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!