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!