New schedule

I got sick right after returning from vacation (it figures) but am feeling better now.

The new work schedule is all right. It's VERY nice when I have a long weekend; less so when I have to work on Saturday and get split days off. The new doctor seems very nice and has made it easier for us to book more same-day appointments when clients need them.

Some days are ridiculously slow and others are jam-packed (like today) with very sick patients. There doesn't seem to be a pattern, either. I'm still planning for a slow down and have cut back on a lot of things in preparation for that. We'll see how it goes.

Vacation

Hello from Southern California!

D and I are here for a long weekend since one of my good friends from vet school got married yesterday.

Friday we went to Disney's California Adventure, which was fun. Today we went to the Getty Museum. Gorgeous buildings and gardens but the art is generally not my cup of tea. There was a lot of medieval and religious artwork - I prefer more modern artists. There was a really great visiting photography exhibit however. Tomorrow we're going to Disneyland and then back home.

This week our hospital will start being open later on Mondays too. I will now work Monday - Thursday and every other Saturday (yay!) I haven't spent much time with the new doctor so no opinion yet. I really hope they are easy to work with because I'll be spending a ton of time with them!

2nd Opinions

I've had a few 2nd opinion appointments lately - some for skin issues, some for (ugh) internal medicine issues.

Sometimes I want to scream "Really?! You really expect ME, who has been a doctor for only 16 months, to provide a second opinion?! Are you high?!"

Appointments like that scare the beejesus out of me. I feel like such an imposter.

Farewell, old friend

Our old lady kitty went downhill quickly over the past few days and we let her go this morning. My colleagues were amazingly supportive and compassionate. They let me just be "mom" and not a doctor for which I am so grateful.

I had a lot of things on my to do list today (working 10 days straight means many other tasks pile up), but I don't think I'll get to many of them. I'm too tired and too sad right now.

The Longest Day

Last Wednesday was pretty rough. This was not a typical day for me. Here were my appointments:

- Puppy with vaginal discharge after her spay last week (no, I didn't perform it) whose owner was freaking out. Looked like puppy vaginitis.
- Newly adopted rescue dog, just preventive care. Fairly straightforward.
- Eye recheck for a dog with red irritated eyes, improved but not resolved.
- Rechecks for kittens who had upper respiratory infections, now resolved.
- Dog with recurring urinary tract infections, unable to get urine since she went just before her appointment.
- Dog with horrible skin issues (a breed who is notorious for severe allergies) whose owner repeatedly declines workup, changes the dog's diet frequently without consulting us, and sometimes forgets flea preventative then wonders why the dog's skin is always messed up. Repeat my speech on dog allergies for the 3rd? 4th? 100th? time with that client.
- Dog who needs vaccines but the owners have no idea what he needs or when he last had vaccines. They sat there with their arms folded across their chest as though I was supposed to use my magic psychic powers to figure that out.
- Ancient dog with 7-8 major problems and an owner with no money who wants to chat about everything that *could* be done for the dog but that they won't do for the dog. This appointment set me behind schedule by about 15-20 minutes.
- Dog ear infection recheck. I'm only allocated 20 minutes because it's a recheck appointment but hey doc, the dog is limping now too, could you check that out in less time than you usually have for a new problem?
- Itchy cat recheck. Owner just changed to limited ingredient diet and has been keeping all cats on monthly flea preventative. Say a silent thanks for this client because they are awesome.
- Recheck of cat being pet sitted by owner's EXTREMELY high-strung and rude daughter. Ugh.
- Wellness exam for a grumpy cat whose owner is pretty awesome.
- 30 minutes before closing emergency hit by car stray kitten who is 95% dead. Have to help it the rest of the way.

I came home, had a beer, and cried.

Ultramarathon

Scratch that previous post. My colleague is sick so I'm working this afternoon to cover them. That's day 7 in a row and by Thursday it will be 10 days in a row.

I like my job but this is getting ridiculous.

Marathon

I survived this week!

6 days in a row:

Tuesday - volunteered at the shelter in the morning, then went to work for a full shift
Wednesday - worked and had a crazy draining day (more about that later)
Thursday - worked
Friday - covered one of the other doctor's shifts at work
Saturday - worked
Today - worked my very last vaccine clinic (YAY!!!)

Unfortunately I only have tomorrow off and then it's back to work again for 3 days - including that mastiff puppy spay on Thursday.

Starting surgery (again)

I've been getting 1-2 surgeries per week fairly regularly at work now, which has been nice. The past 2 weeks I've had 1 kitten spay with 1 kitten neuter. I have the same on the schedule this week, and then next week ...

... a mastiff puppy spay.

I vomit a little in my mouth every time I think about it. As long as one of the boss doctors is in the building at the time I should be fine. I seem to be able to tackle tougher surgeries if there's a senior doctor on site, even if they don't scrub in. There is comfort (and confidence) in knowing that help is available, even if you don't use it.*

*Key point that ex-hairdresser-practice manager at my old job never understood!

Down time

As a veterinarian your entire day is spent interacting with people - coworkers, clients, and colleagues at other hospitals. As an introverted veterinarian, this is completely exhausting - especially when one or more of the people you deal with is, shall we say, high-maintenance.

It's REALLY important to recharge, otherwise you will completely burn out.

For the past month or so I've been teetering on that red line, so to speak. Between traveling, working extra days at the vaccine clinic, and taking care of household tasks, I'm pretty near fried. As a result my old friend anxiety is starting to show up again as that non-specific clenching in my gut.

I've been trying to force myself to do less - clean less frequently, not spend so much time reading veterinary-related material (the number of emails and journals I get is overwhelming sometimes), and do things like just watch mindless TV or just sit outside on the patio.

Let me tell you, this is HARD to do. My mind keeps coming up with endless things that I *should* be doing instead of relaxing. There is literally no end to the things you could learn in medicine, or the things you could clean or organize in a home. I'm the kid who earned ALL the merit badges possible in Girl Scouts because I wanted to finish, dammit, so intentionally saying no to doing extra feels like slacking.

Here are some things that I did/am doing to help:
- Quit the vaccine clinic (I have one more day and then I'm done). The extra money isn't worth the stress.
- Asking D to do more things around the house that I normally take care of (get groceries, vacuum, etc.)
- I am thinking about hiring a housekeeper. D is worried about someone having access to the house when we are away, so I could have them come clean while I am home.
- Also thinking about hiring pest control services to spray the perimeter of the home periodically so that I don't have to battle the near-monthly ant invasions
- Bought a season pass to my favorite ski resort

Hopefully I can get back on track. I'm terrified of getting as burned out as I did at the corporate practice.

Speaking of emergency ...

I found this great blog entry today containing tips for dealing with veterinary emergencies (as an owner/client).

Same situation, VERY different response

Once in a while you have a complication with a patient under anesthesia. I have now twice seen instances where a cat, while under anesthesia for a dental, developed a cardiac arrhythmia. (For those who care, they started getting individual VPCs and then developed into runs of them.)

As you may imagine, abnormal heart rhythms are a pretty big concern for us because they sometimes lead to death.

In both cases we aborted the dental and woke the patient up from anesthesia. Fortunately in both cases it was during the scaling (cleaning) part of the procedure and not during any extractions (surgery).

Case #1 at the corporate practice - I talk with the owner. Owner's response includes questions such as the following:
"So we used up the dental on my plan and I can't have it done until next year now?"
"Why couldn't you just finish?"
"How much would it cost to see a cardiologist?" (Ok, this one is a fair question but it illustrates the mindset of the owner - greater concern for money than for their cat - or at least that's the way it appeared!)
I had to bite my tongue from saying to this owner "So you wanted your cat's teeth cleaned even though he could be DEAD with clean teeth?!?!?!"

Case #2 at my current practice - my colleague talks with the owner (it wasn't my case this time.)
Owner's response:
"Thank goodness he's okay!"
"What should we do next to find out why this happened?"

Which owner would you rather work with?

Emergency conference

A few days ago I returned from the IVECCS conference in San Diego. It was fantastic! There were 7 or 8 different learning tracks ranging from complex specialty center care (ventilators and the like) to things useful for a general practitioner like me. There was also a technician track with 2 different lectures to choose from at any given time.

Here are some examples of the lectures I went to:
Anaphylaxis
Lymph node cytology
Blood smears
Respiratory distress in cats
Anesthesia for patients with pre-existing disease (heart disease, diabetes, etc.)
What's new in the treatment of parvovirus infections

In addition to the excellent learning content, I got to catch up with many of my friends from my old hospital where I was a tech as well as friends from vet school. I also had time to visit the San Diego Zoo, Sea World, and to go to this crossfit box for a workout!

Here are some of my favorite pictures from the trip:

Turtles at Sea World

Flamingoes at the zoo

Manta ray at Sea World

Hilarious!

Next year the conference is in Indianapolis. I'd love to go again but may choose a different conference such as a feline-focused one.

How veterinary medicine ruins food

The other day I saw one of the worst ear infection cases I've ever seen. While cleaning out the foul-smelling sticky yellowish-white gunk from the dog's ears the tech commented that it looked like Alfredo sauce.

Eww.

We make a lot of comparisons to food in our field because the various things that come out of our patients resemble food items. These comparisons also make it easier to converse with owners and to get a good description of vomit, diarrhea, pus, and so on. Some examples:

- The diarrhea from patients with hemorrhagic gastroenteritis looks almost exactly like raspberry jelly (but smells NOTHING like it)
- Diarrhea can be liquid, "milkshake," or "soft serve" consistency
- Ear mite debris and vomit containing digested blood can look like coffee grounds

Eventually you get used to it, although it may be a while before I eat fettuccine Alfredo again.

It worked!

I'm still surprised from time to time when my treatment plans actually fix a problem with a patient. It seems to be those cases where I have to reason my way through the case and make up a plan for something I've never seen before. Since there is absolutely no way to learn a rote approach for every single possible problem in veterinary school you have to go back to basics and think your way through a lot of problems from scratch.


I'm also (sometimes) surprised when my clinical suspicion is later proved to be right through diagnostics or through a specialist referral.

The worst disease

Today I euthanized a 4 month old kitten who had FIP, like my foster kitty Reggie did.

I'm sorry little guy.
I'm sorry that your life was cut short by a horrible fatal illness which can neither be predicted nor stopped.
I'm sorry that you didn't get to spend more time with your people who loved you to pieces.
I'm sorry that you never got a chance to grow into a grumpy old man cat along with your adopted kitten sister.
I hope you know that all our hearts are breaking a little from losing you.
I hope you enjoy running around with all the other kitty angels and eating all of the chicken and steak and cheese that you want.

Growing

My hospital just hired a new RVT and they are in the process of hiring a new part-time doctor. This is in order to offer evening hours on additional days and to have a 2nd doctor with me on some evenings. It's not (at least I'm not led to believe it is) due to me being inefficient, rather the business has grown to the point where we could support additional appointment slots. Crazy!

Of course good old skeptical/paranoid me is wondering how things will be during the dead of winter when most clinics slow WAY down. I guess we'll see!

Grump

Yesterday I went into work an hour early with the intention of catching up on phone calls. I had a lot of lab results and surgical estimates to discuss with clients.

OF COURSE then the phone rings - new client, dog got into a fight and sustained bite wounds, could we see them? Receptionist asks Dr. Bosses (one in surgery and one in appointments) and they say that we can probably have one of us work them in - perhaps me.

My heart sank. I told the receptionist that I could see the dog if no one else could but that I would really prefer to catch up on everything that I was behind on. You see, I don't have access to our computer system from home and so all my callbacks and records writing has to happen at work. I didn't want to stay late to do it or call people at 8:30 pm, so stupid me thought it would be a good idea to come in early.

Guess who saw the emergency. Guess who became 30 full minutes behind as a result and ended up apologizing to people the rest of the day for being behind.

To make things even more fun challenging, we had:
- A fully booked appointment schedule
- 2 dentals and 3 surgeries (dentals take up 2 techs and surgeries take 1, thus tying up about 50% of our techs all day)
- 2 other urgent care appointments earlier in the morning
- 2 ultrasounds (those took up the remaining 50% of the techs)
- 1 tech out with a sick kid

Net result: I had NO help with my first few appointments after that emergency.

I ended up being fairly grouchy and having to mentally check myself from biting people's heads off. I failed one time unfortunately and then felt horrible because that is how I felt and acted ALL THE TIME at the corporate practice.

There are certainly some efficiency things I can work on, such as completing more of the records in the exam room and maybe calling people back at night if necessary. However, I also think we had far too many procedures booked for the number of techs we had. When Dr. Boss is cleaning exam rooms and restraining animals we are definitely short on support staff.*

One of the challenges that I face with completing the records in the exam room is that the main tech I work with is slooooow on the computer and regularly makes errors, so I've lost trust in her being able to do any of my records or charges. How do you help coach someone to get better when you don't have the time to do so? Other techs are really good about entering charges and entering history and treatment plan into my records so I only have to complete the physical exam and assessment portions. With this other tech the history becomes a verbatim transcript of what the client said in run-on-sentence form (so it's unreadable) and it's a rare time when either a charge or a prescription direction or both are incorrect.



*Note: I am absolutely NOT saying that doctors are above doing tech work. It's just that when a doctor does tech work you are spending more money to get the same job done - AND you are taking away from time that could be spent making diagnoses and coming up with treatment plans.

Good surgery day

I performed my first cryptorchid (testicle(s) not in the scrotum) surgery on a kitten today! I'd done one before on a dog but:
a. Dog testicles are WAY bigger than kitten testicles
b. The dog at least had one testicle where it should be so I only had to locate the other one (the kitten did not have either testicle in the scrotum)

Fortunately I have an awesome mentor at the shelter who talked me through an approach that worked like a charm!

All in all I performed 7 surgeries in 2 1/2 hours. That's not impressive if you're a shelter vet, but for me it's pretty darned good.

Exotics

My clinic has been heavily publicizing the fact that I also see small exotic mammals (rabbits, rats, guinea pigs, chinchillas, and the like). As a result, I have been getting a lot more appointments booked for those animals. It's interesting and I like working with most of them* but it is also stressful. Unlike with cat and dog appointments I don't have a mentor readily available to help when I get stuck on a case. If it is anything other than hair loss, wounds, or respiratory infections then it is probably a brand-new problem to me and I have to look things up. Finally, I don't yet have a ll of the drugs and equipment I would like - admittedly a more minor issue.

I'm just doing the best that I can, asking old classmates for help when needed, and trying to not obsess over whether my way of treating something is "the right way" of doing it. The fact of the matter is, as long as I have sound reasoning behind my treatment plan then I should be helping the patient at least a little. It may not be THE optimal plan from the get-go, but I always schedule rechecks that help me make course corrections if needed. It's just taxing, that's all.

This week we are headed to Phoenix for D's grandmother's 95th birthday. I've never met her so that should be nice. I also finally was able to do pistols (1-legged squats) today!



*I'm not such a fan of undersocialized exotics who like to bite me (usually mice and hamsters)

Oh my.

Yesterday was a ridiculously crazy day. I had:

- A full appointment schedule
- 2 kitten spays
- 3 4 unanticipated emergencies (1 decompensating cancer patient, 1 vomiting and limping, 1 blowout vomiting and diarrhea with a VERY challenging owner, and one anesthetic emergency during one of the spays)

I ate my lunch at 6:30 pm. Oh, and I got my period too - fortunately I had the supplies on hand to deal with that.

The combination of all of these factors made me extraordinarily grumpy (however my mood improved quite a lot once I actually got to EAT). Looking at the bright side of things, though:

- I finished both spays in about 25 minutes each - so I'm getting more efficient, and both kittens did well post-operatively
- I generally DO have a full appointment schedule, which is pretty awesome considering the economy and that fact that I'm still a new grad
- I successfully channeled all of that stress into cleaning the house and kicking butt on a very challenging workout today
- With the exception of 1 appointment (the one with the challenging owner), I felt as though everything got handled very well and the clients were happy

Today was a nice chance to sleep in and relax. Tomorrow will likely be busy again!

Conquered

Dr. Boss asked me to spay and neuter their foster kittens since I have a lot of experience with pediatric surgery - I did and they went well.

Today I did 6 rope climbs (20' high) in crossfit. Did I mention that I'm terrified of heights?

It's been a pretty good week for doing things that I'm afraid of.

Old and new friends

Sunday I went to a baby shower for one of my vet school friends. It was great to catch up with everyone! Some were finishing up internships and about to start new jobs, others were in the process of buying their first house, and everyone seemed happy and settled in their new lives. This was a stark contrast to a year ago when we were all scared newbie vets, much less 5 years ago (!) at vet school orientation when we were all wondering what exactly we had gotten ourselves into!

Later that afternoon we had a party at work to celebrate the first anniversary of the hospital. That was fun too - seeing people out of their scrubs and talking about non-work-related things was a nice change.

I wish I wasn't so ridiculously shy sometimes because days like those are great, but I'm too afraid to set up social events. Instead I rely on others to make the arrangements.

Well, today is going to be pretty busy at work - better finish my coffee and get ready!

Happy 1-year to me!

Tuesday marked my 1-year anniversary as a practicing veterinarian. Whoa.

I've learned a TON over the past year - things like:
- Common skin masses and what their cytology looks like (things like histiocytomas weren't covered very well in school)
- Perfecting my "canine allergic skin disease" talk
- How to perform a cysto without ultrasound guidance
- Getting a LOT more skilled at drawing blood from the jugular vein (hey, I learned on peripheral leg veins and was much more comfortable with those)
- How to pretend I'm confident (even when I'm not) in front of clients (and then research the crap out of it later so that I actually come up with a good answer for them)
- I'm apparently pretty good at euthanasias (got another thank-you card this week for one)
- What my standards of medicine/care and ethics are (hint: not a good fit with my previous clinic)

Looking forward to the future now that I'm (finally) doing what I was meant to do!

Day 6/6

This week I worked an extra day at the hospital to cover for one of the other doctor's vacations. It was BUSY! Unfortunately I had several more euthanasias, but I got a lot of new and interesting cases such as a broken toe, a thromboembolism (unfortunately that turned into a euthanasia) and others.

Today was my 6th day working in a row - at the vaccine clinic. The tech and I both got bitten and scratched by a very ill-tempered cat which was no fun, especially since it was within the first 30 minutes of starting work. Cat bites really suck - even if you wash them out thoroughly they often get infected.

Fun quotes from this past week:
"Have you lost weight?" (- Crossfit coach and massage therapist both asked me this on Monday ... actually I've GAINED a little weight)
"You're doing REALLY well." (- Dr. Boss)

Grim

This week was rough. I'd estimate that 25% of my appointments ended up with the clients crying - either because I euthanized their pet or I gave them a cancer diagnosis. That's a pretty high percentage when you're not an emergency doctor!

I've also got my first client who I suspect is mentally ill and it has been exhausting for everyone who has dealt with them. Fortunately Dr. Boss is calling them later today and we'll see what comes of that.

Thankfully I have the rest of the weekend to unwind. Think I might have a beer!

The Profession

There is a website address that is currently circulating in the veterinary community. Its focus is to petition for changes in the AVMA.

In short, the job market is still pretty terrible for veterinarians (I have been lucky, horrible corporate practice notwithstanding). The number of graduates per year consistently outnumbers the open positions available. Student debt is crazy. You can make a lot more money for a lot less heartache.

The idea behind the petition is to get the AVMA to stop saying the field is full of opportunities and to stop approving the accreditation of so many new (foreign) schools each year and instead work on generating public awareness and demand for veterinary services.

I haven't signed it. Why? This may seem silly but I'm afraid my professional liability insurance through them will be cancelled. Next year I plan to get my insurance through my state veterinary association and to not renew my membership with the AVMA (because I do think in their current state they are useless and possibly even detrimental ... except their journal is interesting).

p.s. I found out that a horrible tech/receptionist I worked with at the corporate practice got hired by my old practice (you know, the one I used to dream of joining?) Eesh.

Prime Time

Summer is always the busy time of year in veterinary medicine. Pets go outside more often and therefore get into trouble more often - snake bites, heat-related illnesses, plant foreign bodies like foxtails, cat fights, and so on. My appointments have been booked nearly full most days, which is great considering the other 2 (senior) doctors on duty get priority for appointment bookings.

I've met a lot of nice pets and nice people and am really enjoying this job (which is a relief considering the $106,000 in educational debt I still carry!) Yesterday is a good example of why I like general practice. I had a huge variety of cases such as:
- Annual exam and vaccine visit
- Inappetance
- Back pain
- Vomiting
- Eating dirt
- Euthanasia (very old pet with multiple chronic diseases)
- Foxtail in ear
- Snotty nose/upper respiratory infection
- Diarrhea

I know that probably doesn't sound exciting to a lot of people. I LIKE the "boring" visits where the pets are healthy and I can just chat with the owners and pet the dog or cat. It's gratifying to do a relatively simple procedure like removing a foxtail and watch the pet immediately feel relief. Although there are common themes the variety of things I see in any given day is great. I would be sooooo bored if I only saw GI cases all day, or cardiac, etc.

Who knows, maybe in 10 years I'll be totally sick of well pets and vomiting/diarrhea/itchy skin cases. If that's the case maybe I'll switch to emergency.

YC Fabulous

As it turns out my old lady cat has HCM (hypertrophic cardiomyopathy). It's mild, but it's enough to make her anesthetic risk WAY too high to perform an elective procedure like a dental. She's just about on life 9 1/2 at this point, I swear.

She came to our yard almost 8 1/2 years ago. It was pouring rain day after day and she huddled in the shrubs on the side of the house. She went into heat shortly thereafter and had many, um, suitors visit. I decided to trap her and get her spayed, and after that we started feeding her.* At one point she had a bad wound on the back of her neck but we couldn't catch her to get medical attention for her.
We named her Yard Cat, or YC.

Over the following months as summer came she would visit with our other cats through the screen door. Eventually we would crack the door and she would walk in - for a little while at first, then longer and longer. Around Thanksgiving time she decided to stay for good.


The first year or two we had a challenge catching her to take her in for exams and vaccines. Once she was diagnosed with chronic kidney disease she allowed us to pet her more - sometimes with both hands! At one point she developed Horner's syndrome from an unknown cause.









Then she was hospitalized when her kidney disease progressed. After that she required fluids every other day and she became even more friendly.


She's a great cat and I am dreading the day we will have to let her go.






*We believe in feeding stray cats as long as they are spayed or neutered - otherwise you end up with a cat population explosion!

Burned, Murph, and lots of neuters

Last week's surgeries went well. I performed 6 uncomplicated surgeries at the shelter on Tuesday morning and one uncomplicated spay on a fat 6-year-old dog at work on Wednesday! The one at work had me sweating quite a lot. When a dog is older and has a lot of fat in the abdomen it is very difficult to see important things like arteries. When you tighten your ligatures they disappear into the fat and it's disconcerting when you can't SEE your knots tighten nicely. Your gloves get covered with a slippery oily film so you have to keep wiping your hands on a towel. They have more vessels in the broad ligament you have to deal with. All in all it's a huge pain in the bee-hind.

Over the weekend we went to the Crossfit regionals. It was SO fun! Several of our coaches competed, and 2 of them are going to the Crossfit Games this summer, which is a big deal. Our region is a notoriously difficult one with a ton of good athletes so it's even more impressive. I ended up getting quite the sunburn while spectating, however. Should have applied another layer of sunscreen, I suppose.

Monday I had the day off and for Memorial Day we did a hero workout at Crossfit. This one was called "Murph":
1 mile run
100 pull-ups (I used an assistance band)
200 push-ups (I did them from the knees)
300 air squats
1 mile run
At the 40 minute mark they had us stop our pull-ups/push-ups/squats and go for the second run, so in 50 minutes I did:
1 mile run
95 pull-ups
190 push-ups
285 air squats
1 mile run
I'm a little bit sore today :)

Yesterday I went to the shelter again and lost count of how many kitten neuters I performed. We totaled 50 surgeries for the day, which is a record. They are trying to get as many surgeries as possible performed before this weekend because they are having a huge adoption event.

Fear

Last week I went back to the shelter again as a volunteer surgeon. It went well, except ... as I was closing my last spay a loop of the animal's small intestine popped up riiight as I threw a suture and my needle hit a mesenteric artery. It's a one-in-a-million thing (ok, maybe one-in-a-thousand?) but it freaked me the heck out. I pulled out that loop of intestine and applied pressure - fortunately the thing stopped bleeding and the intestine stayed nice and pink.

Now I'm scared about going in again this week. I KNOW it's not entirely rational. That doesn't matter. Every time I have a rather large issue like that it takes me several weeks to get back on the metaphorical horse.

I used to like surgery much more when I was still in school and not expected to do a good job at it.

In unrelated news, our group ski trip in February will be to Steamboat! I've already been ogling the trail maps.

Objectivity

Tomorrow I'm taking my old lady cat to the specialist. She is in desperate need of a dental (I'm talking black teeth here, people) but she has kidney disease and a heart murmur.

Let's see.
Kidney disease = you need lots of fluids to keep them hydrated
Heart murmur (heart disease) = don't fluid overload them because it's too hard on the heart

Basically the thought of her being anesthetized on my watch is too nerve-wracking so I'm sending her to a place with all the bells and whistles. The specialist is double boarded in dentistry and internal medicine, which is great. I'm actually nervous for the appointment tomorrow though! When it's one of our pets I have a much harder time being calm and objective.

Adding to the database

Veterinary school can only teach you so many things. You learn the basic pathophysiology behind diseases and how to treat them. However, you need a lot of clinical experience before you develop intuition - the art of practicing medicine.

To do this, you need to see case after case and keep mental notes for later. That's why a veterinarian who has been in practice for a long time may come up with differentials that don't (yet) occur to me. Yes, there is a danger of falling into a rut based on what you've seen before, so you need to be careful to not jump to a diagnosis too soon.

Right now I'm enjoying adding to my "file." Two recent cases in point:
- Young dog, started eating lots and lots of dirt recently. I recommended a fecal, which showed that the dog had Giardia (an intestinal parasite).
- Another young dog had partial hair loss that looked similar to Demodex (mite) cases I'd seen before, however a skin scrape showed no mites. Dr. Boss saw the case later and diagnosed bacterial infection based on impression smears - they said that they've seen short-haired dogs present like this and agreed that yes, at first glance it does look like Demodex. I'd never considered bacteria!

Spoiled

Last weekend I worked at a vaccine clinic. It made me extremely grateful for my current job!
Most of the clients were pretty nice, but several were just plain grumpy. I don't really see that anymore at my job. The assistants/techs were also nice but not very skilled at restraining pets. The techs at work, however, are rock stars.
This weekend I'm doing another vaccine clinic - hopefully it goes better this time, but I'm not holding my breath.

Measurement

One of the hardest things about leaving veterinary school (for me, anyway) is that there are no more concrete measures of success like grades. How do you tell if you are a good doctor? How do you measure improvement?

Is it the number of cases you see per day?
Financial measures like average client transaction amount or gross production?
The number of thank-you cards and gifts from clients?
The number of lives you save?
Getting corrected (or reprimanded) fewer (or zero) times?
The number of cases you can resolve with just one visit? Without referring?
Feeling satisfied at the end of the day, as though you made a difference?
The number of new procedures you learn?
The number of clients who ask for you specifically?
Having techs and support staff respect you? Like you?

I don't have a good answer right now - in all likelihood it is a combination of these factors and more. I *think* I'm doing a pretty good job, especially being out of school less than one year, but I can't prove it definitively. That's a difficult thing to deal with when you're a ridiculous goal-oriented Type A person.

Good at death?

It seems as though the best compliments and thanks I get from clients are my euthanasia cases. I'm not sure why that is - maybe it's the same reason why oncologists seem to have very grateful and nice clients?
Perhaps the clients have accepted what is going to happen. Maybe they appreciate that I explain what is going to happen, explain again as it happens, and ask them if they're ready for each step. Maybe there's something about having gone through it myself as a client multiple times that makes me more empathetic - I'm not really sure. All I know is that I've received positive Yelp reviews, really nice thank-you cards, or profuse verbal thanks from just about all of my euthanasia cases.
It's a running joke with my friends from veterinary school now - that I'm "good at death."

Mistakes

It seems like at least once every week or two I make a mistake and get talked to by the management about it. I get it - it's your money and reputation on the line, it's a new hospital, and I need to be made aware of my mistakes so that I can improve. Frankly I WANTED a place where I could get some feedback (both positive and negative) so that I can become a better doctor!

The latest one was where I didn't explicitly spell something out in the medical record - essentially the client did not agree to the recommended plan so we compromised. We discussed the consequences and risks of said compromise and I put it in the discharge instructions but wasn't explicit enough in the rest of the medical record. Long story short, the thing I warned the client about happened and the client didn't want to pay. Since it wasn't documented super-well in the record (note: my record was NOT finalized because I wanted one of the doctors to review it first, but the client came back before I could get that done) the management comped about $200 worth of services for that client. Oh, and as it turns out the client didn't want to see me or the other doctor on duty that first day but her preferred doctor was off and it was an urgent issue. I'm expecting some more meetings next week to discuss it - sigh. Lesson learned.

D says it takes about 1000 "atta boys" to make up for 1 "oh shit." I need a helluva lot more atta girls ...

The emergency queen rides again

This week has been slightly crazy at work. We're a general practice open daytime-only and yet I've managed to have an emergency every day; the other doctors have had a few as well.
Here's what I saw:
Tuesday - foreign body ingestion
Wednesday - bee-sting allergic reaction
Thursday - urinary obstruction
Today - hit-by-car AND bit-by-dog

Good thing I renewed my membership to the emergency special interest group! I'm also planning to go to their conference this fall. If these things are literally going to walk in the door when I'm on duty I should keep learning how to best treat them, right?

New goals

Here are my goals for the rest of 2013:

1. Get 3 pull-ups in a row (strict would be great, but kipping is okay too)
2. Get 3 toes-to-bar in a row
3. Take a vacation and go to a conference (I'm planning to go to IVECCS in San Diego in the fall, but AAFP in Dallas looks good too)

Inexperience

Sometimes It’s hard being the most recent graduate in the practice. There are clients who have followed some of the other doctors over the (10-20) years and who have a lot of history with them. I’m certainly not offended when they prefer to schedule their appointments with the doctor they know – particularly if their pet has a long and complex history.

I had one such client agree to see me a couple of days ago because I was the only one with appointments available and their pet was sick. Our practice has a policy of doing blood draws and injections in the exam room wherever possible, so I attempted to do so. If I had known (or picked up on?) the fact that the client was SUPER protective and nervous about their pet, I would have brought the pet to the back. Instead it took a couple of attempts to do the blood draw (my fault) and a couple of attempts to get the injection fully in (the tech’s fault).

The client emailed their “regular” doctor and asked them to take over the case as a result, which is hugely embarrassing. Now that doctor (who is my boss and an owner) wants to talk with me and the tech about how to improve.

I know that this is how you learn but it really bruises the ego. One of my mentors says that veterinary medicine is a constantly humbling endeavor – whenever you feel like you know what you’re doing you get knocked down a couple of pegs.

2013 goals met!

Remember when I said I had 2 goals for this year?

- I got the new job
- Today I managed an unassisted pull-up. It wasn't pretty at all, but I did it!!

Now I have to think of some new goals. I'll get back to you once I have.

Getting the routine

I still really like the new job. Some days it's a little slow, but days like today are great. Most of my cases today were really interesting (intestinal foreign body, fluid-distended abdomen, fever and lethargy, and a few others) and I am learning a ton by working with the other doctors!

I'm still figuring out the computer system, which lab tests are which, and things like that but overall I think it is going well. The only down-side is that I don't get to do as much surgery as in my previous job. The up-side is that I see a lot more complicated medicine and emergency cases than I used to.

The Crossfit open is going fairly well. Last week's workout left me coughing and sneezing (a sure sign of a tough workout for me aerobically) and this week's workout was challenging - I didn't get a high score because I haven't (yet) mastered toes-to-bar. Oh well!

Crossfit Open 13.1 and 13.2

Remember when I said I'd signed up for the Crossfit Open? Well, I've now completed 2 of the 5 weekly workouts.

Workout (WOD) 13.1 involved 2 of my least-favorite movements: burpees and snatches. The burpees were REALLY hard both on my lungs and on my arms. I managed to finish the first set of snatches but didn't finish the second set. I wish I had been able to do more but my arms just would not cooperate. Considering my 1 rep max for the snatch is 80 pounds or so, managing to heft up 75 pounds a few times was pretty good. Final score: 105

13.2 was more my thing: lifting a barbell overhead from the shoulder (you could do it a number of ways), deadlifts (my very favorite thing in the world!) and box jumps. I decided to use push jerks to get the bar overhead because 75 pounds is pretty heavy for me, and I did a few box jumps before quickly switching to step-ups. Had a wicked allergy attack afterward, which usually happens when I have an all-out cardio effort. Final score: 205

All in all, I'm happy that I've been able to complete the WODs as prescribed - normally I have to scale weights back. If past years are any indication then I might not be able to do some of the later ones as prescribed.

Tomorrow I go back to work after 3 days off. I'm looking forward to it, and not just because I'm bored out of my skull here at home!

First day, new job

I started at the new clinic today. It was a little bit slow but went well overall.

The clients are nice and don't yell at me! The techs and receptionists are amazing! There was another doctor there who helped me with a case I wasn't sure about!

I really like it so far. It's a big (and welcome) change from the mega-corporation.

Out with a bang

My last day at the corporate practice was a lot more memorable than I had hoped it would be. One tech brought a cake and another brought a card thanking me for how much I taught her, which was awesome. I got bit by a cat while holding it during anesthetic induction, which was not so awesome. The same cat had a serious arrhythmia under anesthesia so we had to wake it up without doing the dental and then proceeded to completely flip out on recovery, fly around the treatment room, and break a toenail in the process.

I had to take a moment to go to the bathroom and cry for about 30 seconds after all that. Then it was back to work.

We had no receptionist (they called out sick ... again) and were short 1 tech as well. Oh, and one of the new doctors who will be backfilling me was visiting and got to see all this madness! I'm sure they are freaking out a little about joining this sh!t show.

Anyway ... then we had another cat dental and the cat was so amped up that the maximum dose of intramuscular anesthetic barely affected it, so we had to abort that one as well. Needless to say I had some super fun client phone calls to make.

I had no lunch and ended up staying an extra hour because we were so busy.

Did I mention how glad I am to be leaving?

The last of the Saturday madness

Today I saw 28 patients, of which maybe 7 or 8 were easy vaccine appointments - the rest were surgeries, emergencies, and sick pets.

That, my friends, is a ridiculous number. I had no time for lunch and no time to even pee all day. The techs had no time for lunch and probably no time to pee either.

The sad part is that regional management will say 2 things:
1. Great job making lots of  money!
2. Stop clocking so much overtime

To which I (and probably the techs too) would respond: Make the schedule match the staff you have available, you j@ck@sses.

The former practice manager is now back as a customer service consultant. Problem is, they still act as though the practice manager. They said yesterday they were "so proud" of me because I was "living up to my potential" and if I "showed just a bit of that" in my new job I would "do great." See, they are convinced that I'm scared to take on cases and holding myself back due to a lack of confidence - even after I flat-out told them when I resigned:
"No actually I have plenty of confidence. The problem is that veterinarians who have been out of school 10-20 YEARS say the volume we're expected to do here is insane."

I feel bad for my classmate who will be backfilling me.

5 more days - and why did I sign up for that?!

Only 5 more days at the current job, thank goodness! In one way it's easier to deal with all the madness and BS knowing that I'm leaving, but on the other hand these seem like some of the longest days I've ever spent there.

I also signed up for the Crossfit open. Frankly I'm not even sure I will be able to complete all of the workouts but thought it would be a nice challenge - plus it's not very expensive to register, so what the heck. I've no illusions about making it to any sort of competitive level (regionals or obviously the Crossfit Games) - just want to keep pushing myself.

It will be nice to have that week-and-a-half off between jobs too. I'm still going to the new place once a week and still love it, so that's good!

Start date

I got the official offer today! I start the week of March 18th. Yayyyyy!!!

Leap

I turned in my resignation first thing this morning with 2 weeks' notice. Exactly no one was surprised, and most people seemed pretty happy for me.
Even if for some reason this other job offer doesn't pan out (and it sounds like it will - they've hired a tech and are working on a receptionist to support the extended hours that I will cover), I have some possibilities with relief work so we won't be flat broke.
I'm relieved that the end is in sight at this horrible place. I'm excited at the prospect of working somewhere where I feel like the best version of myself and not the worst - and where I fit in. I'm scared that I will fail.

6 days a week

I'm still at the current (hopefully soon-to-be-old) job 5 days per week. On one of my days off I've been continuing to go to the shelter to do surgeries and then head to the other practice (the one where I have a potential job pending) to sorta work and get used to everything.

At this point I have a verbal offer from them and they are in the process of hiring 1 more tech and 1 more receptionist to help support the extra doctor (me). Once those people are in place then they can give me a start date. Hopefully I will get the good news soon!

If not, I'm also working on getting paperwork together (mainly liability insurance because I didn't need it while working for the corporate behemoth) so that I can work at vaccine clinics part-time if needed.

Bottom line: I should be able to quit very soon! In the mean time I'm very very very tired. Sundays are pretty much my only days off right now.

Shameless plug

I bought a spay retractor recently and used it for the first time this week. It's a little bit hard to explain, but essentially it's a device that acts like a 2nd pair of hands to hold things up so that it is easier to place ligatures.

I LOVE IT.

It cut 15 minutes off my dog spay time - from 45 to 30 minutes. Nice!

More phone message fun

On my desk yesterday, a message to call Ms. D regarding Her dog. The dog is feeling much better, so can she stop the antibiotics? Please call.

Um, NO.

I was more flabbergasted at the receptionist's forwarding that question to me. After working in this field for years they should know better. Just take some initiative once in a while? Please?

Hope

I don't want to write too much about it right now and jinx it but it appears as though I may have found a new and AWESOME job! I adore the clinic and the people who work there. No written offer yet though (they need to hire support staff to correspond to adding another doctor). Once I have more details I'll share. Obviously I'm very excited!

The rest of the ski vacation/honeymoon was good. Work is insane - apparently either a lot of clients were waiting for me to come back or the staff is making light appointment schedules on my off days purposefully. Who knows. I've already made my production goal for the week and still have 2 more days to go ...

Double black diamonds

Yesterday when I started to get a little afraid on an extremely steep and bumpy run, this is what I told myself:
This is way easier than spaying a big dog.

Tomorrow morning we head home. It will be good to see the cats and to sleep in my own bed.

Hello from Aspen!

I'm currently taking a desperately-needed vacation in which I am riding my snowboard, eating and drinking well, and NOT WORKING!

Seriously, though, it's extremely important to take time away and remember who you are as a person outside of work. Snowboarding also has a zen-like quality for me because I have to concentrate on the next turn. That's it. No worries about work or money or anything except the next turn.

It also helps when you get time to hang out with old friends and to watch the X Games in person.

Next week when I get back I have a working interview at a fantastic hospital that I love. I want this job SO badly it's not even funny. Fingers crossed.

Part-time request

I emailed the interim practice manager asking if I could switch to part-time starting in March. I copied the region directors (medical and sales). The sales director emails back a one-liner "This needs to be discussed with me and the medical director. Please schedule a call to discuss." So I did.
My request got shot down, which isn't surprising. What WAS surprising is that the sales director immediately attacked me for having a "bad attitude."

Okay, I'll bite. If I do indeed have a bad attitude, maybe there's a REASON for that? Maybe there's a REASON why you can't keep a doctor in that hospital for more than a year?
Also, if I have such a bad attitude then how am I still making the hospital money AND maintaining the highest client satisfaction scores in the region despite having no other doctors, no practice manager, and only 1 part-time receptionist?

I've already drafted my resignation letter. Now I just need another (better) job to come along so that I can send it. I have another interview today - fingers crossed!

Married

The wedding was great - my hair and makeup turned out well, the flowers were beautiful, the food was excellent, and the company was awesome. I didn't get nervous until about 10 minutes before the ceremony - mainly because I was worried that I would trip and fall. Once I started walking up the aisle and saw D I relaxed. We also got to go skiing for a couple of days afterward, which was nice! Our official honeymoon starts in about a week - a well-earned ski vacation.

Work is more of the same. I've become more efficient at handling cases which is good. We still have no 2nd doctor or full-time practice manager which is bad. I've been interviewing at a few other places which is good. I have no other offers yet which could be bad. At any rate, D and I talked and worked the numbers, and at the very least we can afford for me to drop down to part-time. 3 days per week would hopefully a.) make me a little less fried and b.) give me more free time to look for a better job.

I started medication after visiting my GP and it seems to be helping somewhat - full effects aren't expected for another week or so. I also have an appointment pending with a therapist. I HATE that I had to ask for that extra help and that I couldn't soldier on as usual, but when it gets to the point that I don't want to eat, well ...

Help yourself

I'm going to my GP this afternoon. When I made the appointment several weeks ago I wanted a routine physical to make sure my heart was healthy, blood values were okay, and so on. I was worried that the amount of stress I was under, coupled with my Dad's family history of widespread cardiovascular disease, would make me a heart attack or stroke waiting to happen.

This past week I've realized that not only do I need that assessment, but that I've probably slid into clinical depression. I've had it in the past twice before (about 10 and 20 years ago, respectively) and recognize the signs in myself:
- The clearest sign is having to force myself to eat. I ordinarily have too much of an appetite!
- Other signs include frequent crying, feeling like everything is a herculean effort, and a weird hollow feeling in the pit of my stomach. Check, check, and check.

I feel guilty because for crap's sake, I'm getting MARRIED on Saturday! I should be on top of the world! While I'm looking forward to it and happy (as much as I can be, anyway) about it, in the rest of my life I feel like I'm drowning. I am working very hard at finding a new job, which is the biggest issue, but can't do much about my sister bailing on the wedding and my grandpa being in hospice.

So I'll be asking my GP for a referral to a therapist and some SSRIs because try as I have for the past few months to keep myself afloat, I need a little extra help right now.

Flamed

I received my first piece of hate mail today.

It was a patient I saw 3 weeks ago - new client, new patient. Presenting complaint - intermittent gagging every few months. Talked extensively with the client about history, did my physical exam (which was unremarkable), then talked some more with the client about possible causes. Discussed x-rays to help with diagnosis. Recommended that if it happens again, since it wasn't reproducible in the exam room, that they try to get video of it as that can be helpful.

According to this letter I was extremely rude and unprofessional, the tech knew more than me, all I did was run my hands over the dog, and I also apparently cut off the client and said "I think we're done here." (I've never used that phrase in my entire life.) The letter was also apparently sent to the president of the company.

WTF?

Oh, and that particular office visit was FREE, by the way (pretty much all new clients/new pets are free for their first visit), so I'm not sure what this person stands to gain by complaining. I'm also not sure why it was written 3 weeks after the fact. Did they really spend this whole time stewing over imaginary things?

Ugh. I just have to remember that this is one out of hundreds of clients and thousands of patients I've dealt with.

Pull-ups

I got my first unassisted kipping pull-up today. Hopefully an unassisted strict pull-up won't be far behind!

Goals

I only have 2 goals for 2013:

1. Do one unassisted pull-up
2. Get a new (and better) job

Today was actually slow at work, which was a nice change of pace. I got a chance to catch up on back issues of JAVMA. The rest of the week looks pretty busy though. I have tomorrow off and then it's back at it Thursday/Friday/Saturday.

On tap for tomorrow:
- Take the truck in for routine maintenance (I made a 7 am appointment so that I wouldn't catch the mechanic running late, however this also means I have to get up earlier than I do on work days)
- Go to Crossfit. It will be interesting to see how crowded it gets over the next couple of weeks - and then how much the crowd dies down come February or March.
- Meet with the pet sitter to go through the cats' new care routines. We have someone come to the house, but now one of the cats needs subcutaneous (under the skin) fluids daily and they're all on different food. Sigh. At least the other one doesn't need insulin anymore.
- Have my final dress fitting and pick it up(!)
- Check into getting one of the TVs fixed

It's going to be busy. Happy New Year everyone!