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.