We Are All Partners In This

Despite being barely two years out of vet school, I apparently project an air of confidence and competence to my veterinary peers. I've been thinking about this ever since my conversation with Dr. M that I mentioned in my last post. It's absolutely true that I don't know everything about vet med. I've got a lot to learn. But I bring so much more to the table--years of experience with scientific writing, public speaking, and critical thinking. And my own personality contributes a lot as well--I have always had a habit of calling things like I see them.  

On Tuesday, one of the regional USDA-APHIS vets emailed me to see if I could help them out. They felt like they were not fully prepared to conduct poultry necropsies if there was an FAD event in Arkansas. 

FAD means Foreign Animal Disease. There is a very long list of FADs that are of concern to the USDA, but in the poultry world, we are mainly talking about HPAI (highly pathogenic avian influenza) and vNDV (virulent Newcastle Disease Virus). If either of those were to appear in Arkansas, it would be devastating to the poultry industry here. Containment and sampling are critical. It is far beyond the scope of my blog to talk about the training that USDA-APHIS and USDA-accredited veterinarians receive (I have Category II accreditation), but if there was a disease outbreak, USDA and other federal agencies would run the show. Their people would go into the poultry houses and conduct necropsies and collect samples which would then be sent off to the various national labs. 

So back to my vet colleagues, who reached out to me for help. The vet that emailed me asked if I could run a workshop for them, a wet lab with hands-on instruction in poultry necropsies. Sure, I said, that sounds like fun. I mean, what else would I say? I love teaching. I love working with poultry. I put in a lot of effort during vet school to gain knowledge and experience in poultry vet med. Only 2 or 3 vet schools teach about poultry, so most vets never even touch a chicken during school or during practice. 

The only problem was that I can't predict when poultry cases come into the lab. We needed birds for this workshop. Then I had an idea. We do a lot of serology testing for the big poultry companies in Arkansas. Most of them regularly send us necropsy cases too. But one of the bigger companies hasn't used us much for necropsies in the past. However, since I joined the lab, their regional rep has been sending me tough cases that really allow me to stretch my diagnostic skills. He never fills out the history on the submission form, instead preferring to call me up and chat for half an hour about what is going on at that particular farm. 

My idea? I emailed him, told him that USDA wanted a workshop, that I was happy to run it at the lab, and would he be willing to donate birds? He didn't hesitate. He immediately grasped the larger picture--if USDA vets are better prepared for a FAD event, his company would directly benefit. We are all partners in this. 

A flurry of emails ensued, and the workshop was arranged for Friday. I downloaded the training manuals that the USDA vets use so that I could see what they were being instructed to do, and I wrote a brief outline for the workshop to ensure that they would learn how to collect the samples they needed to collect.

I told them, if there is a FAD event, you will be working in some seriously adverse conditions--taped into PPE head to toe, kneeling in hot, dusty poultry houses surrounded by dead and dying birds. I told them I was going to show them tricks and efficiencies to quickly collect the samples they needed, and to make sure they were diagnostic. And then I proceeded to do just that. 

 

Me on the left. These are broiler breeder hens. They lay eggs that are hatched to become broilers, which become chicken nuggets.

It was a great workshop. I can assure you those vets know a hell of a lot more about poultry anatomy now than they did when they woke up on Friday morning. They know how to hold and use scalpel blades without cutting themselves. They know how to get blood samples my way (my way is heresy, to be sure, but it works, it's amazingly fast, and the samples are just as diagnostic as those obtained the traditional way). They know how to perform tracheal swabs on live and dead birds. All of this delivered in less than 3 hours. It was so successful that I will run another one in May for the four vets that couldn't make this one.

To be sure, this was quite a professional accomplishment for me. My USDA colleagues valued my expertise enough to ask me to share it with them. I am empowered in my own job such that I can use state resources for this kind of activity without seeking permission (although I let the upper levels know what I was up to). I really value my personal relationships with lab stakeholders, and the effort I put into them paid off nicely.

We are indeed all partners in this.

Absurdly Alice

Here are some (slightly edited) conversations I've had at work in the past few days.

Backstory: One of my favorite vets called me up to get my opinion on a recent case he submitted last week. He knows now that our reports are strictly factual--we observed this, we measured that. But on the phone or in person, he is also aware that I will share any and all theories that my colleagues and I might have about the cause of death of the animals in his cases. That's what he called me to get--the crazy theories and speculations. 

Many of his clients are cow-calf operators in the southwest part of the state. It's a long haul for those producers to bring a cow or calf into the lab so he often does field necropsies and sends us what we call "a box of parts." After a fair bit of coaching from me, he sets the bar pretty high with his submissions, generally collecting diagnostic samples for most of his cases. He sends fresh tissues and feces and rumen contents knotted up in disposable obstetric sleeves, and cuts off pieces of affected tissues and drops them into a container of formalin. Pretty much every time he sends us a BOP, the container he uses is a large bottle that used to contain 500 tablets of cephalexin, an antibiotic that can be used in food animals. Since he submits cases almost weekly, well, that's a lot of cephalexin. 

Me: So, another fabulous field submission from Dr. M. I have to know, what's up with the cephalexin bottles? 

Dr. M: Well, it's a big bottle.

Me: I know, but why do you have so many empty ones? What do you do, give them out like M&Ms?

Dr. M: Yes, exactly, everyone that comes into the clinic gets some!

Me: Like Oprah! Cephalexin for you! And cephalexin for you too! Cephalexin for everybody!

This same vet submitted the headless, legless torso that I mentioned in my previous post. That came up in today's phone call too.

Me: Um, so why did you cut the head off? Why?

Dr. M: The calf wouldn't fit in the container and...

Me (interrupting): ...hahaha!

Dr. M: ...it wouldn't fit and the courier was getting upset, needed to leave...

Me: ...so you cut off the head but you so thoughtfully left the tail! You left us a handle!

(Me and Dr. M cackling like chickens)

Backstory: I'm on a committee at the lab that handles quality management issues. We are only a committee of three. We had an event that needed to be assigned to one of us. 

Committee leader: Which one of you will take this?

MBF and I look at each other. 

Me: Rock paper scissors?

MBF: Sure. But I'm terrible at this. My wife always wins.

Me: I'm glad to hear you and your wife have a healthy process for conflict resolution.

MBF: So, on 1-2-3-go?

Me: Yes.

MBF: 1-2-3...

And on "go", I throw out paper. 

MBF: No! After I say go!

Me: Oh. Okay.

MBF: 1-2-3-go...

And I throw rock as he throws scissors.

Me: I win!

Always setting a high bar for professionalism! 

Backstory: I was approached by our local colleagues in USDA APHIS about leading a wet lab for them in poultry necropsy and diagnostics. They wanted to be better prepared in case of a disease outbreak. Sure, I said, I can do that. But we need some birds, and waiting for a regular submission is not really a workable solution. I have developed a good relationship with a high level guy in one of the broiler breeder companies in Arkansas. He submits crazy cases that keep me on my toes. I decided to ask him to donate birds for the wet lab, either spent hens scheduled for slaughter or birds from a problem farm. He'd get a full report and diagnostics at no cost.

Me: I have an unusual request. blah blah wet lab blah blah USDA blah blah warm fuzzies all around. I only need about 10 live birds.

SL: Sure! But how will we get them to the lab? 

Me: I'll bet we can get one of those USDA folks to pick them up from your folks. And I almost forgot, they wanted some deceased birds too. Can we get a few of those? 

SL: How many dead ones do you want?

Me, reading the email asking me how many dead ones I wanted: This is a strange email conversation. I want five dead ones.

SL: It's always a strange email conversation in this business. Done!

My job challenges me in many ways. I would never have expected days that leave me feeling like Alice in Wonderland.

Surprise!

I've discussed before about how we approach each necropsy case with a list of differentials for the cause of death. Before you even see the animal's remains, you can posit a decent list just on signalment (age, sex, breed) and clinical history, if one is provided. The time of year and the weather can suggest a few differentials too. And I'd say that, for most cases, our differential lists don't change much, other than to usually get a lot shorter. 

Then there are the surprises. 

Oh, a calf was sent in for necropsy? It's wrapped up and packed in a styrofoam box, and Receiving won't open it up, of course. They leave that for us in Necropsy. The box seems small but maybe it was a neonate? Surprise! We opened the box to find a single, long-ago melted ice pack and a trash bag. Inside the trash bag was a torso. A calf torso, minus the head and four legs, removed to reduce weight and thus reduce the shipping cost. They thoughtfully left the tail, however. But because the torso was shipped without enough ice, and because they had removed the head and didn't take quite enough care when removing the legs, fluids produced by rotting tissues had mixed during shipping with the diarrhea that had oozed out of the anus and blood that seeped from everywhere else to create a foul ichor, a marinade that penetrated all crevices of the torso. Except for a PCR test for mycoplasma pneumonia, the tissues were not usable for anything else. 

We see many dogs who died from heartworm infections. These cases make me angry because it was a completely preventable death. And we can often predict which cases these will be: owner-submitted, large breed, intact male dogs are vastly over-represented. Even if you are expecting to find heartworms in the heart, there are always the surprises, in which you find literally hundreds of worms packed into the heart, worms in the pulmonary arteries and even in the smaller vessels deep in the lungs. By far the worst are the dogs who died of caval syndrome in which the worms migrated upstream, back out of the heart into the caudal vena cava. Surprise! It's a plug of worms thicker than a broom handle blocking the largest vein in the dog's body. 

We handle about a dozen legal cases per year. They are always difficult since most involve animal abuse of one form or another. But we have a process that we follow, and focusing on the process helps us get through them. But there are the cases that take unexpected turns and become legal cases based on our findings at necropsy. Last year, I had a medium sized, mixed breed dog submitted for necropsy. I started by conducting a thorough physical examination. Surprise! That looks like a projectile entry wound! I ripped off my gloves and called the vet listed on the submission form and asked her, why didn't you mention that the dog had been shot? Turns out she never even saw the dog, just directed the owners to take it to the lab when it died suddenly. I took the dog over to the Crime Lab for radiographs, identified the location of the projectile, and retrieved it later during necropsy--a 9 mm slug.

And of course there are always rare congenital anomaly cases that you really just can't predict at all. The animals may have died as fetuses, or lived for a few days or even years. But they did die eventually and ended up on our necropsy table. Surprise! This Hereford calf fetus is missing most of its brain. Skull is normal, brain, not so much. Surprise! This 10-day old Angus calf doesn't have a rectum or anus! Its colon ended about 6 cm too early. Surprise! This obese 6 year old cat that died after a vet visit had two tracheas! Two tracheas all the way down, one going to the left lung lobes and the other to the right lung lobes. It also had feline cardiomyopathy, which was not a surprise. Surprise! This pure bred cat that has been genetically selected to have defects in how it makes collagen so that it will have folded back ears has malformed collagen everywhere else too, including the heart, blood vessels, skin, liver, kidneys, ligaments holding vessels in place. Nothing was normal in that cat. It was like working with a Picasso vision of a cat necropsy. A 10 month old German Shepherd pup, purchased at great expense by a breeder hoping to use him for stud work, was a "poor doer" from the start with vomiting, diarrhea, and poor growth. Surprise! The poor pup had two kidneys but they were very small. Under the microscope we could see that the usual renal structures had not formed, and the kidneys were mostly not functional. He had full thickness, bleeding ulcers in his stomach from the uremia, because the non-functional kidneys were unable to remove urea from his blood.

We approach every necropsy case with a plan, a list of differentials and tests we might want to run. We also need the flexibility and knowledge to modify that plan on the fly based on what we find, whether we expect it or not.

At Last

Yesterday, we received notice that agricultural workers and veterinarians (and their staff) could at last sign up to get the COVID19 vaccine in Arkansas. As a veterinarian who works for the Arkansas Department of Agriculture, I was in line at last.

After some quick computer work, I was set up. I somewhat randomly chose a local pharmacy about 5 or 6 minutes from the lab. Although it may have been a bit overkill, the pharmacy sent me multiple email and text confirmations and reminders. I'm okay with that. I looked at each one of them with a smile.

I got my shot today at 9:50am. The pharmacy is in a somewhat upscale strip mall on the western side of Little Rock. They set up the vaccine clinic in an empty storefront in the same strip mall, and it was a straightforward experience. The storefront didn't even have finished walls, it was just a big, empty, concrete-floored space. Plenty of room for social distancing. 

Which vaccine did I get? Does it really matter? For the record, I got the Pfizer-BioNTech vaccine. And I have a confirmed appointment for my second shot in three weeks. My colleague Xie got his shot today too, and he got the Moderna vaccine. Science for the win!

Reactions? My arm hurts. Eh. Tetanus boosters are far worse. After one of those fuckers, I can't lift my elbow higher than my waist for a couple of days. But here's the thing. Rabies and tetanus--they will kill you. As a veterinarian, I'm happy to line up for the vaccines and titer checks (my rabies titer is checked annually, at no cost to me, at the lab) and boosters. COVID19 is now just another check box on the list.

I'm quite over-committed at work right now, yet I feel like a huge weight has been lifted from me.

Solarium

 Repurposing the guest bedroom. Best seat in the house on a cold but sunny winter morning.

Digging Out and Warming Up

 By no means did central Arkansas get hit as hard as Texas by this terrible week of terrible weather. Sure, there were some power outages, some burst pipes, but these were isolated incidents. For the most part, everyone hunkered down for a week, waiting for the snow to stop, waiting for it to warm up. 

I ended up getting more than 20" of snow at my house. The daytime temps remained in the teens, nighttime temps dropped into single, even negative, digits, for almost 5 days in a row. 

I overestimated my van's ability to handle the snow and ice, and got it stuck trying to leave the subdivision on Thursday. There are only two ways out of my subdivision, and both require climbing multiple, steep hills. At least I managed to slide it parallel to the curb on a relatively flat spot of road located about 0.5 miles from my house. That night, I made two trips to the van with my cart, hauling expensive dog crates back up the hills to my house. When its wheels iced up, I dragged the cart over icy ruts.

On Friday, the sun rose in a clear sky that morning, and it was 36F by 3pm that afternoon. I visited my car twice during the day. But the icy, packed snow was too deep and the roads were still too treacherous. I whiled away the hours by shoveling my very long driveway, front walkway, and back deck. I had to use a regular shovel, which just sucked. 

I anxiously waited for sunrise on Saturday. I planned my morning to the minute and arrived at my car just as the temperature reached 34F. It was going to be a warm, sunny day (it's 45F as I write this) and large sections of the road were now covered with icy slush. 

Using another shovel that I had left in the car on Thursday, it took me almost half an hour to dig my car out so I could get it up onto the packed snow/slush on the road. I managed to white-knuckle that van up and out of the subdivision at last! I aged 10 years and acquired more grey hairs in the process, but once I hit the main road, which had been sanded and plowed, I started breathing again.

Apparently my nutritional choices diverge from a lot of other people's because although there were plenty of bare shelves at Trader Joe's, I managed to get enough food to last for another 10 days or so. I stocked up on cat litter at PetSmart, and decided that was enough of an outing for the time being. I'm back home, van parked in the driveway again, planning to spend the rest of the day cooking.

Disposition of Remains

 The lab director and I often talk about lab activities that would make good PR photos and short articles in the Department of Agriculture and State Veterinarian newsletters. The Pathology section of the lab almost never makes the cut (heh, unintentional pun there). There is no way to make a necropsy visually palatable for public consumption. There is no way to make slicing up hunks of formalin-fixed cow liver into thin sections to make microscope slides fun. And there is a very important component of our section that we can't ever discuss--the incinerator.

I didn't anticipate becoming an expert on incineration as a part of this job, but so it has come to pass. While the monthly totals vary wildly, our small lab incinerates about 25 tons of animal remains a year. Somebody has to be in charge of that, and that somebody is me.

The lab building was constructed around 1973 or 1974, and there is an incinerator built into the necropsy floor. I've been told tales of former pathologists who would perform necropsies on cows and other large animals hauled up on the hoist directly over the old incinerator. Fortunately, that generation isn't in charge anymore, because while it may be efficient, that sort of thing is fucking appallingly sloppy. By the time I arrived at the lab, the old incinerator was being decommissioned and the new one starting up.

The new incinerator is a stand-alone unit attached to a very large propane tank, located in a fenced lot across the street from the lab. It took almost six months of nearly weekly crises to get that damned thing up and running. I made significant contributions to that success, and consider it a professional achievement that I mention on my resume. 

If you were paying attention, you may have noticed that I mentioned the incinerator is across the street from the lab. So how exactly do we get those 25 tons of animal remains over there? It involves very large woven plastic sacks designed to hold many hundreds of pounds, large containers, a truck, and a forklift. It required a lot of planning and training to work out the details. We had to consider optics (can't be hauling bloody bits and leaking bags across the street) and safety while still designing a process that would work.

I know how many pounds we incinerate per time unit, how many gallons of propane we use per hour, the cost, in propane, per pound of material incinerated. Based on observations of burn efficiency, I developed a simple formula to calculate the number of hours we need to run the incinerator per 100 lbs of load. I analyze temperature logs of every incineration event. I have the cell phone number of the propane delivery driver. I arranged forklift operation and safety certification for 10 lab personnel, including myself. I have been on top of the incinerator messing around with one of the thermocouples a dozen different times. I wrote instructions on how to trouble-shoot the controller on wet days. I have chipped ice out of the tracks that the lid travels on to get the incinerator open. I have spent hours out there in all weather with various repair and maintenance guys learning how the burners work. I made worksheets for the technicians to collect the information that I need to fill out official logs related to our operating permit, and when those worksheets proved to be a bit too complicated, revised them and revised them again until everyone can use them correctly.

I expend mental and physical energy on the incinerator nearly every week. The skills I've gained seem fairly esoteric, but they are actually part of the general problem-solving aspects of my job. Incineration of animal remains is an important contribution made by the lab to general public health, but we'll never be able to "showcase" it.