Tuesday, February 24, 2009

Terminal surgery part 2

Okay, I know what you're thinking. I write a big long post about why I think terminal surgeries are justified practices in vet schools, and end it with "but oh yeah, I opted out anyway." So what's the deal? Cognitive dissonance?

It wasn't an easy decision to make. I spent a lot of time arguing with myself about it. I actually started off very much in support of performing the terminal surgery, way back in my senior year of undergrad when I wrote an ethics paper about why I thought the experience was both ethically justifiable and unequivocally the best way to learn surgery. We get exactly one opportunity to perform a gastrotomy, cystotomy, and intestinal resection/anastamosis, and that's during the terminal surgery lab. You can learn the techniques and approaches from a textbook, but until you actually perform the procedures, you really don't know what you're doing. It's a bit like the difference between taking the driver's ed class and getting behind the wheel for the first time- you know the rules and the general idea, but actually controlling a car is a whole other story.

So why did I decide not to do it? There were a few reasons, some of them logical and others emotional. My biggest logical reason was that I'm aiming for an internship after I graduate, which not all students plan to do. An internship will offer me the mentorship and guidance that I'll need as I perform surgical procedures for the first time. If a student isn't planning on an internship, the value of performing the procedures during the terminal surgery is much much greater, as it's the only time they'll do them under strict supervision before doing them on someone's pet. But for me, the value drops- I'll (hopefully) have the opportunity to have some hand-holding through my first surgeries with a good mentor.

Secondly, opting out of the terminal surgery lab doesn't mean I'll graduate without ever having done surgery on a live animal- the U of MN and Animal Humane Society give us the wonderful privilege of performing spays and neuters during our second year surgery course and during a fourth year elective small animal surgical rotation. Tissue handling, suturing, and aseptic technique can all be learned during survival procedures.

Lastly, like I said in my previous post, the vast majority of surgeries will be performed for the first time on a client-owned animal. We can only do so much in vet school, even with terminal procedures as part of our program. Some people react to that by insisting that we take advantage of every opportunity provided us in school to learn procedures on unowned animals so that at least not everything we do will be learned on client-owned animals after graduation. My reaction was that I'll need some serious mentorship after graduation regardless of whether or not I've performed a gastrotomy on a terminal surgery patient. Having performed one or two more procedures on a live dog is good, but what about all those other procedures I'll do for the first time on client's pets? I'd better get comfortable with the idea that I'll be learning on people's loved ones, since it will happen regardless of how much I get to do in school.

On the more emotional side, I was much more attracted to the alternative that the U of MN offered than I was to the terminal surgery itself. The alternative consisted of carrying around a pager for the teaching hospital and getting called in when a pet was heading into surgery for an abdominal surgery of some sort. Then we got to scrub in and watch while one of our clinicians, residents, or interns performed the surgery. The disadvantage was that I didn't get to do any cutting. The advantage is that, rather than seeing procedures performed on a healthy animal, I got to see what happens to the stomach when it twists in a GDV, or what happens to the intestines when a corn cob eaten two weeks ago wedges itself in the jejunum. The animals came with histories, emergency exams, bloodwork, and radiographs! It was okay for me to root for them, and be happy when the procedure went well because that meant the animal would go home with people who loved it. With the terminal surgeries, your anatamosis might look great, but the rest of the picture isn't there. You don't know what the traumatized tissue would look like, or how it feels or handles, and you don't know how well your repair would hold up if the animal were allowed to recover.

I also felt like participating in the terminal procedure was unfair for the particular animals we used- the U of MN purchases dogs that have been research animals their whole lives and are at the end of their research careers. My logical side argues that whether or not the terminal surgeries are performed, these animals will be euthanized. But my emotional side says that these dogs have already given their entire lives for the sake of human or animal research- is it fair to squeeze one more learning experience out of their bodies before they are put to sleep? Is it fair that their last memories will be of transportation to a new scary place, getting shots, having IV catheters placed? At least if they were shelter dogs, I could believe that at some point, those animals got the experience of being pets rather than just being used for the sake of science. To be fair, the U's justification for using research dogs is that shelters will never release live animals to vet schools due to the potential for bad PR for the shelter... So it's not necessarily the school's fault that they use research dogs, but that doesn't make me feel better about it.

Finally, I decided not to participate simply because I didn't know if I could do the surgery and still be able to look Winnie in the eyes when I got home. How can I believe that she is worth so much, but used-up research dogs are worth only one last procedure before death? We (as students) love the opportunity to work on unowned animals before we work on owned animals because we hate the idea of messing up a procedure on an animal that someone loves... But I also have to believe that animals have intrinsic value as well, regardless of if they have an owner. Performing a terminal surgery felt, to me, like I'd be completely disregarding or desensitizing myself to the intrinsic value of those animals. I couldn't do it, and yet I don't feel like I'll be a worse surgeon for having missed the opportunity.

I understand my classmates and fellow vet students who do perform terminal surgeries, because I know how valuable the experience is. After all, I use cadavers for plenty of learning experiences, and, in the words of Dr. Rasmussen, "A cadaver killed at the pound is just a live terminal surgery dog that was spared 24 hours of transport to the university." We all have to make decisions about the costs and benefits of the things we do to become effective veterinarians. It's a very intensely personal decision, and certainly not as black and white as some people (cough cough Ms. Pickens) would have you believe.

Monday, February 23, 2009

Terminal surgery

Vet schools are in the news lately with a story broken today by Oklahoma State's student newspaper. According to the article, Madeleine Pickens, the wife of billionaire T. Boone Pickens, withdrew a 5 million dollar donation to the Oklahoma State vet school when an anonymous vet student told her about procedures performed as part of the training program.
“Right now, when they buy these dogs, they bring them in, and they do a surgery, put them to sleep, do the surgery, wake them up, next day, put them to sleep again, maybe take out a kidney, wake them up again, put them to sleep again, maybe break a leg, fix it, wake them up again and then they kill them,” Pickens said. “That’s barbaric. That’s what you did years ago. Medicine has changed.”
So what's the deal? That sounds terrible, and I wouldn't blame her for not wanting her money to support such a program... The problem is, it's just not true. Yes, vet schools have students perform terminal surgeries. No, they don't have them perform multiple painful procedures on the same animal and inflict harm on the animals like breaking legs.

This story brings up a lot of questions. I'll try to give a vet student perspective on the issue...

The first question is, what is a terminal surgery? Also known as non-survival surgeries, these are surgeries in which an animal is anesthetized, a surgical procedure is performed, and at the end, the animal is euthanized rather than recovered. These are usually relatively painful procedures that are not necessary for the animal's sake (i.e. at the U of MN, our one terminal small animal surgery lab consists of a gastrotomy, an intestinal resection and anastamosis, and a cystotomy, which are all procedures performed to correct problems that the animals used for the lab don't have). Most schools consider it unethical to perform unnecessary surgical procedures, then put the animals through a painful recovery. So instead, terminal surgeries are performed on either shelter dogs or research dogs that were due to be euthanized. The ultimate outcome (euthanasia) is the same, but the animals provide a learning experience for a vet student before being put to sleep. They are given the same pre- and intra-operative care that we would give an owned animal, including pain control, inhalent anesthesia, IV catheter, and fluids.

The next question is, why do terminal surgeries instead of working on cadaver animals that have already been euthanized? While we do work with cadavers fairly often (two or three times a semester, plus during the entire first year anatomy course), working with live tissue on a breathing animal is far different than working on on dead tissue. Plus, there are lots of aspects of performing surgery besides working with the tissue itself- live animals require anesthesia, and live animals bleed, and live animals can have changes in their heart rate or blood pressure in response to what you're doing. You can do an awful lot of damage with poor surgical technique on a cadaver without ever realizing it, because a cadaver can't respond the same way that a live body can.

Lots of people wonder why vet students learn by performing terminal surgeries while med students (obviously) never use terminal procedures to learn. One of the biggest differences between human and vet medicine is that, as vets, we are qualified to do essentially anything to any species (except humans) after 4 years of school. That includes surgery, radiology, oncology, cardiology, and anything else. Human doctors, on the other hand, are required to do an internship and complete a residency program in their specialty of choice after graduating from med school. Human surgeons go through 5 to 7 years of training beyond med school to learn to perform surgery under the guidance of experienced surgeons. That's not to say that vet med shouldn't consider going the same way as human med- but the extra training comes with a big price tag. Also, human surgeons may not perform terminal surgeries on humans, but they do perform terminal animal surgeries as part of their training.

That's not to say that performing a terminal surgery is an essential part of becoming a veterinarian. There are plenty of great veterinary surgeons who never performed terminal procedures. Most schools offer alternatives for students that would like to opt out of terminal procedures. There are schools that only perform survival procedures (our only required surgery at the U of MN is a survival spay/neuter surgery on shelter animals, which I did last year on little Malibu, the dog in the picture). There are schools that use a combination of observation and practicing on models and cadavers. It still isn't clear what the best method of teaching surgery is, but at least schools are recognizing that not all students feel the need or desire to perform terminal procedures to learn. Frankly, the vast vast majority of surgical procedures will be performed for the first time on a client-owned animal anyway- we have the chance to practice just a few during vet school, while all the rest will be learned after graduation.

So, to bring it back to the original topic- Ms. Pickens has her facts wrong. There is absolutely no way that the Institutional Animal Care and Use Committee (IACUC) protocols would allow schools to use animals for painful surgical procedures over and over. OSU uses the animals once for a relatively routine procedure (spay or neuter), recovers them with good pain control, and then uses them several days later for a non-survival procedure (for the same types of procedures as we do at the U of MN- gastrotomies, cystotomies, etc). There is no breaking of legs, no removal of kidneys, no recovering these dogs over and over. Ms. Pickens is right that medicine has changed- we don't do things like that today.

In these sensationalists type stories, people tend to forget that vet students are vet students because we love animals. Intentionally breaking a dog's leg so that we can fix it? That's just sick. We hate terminal procedures, but understand the need to learn everything we can from these animals who give their lives for our education. We cry. We kiss their heads. We tell them thank you and we're sorry. And we use the knowledge we gain from their bodies for all the animals we'll perform those procedures on in the future.

(For the record, I opted out of the terminal surgery.)

Update: Part II of this post is here

Thursday, February 19, 2009

The Crisis of Credit

I saw this video on BoingBoing and think that everyone should see it! It lays out the housing bubble and resulting credit crisis as good as I have ever seen it and then some with fantastic graphics and narration. CrisisofCredit.com Take a look!

The Crisis of Credit Visualized from Jonathan Jarvis on Vimeo.

Tuesday, February 03, 2009

No Middle Ground

What has struck me in the post election debates is the clear lack of any middle ground between Republican and Democratic law makers. Krugman writes for me:
"You see, this isn’t a brainstorming session — it’s a collision of fundamentally incompatible world views. If one thing is clear from the stimulus debate, it’s that the two parties have utterly different economic doctrines. Democrats believe in something more or less like standard textbook macroeconomics; Republicans believe in a doctrine under which tax cuts are the universal elixir, and government spending is almost always bad.

Obama may be able to get a few Republican Senators to go along with his plan; or he can get a lot of Republican votes by, in effect, becoming a Republican. There is no middle ground."
When you have the new leader of the Republican National Committee believing that, "Not in the history of mankind has the government ever created a job," well what can you say?

And last night, Jim DeMint tried to eliminate virtually all spending form the stimulus bill and instead do this (PDF):
  • Permanently repeal the alternative minimum tax once and for all;
  • Permanently keep the capital gains and dividends taxes at 15 percent;
  • Permanently kill the Death Tax for estates under $5 million, and cut the tax rate to 15 percent for those above;
  • Permanently extend the $1,000-per-child tax credit;
  • Permanently repeal the marriage tax penalty;
  • Permanently simplify itemized deductions to include only home mortgage
  • interest and charitable contributions.
  • Lower top marginal income rates – the one paid by most of the small businesses that create new jobs – from 35 percent to 25 percent.
  • Simplify the tax code to include only two other brackets, 15 and 10 percent.
  • Lower corporate tax rate as well, from 35 percent to 25 percent.
He claims doing this will create 18 million jobs in 10 years - which isn't even very good! The US economy needs to add 1.6 million jobs a year just to keep up with a growing work force, and his would be 1.8. But that doesn't matter because DeMint's bill would be the worse possible bill to pass. The entire point of a stimulus is for the Government to spend money because the private sector has stopped, and because the Government still has the power to borrow. If you want a wonkish paper about what does and doesn't work, check out this PDF from economy.com. The short version is this table on the right, where the number is the dollar result of $1 spent. So the DeMint amendment is utterly backwards from what works, yet he really believes that his way is best.

But here is the rub, in the senate, only 4 Republicans voted No on this amendment. Four. Out of 40 voting (Gregg (NH) didn't vote because he is becoming the Secretary of Commerce).

So if there is a middle ground it is in those four: Collins (ME), Snowe (ME), Specter (PA), and Voinovich (OH). And the house is another story, with their famous Zero vote last week.

There is not much to work with here is there?