Winnie update, thoughts on Tucson, and NAVC

I'm in the Tucson airport waiting for my flight to leave, and since the airport kindly provides free Wi-Fi, I thought I'd post a little update...
Winnie Bear is pretty much back to her old self. None of the tests we ran found any cause for her pneumonia, but after her lung biopsy she turned around and seemed to get better every day. Her chest x-rays that we took on Monday looked normal, so whatever happened seems to be behind us. The going theory is that the lung biopsy released the evil spirits ;) Whatever works!

Of course the whole country has had its eyes on Tucson for the past week... It's still all a little surreal. I keep seeing the mountains in the background of photos and thinking, "Wow, that place looks just like Tucson." I think everyone is still absorbing the full impact of what happened. I don't live very close to where the shootings occurred, but it's certainly a familiar area. Gabrielle Gifford's office is on my way to work, so I have been watching the number of flowers, signs, candles, and other memorials grow every day. President Obama's speech seemed to resonate well with everyone. I hope we eventually get some insight into what drove Laughner to do what he did and destroy the lives of so many people.

For now, I am leaving sunny Tucson behind for a week in sunny Orlando at the North American Veterinary Conference. This is my first time off from my internship since I went home in August. I've never been to NAVC, but it's supposed to be completely amazing and overwhelming. There are over 20 lectures to choose from every hour for 9 hours a day, plus breakfast lectures before the official lectures start, plus lunch-and-learn lectures, plus dinner lectures after the official lectures end, plus wetlabs and master classes. There are tons of avian and exotics lectures this year, and I'll be attending a master class about avian medicine that should be really valuable. They say you need to set aside a whole day just to peruse the exhibit hall and look at all the fun new gadgets, medicines, books, and supplies available in vet med this year. Should be great! I'll also get to see a handful of classmates, so it will be fun to catch up and see how everyone's been doing since graduation.

Hooray for travel and seeing vet friends!

Day 4

After having a couple of rotations on emergency overnights and spending some time with urgent care on days, I'm starting to get a good sense of situations when owners should get their pets in ASAP. Sometimes it's safe to wait for a day or two to see if things resolve on their own, but sometimes there just isn't time to wait. For example:

• The dog/cat/ferret/etc ingested something potentially toxic, like chocolate, rat poison, ibuprofen, Tylenol, or an entire bottle of Rimadyl chew tabs. Especially in cases where there is known ingestion, pets should always be seen as soon as possible to have vomiting induced. Some people think it's better to wait and see if their pet starts showing clinic signs of toxicity, like vomiting, not acting right, etc, but some toxins can take days or weeks to show their full effects. Rat poison can cause bleeding into body cavities that wouldn't be noticed by the owner until the pet is severely anemic. Ingestion of Tylenol can cause irreversible liver damage that might not make a pet clinically ill for several days. It's always better to get the toxin out by induction of vomiting and try to absorb as much of the remaining toxin by administration of activated charcoal than it is to take a "wait and see" approach.
• The pet is seizuring. I'm not sure why owners seem to panic over vomiting and diarrhea but don't seem to be as concerned by seeing their pet have a seizure. We get a lot of phone calls asking if a seizuring pet should be seen right away. Seizures that end quickly generally don't cause much damage (aside from making the pet disoriented/distressed and possibly injuring themselves by falling into or off of furniture, or biting their own tongue). Seizures that are prolonged can cause significant brain damage and other organ damage as the body because hyperthermic. There is no way to know if a seizure is going to be a solitary event or if it will become a pattern. Observation at a clinic is important so that, if your pet begins seizuring again, the seizures can be stopped immediately. There are a lot of underlying causes for seizures, so a thorough exam is important to try to determine why the pet started seizuring in the first place.
• Cats who can't urinate. Oftentimes, owners mistakenly think that a cat who is straining in the litterbox is "constipated", when in reality, they are straining to urinate. Cats- especially male cats- can develop blockages in their urethra that completely obstruct the flow of urine. Their bladders can fill to the point that they ultimately die of severe electrolyte abnormalities or bladder rupture. A typical (unfortunate) scenario is that an owner sees their cat straining in the litter box in the morning, leaves for work, and comes home to find a dead cat. Urethral blockage is extremely painful and should be addressed immediately.
  
• Multiple episodes of vomiting in a short period of time, vomiting blood, projectile vomiting, or unproductive retching. Little stomach bugs or a single episode of dumpster diving cause vomiting, but typically not vomiting with the above signs. When we see these signs, we start to worry about problems like foreign body ingestion, gastric ulceration, parvovirus infection in puppies, or GDV (especially in large, deep-chested breeds). This is not "wait and see" sort of vomiting- vet examination ASAP is indicated.
• Exotic pets acting abnormal in any way. Aside from ferrets, almost all exotic species are prey animals that are hard-wired to never show signs of disease or injury. If these animals go off of food, start sleeping more than normal, stop vocalizing (if it's a bird), start vocalizing (if it's a small mammal), hide when they would normally be active, or do anything out of the ordinary, it could well be a sign of disease. Often, by the time you can obviously tell there is something wrong, exotic species are severely compromised. Better safe than sorry with exotics!
• Pets who have been hit by a car or attacked by another animal. Even if it doesn't look like there are any injuries, many severe internal injuries don't make themselves known right away. Splenic rupture, bladder rupture, or penetrating wounds into the chest are all examples of wounds that a pet owner might not notice, but that could ultimately become fatal. Cats in particular are masters at hiding severe injuries until they decompensate. Don't wait until pets show signs of injury after major trauma- have them evaluated as soon as possible to give them the best shot at treatment and recovery in case there are some hidden injuries.

In general, pet owners should ask themselves what they would do if this same scenario were happening to their baby or toddler. Pets, like young children, can't tell us what's wrong or where it hurts, so a physical exam by a doctor is really important in cases of injury or illness. Early intervention is almost always better than playing the "wait and see" game, and it's certainly cheaper to catch a disease or injury early on when it can be treated on an outpatient basis than to wait until the pet needs to be hospitalized.

And it's always a good idea to have a pet emergency fund (or pet insurance) squirreled away should you need it! Emergency vet visits ain't cheap :-/

Day 3

OCD could stand for Obsessive Compulsive Disorder (which pets can suffer from), but today it stood for Osteochondrosis (or Osteochondritis Dissecans). OCD is a developmental orthopedic disease that typically causes lameness in puppies 7 to 12 months old, and most commonly affects the shoulder, elbow, stifle, or hock joints. OCD occurs when part of the smooth cartilage that lines the joint surface doesn't form correctly, resulting in a defect in what should be a nice smooth joint surface. The joint ends up arthritic and painful, leading to limping in puppies that should be bouncing off the walls.

In the case today, we saw a 9 month old female Goldendoodle with forelimb lameness. She was painful on manipulation of her shoulder joint, and her radiographs showed the typical abnormalities associated with shoulder OCD. Unfortunately for her, the options for treatment are either surgical removal of the abnormal cartilage or long-term medical management for arthritis. And while dogs usually return to full function after surgery, the joint usually (eventually) goes on to develop arthritis anyway. And the disease is very commonly bilateral, which means her other shoulder will probably become sore soon and require the same sort of intervention.

This is a major financial burden for a pet owner who thought the most expensive surgery her pet would be facing is her spay. It's also disappointing for the owner, who thought her pet might make a competitive agility dog. She also thought that getting a "mixed breed" dog would lessen the likelihood of congenital disorders... but unfortunately, Doodles are just as prone to the developmental disorders of Goldens as are purebreds, and they're also prone to the developmental disorders of standard poodles.

So, today I learned:

• it stinks to tell a pet owner that their animal has a limp that won't go away on its own, that requires surgery to correct, and that will give the pet lifelong predisposition to developing arthritis
• it stinks to see a happy bouncy puppy walking with a painful limp
• it can be hard to convince an owner that, despite being happy and bouncy, your puppy is in pain (otherwise, why would she be limping?)
• sometimes pet insurance really is worth it
• don't buy into that "hybrid vigor" nonsense that breeders of "designer dog" breeds try to push
  

Day 2

Arizona is a very dangerous place to be a domesticated animal. Here is a list of presenting complaints that have come through the clinic while I've been working:

• attacked by javelina
• attacked by coyote
• attacked by Africanized killer bees
• ran through cactus
• stung by scorpion
• bitten by rattlesnake
• bitten by spider
  
• Colorado river toad intoxication
• Valley fever
• Tick fever
• heat stroke

So, if you are a pet in Arizona, stay indoors, stay on leash, and don't exercise in the heat!

What I learned today

Hmm. I've been stuck in a blogging funk lately, writing posts that sound a little too negative to actually publish... I don't want to turn this blog into a spot to vent, but I hate to let it sit idle too!

So, here's my goal for the next month: one post a day about something I've learned- about medicine, or surgery, or Tucson, or communication skills, or whatever. An internship isn't valuable if you don't take time to reflect on it. So, here goes day 1:

Feline malocclusions. A fancy way to say that the teeth aren't lined up right, malocclusions are much more common in dogs than cats because dogs' heads come in a much wider variety of shapes and sizes. The photo to the left is a canine (dog) canine (tooth) malocclusion, in which the lower tooth is contacting the upper hard palate, causing damage to the tissue. Despite being more common in dogs, cats do indeed get malocclusions, and I learned that thanks to my own kitty, Taiko.

Taiko turns 7 months old tomorrow (happy birthday kitten!), and so just finished getting his adult teeth in. I was trying to be a good cat mom and start brushing his teeth early, so that we get used to the routine. A couple of weeks ago, I was brushing and noticed that his breath smelled extremely foul. A 6 month old kitten should NOT have stinky breath (of course, neither should older cats- halitosis is a sign of dental disease as well as many other diseases). I examined his mouth a little closer and discovered that he had a malocclusion of his fourth premolars (teeth #108 and #208, for you Triadan folk). They were set too narrow, so the sharp points of his premolars were digging painful pits into the soft tissue and gingiva of his lower jaw. The foul smell was the infection setting into the gingival tissue. Taiko had both of his 4th premolars extracted and had x-rays taken of his lower first molars to assess the damage caused by the malocclusion. While he had some damage to the gingiva and some horizontal bone loss, he was able to keep his lower molars for now- hopefully we stopped the damage early enough that the integrity of the molars wasn't too compromised. In some specialty dental centers, the sharp points of the 4th premolars can be smoothed down and the teeth can be spared, depending on the severity of the malocclusion. In dogs, some malocclusions can be corrected with orthodontics (yes, seriously).

So, lessons learned:

1. Always check the occlusion of teeth in puppies and kittens- even babies can have dental disease
2. Cats get malocclusions too
   
3. Foul odors in the mouth of any animal should be investigated ASAP

Life after vet school

Wow- long time, no blog! It's only been a couple of months since graduation, but it feels like forever since the last time I was in VMC. Since then, I've been across Europe and back, up to the cabin, and on a marathon 33 hour drive from Minnesota to Tucson. We managed to squeeze everything that I thought I'd need for my internship (including the cat and the hedgehog) into the Fit. I brought every book and set of notes that I thought might be useful, which turned out to be quite a lot... and poor Chris had to haul all my boxes of books into the new apartment in 108 degree temperatures. Welcome to Tucson!

We spent the first week in Tucson exploring, looking especially for the best food Arizona had to offer. We found the best tacos at the Taqueria Pico de Gallo, a little hole-in-the-wall that used to be a taco stand. They've since grown to have enclosed seating, but you still bus your own food and clean up after yourself. They make fresh corn tortillas while you wait, and serve a type of pico de gallo made of big chunks of fruit covered in chili powder and salt. Yum! The farmer's markets had the best tortillas and salsas, although fresh produce is sort of lacking at this time of year.

We also discovered tamales, delicious concoctions of corn masa and some other delicious filling (like peppers, mushrooms, corn, cheese, etc), wrapped in a corn husk. We visited the Tucson Tamale Company based on an article from roadfood.com. When we told them we were new to Tucson and to tamales, they served us a free tamale and taught us how to prepare and eat them. Delicious, cheap, and easy to prepare? We were hooked, and have a freezer full of tamales to show for it.

After a week of getting oriented to Tucson (and trying to adjust to the temperatures), it was time for Chris to head back to Minnesota and for me to start my internship. I was a little scared that after six weeks of thinking about anything but veterinary medicine, I would be completely useless as a new doctor. Of course, I hadn't forgotten everything, but I've also been eased into my role as an intern. We spent our first week getting oriented to the clinic, learning where things are and how things work. The next week, we split into our separate shifts- I started on days, and the other intern started on nights. We'll spend two weeks on each rotation until October, when our rotations switch to three weeks long.

So, what did I learn during my first couple of weeks as a doctor?

• private practice medicine and university teaching hospital medicine are very different things- at the university, most people are coming in knowing there's something really wrong with their pets. In private practice, someone might come in for what they think is a routine wellness exam and leave with a diagnosis of heart failure or cancer. You surprise people a lot more often in private practice.
  
• sugar gliders make terrifying sounds and will definitely bite you given half a chance.
• my hands, generally pretty steady through things like surgery or blood draws, get shaky during euthanasias.
• good technicians are worth their weight in gold (I already knew that, but now that I'm a doctor it's even more obvious).
• During vet school, I got very good and thinking very thoroughly- we saw relatively few cases each day, so there was a lot of time to dig into the disease, the pathophysiology, the pharmacology of the medications involved, or all the different possible approaches to the surgery or procedure. At my clinic (and in most private practices), the pace is much faster and I'm going to have to get a lot better at thinking on my feet and trusting the knowledge base that I built during clinics.
• puppy and kitten visits are important antidotes to euthanasia appointments.
• I'm still not used to being called Dr. Schommer, but I kinda love it when clients call me "Doc".
• tortoises can be hypothyroid. Who knew? (I feel like "How can you tell your tortoise is hypothyroid?" is sort of like "How can you tell your accordion is out of tune?").
• baby hummingbirds are the most adorable animals ever.
  

I think everyone who went to an internship after graduation was a little nervous about what their clinic would be like- we all heard stories about programs that use interns as slave labor rather than doctors, or programs where the residents get priority for interesting cases, procedures, surgeries, etc and interns get whatever is left over. I've only been at my clinic for a few weeks, but I feel lucky. There aren't any residents to compete with, the doctors are supportive and always open to answering questions, and we're treated as full-fledged doctors (even if we're still just partially-fledged doctors ;) ).

Tonight, I start my first stretch of overnights. Wish me luck!

Match Day!

Congratulations to Megan for getting an internship in Tucson Arizona! It sounds like a great hospital, with a great program and we are very excited to learn more. Megan's first day would be June 16th, and the program goes for a year and a week. The photo on the left is downtown, with the hills behind on one of their rare snowy days. I could have put up a photo of the many cacti but I am sure you will see many of those in the future! (Average high, 100˚ in June)

So if anyone knows anything about Tucson, let us know. So far I have learned:

• how to spell "Tucson" (Not Tuscon)
  
• that rent is cheap
  
• It gets hot in the summer, and they have a monsoon
  
• but it is still a desert climate due to its high evaporation rate
• the surrounding hills are very pretty
• it has a big Wiki page that I am going to read up on

Congratulations!