The New Vet in The New Job

I'm settling in to the new job. I've had to make some mental adjustments--I still feel a twinge of anxiety when I leave at 5pm, after everyone else already left at 4:30pm. Vet school leaves deep scars, that's for sure.

I have had a string of very interesting cases these past few weeks and have really been knocking out some cool diagnoses based only on what I see in the animal remains--which are later confirmed with ancillary tests or by looking at microscopic slides of tissue. I think it's a combination of beginner's luck and a fairly decent vet med foundation.

There is a rule of thumb in vet med that goes like this: "don't go looking for zebras." I've also heard it expressed as "common diseases present uncommonly." In other words, if you see strange things, you shouldn't be thinking strange problems, although those are always possible. You should be thinking about common, garden-variety problems first.

Here are two good examples of this.

Case 1: intact female pit bull mix, 5 years old, history of vomiting, died suddenly. Before I even touched her, I took one look at the dog on the table and told my tech, "it's pyometra." Sure enough, there was more than 400 mL of brown, cloudy fluid in her left uterine horn. She died of sepsis as the bacteria and their toxins started leaking out into the rest of her body. It was not a good death. But it is a very common one for intact female dogs with this signalment and history. Her breed was one red flag. Her age was another. Five years old and still intact? Either a stray or a backyard breeder. A rescue org or a shelter would have spayed her. Sure, a foreign body or gastric volvulus (twisting) would have caused untreatable vomiting and death. And both were certainly on my list. But vets are trained to make a ranked list of differentials. And pyometra was at the very top of the list for this dog.

Case 2: neutered male Boxer, 5 years old, progressive neurological signs over period of 18 months that were not responding to anti-seizure meds. I told my colleague, "it's a brain tumor, probably a glioma." Sure enough, I found a huge gelatinous tumor in the left cerebral hemisphere, confirmed by a board-certified pathologist to be a malignant oligodendroglioma. Boxers are poster-children for gliomas. I also found changes in the valves and right side of this dog's heart that I carefully described in my report. The pathologist confirmed a right-sided cardiomyopathy of a kind that is very specific to Boxers. While in school, I learned about diseases that are more common in certain breeds of animal, and I went looking for those particular lesions. And found them, to my great satisfaction. This was a good case because it gave a lot of closure to both the referring veterinarian and the owners--there was nothing they could have done differently to change the course of disease or the outcome.

Cases 3 and 4: backyard laying hens, history of losing weight, died suddenly. Both submitted today from different owners. I told my tech, "it's either ovarian/oviductal carcinoma or it's yolk peritonitis. Equally likely." It was aggressive ovi carcinoma in both cases. In a surprise zebra finding, one of the birds had right-sided dilational cardiomyopathy and ascites. Didn't expect that, it's more common in broilers and even then you rarely see it in the U.S. But this hen had what I think is a metastatic tumor in her left ventricle, which appears to have caused upstream problems in the right side of her heart and so on and so forth. Histopathology on the heart nodule will confirm whether I'm just making shit up or whether I'm right.

Don't misinterpret these tales. This is not some game of pool where I'm calling 8-ball in the corner pocket. It is appropriate to think of differentials for any case before you begin the necropsy. You want to be prepared.

For example, whenever I am presented with an exotic animal (for example, I've worked on a snake, a bobcat, and a kangaroo), I research possible zoonoses before I even walk onto the necropsy floor. Zoonoses are diseases (or parasites) that humans can get from animals. We can get zoonoses from pet dogs and cats but there are some increased risks when you work with exotic animals. I want me and my support staff to be prepared with appropriate protective gear. I want to be able to specially identify samples if there could be a risk to other lab personnel.

As a newly minted veterinarian, it's validating to do a necropsy, find lesions, describe them, suggest some possible diagnoses, and have other tests confirm my analysis so definitively. Sure, I make mistakes. Sometimes I miss important lesions. Sometimes I don't collect the right samples. But I'm learning, and I'm gaining confidence in my ability to recognize when something is not normal. I may not always identify the disease process in detail, and I may not always properly rank what I see (abnormal doesn't mean important). But I'm getting exposed to a wide array of disease processes in lots of different species.

And I am slowly learning that I can leave work at 4:30pm and everything is just fine.

Archie, The Delicate Flower

For weeks, the outside temperature has been only a couple of degrees cooler than the surface temperature of the Sun. Nonetheless, Archie is convinced that he is not able to get even a moment of proper sleep at night unless his entire body is in contact with mine and he is covered with a blanket. As soon as Archie is ready to sleep (there's always play time first!), he will begin pawing at my arm, which means he wants me to lift up the edge of a blanket so he can slide under it, preferably right next to me. A complicated dance ensues as I try to cover him without having the blanket cover any part of me. Why would I need a blanket? I’ve got a 12-kg, fur- and blanket-covered heat factory attached to me all night long. 

I'm quite excited that Archie starts agility class this week. The local club holds its agility classes outside, so I hope that it cools off as predicted in the next couple of days. I am not sure my delicate flower from the PNW is ready for the heat and humidity. I bought him a cooling vest, and plan to have plenty of cold water and a fan for him. For us both!

I introduced Archie and myself to the club via email. They asked me to do a brief skills test with Archie and one of their instructors. I thought that was reasonable and readily agreed. The instructor had come up with a rather difficult Jumpers-style course that was 17 obstacles in length but that only used 9 obstacles so most were repeated in various tricky ways. Archie of course crushed it. She then said, what about his contacts? I ran him up and down the Aframe a couple of times. He nailed that too. Weaves?, she asked. To show off a bit, I rear-crossed him as he flew through a set of 12 poles. No surprise, then--we are in the Advanced Class. It will be interesting to see how this goes for us.

I'd like to find a private instructor but that is going to take more time. We are going to need to start going to trials, get known by the AKC agility community out here, let word get out that I'm looking for that.

I Smell Funny

So it's really hot and humid here in Little Rock. The necropsy floor opens onto a loading dock and temperature in there is only tolerable at best.

I wear business casual clothing to work, but change into scrubs for necropsies in the afternoon. I add a swaddling, impermeable, disposable lab coat and long-cuff, heavy-duty gloves. And I sweat like a beast of burden.

Humidity, sweat, and dead animals create a potent odor combo. I wash my hands and face. I change back into normal clothes.

And I still smell funny when I get home.

Thankfully I live with dogs and a cat. They don't seem to notice. They probably think that I smell better.

I Discover A Superpower

Convo, regular version:
"Happy Pets Animal Hospital. Can I help you?"
"Hi, yes, is Dr. X available?"
"She is in a room with a client/not here/gone home/not available. Can I take a message?"

Convo, superpower version:
"Happy Pets Animal Hospital. Can I help you?"
"Hi, this is Dr. A at the Veterinary Diagnostic Lab in Little Rock. Is Dr. X available?"
"Oh yes, just a minute, she really wants to talk to you!"

When I interviewed for this job, I got the impression that communication is one aspect that previous occupants of this particular job have not performed well. This has been confirmed more than once in my discussions with the director. Our clients are better served when they get information sooner. The reputation of the lab is bolstered when we add an invested, concerned name and voice to our necropsy cases. So I've been trying to call every referring veterinarian (or commercial producer) as soon as I complete their necropsies to chat about my preliminary findings.

This is how I discovered that I now have a superpower. It turns out that they quite value having a peer give them a ring to chat about their difficult cases. And I don't even have to wear a cape.

Lions and Tigers and...Snakes

Yesterday I did a necropsy on a 16-year old albino corn snake. In vet school, our lectures on snakes and reptiles and amphibians were cursory at best, and covered nothing at all on the anatomy of these animals. When I got the email that the snake was coming in, I hustled over to the bookcase and grabbed the first relevant textbook that I saw. It took me about an hour to read and take notes on the chapter on snake anatomy. There was a decent figure in there, so I photocopied it to take down to the necropsy floor. I skimmed other chapters to get an idea of what kinds of diseases were most common in snakes. I also specifically researched zoonoses. I already knew about Salmonella (any reptile can give you salmonellosis), but I also learned that snakes commonly have cryptosporidia in their gut and those little parasites don't care who or what you are, they will make you so fucking sick with the vomiting and shitting that you will wish you had salmonella instead. Right--everyone on the floor was going to wear full PPE (personal protective equipment) including face masks.

And of course, I also immediately sent up the bat signal to one of my classmates who keeps snakes as pets. He was super helpful, giving me tips on how to determine a body condition score for snakes (that's an important thing in vet med, we do it for all species but you look at different parts of the animal depending on the species, and we never talked about determining a BCS for reptiles during school). He also kindly shared other miscellaneous bits of knowledge that one can only acquire by actually keeping snakes around all the time. Not my cup of tea, snakes, but this is my job now.

Snakes appear to have gone out of their way to make their anatomy as weird and difficult as possible (no diaphragm, one lung, three-chambered heart, two aorta, no urinary bladder, tongue hidden away in a pouch in the mouth; I could go on). Thankfully, livers and kidneys are fairly recognizable organs in most species and serve as good landmarks. I did my best, and to be honest, I found some surprises in this snake that may actually provide a cause of death. That's a rare enough outcome for any necropsy in any species, but even better because this one was so unusual.

And today I did a necropsy on a bobcat. The bobcat came in last week but we had to submit brain tissue for rabies testing before we could proceed with the necropsy. It was negative.

So when I was in vet school, still in second or third year, a cougar came into necropsy. Everyone was super excited and it was the talk of school...until that darned thing tested positive for Yersinia pestis, otherwise known as The Plague. Yeah, THAT plague! That's a reportable disease and Homeland Security got involved because bioterrorism. All students in necropsy at the time had to take a course of antibiotics (no opt-out on that), and a mountain of paperwork was created. The pathologist in charge of the case still tells stories about it.

The director of the lab told me during my first week here that tularemia was pretty common in Arkansas. Tularemia? That is a horrible disease! It affects rabbits, but also quite often affects felids. Felids...like bobcats.

So I spent this morning researching gross lesions that I might expect to see for Francisella tularemia, Yersinia pestis, and what the hell, Bacillus anthracis too (anthrax). Going for the full apocalypse. All three are zoonotic (nasty deaths for humans) and reportable. I made notes on the tissues I needed to collect, what tests I needed to request, and where I might send all this shit because we don't test for any of those diseases at our own lab.

I emailed one of my mentors at Oregon State (had some questions about the snake) and told her I had read up on these three diseases before doing the bobcat necropsy. She replied, "I'm so proud that you are considering the absolute worse case scenario before going on the floor!" Snark? Humor? True compliment? All of the above! I'm nothing if not cynically thorough.

So the bobcat had a femur fracture and likely died of starvation/dehydration. No evidence of infectious disease. Even so, I was ready.

Schmoozing

I was quite shy as a young child. Later I became bookish and nerdy, which added an air of stand-offishness. Neither is a winning formula for social popularity.

But my first pass through graduate school changed things significantly. My advisor had a large group of advisees, 7 or 8, with about half of the group working on master's degrees and half on PhDs. He held regular weekly meetings during which one of his students had to report on their research progress and results, and then subsequently defend themselves, with no props other than maybe a chalkboard, against the bloodletting that followed from the rest of the group. It was brutal. It was exhilarating. It was eye-opening. After a couple of years of that, the dissertation defense was a breeze.

Don't start thinking that this was in any way abusive--it was well managed, and no personal attacks or calling people poopy-heads were allowed. The result was that I learned how communicate my research ideas clearly and effectively. But that is only one part of being a functional monkey in the monkey troupe.

The job that I took after that graduation required me to convince petroleum companies to part with their dollars to fund research projects based on ideas that my colleagues and I would come up with. Within the budgets of those projects, I had to cover my salary, including sick leave and vacation, the salaries of colleagues and support staff, and overhead. I had to convince the companies that the results would be of greater benefit to them than the relatively modest cost of paying us to do the work. The first few years were a bit rough but eventually I learned the art of schmoozing. And I got pretty darned good at it. I came to enjoy being good at it. I'm still bookish and shy, but when I turn on the schmooze, I can be formidable.

I have little interest in social schmoozing, although a bit of that is necessary. I'm more interested in technical schmoozing, in which me and other monkeys talk about science-y things.

Now I am working again. Although the role is different (public sector veterinarian), this week I learned three things about my new job: there is plenty of schmoozing to be done, it's been a long time since I was able to schmooze, and I really missed doing it.

I have started lurking around the receiving area when people bring in submissions (that is, animals for necropsy) so I can chat with them. I learn a lot about production practices and problems that are of concern to them, not to mention I get a much better history than the clients write down on the submission form. I was initially worried that I might be annoying the receiving staff, who do an excellent job and whose toes I definitely do not want to step on. But I got an email from them yesterday thanking me for talking to clients! And as soon as I complete a necropsy that has a fairly definitive finding, I call the referring veterinarian and chat with them on the phone. The lab director told me last week he was so pleased to hear all the "hubbub" (that's the actual word he used) coming from my office as I chat on the phone to veterinarians and owners.

How lucky I am to have found a job that lets me do fun vet med things then chat with people about those things all day long.

My Money Is On The Shitty Greek Yogurt

On Thursday night, I spent several hours in one of the local vet ERs with Archie. He had been vomiting for about 18 hours, and wasn't keeping any food down. He would eat food but he would vomit it right back up. He was also lethargic and not his usual cuddly, interactive self. I had some bloodwork done just to be prudent (although I declined the pancreatic lipase blood test since hanky panky pancreatitis was pretty low on the differential list). All of his bloodwork was totally normal. He got a shot of maropitant (Cerenia) and was back to his usual bouncy hijinks the next morning. He did have some fairly violent, watery diarrhea the following evening but as far as I can tell, it was only that once.

But then Mimi started vomiting yesterday afternoon. She refused to eat any dinner. During the night, she got me up every hour with dry heaves, producing only a little bit of foamy bile every so often. And boy, was she fighting the nausea. Archie just opened his mouth and bleagh! Out came the food and that was that. Mimi made such a production out of it. We got no sleep at all. Mimi's eyes became sunken and she became slightly wobbly and disoriented. She was drooling and groaning in pain when I had to pick her up or move her. She was passing horrific gas all night and had a bit of bloody diarrhea this morning. So off again we went to the vet ER. We waited for over an hour but they had a couple of emergencies come in so they sent us off to another vet ER.

Poor Mimi was not doing well at all by the time we arrived at the second vet ER. I had full bloodwork run on her too, including the pancreatic lipase test. I was actually more worried about acute kidney disease than pancreatitis but all of her bloodwork came back normal. She got a shot of maropitant too, but we all agreed that she was clinically dehydrated so she got a big slug of subQ fluids. She wasn't quite sick enough to warrant an IV catheter and IV fluids although I was considering it.

I declined abdominal imaging (they suggested rads and I would have also requested ultrasound if possible). But if Mimi doesn't get better by the morning, I will probably have to get this imaging to rule out some pretty scary things such as an abdominal mass (GI lymphoma would be at the top of the list). And we'd probably have to do some aspirates of lymph nodes to go along with that. And we'd also have to get chest rads because lymphoma fucking loves to met to the lungs. What a mess.

Mimi definitely became more sick faster than Archie. Several possibilities could explain that--whatever was making her sick was different than what made Archie sick (unlikely, but possible), and she's old and slightly underconditioned so she doesn't have a lot extra to expend in being sick (most likely).

So let's hope she starts feeling better! She's been resting and seems to have stopped the dry heaving, which is a relief.

What could have caused this? If we assume that both terriers got sick from the same thing, then we have to look at environment and diet. With respect to diet, they eat different kibbles, and I brought their kibble with me from Oregon, so that hasn't changed. But I was not able to find a good quality yogurt to add to their morning meal and was giving them a store-brand greek-style yogurt. Personally, I detest greek yogurt. It is too thick and tastes like paste. I like real, full-fat yogurt with live bacteria, and that is what the terriers have been eating for years (Nancy's brand). I've tossed the shitty greek yogurt and am on the hunt for some decent yogurt that they can eat. They could have become sick from some toxin in the yard. If that were the case, I might expect Azza to show some signs of exposure as well, especially since she spends more time out there than the terriers but so far she seems fine. I did learn from the ER vet this morning that campylobacter infections are somewhat common here and can be passed back and forth in a multi-pet household. Nothing in the test results for either dog suggested an infectious agent but that certainly doesn't rule one out. And of course, the dogs were uprooted from their home and dragged out here and they have no idea what's going on. Stressful for all involved. Right now, our presumptive diagnosis for both is acute (hemorrhagic) gastroenteritis of unknown cause. My money is on the shitty greek yogurt.

I start work tomorrow so all of this has been taking place with fairly crappy timing. More stress for everyone!