For love or money?

I'm gonna let you all in on a secret. A lot of veterinarians are paid at least partially based on commission, for lack of a better term. Many places use a "pro sal" compensation scheme, where "pro" stands for "production" (i.e. the gross income you make for the practice) and "sal" stands for "salary" (i.e. a base amount of pay that the veterinarian gets no matter what).

That part doesn't bother me. Most base salaries are decent (not nearly as high as MDs or even RNs, but that's another issue), and my personal philosophy is that if you consistently try to do right by the pet and the client, the money will follow.

However ... not every veterinarian thinks that way. Unfortunately there are also places (like the corporation I work for) who go report-happy and publish and track production statistics on a VERY frequent basis. Couple that with regional managers who don't have a veterinary background, and let's just say you get what you reward.

On paper (money-wise), I look like a crappier veterinarian than Dr. Relief. Their average income per patient is around $130 and mine is more like $110. However, Dr. Relief does things like prescribe antibiotics in about 80% of the cases that they see - even if it's something minor like the animal sneezed twice or has a localized hotspot. Oh, and had the techs not caught a couple of MAJOR medication errors, Dr. Relief may have killed a couple of animals (not kidding). So the company keeps people like Dr. Relief on staff and nags doctors like me to increase their production*. Nice, eh?

*I should note that no one has bugged me about my production - yet. Apparently after you've been there a year then they start nagging you if you're not hitting their targets. I should also mention that I'm very close to hitting their targets without practicing scheisty medicine.

On the hunt

I've been checking the classified ads in several places and have applied for 3 other positions so far. I've heard back from one who said that particular clinic needed someone with more experience but would I be interested in this other one? You betcha.

This week I've felt like the grim reaper. Thursday - euthanasia. Friday - euthanasia (of a young cat with a horrible tumor). Today - told someone their beloved dog has a mid-abdominal mass, probably in the spleen. Ugh. Keep in mind that I don't work emergency so this string of events is very atypical for us. Aside from that I'm managing fairly well at work. Unfortunately the doctor who covers a lot of my days off:
- Says they don't know how to do spays
- Nearly overdoses about 1-2 patients per day (except the techs catch the mistakes)
- Takes about 2 extra hours per day to see 2/3 the number of patients I do
- Prescribes antibiotics like they're candy (I'll write another post about that soon)
- Doesn't write ANY notes in the record on about half the patients they see so I have no clue what to do if I get stuck with the recheck
So when I come back to work I get to deal with pissed off clients and pissed off techs. Yes, we have ALL discussed this with management. The harsh reality is that there aren't enough vets to cover all the clinics so rather than close one for a day they keep a warm body around. Especially when that warm body makes a lot of revenue by prescribing unnecessary medications.

Too much.

I spent Sunday volunteering at a Crossfit competition held at our box (gym), which basically involved setting up for the different workouts and keeping score/judging teams as they went through the workouts. The competitors had to meet certain standards in order for their reps to count. It was a lot of fun, and I almost lost my voice from yelling out rep counts through the day!

The rest of this week has been rough. Tuesday I went to the shelter and got to do several spay/neuter surgeries and help with an FHO (cool!) Wednesday and yesterday at work were very busy and full of difficult cases and difficult clients, and yesterday I had a migraine and stomach pain all day – not good when you have several loud dogs as day cases.

Unfortunately on Tuesday I also found out that my sister and her family are no longer coming to the wedding. My sister was going to be my only bridesmaid and my niece was going to do a reading in the ceremony. I am still processing the whole thing. The reasons have nothing to do with me but I’m still pretty devastated.

Between that and all the crap with work I’m calling shenanigans on the whole “God doesn’t give you more than you can handle” thing. I'm totally overloaded and just praying I can make it through the next 3 weeks until I can get some time off.

Mass exodus?

Yesterday we got the news that one of our long-time (and, I might add, pretty darned good) techs is leaving too.
She's headed to my previous hospital where I worked as a tech. You know, the dream one.

So here's the tally of who's missing now:
- 1 veterinarian
- a practice manager
- 1 RVT/LVT
- 2 receptionists (one on maternity leave, the other on disability ... did I mention that we only had 2 receptionists in the first place?)

Awesome.

D said something very profound yesterday:
"It's hard to be onboard when everyone is jumping ship; worse yet when you don't have anywhere to jump to."

At least I have tomorrow (Sunday) off. Yeahhhh!!

Insomnia

I've been having a lot of trouble staying asleep lately. I wake up in the middle of the night and then can't go back to sleep because I'm either worried about something (usually work) or have just had a nightmare.
The other night was the worst because I had a nightmare that my friend, a tech at my old clinic, told me that my old clinic would never hire me because "They think you're like 12 and will never be able to catch up with the type of medicine practiced here." I was completely devastated. D says the dream is a sign that it is something I really want badly (true) and not a premonition (I hope not).
As a result, I've resorted to taking an OTC sleep medication and it's been working wonderfully. I fall asleep quickly and - more importantly - I STAY asleep all night. Even though tons of people I know take prescription sleep pills or antihistamines I still somehow feel guilty for having to resort to this kind of help.

Friday was a bit of a cluster - I ended up driving 1 1/2 hours each way to cover a clinic that had no doctor onsite and only being at that clinic for 3 1/2 hours worth of work. Hey, if they want to pay me to drive all day (and reimburse my mileage), whatever. I've got tomorrow and Tuesday off!

Don't know how to feel about this

Dr. X resigned. Their last day is Friday.

On the one hand ...
- I don't have to worry about tiptoeing around them and maybe whoever replaces them will be easier to work with
- I'll now get to work 5 shorter days (we are keeping the clinic open fewer hours in the interim and I'll switch to a 5x9 schedule instead of 4x11*)

On the other hand ...
- What will happen to the handful of ridiculously difficult clients they managed? (I don't want them - have some of my own, thankyouverymuch)
- With our practice manager also leaving soon, there's a gap in who will manage client escalations, tech scheduling, and other admin tasks. I guess a PM from a different clinic will pinch-hit for ours in the interim, but still.

This is gonna be a sh!t show, I fear.



*Why not 5 x 8 or 4 x 10? Supposedly those 9 or 11 hours include a 1 hour lunch break. I think there was one day where I got to take a 30 minute lunch. Of course the techs were calling me during that time about something or other.

Holiday cheer (not)

According to the techs at work December usually has a higher-than-average number of a-hole clients. The techs' theory is that people are stressed out over the holidays because clients have limited funds and have to deal with various family things, so they (the clients) take it out on us. Based on last week I believe it. We had a handful of clients who were told that they were more than welcome to take their pets elsewhere. Believe me, this is a BIG DEAL at a clinic where the culture is to bend over backwards to accommodate clients. Hopefully that gives you an idea of how out of line the people were. I won't go into details, but let's just say that screaming obscenities is not okay.

Yesterday Dr. X apparently called in sick and work was trying frantically to reach me to come in. I wasn't available (and if I was, I probably still would not have agreed to come in because I was completely fried). Hopefully they got someone to cover so that they didn't have to close the clinic, but if that was the case - well, then the company needs to do a better job of scheduling and getting a pool of relief vets. There isn't really any incentive to come in on your day off, either. Yes, you could earn more toward your production. No, that's not a sufficient reason for ANY vet I know to come in on their day off. I guess if Dr. X and I got along better I'd feel more team spirit or whatever and might be more inclined to help, but that's not the case.

Bit by bit the wedding is coming together. Although I'm excited for it, I will also be soooo relieved when it is over! We're doing a fairly low key event with few guests and a coordinator and I'm still super stressed over it.

Click (maybe)

Happy belated Thanksgiving! We ran a 5k trail race that morning and my knees are still a little sore from that.

Work is going a little better. I had a relief shift at a totally different clinic the day after Thanksgiving and there was only 1 neurotic high-maintenance client I had to deal with. ONE. It was amazing! It also helps that it was located in a beautiful coastal town. My usual clinic is chock-full of clients who need constant talking off the metaphorical ledge, which is frankly exhausting.

The weekend went well too. Saturday was kind of slow. Sunday was very busy but I feel as though I handled every case reasonably well. I saw several new things - mastitis (probably secondary to a big mammary mass that I felt), liver damage from a suspected toxin, an eosinophilic granuloma, and more. For some reason I didn't freak out and have my usual "OMGI'veneverseenthisbeforeI'mgonnascrewitup" train of thought. I think a lot of it has to do with having to deal with my own diabetic cat. It's HUGE pressure to diagnose and treat your own pet, and you all know my insecurities about internal medicine. Yet if I can manage him okay then I can probably handle a lot of things.

So at least for now I feel as though I'm settling into a bit of a rhythm - at least with non-surgical cases. I still need to get my surgery mojo back.

Oh, and in other news our practice manager is quitting. I've no idea if someone is lined up to take their place, and if not how that role will be managed. It could be ugly ...

Antsy

I am taking it easy easier today because not only am I on the verge of burning out at work, I went to Crossfit the past 2 days in a row (and yesterday's workout was so challenging that I actually felt sick afterward).
Forcing yourself to do fewer things when you're used to going a hundred miles per hour is a bigger challenge that I expected. I have had to constantly remind myself today to slow down and take breaks, even though there is a lot of housework to do and errands to run. Those things will all get done eventually, they aren't life-threatening emergencies, and I need to REST.
I even managed to go see a movie today. In a theater. Believe me, that's kind of a big deal when you've become so used to work-sleep-work-Crossfit-work-work-work-wedding planning-work.

Tomorrow I don't have much planned either. The shelter is not doing surgeries so I have the morning off. I will be going to Crossfit, and then I have to have my truck looked at by the insurance adjuster for repairs (long story short - I backed into a fence post in my own driveway a few weeks ago because I was exhausted and not concentrating).
Wednesday I'm taking 2 of the cats to work - the one with chronic kidney disease to monitor her PCV after being treated for anemia, and the one with diabetes for monitoring on his first day of insulin treatment. We're closed on Thanksgiving (YAYYYY!!!) and then Friday I'm working at a different hospital to get away from Dr. X provide coverage while their doctor is off. Then it's another action-packed weekend of work.

The 'beetus

One of my cats recently started drinking a TON of water and urinating more than my cat with chronic kidney disease(!) I went back and looked at his pre-op bloodwork from last month (before his dental cleaning) and his blood glucose was 529. Normal is around 100.
At the time I had dismissed it as stress-induced. Cats are especially well-known for their ability to spike a high blood sugar reading when stressed. However, his BG had never been greater than 200 before.
Hmm.
I brought him in to work today for recheck. Urine is pending (I sent it out), but his BG was 496.
Persistent fasting hyperglycemia + persistent fasting glucosuria + clinical signs of diabetes probably = diabetes.

So it appears that between him, my other cat, and several of my patients, I will learn the ins and outs of internal medicine despite my wishes to the contrary.

I'm also thinking of switching back to a 5-day work schedule so that I can (maybe) be a little less tired and only be alone 60% of the time instead of 80-90%. I just have to figure out how to pitch that when Dr. X probably wants to stay on a 4-day work schedule AND the clinic hours are 8am - 7pm.

T minus 2 months

Yesterday marked 2 months until the wedding. Eep! We still have a lot of things to iron out, such as the ceremony, some of the music selections (we have some decisions made but not all), where to have the rehearsal dinner, and more. I know that we will get it done but it sometimes gets a little overwhelming. I have to meter the number of things I discuss with D at a time because his job has been insanely stressful and I don't want to make his brain explode.

I also went to Crossfit yesterday - we did this hero workout. I used an assistance band for the pull-ups and 75 pounds for the lifting (Rx'ed for women was 95, so not too shabby). Afterward, I had a short conversation with the coach:
Coach: "Did you do the whole thing with 75 pounds?"
Me: "Yep."
Coach: "How was it?"
Me: "It was pretty challenging. I can't feel my arms right now."
Coach: "That's what I'm TALKING about!"

So basically we're all just a bunch of masochists.

Speaking of masochism or self-flagellation ... I went in to the shelter this morning to do surgeries again and had my second scrotal bleed from a kitten neuter (the first was the last time I was there 2 weeks ago). I KNOW that my knots are secure and the kittens are fine once pressure is applied to the scrotum but it is still making me paranoid. In addition, apparently a couple of kittens from the same litter that I neutered a few weeks ago developed pretty severe infections afterward.
My confidence is already so shaky from work that I question my ability. I KNOW that I'm using good sterile technique. I make SURE to snug down my figure 8 knots firmly and check for oozing as I release them. Yet I still think I must be screwing up somehow ... (even though I can't think of anything).

This run of post-op complications is NOT HELPING, universe.

Travel and training

Last week I spent 3 days in BigWestCoastCity for a training program designed to orient new veterinarians. The training itself was fine - I learned quite a lot and got to meet a ton of people from all over the country. It was comforting in a way because I met one other person who is struggling with being the only doctor on duty all the time, however the vast majority of people were either never alone or almost never alone. I got to meet up with an old friend who lives in the city, eat excellent food, and even go to one of the local Crossfit boxes!

The very next morning I had to go to work. I was completely exhausted and before I could even get my things settled the practice manager was firing questions and notifications at me.
A. I am not awake before 9am most days anyway and never do well when expected to process a ton of information before that time
B. I need time to settle in before going 100 mph - even if it's 5 minutes to put my bags down!

It was probably pretty obvious how peeved I was because she pulled me aside later and asked me what was wrong and that I had seemed a lot more stressed/angry/upset lately. I laid it all out -
How ridiculously stressful it is for me to be the only doctor at a hospital with complicated cases and techs and front desk staff who want the doctor to make every single little decision for them,
that I was considering asking to transfer to a different hospital,
and that I simply was not ready to essentially be the chief of staff since I STILL NEED TO LEARN HOW TO BE A DOCTOR.
I told her that I was burning out and that the current state is not sustainable for me.

They made an offer to an acquaintance of mine to help in the hospital part time, and that person accepted. The practice manager said she would make sure to schedule that person in on my single doctor days to help me. That's great, but they need to go through their 2-3 months of training first.

So ... while I feel a tiny bit better (I first accidentally typed bitter ... Freudian slip?) that the stress is noticed and that they are trying to do something about it, I am still looking to change jobs after 6-12 months in this one.
I also made a deal with myself to speak up sooner if things bother me as opposed to taking and taking and taking it until I can't take it anymore. That's a tough one for me and always has been.

A whole week off! (Sort of.)

I have an entire week out of the hospital! This week I'm traveling to BigWestCoastCity for a 3-day corporate training event that all the doctors have to go to. I'm looking forward to seeing a classmate again and to meeting up with an old friend for dinner. I might even visit the Crossfit box up there if I have time.

Last week was slower that it has been. I suspect this is the start of the slow season, which is fine with me. Of course we had the requisite tragic grooming accidents and even a mixup where the boarding facility brought us a dog that wasn't sick (whose owner FREAKED OUT at the thought of her dog being sick) then later said to us oopsie - wrong dog. Nice. Apparently they ended up comping the well dog's stay because the owner was really (and understandably) angry.

Progress, not perfection

That's a phrase often stated in discussions about Crossfit, weight lifting, and other athletic activities. I like it a lot and am usually able to internalize it. For example, yesterday I was finally able to kick up into a handstand against the wall and hold it for about a minute. For months I wasn't kicking hard enough because I was afraid I would hit my head against the wall, afraid my arms would give out and send my head into the floor, etc.
I was ECSTATIC when I finally did it. I didn't mentally kick myself for not being able to do full-on handstand push-ups like most of the other people at the box, or for not "getting" the handstand sooner. I was just happy that I could now do it!
It was the same situation when I finally figured out the movement involved in kipping pull-ups. Again for months I just couldn't seem to get the coordinated movement together to make it happen, and then suddenly bam - I could. Now I can use a lot lighter bands to do my pull-ups.

Okay, so if I'm able to celebrate baby steps in the area of fitness, why am I having so much difficulty extending that toward other areas of my life such as work? Why don't I pat myself on the back when a recheck exam reveals that my diagnosis was correct and the treatments were effective, or when a surgery goes well, or when I research a complicated case and manage to look halfway competent when handling it?
I suppose it is because I've always considered myself good at intellectual pursuits and NOT good at physical ones, and therefore cut myself a lot more slack with sports because I "don't have any natural ability" at them.
At any rate, that attitude shift is definitely something I need to work on or else I will drive myself crazy.

Low

Last week I worked by myself – again. They sent Dr. X to a different location on what was supposed to be a 2-doctor day to cover a different hospital. Last week I also made the decision to start looking for a different job sooner vs. later.

The last straw, if you will, was a client who called and was extremely offensive over the phone. They had seen me a month earlier for a potential ear problem, declined all diagnostics, and then left. They demanded a free second exam because they didn’t feel they had seen a “real” doctor the previous time. Our practice manager said “I don’t have time for this. Book the appointment and waive the fee” without ever talking to the client.

So basically she rolled over and tacitly said yes, Dr. S really sucks and why don’t we give you a free visit to make up for it?

It is bad enough that I am working alone all.the.time just 3 months after graduation. Being thrown under the bus too? Not okay. Not even close.

I talked to the practice manager the next day and told her how much that upset me. She said she didn’t mean it like that at all and that she was trying to avoid the client calling corporate which apparently kicks off some big administrative hoo-hah.

Doesn’t matter. As one of my clinicians in vet school said, once you have 6 months of experience, you have experience. Don’t stay in a job where you are miserable.

I knew when I took this job that it wasn’t my dream job. I envisioned days of itchy skin and lots of protocols – not being thrown out on my own with adult big dog spays, crazy endocrine cases, critical emergencies, and no help whatsoever.

(Not so) fast on my feet

When I don’t handle a case as well as I think I should have, I try to go back and do some research so that I will do a better job next time.  The frustrating (or encouraging?) thing is that I DO come up with a better plan, just a day or two later. Here are some recent cases:

1. Indoor/outdoor cat with presenting complaint of inappetance and lethargy for several days; had a fever on physical exam. The client couldn’t afford both diagnostics and treatment. I wanted to use a broad-spectrum antibiotic – possibly something like Baytril because I’d seen it work well on cats with fevers. We had no Baytril. I panicked. I prescribed Clavamox. Later that night once I got home I realized we had Orbax available (in the same drug class as Baytril) and smacked myself on the forehead.

2. First thing on a Sunday morning a puppy was presented for suspected intoxication. The clients didn’t know which drug (an opioid or an antibiotic – they were taking both) or how much was ingested.  The puppy was obtunded, bradycardic, and pale. I strongly recommended that the puppy go 2 blocks down the street to the emergency clinic because all I could think of to do was make the puppy vomit (possibly a questionable choice if he was obtunded) and bolus IV fluids. The next day I remembered that we had naloxone and I could have tried a small dose of that IV to reverse the opioid (which is what I suspected it had ingested.)

To be fair, I don’t feel like I royally screwed up either case. Clavamox is a valid choice for case #1. Case #2 would have needed intensive nursing and monitoring (maybe even a ventilator) which I could not provide, and the puppy was stable enough to make the 5-minute drive to the e-clinic. I just wish I had thought of those extra ideas a little earlier, that’s all. These are the times where it would be really nice to work with even one other doctor to bounce ideas off of!

p.s. Given the number of crazy emergencies that presented to me yesterday, I REALLY should just throw in the towel and go work at an e-clinic. Seriously.

Big sick vs. little sick - and all about the benjamins

I feel like I'm starting to develop a sense for what cases are within my (and my clinic's) capability and those which require more expertise.

Recent case in point: 11 year old dog from local boarding facility presenting for lethargy and bloody diarrhea. Physical exam - hemorrhagic diarrhea leaking from her anus, weakness in her pelvic limbs, and an abnormally large firm mass-like object in her cranial abdomen (huge liver? hard to say).

At this point I knew in my gut that this was a "big sick" case - i.e. something requiring overnight hospitalization and intensive care, plus some diagnostics to decipher an underlying cause.
I offer to the clients to start the workup and hospitalization, knowing that she would have to be transferred overnight to an emergency clinic (we do not hospitalize patients overnight), then transferred back in the morning - lather/rinse/repeat until she gets better - OR to transfer her to a nearby 24-hour facility. The clients elected to have her transferred to the the 24-hour facility for workup and hospitalization.
Diagnosis - pancreatitis. She was hospitalized for 3 days and then discharged.
Score one for the doctor, right?

Not so fast. The boarding facility questioned why I sent her over to a different (i.e. in their mind more expensive, although it really wasn't) facility. I explained the above. They asked me if pancreatitis is serious. I said "yeah, they can DIE from it."

Let me clarify this by saying that the local boarding facility is housed in the same building as the clinic where I work and is owned by the same company.  People above my pay grade in same company are ridiculously finance-focused. Get the picture?

On one hand, I'm happy that I can pick out what needs to be done and to know enough to give clients options. On the other hand, I'm still very frustrated that I work in a facility that is realistically only equipped to treat "little sick" cases like abscesses and minor lacerations or gastroenteritis, yet am expected to tackle these "big sick" cases in the name of money - even if it isn't what is best for the animal.

Some day I will probably get in trouble for offering the best care for my patients, and that makes me sad.

More firsts, more good stories, and sick.

Yesterday I had my first diabetic patient present for blood glucose curve monitoring. I'd done exactly one before in school and only had a fuzzy idea of how to interpret them (Thank you VIN for clearly explaining what my professors couldn't!)
Today I had my first seizure patient. He wasn't actively seizuring (thank goodness, because we carry no drugs to break status epilepticus, or a prolonged continuous seizure). Turns out he had been placed on an anti-convulsant but the owner stopped the meds because he had no more seizures. While on the meds to prevent seizures. Headdesk.

Now, for a gem of an exchange that happened yesterday while I was frantically writing up records:
Receptionist: "Dr S?"
Me "Yes ..."
Receptionist: "Jojo, our drop-off annual exam? He needs to go to the groomer and he also needs vaccines, and I know that the groomers don't like to take them after vaccines so he'll be going to the groomer first and then coming here later in the day."
Me "Okayyy ..."
Why was that worth interrupting me? I DON'T CARE.

Also yesterday Dr. X got pissed because I called her on her day off to clarify WTF she wanted to do about a prescription for a patient that she has been managing (I'd seen this patient once - 6 weeks ago - and convinced them to go to a specialist, but Dr. X had been following up with the specialist and subsequent prescriptions which I knew NOTHING about.) The clients were out of medications and screaming over the phone.
Yay.
Dr. X sent an email today apologizing. I haven't responded and probably won't. Not cool, Dr. X. Not cool. Just screen your calls like the rest of us do and call back when you've simmered down!

Finally, it seems that I am coming down with a cold. Extra yay.  3 more days to go this week!

Important things

No, not work. More on that later.

Today was a good day. I went to Crossfit and did a very hard 35-40 minute workout (it involved 30 clean and jerks, 40 pull-ups, 60 burpees, and running 2 miles!) We got desperately-needed groceries. Now I'm plopped on the couch watching "The Walking Dead" marathon.

Work-wise, this week was okay. Wednesday and Thursday I was the only doctor on duty. I had a bizarre emergency on Thursday where a dog got part of its tongue cut off in a grooming accident. Fortunately it wasn't bleeding anymore so no emergency surgery required - just an oral antibacterial rinse and some antibiotics. Friday I was on with Dr. X and it was ridiculously slow so I left 4 hours early and took a nap at home instead (yes!)

I'm also scheduled to attend a 3-day training session in a few weeks at company headquarters in BigWestCoastCityThatILove, so that's cool. I'm planning to visit with friends, eat great food and drink great beer, and maybe visit the Crossfit box there. Should be fun!

Theme of the day

I swear, some days it seems like every patient you see has the same issue. Vomiting. Diarrhea. Itchy skin.
Last Thursday? Gastrointestinal foreign bodies.

Keep in mind that I work at a "day practice" - i.e. a clinic set up for wellness visits, vaccines, and patients with itchy skin. We don't have digital x-rays. We don't have an ultrasound machine. We have a fairly limited pharmacy of drugs to choose from. There's just one doctor on duty (yours truly) so emergency surgeries have to be sent somewhere else unless I want to shut the clinic down and cancel a ton of appointments (boo).

One patient's foreign body (pieces of a toy) was in the stomach according to radiographs taken the day before. Repeat radiographs showed that it had traveled to the colon. Great - discharged the patient, advised the clients to feed a small meal and watch for poop.
One patient's foreign body (suspected bark) was in the intestines. Radiographs showed a distended loop that appeared connected to the colon on the lateral view but not on the v/d view. The patient had been inappetant and vomiting for 2 days. Sent that one to a nearby emergency clinic for a second opinion on the radiographs and possible surgery if needed.
(As an aside, it SUCKS that we don't have digital radiographs - otherwise I could email them to a radiologist for a second opinion and get an answer back in 1-2 hours!)
The last patient? I'm not entirely sure that he had a foreign body, but he had a history of ingesting string and had surgery in the past for that. He was inappetant, vomiting, and had a fever of 106(!)  Started him on IV fluids and IV antibiotics, advised the clients that he would need overnight care, and transferred him to the nearby clinic as well.

By the way, the clinic that I transferred both of those cases to was where I worked as a tech prior to veterinary school. It is also the clinic where I really really really really wanted to work after school but could not get in (they wanted someone with 3+ years of experience). My goal is still to either work there or a place like that because a.) I attract emergencies so might as well work at a place equipped to handle them and b.) this being the only doctor on duty thing has gotten old already.

More firsts (and another funny question)

Last week I dropped an ovarian pedicle for the first time. They say it happens to everyone sooner or later and I had been dreading it, so I guess it was good that it finally happened?

For those of you unfamiliar with what I mean, this can happen when you are performing a spay surgery. You basically have to tie off 4 big arteries in order to remove the uterus and ovaries – one at each ovary and two that travel with the uterine body. I had clamped the first ovarian vessel and was trying to break down the suspensory ligament to better expose the area and ligate it when boom – the ovary and its supplying artery tore away from my clamp and sucked back down into the abdomen.

Fortunately it was a small dog and it hardly bled, and fortunately my training kicked in (extend the incision – make it longer – so that you can move the other organs out of the way to find the tissue, then retrieve it and ligate it). With shaky hands I managed to do that. Then I retrieved and ligated the other ovarian pedicle no problem. I inspected the abdomen before closing and saw no bleeding.

However … this was yet another dog who had a lot ofsubcutaneous bleeding and FREAKED OUT on recovery so the incision kept oozing. I was absolutely terrified that somehow my ligatures slipped and that the dog was going to die.

To make things worse, the owner had never had a dog before so I knew they would freak out with any little issue. I spent a lot of time at discharge explaining the subcutaneous bleeding, that it was imperative to keep the dog quiet and calm to avoid more oozing, what the signs of shock were, and of course the name and phone number of the night emergency clinic.

I hardly slept that night – felt totally sick to my stomach. The next afternoon the owner called and said the dog’s gums were pale and that she was not moving much. I told her to bring the dog down right away, but then the owner backpedaled and said maybe it wasn’t that bad after all. I prepped the techs for potential emergency surgery and tried not to crap myself. About an hour later the dog comes in and looks fine.

That. Sucked.

I also had my first ear hematoma last week. Decided I hate them because they seem to take multiple treatments before they go away (unless you get permission to anesthetize the dog and suture the wound open, which the clients never want to do first) and the dog always has some horrible underlying allergy that the clients are frustrated with.

Today’s stupid question:

Receptionist: “Doctor, you wrote that you want to recheck Fluffy in 1 week but you’re not working next weekend – what should I do?”

Me: “Why don’t you schedule the recheck for the next day when I am working?”

In other news, we visited our wedding and reception site and got a lot of details nailed down such as the menu, flowers, photographer, and minister. That was a huge relief!

No stupid questions?

Conversation yesterday:

Tech - "Doctor, the boarding facility nearby is on the phone. Have you heard of alprazolam?"
Me - "Yes, it's a sedative like diazepam or midazolam."
Tech - "Doctor, they are asking because they have a (insert your favorite old aggressive large breed dog here) and they want to make sure the dose is appropriate to control (his/her) aggression."
Me - "Then they should call the doctor who prescribed it in the first place. How the hell should I know having never seen the dog?"

Yep, I get questions like these several times per day ... hence my previous post.

Pink juice and baby teeth

I woke up this morning a pretty strong migraine. I slugged down some Excedrin migraine, dry heaved a bunch of times, and then went to work. After a few hours it finally went away. (Stress? Lack of sleep? The McFlurry I had last night?)

My first case of the day ended up being my first euthanasia. I’ve assisted with dozens of euthanasias before – emphasis on assisted – but I’ve never been the one to give that final injection. Although the patient was gravely ill and it was definitely (in my opinion) the best an acceptable choice for them, it was still a pretty heavy responsibility.

One of my last cases of the day involved a dental cleaning and extracting retained deciduous teeth in a dog. Up until now all my extractions have been for diseased teeth that were practically falling out of the patient anyway. Extracting well-seated teeth is a whole different kettle of fish, my friends.

Another interesting aspect of today was this:

Even though I saw nearly as many patients as yesterday, and even though the euthanasia presented as an emergency to be worked in, I was MUCH less stressed than yesterday. I think it was because some of the staff was different today. Overall they were a much more calm and organized crew. When others run around like chickens with their heads cut off it tends to stress me out.

Today is my Friday! Can’t wait to sleep in.

Use your brain. Please.

I’ve quickly realized that the clinic where I work is the type of place where all roads lead to the doctor. In other words, nearly every problem and nearly every question gets turfed to me.

That would be great …

• If we weren’t a high volume super crazy busy clinic where I need to see 25-30 patients per day (for perspective that’s about double the number of patients that my classmates in other clinics see per day)
• If we didn’t have a practice manager to deal with issues (example: payroll questions ARE NOT MY PROBLEM)
• If I had several years’ (or even a year’s) worth of experience to draw back on
• If all of these problems and questions actually waited until my blocked (no appointment) hour for me to deal with instead of interrupting me about every 5 minutes (no joke)

It is ridiculously hard for me to get anything done when I am interrupted so often. I literally have 2-3 techs working on 2-3 different patients simultaneously (example – a dental, a drop-off annual exam, and an appointment), plus 1-2 receptionists fielding phone calls and front desk queries, plus the practice manager popping in with questions. It has gotten to the point that I’ve come home and cried a couple times this week. I’m scared that I will make a HUGE mistake due to this broken process. Here's an example of a smaller mistake: I under-dosed an antihistamine for an itchy patient because I looked at the weight in kilograms and not in pounds; I was ordering up the meds with 2 different people talking at me at once about other things.

At my training hospital it was not like this. The receptionists didn’t come to the back asking for help with every phone call not involving appointment scheduling. The techs didn’t ask me for my opinions about stupid stuff like whether or not I want to give dewormer or to wait 2 weeks until it is "officially" due in an adult (i.e. probably doesn't even need the damn dewormer) dog – WHO CARES? The practice manager was the go-to person for questions about company policy, payroll, and so on.

What makes it worse is that the practice manager keeps going on and on and on about how they’re so happy that Dr. X and me are “here to stay” for “at least a couple of years.” If things don’t change soon I may not make it to the 1 year mark. Or the 6 month mark.

Ugh. I know that I’m going to have to put my foot down about all this crap. Here’s hoping I can do it without losing my metaphorical, um, poop.

Long weekend

The schedule this week at work was a little weird so I ended up getting 5 days off in a row (this is day #4). Here’s what I’ve done so far:

Friday –

Went to Crossfit, PR’ed my 1 rep max back squat while there

Scrubbed the shower

Got a much-needed deep tissue massage

Saturday –

Went to Crossfit, did the WOD (workout of the day) as prescribed (i.e. used the weights prescribed for advanced women … usually I have to scale it to intermediate or even beginner levels, depending on the elements)

Worked in the yard

Got groceries

Sunday –

Went to yoga

Cooked a ton of food for the week

Cleaned the kitchen and bathrooms

Watched football

Took a nap on the couch

Today –

Went to Crossfit, did a handstand for the first time in about 30 years while there (!)

Did the laundry

Took a nap on the couch

(Plan to watch Monday night football)

The plan for tomorrow? Go to the shelter and perform spay/neuter surgeries, then go to Crossfit, then probably take a nap on the couch.

Incidentally, I found this new cookbook whose approach I really like. It talks about weekly “cook-ups” where you pre-cook the meats and par-cook the veggies, then during the week you put them together with sauces for “hot plates.” It is a paleo cookbook, but you could definitely use this approach with pasta and non-paleo meals – something I plan to do because I’m not completely sold on the zero grains, zero dairy, zero legumes thing. Cutting out sugar and refined grains? Sure. Booze? Yeah, mostly. Don’t make me give up my cheese, though …

Yep. Still hate internal medicine.

The other day I had a seemingly endless stream of patients with internal medicine problems. Here are some examples:

• A patient with previously diagnosed (and documented) hypothyroidism under treatment, previously diagnosed (but I couldn’t find ANY past lab work to support the diagnosis) Cushing’s disease under treatment, and historical ridiculously high liver values with diarrhea and inappetance. Hmm – if the dog is under treatment for Cushing’s disease and doesn’t really have Cushing’s disease, she could be Addisonian now. Commence freak-out.
• A patient with persistent diarrhea despite multiple work-ups and past therapies.
• A patient who developed lethargy, abdominal pain, and inappetance after starting NSAID therapy for osteoarthritis.

It takes me FOREVER to deal with these cases. My process goes something like this:

1. Panic. Remind myself that I got crappy grades on my internal medicine rotations and that it’s a subject that I just can’t seem to “get.”
2. Scour the patient’s medical record.
3. Curse the previous doctors who didn’t document drug doses, lab tests, or much of anything on the case.
4. Look things up in my Clinical Veterinary Advisor.
5. Look things up on VIN.
6. Make up a treatment plan of some sort.
7. Talk to the clients and try to seem confident.

I can usually cobble together something that makes sense – it just takes about 3 times longer than any other case I see (ophtho, derm, heck – even surgeries!)

A thousand decisions

In the course of a day I feel as though I need to make hundreds (maybe even a thousand?) decisions. What problem is most pressing for the patient? What treatments should I choose? Doses? Durations? When should they be rechecked? Should they be referred? If so, where?

Sometimes it’s stressful (especially when I have to look a bunch of things up for a case), and I’m definitely tired at the end of the day, but it’s also kind of fun in a strange way.

Learning the hard way

A couple of days ago I had a full surgery schedule. My first case of the day was a routine spay on a 5-month-old small breed puppy. Pre-operative bloodwork and physical examination were unremarkable.

The surgery went well, although the skin and fat just below the skin were bleeding a fair amount and continued to ooze after I closed. I figured it would stop in a few minutes.

I didn’t count on the puppy becoming dysphoric from her post-op pain medication (buprenorphine). I’d only seen patients trip out before on morphine, hydro, and the like; buprenorphine uniformly made patients calm and happy in my experience. While the patient was freaking out her incision continued to ooze at a pretty good rate.

At that point I was starting to freak out too. What if one of my ligatures slipped and that was why she was bleeding? Well, her color was good, pulses were strong, temperature was normal and she was alert so she likely wasn’t in hypovolemic shock …

Thank goodness one of the experienced RVTs mentioned she had seen oozing like that before and suggested a pressure bandage (although I’ve probably done 50-100 spays so far I’ve NEVER seen that before). We applied the bandage. Then I mentioned that I thought the puppy was dysphoric from her meds, and she (the RVT) mentioned that we had naloxone on hand and could partially reverse the drug. So we did that too. Puppy stopped freaking out, and when we removed the bandage an hour later the bleeding had stopped.

What I learned:

• Buprenorphine can cause dysphoria (I also think that this patient’s dysphoria may have caused higher blood pressure and made it harder to stop the subcutaneous bleeding)
• Most of the time your closure will stop subcutaneous bleeding, but occasionally you will need a pressure wrap
• A good tech can save your butt

I suspect (fear) that this will not be the last I-want-to-crap-my-pants-from-fear experience in my career. There are only so many things you can see and experience in your senior year of veterinary school. I can only hope that I have enough basic knowledge to reason my way through things and solve problems as they come up – and that I have a great tech nearby too.

Variety

Today was a good example of why I chose general practice. Here are some highlights:

• Performed spay and neuter surgeries
• Diagnosed a pet with a complicated corneal ulcer (ended up referring to an ophthalmologist)
• Inherited one patient with diabetes and another patient with Cushing’s disease from the previous associate veterinarian
• Rechecked a kitten’s neuter incision site by having the tech hold the cat’s butt up to the surgery suite window so that I could look without scrubbing out
• Unstuck a dog’s toes from grates that a grooming salon uses in their tubs (hint: use a lot of lube and a lot of patience)
• Treated multiple pets with skin problems and others with diarrhea

I rather like having new surprises every day. I suppose that's why I like emergency too!

Getting my surgical mojo back

Today I spent a few hours at a local shelter (the one where I volunteered and then worked prior to veterinary school) doing spays and neuters. In 3 ½ hours of surgery time, including breaks while I was waiting for the next patient to be prepped, I performed 9 surgeries.

To put this into perspective, I’ve done maybe 5 or 6 surgeries the past TWO MONTHS in practice.

Being in the OR is weirdly relaxing for me (unless things are going to you-know-where). I guess it reminds me of being a kid and doing all sorts of needlepoint and counted cross-stitch.

Anyway, it went very well and they are happy to have me come in and help out every week. They get extra help to perform more surgeries and I get to sharpen my surgical skills (and play with super cute kittens!)

First solo weekend

Saturday and Sunday I was the only doctor in the hospital.  Before that I’d only had one solo day at a pretty slow hospital so I was ridiculously nervous beforehand.

Overall I think it went quite well. I handled all of the cases without having any meltdowns. We only had 1 anesthetic procedure each day – both dentals with no extractions needed.

From what I understand the caseload was lighter than a typical weekend, likely due to it being a holiday. I feel as though I could have handled 5-10 more cases per day. There were periods of time where I was even bored! Weird.

It was nice to have the day off. I slept for 11 hours last night (must’ve been tired after working 6 out of 7 days), went to Crossfit, and got some errands taken care of. Tomorrow I’m headed to the shelter as a volunteer spay/neuter surgeon!

Wedding planning

It's hard to believe D and I are getting married in a little over 4 months. Our to-do list is still extraordinarily (frighteningly?) long. Toward the end of September we’re headed to the wedding site to meet with the coordinator and some vendors.

We decided to get married in the mountains since we met through a ski club and because we love skiing and snowboarding so much, but the distance makes planning more challenging. We chose a resort that provides a package deal and a coordinator to handle a lot of the details. It means fewer choices of vendors, but that’s okay. I’m personally only picky about food (including cake!) and music. As long as the officiant isn’t offensive and as long as we get some pictures taken I don’t really care who does them.

Wedding websites are hilarious though. They could definitely make you crazy if you took every suggestion seriously. For example, one website recommends that you come up with a “signature cocktail” and serve it at your reception. More power to you if you want to do that, but that’s so not me.

I do have my dress and accessories, though! That part was pretty easy because I've had 38 years (!) to contemplate what I like and don't like.

I didn’t expect to be BFFs, but

Today was a moderately busy day at my “home” hospital (which equates to a slow-ish day at my "training" hospital). I worked with a colleague – let’s call them Dr. T.

Up until today when I have worked with Dr. T it has been SLOOOOOOOOW. They seemed fairly quiet but overall okay.

Not today.

Dr. T got behind on surgeries (and was freaking out during said surgeries over a million little things). There were also drop-off patients to be seen.

Me, after watching one surgery I hadn’t seen before (which a specialist came in to perform): “Hey, once this surgery is done I can start on the drop-offs while you keep going on surgeries.”

Dr. T: “I can help you.”

Me: “Okay.”

Then, while Dr. T’s next surgery patient is on the table ready to be induced, s/he decides to deal with 2 drop-off patients. Then s/he dithers about whether or not to deal with one of those 2 drop-off patients and asks me to take it. I say yes, then s/he says “No, I’ll take it.”

WTF?

Then 5 minutes later Dr. T asks me to take that same patient again, saying “because I can’t be doing everything.”

Again, WTF??

I’m pretty sure I didn’t give a look or other indication that I didn’t WANT to take that patient.

So I take that patient AND all but two of the drop-offs AND several more appointments while Dr. T hovers over a dental cleaning (that s/he is not performing, s/he just gets “nervous” about anesthesia and hovers THE ENTIRE TIME even though RVTs are there!)

Then while I’m in yet another appointment, s/he asks me if I’m already in an appointment and if I could take one that just rolled in.

At this point I said “Yes, I’m with Fluffy right now. Would you like me to take Spot as well?”

S/he took that appointment after all.

I have no tolerance for passive-aggressive types. Don't say you can take something and then play it like I'm slacking.

I’ve decided screw it – no more trying to be nice and defer to the “senior” doctor by asking if s/he wants to take an appointment. If one comes in and a tech asks who can take it, I’m your girl.

Of course I guarantee that Dr. T will get pissed off about that too.  Fortunately I will only have to work with them one day a week going forward.

New Schedule

Next month week I officially, officially start full-time at my “home” hospital. There is one other doctor and myself, and we’re working 4 days per week, 10 hours per day. Realistically it’s more like 11 hours per day because we almost never take a full hour for lunch.

Of those 4 days per week, I’m the only doctor for 3 of them. I’m a little bit nervous but think I’m ready. If it were my training hospital I’d be crapping my pants because that place is a LOT busier.

Back to the shelter?

Yesterday I met with the volunteer coordinator from the shelter where I used to volunteer (and later work) before going to veterinary school. We talked about possible help they might need from a veterinarian including performing surgeries, assessing sick animals, and prescribing treatments for them.

I’m pretty excited to get back volunteering for a couple of reasons. One, I firmly believe that volunteer work is good for the soul. Two, it gives me a change of pace and perhaps a chance to practice different skills (high volume surgery, infectious disease management) than I would at my day job.

The people I met seemed SUPER excited at the prospect of having me back, which was flattering and also a little weird because I didn’t feel very valued as an employee there. (That could have been due to weird politics and the way the organization was set up – who knows.) At any rate, a couple of the people-in-charge hinted at me potentially working there again. Also flattering, but unless the politics have radically changed there I’d rather just volunteer and stay out of that mess, thankyouverymuch.

(Trying to) Eat Healthy

For the past 2 weeks I’ve changed my eating habits. I’ve been cooking all but 1 meal per week at home and have cut out potato chips, candy, and (except for 1 time) soda. I haven’t gone completely Paleo like a lot of Crossfitters do, but my grain/bread consumption has gone way down also (2-3 servings per day instead of 6-8).

Not gonna lie, it’s been really tough. The first couple of days I had a dull headache all day. I suspect it was due to withdrawal from something (Sugar? Junk food in general?) Eventually that went away, thank goodness.

It’s also more expensive and inconvenient to cook at home. I’m spending about 1 ½ times more at the grocery store to get fresh produce and real food vs. boxed and canned starchy pre-packaged meals. I’m also spending about twice the time preparing food – prepping veggies, cooking large quantities of meat for the week, etc.

I think it’s worth it – I feel a lot better now. I’ve also lost a little bit of weight (that wasn’t a primary goal, but anything that helps me with achieving a pull-up is all right by me!)

A Study in Contrasts

Sunday:

Worked at my training hospital

Saw 18 patients – 10 sick, 8 healthy(ish)

1 surgery (spay on an older fat dog – ugh)

Worked 9 hours

No potty breaks, no lunch breaks – just straight madness all day

Monday:

Worked at my “home” (destination) hospital

Saw 11 patients – 4 sick, 7 healthy

No surgeries

Worked 9 hours

Sat around a LOT and got very very bored

I’m not entirely sure why the days were so different. I think it’s because at the training hospital I end up haggling a lot more with clients about treatment plans so every appointment takes longer, but I can’t prove that.