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!