagnostic services (largely pathology and necropsy through the Oregon state vet lab which is housed in the teaching hospital), clinical pathology (laboratory analysis of fluids and tissues from patients submitted by LA and SA services), and SA ICU (can be day or overnight shifts) and LA hospital overnights.

Finally, OSU has an unusual clinical rotation that I don't think any other vet school offers. Through a long-standing partnership with the Oregon Humane Society in Portland, every OSU vet student spends three weeks with OHS doing lots and lots of spays and neuters. That is actually my first rotation.

Every track has a set number of elective hours that a student is required to take. These are courses that we take at OSU. They are compressed into one or two weeks and do not stretch out over a full term like a regular course. I took most of my electives in my third year so only have one left to take next year. It's worth pointing out that if I took a similar "elective" at another school, it would count as an "internship" for my vet med program at OSU.

For three years, my class has been moving through our program as a cohort. The big change comes on Monday. There are two or three students per rotation, but every student has a different rotation order. As a result, I will not see around two-thirds of my classmates at all next year. Literally not see them--our rotation schedules are so different that we may not even be in the state at the same time, much less in the teaching hospital at the same time.

On top of all of that, each student has to arrange internships and preceptorships for the gaps in his or her schedule. Our vet school lacks any sort of career services, and all of us have to find and arrange those internships on our own. We also have to pay travel, food, and lodging for those weeks IN ADDITION to paying tuition for that time. It's a racket, plain and simple. I have arranged some preceptorships that I will not officially put on my schedule so I don't have to pay the tuition for them.

If you are observant, you will have noticed that one thing that I have not talked about is vacation. That's because there is none. You may have a week here and there that you didn't fill with an internship but that's all you get. It will be a year-long push to the end goal: the DVM.

I think this is a decent introduction to fourth-year vet student rotations. The next post will be about the national board exam. It's on all of our minds!

Diary of a Third-Year Vet Student: I'm Not A Third-Year Vet Student Anymore

At 9am this morning, my class sat down to fill in bubble sheets for our last lecture-based exam of our vet school careers (Small Animal Medicine dermatology unit).

After the exam, almost the entire class decamped to a parking lot across the street from the vet school, in order to create a plausible-deniability barrier, and proceeded to become raucously, publicly intoxicated.

Fourth-year clinical rotations begin in just a few days (more details on that in the next post). We will no longer be a cohort of fifty-six, and that's both exciting and bittersweet. I will not see some of my classmates again until graduation, a full year away.

We of course all face one more exam: the national veterinarian licensing board exam, known by its acronym NAVLE. The testing period is mid-November to end of December. More to come on that too.

But that seems a lifetime in the future. Right now, we are still together, celebrating this momentous transition.

Diary of a Third-Year Vet Student: My Study Group Plus Bonus Terriers

Last night my study group (dubbed "The Inclusion Bodies") gathered at my house to argue our way through three or four hours' worth of Large Animal Medicine lecture notes in preparation for an exam on Thursday. It's the way we work--each one of us catches a key bit, and by talking it all through, we can put together a bigger, more complete picture.

It's spring here, and we have had a couple of sunny days which makes everyone want to be outside as much as possible, so we decided to spend our first study hour sitting out in the backyard. Of course, since it's spring, it's still freakin' cold, so I ran around the house scooping up clean blankets for everyone. (With only a few exceptions, blankets in my house are used by both people and dogs.)

We are drinking Brad's home-brewed cider.

Shortly after this photo was taken, Archie peed on Brad's blanket (and his foot) so once I stopped laughing, I had to rustle up another blanket for him!

Later, Archie made up for being so naughty by wriggling his way onto Claudia's lap and being adorable. He loves belly rubs!

Diary of a Third-Year Vet Student: Up Close and Personal

My junior clinical rotation in Rural Veterinary Practice ended today. But the entire week amazed, astounded, and challenged me.

Yesterday, I rode with the vet, technician, and fourth-year student to a farm call for a horse euthanasia. Turns out those three had been to that particular farm just the day before. Their diagnostic work had led to a very poor prognosis for the horse, and the owners called the vet even before she and the team had returned to campus to request the euthanasia.

Veterinarians confront death on a near daily basis. It is a significant element in compassion fatigue, and contributes to the high suicide rate in our profession. I think that this link should be sufficient to highlight what a real problem this is, and how AVMA is trying to address it.

But we can't stick our heads in a hole and pretend that euthanasia doesn't exist. With that awful power comes an even larger responsibility. Now, when we are students, is the time for us to learn what we can about euthanasia. On the way to the farm, the vet lectured me and the fourth-year about how the euthanasia should go, what variations in procedure were reasonable, what could go wrong, and what contingency plans we might need.

To the credit of the team, the euthanasia went very well. Some contingency plans had to be activated but because the vet had prepared us well, the clients were not aware that we had to shift to plans B and even C. For me, the bar for this procedure has been set very high. It is so important that we learn how to perform euthanasias respectfully and humanely. Every member of the team was wiping their eyes, so I know that we were all grieving for the loss of this beautiful animal along with the owners, but the vet med team was professional and respectful--and I got to see first-hand that that doesn't mean they were cold or distant. It was a good lesson.

Today, I spent the morning at another dairy. I didn't admit this in my earlier post, but two days ago, my success rate at diagnosing pregnancies was 50%. Today, I palpated six cows and I was 100% successful. I predicted pregnancy AND in which horn the fetus was lodged (left or right). After I had palpated her, a very tall, lanky Holstein farted in my face, speckling poop all over my hair and goggles (that $10 investment to protect $400 eyeglasses was incredibly smart), to the great amusement of the vet. But I didn't let that stop me. I am becoming much more confident in recognizing physical indicators of pregnancy in cows. A little poop won't slow me down.

I also got to perform a field castration of a young male calf. I won't go into the details of the specific procedure, since I don't think that is appropriate here. But I will say that when a university vet does one of these castrations, the procedure includes sedation of the animal sufficient to drop them to the ground, a focused nerve block to the spermatic cord, a quick rough scrub of the scrotum using chlorhexidine then alcohol, and tetanus toxoid, long-acting antibiotics, and analgesics afterwards. Not one of those things are used in the real world. Why not? It's all about cost and time (since time = money, it is just another cost).

I was describing the procedure to a classmate who is only interested in small animal medicine, and she was shuddering and shaking her head, saying, no, no, not for me. What factors make her say, my god, castrating a calf like that in a pen in a barn is my worst nightmare, and make me say, wow, that's really cool, can I do the next one?

I am positive that my horrible experience in small animal surgery at the hands of a very poor instructor has colored my perspective for a long time to come. He made me cry during my dog spay surgery, and fucked with my head enough to make my classmates worry about my state of mind for several days afterwards. I will not name him, but I will shame him: to make all of the women in that lab cry, but to openly encourage the men, is to be a fucking misogynistic asshole. I promise you, here, now, that if I have a clinical rotation with him in the next 12 months, I will call him out.

What has changed? How do I have mojo now when I apparently lacked it in fall term? My experiences in the large animal side of vet med are responsible. To date, all of my experiences with large animals have been positive and successful, supported in full by the clinicians in charge of my learning. Sure, those learning events aren't always taking place in a nice, clean clinic or a sterile surgical suite. But I see that as part of the challenge: how to deliver humane, thoughtful, cost-effective medical treatment in a herd/flock setting.

Sometimes we learn by good examples of bad examples. And sometimes we are challenged to do our best by supportive and thoughtful teachers. I choose the latter path.

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.