Last day, last patient

This big beautiful girl is my last patient of my vet school career. What a way to finish up!

Suddenly at the end

It feels like yesterday that I was getting my white coat and heading into clinics for the first time, but suddenly the new fourth year class is starting and I'm just about to begin my final rotation. I get to leave the Teaching Hospital and head next door to the Raptor Center for my Companion Birds rotation. Companion Birds means lots of hands-on learning about avian restraint, bandaging, fracture fixation, and (for some reason) a morning of birdwatching (hey, I'm not complaining).

I've been trying to come up with a blog post that sums up my fourth year, or vet school in general, or all the emotions I have surrounding my upcoming graduation, but nothing comes out sounding right. It's one big mixture of exhaustion, anxiety, and excitement, and I feel like this year has flown by so fast that I've hardly had time to digest it all. For now, I'm just trying to enjoy my remaining time with my classmates and appreciate lovely things like spring, the adorable antics of Winnie and Taiko, and my cute new (er, used) Honda Fit. Only two weeks to go, can you believe it?

Rotations #20, #21, and #22

My fourth year is chugging along, and I suddenly only have a handful of rotations left! Here are my summaries of the past few rotations...

Rotation #20: Small Animal Surgery

I had my second (of two) SAS rotations just two blocks after my first SAS. One of the surgeons asked me how I felt about my second Surgery, and I said I was "doing a lot less pointless running around, and a lot more useful running around." The rotation was still demanding, but at least I had a better idea of what I was responsible for. I improved my orthopedic exam skills a lot, and finally palpated my first cranial drawer (an abnormal physical exam finding associated with a ruptured cranial cruciate ligament, the canine equivalent of a torn ACL). We got to see a few interesting cases, like a string of brachycephalic (short-nosed) dogs who needed their soft palates shortened to help improve their breathing, a naughty Goldendoodle who ate a rock that got stuck in his intestines, and a dog who was romping around his backyard and sliced through a tendon on his wrist when he slipped on a sharp piece of ice.

I did learn a lot on my SAS rotations, even though I likely won't be doing most of the more advanced surgeries personally... It's nice to have an idea of what surgeons are capable of doing and what's involved in the aftercare, since that's what I'll need to know to be able to advise clients in the future. That said, I can't say I'll miss the 6 AM to 8 PM treatment duties, writing up surgery reports, or getting called in at 1 AM on a Sunday for emergency surgery!!

Rotation #21: Cardiology

It's not hard to see how people fall in love with cardiology. Sitting in a dark room, watching an echocardiogram (ultrasound of the heart) display the intricate cycle of contract and relax, or watching the electrical impulses of the heart tick by on an electrocardiogram (ECG or EKG) is mesmerizing. It's even more amazing to give a drug and watch those rhythms change, or put in a device to occlude an abnormal shunt and watch the blood flow shift from turbulent to smooth. Cardiology sees a lot of pediatrics and geriatrics- babies with congenital abnormalities and seniors with congestive heart failure or other chronic degenerative heart disease. Some of the congenital cardiac diseases are really rewarding to treat because they can pretty much be fixed and the animal goes on to live a normal life. Patent Ductus Arteriosus (PDA) is a good example. A PDA is a defect in which the ductus arteriosus, a normal fetal vessel that shunts blood around the lungs, fails to close at birth. This results in abnormal blood flow through the heart and, left untreated, progresses to heart failure within the first year or two of life. At the U of MN, a device called an Amplatz Canine Duct Occluder (ACDO) was developed to allow minimally-invasive surgical correction of PDAs. One of the cardiology residents even helped to develop an ACDO that is small enough for patients under 3 kg (which many PDA patients are, as small breed dogs are predisposed to PDAs). With ACDO occlusion, PDA puppies grow up to be normal active adult dogs.

Other congenital defects aren't so fun- subaortic stenosis (SAS) is a disease seen in larger breeds like Golden retrievers. This is a condition in which there is an abnormal narrowing near the aortic valve, which causes the heart to pump harder than normal to push blood out into the aorta. Dogs with severe SAS can develop heart failure at a young age, whereas dogs with mild or moderate SAS can be asymptomatic for months or years. The sad thing about SAS is that we can't do much about it other than manage the congestive heart failure associated with it. Owners of dogs with SAS have to be prepared to face complications of the disease, which include the possibility of sudden death. No fun at all.

I learned a lot on this rotation about the most common heart diseases and how to manage them, and also developed a strong appreciation for veterinary cardiologists- I'm glad someone out there is brave enough to do heart surgery!!

Rotation #22: Externship!

I spent the end of February on externship at a local integrative medicine practice. I loved loved loved it- after all the complex diseases, awful fractures, poor prognoses, and zebra diagnoses that we see at the U of MN, it was so nice to see patients presenting for annual checkups and vaccinations. I got to neuter my first client-owned animals (and spent about 24 hours post-surgery worrying that things would go bad, until calling the owners and finding out that the dogs were recovering just fine). The techs at the clinic referred to me as "Dr. Schommer", which was both awesome and terrifying. It made me really excited to get out into practice! (note regarding the photo: despite popular opinion, vets really don't get to snuggle with puppies all day... but we do go a little crazy for puppies when we get to see them :) )

Rotation #23: SAM-B

This Medicine rotation was the fourth and final Medicine for all of the students on the rotation block. We all thought that maybe we'd feel a little smarter than we did on our first Medicine, and I'm sure we all were... But, Medicine being what it is, we still all ended up with patients who threw us for a loop. We saw animals with multiple concurrent disorders (diabetes and Cushings disease, hyperthyroidism and GI lymphoma, congestive heart failure and chronic renal failure). We saw animals that presented with one problem and got diagnosed with something completely different (like a dog with regurgitation due to a supposed esophageal stricture, except that he actually had a huge foreign body in his stomach). And then we had animals with diseases that should have been really serious go trotting out of the hospital the day after admission, and animals that had diseases that are usually self-limiting die due to really rare complications. I guess the theme of this SAM block was to keep any of us from getting too cocky or confident, and remind us that there's a reason they call it "medical practice" and not "medical perfect".


Next I'm on to Dentistry, then General Practice, then Companion Birds, then graduation!!

Rotation recaps

Seeing as how I've gotten way way behind in posting about my rotations, I have a bit of catching up to do... So, here's the short-and-sweet version of my last 6 rotations:

Rotation #14: Avian and Exotic clinic externship
I spent two weeks in Indiana at a practice that sees just about everything but cats and dogs- including parrots, rabbits, ferrets, opossums, skunks, zebras, turtles, and arctic foxes. They do all the things that a normal practice does, like spays and neuters, toenail trims, and managing diabetic patients, but they also offer services for the exotic patient's, er, special needs- things like beak trims for birds and turtles/tortoises, de-scenting surgery for skunks, and "bird divorce" for birds who have accidentally sexually bonded with their human owners. Super fun rotation! I got to see so many things that we don't get any exposure to at the U of MN since our teaching hospital doesn't generally see exotics. This externship reaffirmed my desire to specialize in exotics and inspired me to apply primarily for avian/exotic internships for 2010-2011.

Rotation #15: Small Animal Medicine-B
This was my third Medicine rotation, and like the other two, I got to see a fair number of patients with vomiting and diarrhea, diabetes and other endocrine disorders, and coughs/sneezes. But, also like the other two, this one had an underlying theme. My first SAM was all about infectious diseases like Anaplasmosis and Blastomycosis, my second I saw a lot of chronic diseases like immune-mediated hemolytic anemia and diabetes, and my third SAM I saw a lot of urinary system diseases. It probably had a lot to do with the fact that we were on with Dr. David Polzin, one of a tiny handful of veterinary nephrologists (kidney specialists). People will drive a long way to see him, so we got to see quite a few really rare kidney conditions, along with the more common urinary tract disorders like bladder stones and urinary tract infections. It definitely helped me brush up on my renal physiology!

Rotation #16: Radiology
Oh, radiology. Every vet school seems to have a subject that causes vet students much grief throughout their didactic years- for some it's pathology, others pharmacology, and at the U of MN, it's radiology. Part of it is because the senior radiologist is a radiology genius who can somehow make an anatomical abnormality or pathologic change out of the most subtle differences in shades on a radiograph... and the other part is that he assumes other people can see those differences too. Even though the classes were challenging, I actually really enjoyed radiology, and the rotation was even better. There's something very satisfying about being able to tell what's wrong with an animal within a few minutes of taking the x-ray. Of course, radiologists have to be the ones to make the calls like "That looks like a tumor in the lungs" or "That abdominal mass has gotten bigger", which is really difficult in a specialty that can be as subjective as radiology ("Is that tiny slightly whiter patch maybe a tumor, or just an artifact?"). Then there are the really annoying cases where the animal is really sick, but the radiographs look completely normal. Hmph. Either way, I loved the half-science, half-art nature of radiology and learned a lot on the rotation.

I also took boards during this rotation. I prepared using the new Veterinary Board Review Flashcards (hint: they work GREAT with a Trivial Pursuit board!), plus I completed all of VetPrep (approximately 2 bajillion NAVLE-style multiple-choice questions). I tried to use some other study tools like the A to Z Guide and the Ohio board review notes, but they didn't really work for me. I completed the NAVLE in about 3 1/2 hours, even though I took a few 10-minute breaks and tried to force myself to slow down (most people take 5 or 6 hours to finish). I spent the next month panicking that I'd failed because I didn't read the questions closely enough, but as you know, I got the good news last week that I passed! I guess I've always been a pretty fast test taker...

Then, I also had to complete and send in my application for the VIRMP, which is the organization in charge of assigning vet students to internships. I applied to 10 internship programs, one of which withdrew from the match before I had a chance to rank them (hmph, no fair). After applying, we had to rank the programs (first choice, second, etc). Then the programs rank their applicants. Then all the data goes into a big computer who puts them through some fancy algorithm and pops out the program that came closest to matching your rank list. On February 8th (our "Match Day"), we'll be notified of where we matched (or if we didn't match at all), and thus where we'll be spending the next year of our lives. Not all vet students apply for internships, but I'd say my class has 15 or 20 people participating this year. It will be a big day!

Rotation #18: Animal Humane Society externship
I spent two weeks just before Christmas at the Animal Humane Society in Golden Valley. Most of my time was in the OR, performing spays and neuters and other minor procedures on incoming animals. I learned a TON and became a much more confident surgeon. I got to see a really wide range of anatomy (big dogs, little dogs, baby cats, pregnant cats) and experienced almost every common complication that can occur during surgery (except for dropping a pedicle... still haven't done that one yet). I got better at anticipating complications and learned how to be a more efficient surgeon without compromising any surgical technique. Of course, I also fell in love with a bunch of super cute animals and tried to bring these little kittens home at least three times, but... sigh, not the right time for a kitten in our lives, yet.

Rotation #19: Small Animal Surgery
The major branches of vet (and human) med are surgery and medicine. Basically, if you can treat a problem with pills or shots or dietary modification, the patient goes to see internal medicine. That's why the Medicine service sees the animals with endocrine disorders like diabetes, infectious diseases like Lyme, or chronic problems like Inflammatory Bowel Disease. If the problem can be corrected surgically, then they go see the Surgery service (duh, right?). Sometimes problems fall into both categories and the lucky patient ends up seeing both services- like a pet who sees Medicine for bloody urine, and they determine that it's being caused by bladder stones that need to be surgically removed.

Anyway, on my Surgery rotation I got to see some cases that overlapped with what I've seen on other services, but most of my patients had problems that I'd never seen before- things like ruptured cranial cruciate ligaments (analogous to torn ACLs in people), hip dysplasia, and slipped intervertebral discs. I also got to see a number of Oncology patients who were having surgery to remove cancerous tumors- one dog had most of his tongue removed (amazingly, dogs can learn to adjust to a life without a tongue), one dog was being recut after a previous surgery failed to remove the entire tumor, and a cat had a benign tumor inside his ear. The rotation itself was pretty all-consuming, since I needed to be at school early to examine patients, spent all day either in surgery or seeing appointments, then spent all evening writing up surgery reports or discharge letters. I was lucky enough to get called in on New Year's Day for not one, but two surgeries in a row for dogs who had ruptured intervertebral discs and needed emergency surgery to regain use of their back legs (without surgery, they likely would have been permanently paralyzed- which isn't a death sentence, as most dogs can learn to use carts- but most people would rather have a dog who can walk). Lucky me! The rotation was exhausting and trying, especially with a few really sad outcomes, but I learned a lot and got a lot better at juggling multiple cases at a time.

Rotation #20: Behavior Medicine
I was so excited to have my Behavior rotation, and it didn't disappoint. Behavior problems are sort of underappreciated in veterinary medicine, even though they can have major effects on a pet's role in the family and are the #1 reason that people surrender animals to shelters. Behavior was pretty much the exact opposite of surgery- instead of juggling four patients at a time, seven days a week, Behavior sees about two patients a day, three days a week. Appointments last from 2 to 4 hours, and there is a TON of client education involved. I loved being able to help people understand why their pets were doing what they were doing. They would come in thinking their animal's issue- biting people, attacking other dogs, peeing all over the house- were completely random, and we could help them see how the behavior developed and what the underlying cause was. There were a lot of really satisfying cases, but some sad ones too. Just like physical problems, some behavior problems can't be managed easily, and things owners have to do to manage them affect the pet's or the human's quality of life so much that it's just not worth it. But, there were enough cases where we could see the effects of helping an owner understand their pet, and helping the pet become a positive force in the home again.

Also, I can now officially say that I've seen two instances where people used techniques learned from Cesar Millan with really severe consequences. One person tried to discipline her dog by doing a "scruff grab" (you know, using your fingers like a wolf would use his teeth.. right?), and the dog turned and bit her. One person alpha rolled her dog when she growled at kids, and the next day the dog lunged at a child passing by with no warning. There's a reason that his show starts with a disclaimer to "not try this at home". In both cases, the owners interpreted their dogs' behavior as being rooted in "dominance", when in reality both dogs were incredibly fearful and were trying to get the scary things to back off. Rather than punishment, these dogs need to learn how to change their underlying emotional response to the world around them, and need to learn that they can look to their owners for guidance. Does a dog want guidance from someone who causes them fear by throwing them on the ground? Nope... they need to first avoid all situations that make them scared, become desensitized to scary things through a long process of behavior modification, and sometimes need anti-anxiety medication to bring their anxiety levels down to a place where they're capable of learning (although that last one is really hard for some people- even though few people question whether diabetic patients benefit from insulin, or arthritic patients benefit from anti-inflammatories...). But alas, I guess 6 months of behavior modification doesn't make very sexy TV compared to 15 minutes of Cesar's "dog psychology".


Next, I'm on to my second (and final!!!) Small Animal Surgery. We're down to 98 days to go til graduation (on May 1st)... I'm in the home stretch!

my current externship

Busy busy

I've fallen behind in my rotation updates again, but I promise I'll post about blocks 14 (avian and exotics externship), 15 (my third Internal Medicine rotation), and 16 (radiology) soon! For now, I'm putting the finishing touches on my application for an internship and starting my last-minute cramming for boards. I feel pretty confident about small animal and exotic medicine questions, but pig diarrhea, equine colic, anything about poultry, and epidemiology are all still fuzzy. Study study study!

Poor Winnie wants to know when I'll have time to play again...

Rotation #13: Public Health

For vet students, Public Health is a bit of a catch-all subject that includes any situation in which humans and animals interact and may or may not spread diseases to each other. Our Public Health classes have taught us how to recognize lots of different zoonotic diseases (diseases spread from animals to humans) and how we can control the transmission of those diseases. We've also learned about food safety and production, human-wildlife interactions, and how the government prevents and monitors for diseases such as Foot and Mouth. The Public Health rotation was more about seeing these ideas in action through a series of field trips around the Twin Cities and beyond.

Our first visit was to the St. Paul Animal Control, who are responsible for protecting people from animals (as opposed to the Animal Humane Society, who protect animals from people). Animal Control are the people who come to check out dangerous dogs, deal with nuisance wildlife, pick up dogs and cats who are running loose (the traditional "dog catchers", a la Lady and the Tramp), and respond to complaints about people keep illegal pets (like tigers, bears, or in St. Paul, more than three chickens). Our trip to Animal Control was short, but we saw a number of dogs that were examples of the worst sorts of trauma humans can inflict on dogs. Terrified, leaping at their cages doors with barred teeth and fierce barks. No dogs should ever have to feel that scared when they see a human.

The next day was food safety day, with trips to two very different meat processing facilities. The first was to Lorentz Meats in Cannon Falls, MN, a small USDA-inspected slaughterhouse. This is the same slaughterhouse mentioned in Michael Pollan's "The Omnivore's Dilemma," in which the Lorentz family was commended for their commitment to local food and local farmers, as well as high standards for animal care and welfare. The Lorentz facility has a glass abattoir, meaning that anyone who wants to come see the process of slaughter from start to finish can. I was a little unsure of how I would react to seeing the animals killed, as the only animal deaths that I've seen have been through euthanasia- but after watching the process several times, I was surprised at how gentle and fast it all was. First the animal was standing there quietly, then the next second it was down. No screams, no thrashing, just poof, gone. The rest of the process wasn't much different than performing a necropsy, except that the workers were much much cleaner than we were and much more efficient.

We followed that trip with a visit to a live animal market in South St. Paul. While facilities that produce meat for sale to the public have to be USDA inspected, facilities that slaughter or process animals for one's personal consumption are considered exempt from inspection. The most common example of this would be the places that process deer from hunters. In South St. Paul, you can walk into Long Cheng Livestock Market, pick out a live chicken (or pig, goat, sheep, or cow), hand it to a worker who will slaughter it for you, and get it back to finish the rest of the process yourself. The market serves primarily immigrants who are unused to buying meat already processed or who want their animals handled or slaughtered in a specific way. At first the whole place is a little shocking, but I have to admit, I admire anyone who has such an intimate connection with the food they eat. We're often so distanced from where our food comes from that it was quite a change of pace to see people- even whole families with kids- come and take such an active role in their food. From a public health standpoint, while the facilities aren't as pristine as Lorentz Meats, the meat also is much less likely to stay in refrigeration for extended periods of time, reducing the risk of bacterial growth. People who are involved in the processing of their own meat are also more likely to have been exposed to pathogens in small amounts, likely building up some immunity to organisms that might otherwise make people very sick.

Bet you didn't know you could shop for a live chicken in St. Paul, huh?

After our day of meat processing, we checked out some of the interactive animal exhibits at the Minnesota Zoo. The Family Farm exhibit offers several areas where kids and parents can pet animals like goats, sheep, and chickens. We talked about what diseases each species can spread to humans and looked at how the zoo designed each animal enclosure to keep both animals and people safe. Then we went to visit the dolphins because.. well, dolphins are adorable. ;)

We spent one morning at Urban Academy in downtown St. Paul working with third and fourth graders. Each group of three vet students was assigned to a topic like "What Vets Do" or "Food Safety". I ended up with "Hand Washing," which was really more of an exercise in wrangling 15 fourth grade girls into one bathroom than an educational experience. At least they all ended up with clean hands!

We visited the Animal Humane Society in Coon Rapids to talk about how shelters manage their unique population of cats, dogs, and pocket pets, and how they work to prevent disease transmission. As always, it was a bummer to see so many homeless cats and kittens (and everything else too, but there seemed to be cats pouring out of every corner). They said during busy months, they take in 2,000 cats a month... ouch. Diseases that are normally simple, like upper respiratory infections, can become life threatening in a situation where you have that many stressed out cats in one place. I resisted the temptation to bring a kitty home, but if you're thinking of adding a cat to your family, please adopt!

Finally, we visited the Dellwood long-term senior care facility in St. Paul. This nursing home follows the Eden Philosophy, which believes that people are meant to be surrounded by living things. Centers that follow the Eden Philosophy try to incorporate animals, plants, and children into the daily life of their residents. At Dellwood, there were 10 cats, 2 dogs, and numerous birds and fish that lived at the center. The cats and dogs are free to roam throughout the building, although each one seemed to have particular people that they liked to stay with or visit on a rotating schedule. The cats were especially mobile, including one who traveled by elevator (he would enter the elevator with someone, peek his head out when it stopped, and if it wasn't the floor he wanted, continue to wait patiently in the elevator until it moved again). The animals helped transform the place from a sterile, hospital-like environment to a much homier living space. The animals helped everyone connect and provided an instant opening for a conversation ("Have you seen Maggie today?" "No, but go check Charlie's closet in room 203, she's usually asleep in his laundry til about 11!"). The animals present a few challenges as far as patient safety, but in the 6 years that the program has been in place, they'd never had a bad patient-animal encounter. I sure hope that I get to be surrounded by critters when I'm 90...

Although the rotation didn't have much to do with caring for patients in the small animal hospital, it was a good way to round out my experiences with food animal medicine. It was also a great refresher for the major zoonotic diseases (rabies!!), and a reminder of how many different roles animals play in our communities.

This rotation marked the midpoint of fourth year. I am 13 rotations and six months away from graduation. I have one month and two days until I take my National Boards, and just under a month until I have to submit my application for an internship. This next month will be a busy one!

Rotation #12: Oncology

I was fairly certain that Oncology was going to be The Saddest Rotation Ever. Dogs and cats with cancer? All day, every day? Occasionally there are days on Internal Medicine where it seems like all our patients, whether they present for vomiting or difficulty breathing or limping, end up with a diagnosis of cancer. You can tell at the end of the day who had a "cancer day"- they're usually in the Internal Medicine conference room late, typing long discharge instructions and having long sad conversations with pet owners about prognoses and statistics and mean survival times. So, you can see why spending two whole weeks of "cancer days" made me nervous.

But then, I walked into the Oncology Service on day one and was greeted by a small herd of dogs galloping in from the chemotherapy room. During my orientation, a scruffy wirehaired terrier mix kept wedging his head between my knees asking for petting, and a lanky 3-legged lab kept trying to steal peoples' lunches from off the countertops. Oncology felt more like doggy daycare than like a hospital, except that dogs would have to stop their socializing for a few minutes to have a physical exam and blood draw in the morning, then be taken to the chemo room individually in the afternoon for the 20 or 30 minutes that it took to receive their chemotherapy. Go-home time was chaotic, with each dog knowing which leash and collar was his own and going into a wiggle-butt happy dance when they knew it was their turn.

Don't get me wrong, Oncology was not all fun and games. In animals, the goal of chemotherapy (or radiation therapy) is usually not to cure cancer, but to provide palliative care. Often, that means animals go through a course of chemo to get them from a mean survival time of, say, six months to a mean survival time of 12 months. Cancers are very rarely cured, but because we use chemo at much lower doses that in human medicine, animals usually still have a great quality of life throughout their therapy and remission time. Chemo can buy pets another Christmas, another hunting season, or one last trip up to the cabin. But even if the dogs in the chemo room are feeling well and acting like themselves, the inevitable eventually comes. We had four euthanasias during my two week rotation, and they were all more emotional than usual since owners often develop a close bond to the Oncology staff throughout the course of therapy (or even just through the diagnosis of cancer, regardless of whether they chose to pursue therapy).

Cancer makes people feel hopeless and scared, especially if they've had to deal with cancer themselves or with a human family member. Having to deal with the human psychological component of oncology requires a lot of help from Jeannine Moga, the hospital's social worker. She has rounds each week with the oncology department to talk through difficult cases, bad outcomes, or really emotional owners. She also helps out on the hardest cases, like if parents are trying to tell a young child what's happening to the family dog, or if a senior owner's pet has just been diagnosed with cancer and they want to pursue treatment even though they don't have the financial means to do so. Jeannine is a wonderful resource and makes difficult things like the diagnosis of cancer a little bit easier to handle.

So, after two full weeks of cancer days, I have to say that Oncology is not The Saddest Rotation Ever. Somehow, through terrible things like cancer, little rays of hope shine through and pet owners really treasure having that one last Christmas or one last good pain-free week with their friend.

Rotations #8, #9, #10, and #11

My, how time flies when you're getting married! I've fallen far behind in my rotation recaps. Hopefully this post will make up for it....

Rotation #8: SAM-B

Students on the small animal track take four rotations in Small Animal Medicine (SAM). The first SAM (SAM-A) is a chance for us to get oriented and learn the basics of how to approach a medicine case. Clinicians will usually ask us what we think the animal's problem is and how we would proceed with diagnostics and treatment, but they generally lead us along through our first cases. The next three SAMs (SAM-B's) are progressively more hands-off by our clinicians. We're expected to make more decisions about which diagnostic tests to run, which specific drugs and doses to use, and how to manage hospitalized patients. Obviously they'd never let us decide to run a test that would be a waste of money, or use a drug that isn't indicated, but the goal is to make us feel more like the primary doctor on the case rather than just an assistant. We're also expected to know more about pathophysiology (the reasons why a disease affects the body the way it does) and spend more time looking into current literature about diseases and treatments.

Thankfully, even though there are higher expectations, my first SAM-B felt easier than SAM-A. I think it was mainly because I didn't need to spend as much time figuring out logistics (like how to submit a blood sample), so I had more time to research each case. I also got more efficient at taking a history and doing a physical exam, which also helped to streamline things. My cases were in general less intensive than the patients I saw on SAM-A- I saw a lot more patients who were being managed for long-term diseases, like diabetes and hyperthyroidism, and fewer infectious diseases like blastomycosis or leptospirosis. It was a good rotation for working on my basic clinical skills and building a little confidence.

Rotation #9: Vacation!

My 9th rotation block was my second of two vacation blocks. We got married (yay!) and relaxed up in the Boundary Waters. My last break will be in late October, when I get a week off (since our Public Health rotation is only one week long)... then it'll be straight through until graduation. Yikes!

Rotation #10: Anesthesia

I've gotten a nice gradual introduction to anesthesia, starting with being the anesthetist for one dog in sophomore surgery lab, then for six dogs and cats in ESAS. The difference between those experiences and the anesthesia rotation is that my previous patients have all been relatively young and healthy. Under the supervision of our anesthesiologists, our rotation was all about getting comfortable with anesthesia of less-than-healthy animals- for me, it included a geriatric cat in renal failure and a ruptured eye, a dog with a large bleeding tumor on his tongue, and a cat with a heart murmur and several fractured teeth. For the first time, I had to handle situations like low blood pressure, slow heart rate, fast heart rate, waking up on the table (not during surgery, thank goodness!!), and monitoring a patient who's inside a CT machine (where you have to be across the room instead of right next to them).

Also, unlike our other anesthesia experiences, we got access to all sorts of fancy equipment- things like mechanical ventilators, end-tidal CO2 monitors, EKGs, and blood pressure monitors. We were also encouraged to try out anesthestic drugs and protocols that we'd never had experience with, so that we could get comfortable with how each drug and combination affects a patient. Our anesthesiologist is famous for letting us experiment, even if we choose drugs or doses that she knows won't be particularly effective (never putting the patient at risk of course- just leaving them awake enough to lead to phrases like "And then I removed the cat from her face.")... since we learn more from our mistakes than from being corrected. She'd never let us flounder, but she didn't mind watching us sweat a little while we tried to troubleshoot monitors, drugs, or catheters. Anesthesia was easily one of the most valuable rotations I've had yet!

Rotation #11: Ophthalmology

Eyeballs. Aside from derm, I can't think of any specialty that makes people go "Ewwww" more often. It's understandable, considering ophthalmologists have to deal with things like melting corneal ulcers or proptosed eyeballs (warning: links for the non-squeemish only!). But, it's hard to ignore the draw of a specialty that gets to bring eyesight back to animals blinded by cataracts. Most of what we did as students on the ophtho rotation were routine eye diagnostic tests, like measuring tear production or testing the pressure within the eye. We also learned how to do a proper fundic exam, which is an important skill for any general practitioner.

The best days, though, were the surgery days. We got to see our ophthalmologists perform goniovalve implants, which is one of the same procedures done to treat glaucoma in humans. Glaucoma occurs when the fluid produced inside the eye isn't able to drain out normally. The pressure in the eye increases, eventually causing pain and making the eye to go blind (remember Kirby Puckett?). A goniovalve is an implant that looks a little like a computer mouse. The "tail" is a tube that goes into the front chamber of the eye, and the "mouse" is a hole-filled plate that attaches outside the eyeball and allows the fluid from the front part of the eye to drain. It's not a permanent fix, since eventually it gets plugged with cells and protein, but it can buy months of pain relief and sight for an animal with glaucoma.

We also got to see a lip-to-lid resection, a form of plastic surgery for a dog with a tumor on one of his upper eyelids. The lid was removed and replaced with tissue from his upper lip (hence the name lip-to-lid). The lip tissue wasn't able to be attached to the muscles that normally make the eyelid blink, so the dog ended up with a bit of a droopy lid- but the alternative was removing the tumor, eyelid, and eye, so a droopy lid is a small price to pay.

Ophtho was a little light in the hands-on sort of learning, but a fun rotation to see what's possible for animals with eye disease. I still think eyeballs are kind of gross, though... ;)


Tomorrow is my last day of Oncology... hopefully I'll stay caught up on my rotation reviews!

Rotation #7: Dermatology

Dermatology is portrayed in Grey's Anatomy as a magical place where the doctors are calm and relaxed, they serve water filled with floating fruit, and everyone is dressed in pastels. Dermatologists work 9 to 5, no weekends, no on-call duty, and as they say, "there are no dermatologic emergencies."

My experience on the veterinary dermatology service hasn't involved any fruit-filled water, but it has been a nice change of pace from Small Animal Medicine. The biggest difference is that we don't have any hospitalized patients, so we get to focus only on the clients coming in for appointments. We also see a lot of long-term patients and spend a lot more time on client education than some other services, since animals with skin disease can require fairly intensive management to keep their diseases under control.

Derm is a huge part of veterinary medicine (Dolittler puts skin diseases as her #1 and #2 most common types of appointments), so it's been good to get my feet wet working with some of the most common types of skin problems. We've seen food allergies, environmental allergies (aka atopic dermatitis), sarcoptic mange, demodectic mange, endocrine disorders like hypothyroidism, autoimmune diseases like onychodystrophy (where the body attacks the nails) and sebaceous adenitits (where the body attacks the sebaceous glands of the skin), and some unusual diseases like Daschund Pattern Baldness.

Despite the economy, the Dermatology Service is still booked out for over a month in advance. I don't mean to sound cynical, but I suspect the reason that people are so willing to treat their pets' skin diseases is because they are embarassing (dogs with inflammed skin or hair loss are very noticeable on walks or at the dog park) and annoying (the constant licking, chewing, biting, and scratching of an itchy dog can wake owners up at night and drive them crazy during the day). It's relatively easy to ignore a limp, brush off those little lumps and bumps, or think that drinking more or eating less are just signs of old age.

Nonetheless, I think it's wonderful to see owners that are willing to devote all the time, money, and energy that it takes to manage what are often lifelong diseases. The differences that a dermatologist can make in an animal's quality of life can take a long time, but they can be dramatic. For example...

Treatment of generalized demodectic mange can turn a dog from this:
into this:
I don't think I'd ever specialize in dermatology, but it's nice to have a better idea of how to diagnose and manage the most common conditions I'll be likely to see in practice.

Next up is another Small Animal Medicine, then the wedding!

Rotation #6: SAM-A

My last rotation block was actually a vacation (which we still need to blog about too!). We spent half of it up north, and half out in Seattle. I got to attend two days of the AVMA national convention, which was gigantic and awesome and a little overwhelming. We got back Sunday night at midnight, and at 8 AM Monday morning, I was at school for my first day of Small Animal Medicine (SAM). Small animal track students have to take four rotation blocks in SAM. The first one is called SAM-A, where they give us a little more leeway in terms of how efficient we are, how thoroughly we take histories and physical exams, and how well we know our way around the hospital. The other three are called SAM-B, and the standards are higher for SAM-B students.

The Internal Medicine and the Surgery services see the bulk of patients that come into the teaching hospital. In a nutshell, if an animal's problem can be fixed surgically, it goes to see the Surgery department. If it's a nonsurgical issue that doesn't fit into some other specialty (like Cardiology, Dermatology, or Ophthalmology), it goes to the Internal Medicine department. Over the past two weeks, I worked with patients who had:

-Anaplasmosis, a tick-borne disease that infects white blood cells. The hallmarks of anaplasmosis are low platelets and a really high fever. These dogs can come in really sick and need hospitalization, but thankfully the treatment is a widely available, inexpensive antibiotic. Lots of people know that ticks carry Lyme disease, but Anaplasma is another nasty disease that can be prevented with good tick control (i.e. topical spot-on products like Frontline).

-Leptospirosis, a bacterium that is spread through urine. Most dogs get exposed by drinking water contaminated by wildlife that were infected with lepto. Lepto causes liver disease and renal failure. Dogs who make it through the initial infection but are never treated can become lifelong carriers and shedders of lepto. Lepto is a zoonotic disease (you can catch it from your pet), so careful handling and thorough treatment are important.

-Blastomycosis, a fungal disease endemic to Minnesota, Wisconsin, and the Mississippi and Ohio River Valleys. Both humans and dogs can be infected with Blasto, but dogs are about ten times more likely than humans to get infected (likely because the spores are in the soil, and dogs are about ten times more likely than humans to be snuffling around in the dirt). Blasto can infect the lungs, skin, bones, joints, eyes, brain, and just about anything else in the body. Many dogs diagnosed with blasto don't survive long enough to make it out of the hospital. Of those that do, their owners have to be willing to take on a long-term committment to very expensive therapy with an anti-fungal called itraconazole. For a large dog, itraconazole can cost $400-$500 a month, and therapy can last over a year. Blasto is evil.

-a puppy with more congential defects than I've ever seen in one animal. She had open fontanelles (her skull never closed completely), hydrocephalus (excess fluid in the brain), retained baby teeth, luxating patellas (the kneecaps slip out of place), and congenital hypothyroidism. About the only thing she didn't have was a heart murmur. There is no way to fix most of her problems. It was a good reminder that, no matter how cute that puppy in the window is, please don't buy a pet store puppy.

-diarrhea and vomiting. These two problems are truely the bread-and-butter of veterinary medicine, partly because they are uncomfortable for the pet but mostly because they are really inconvenient for pet owners. The list of what can cause diarrhea and vomiting is ridiculously wrong, from something as benign as eating a bag of potato chips to more serious problems like Exocrine Pancreatic Insufficiency or a Inflammatory Bowel Disease.

-cancer. I saw lots and lots of cancer. Dogs and cats can get all the same types of cancers that we can get (including those associated with smoking, if they live in a house with an owner who smokes). Often, cancer in pets starts with really non-specific signs like diarrhea or weight loss, so they come to see the Internal Medicine service. Oftentimes, an abdominal ultrasound is all we need to do to find a large mass somewhere in the abdomen. Some owners opt for more thorough imaging like a CT scan or MRI. If an animal has a single mass, we might send them over to surgery to have it removed. If there are multiple masses or if the mass is in a location where it can't be surgically removed, they visit with the oncology department to talk about options such as chemotherapy or radiation therapy. In animals, our goal with cancer treatment is never complete remission as it is in humans. The goal in veterinary oncology is to prolong quality of life rather than to extend quantity of life, so we generally use lower doses of chemotherapeutic drugs than is used for humans. Humane euthanasia is also often a very kind and reasonable choice for an animal with cancer.

All in all, SAM-A was a challenging but educational rotation. There were a lot of sad diagnoses, but less euthanasia and more happy endings than I saw in my emergency and critical care rotation. Next up, Dermatology!

ESAS, week two

More creatures from ESAS... Does anyone need a sweet dog or cat?

Scrappy the border collie/Australian shepherd mix:
Nipper the 14 week old sheltie mix:Gunther the German shepherd:David the kitten:Soapy the tomcat:Precious the tabby cat:Li'l Tree the grumpy kitten:

More ESAS

I successfully neutered one cat, spayed two kittens, and neutered Bucky (my parents' new dog) this week. Three (or four?) more surgeries next week, and then a much-needed vacation block. Phew!

More critters from ESAS...

Chica post-spay and rear dewclaw removal:

Toes the polydactyl tuxedo kitten:

Annie:
Luna (a.k.a. Lunatic and Looney Bin)- a bit of a wild child:

Max the lab/hound puppy:
A very unhappy, still slightly drugged Flip Flop the kitten:
Bucky the Shiba Inu, who was actually recovering from surgery, and Winnie, who was pretending to be recovering from surgery too:

Rotation #4: Elective Small Animal Surgery

I promised this one would be more exciting! I started Elective Small Animal Surgery (ESAS) today, which means I'll be performing around 6 surgical procedures over the next two weeks. Hopefully I'll get to do a cat and dog spay, and a cat and dog neuter, plus maybe some other types of surgeries depending on the needs of the animals (i.e. dental cleanings, mass removals, etc). All of the critters that we'll work on come from local shelters and rescue groups. Here are our animals that will go under the knife tomorrow...

Chica the chihuahua, who is just as nervous as this photo makes her look:


Jackie the 9 week old calico kitten:


Tiger the tomcat (my surgery!):


There will be three new animals every day- I'll try to remember to post pictures of everyone!

Rotation #3: Lab Medicine

My third rotation put me back in the classroom for Lab Medicine. No, not those kinds of labs...

Lab medicine (or clinical pathology) is the practice of interpreting bloodwork, looking at blood smears, examining cells from masses, growing bacteria from infected tissue, and anything else that you could think to measure in the lab. The clinical pathologists do some of the same work at the anatomic pathologists (the people who perform necropsies in the Diagnostic Lab), except that they generally work with samples from animals who are still alive. The rotation itself was good, but it wasn't much different from being in class like I've done for the past three years.

Stay tuned for an update from my latest (and more exciting) rotation...

Rotation #2, week two: Emergency

I finished up rotation block #2 last night with my final night in the ER. Over the past week, I saw:

• a dog who ate four pizzas, a carcass of some sort, and a bunch of rib bones stolen out of the garbage
• three dogs with pericardial effusion
• a puppy who ate a sock
• a dog who ate a several socks and a pair of nylons
• a dog who choked on grass
• a dog with fluid around his lungs and in his abdomen (probably secondary to cancer)
• a puppy with an infected tick bite
• a dog who bled into his eye after being accidentally hit with a ball during a game of fetch
• a chihuahua who ate half a bag of Dove chocolates
• a cat who had a blood clot in his aorta (a.k.a. "saddle thrombus")
• three cats in a single night who were all having problems breathing secondary to heart disease
• a cat that was hit by a car
  
• a dog who ingested rat poison
• a dog who ate xylitol-containing gum
• a dog who couldn't close his eyes due to facial nerve paralysis
• an anemic cat
• four dogs with hindlimb weakness or paralysis due to intervertebral disc disease (almost all dachshunds)

I also took what felt like a hundred histories from owners, performed a lot of physical exams, placed two IV catheters, and performed my first thoracocentesis (chest tap). The rotation was feast or famine, either crazy busy or totally dead. I learned a ton, but faced a lot more sadness and death than I was prepared for. I'm not sure if emergency medicine is for me... but it is a wonderful resource to have available in our community.

I'm on to Lab Medicine now, which is two solid weeks of practicing looking at blood smears, interpreting bloodwork and fluid analysis, and looking at samples of various tissues (i.e. bone marrow biopsies, fine needle aspirates, impression smears, etc). So, back in the classroom. Time goes a lot slower outside of the hospital, but it's nice to have a little break from patients.

Rotation #2, week one: Critical Care

My second clinical rotation is actually two rotations in one. They decided this year to combine the Emergency and Critical Care rotations into a single two-week block instead of two separate blocks, because so often the animals that come into Emergency end up in the ICU. The two services work so closely that students often end up working on both anyway. Last week, I spent my time on Critical Care.

The Small Animal Intensive Care Unit is a hodge-podge of all sorts of cases. The ICU is where animals go as they are recovering from surgery. It's often where animals who are seen on ER end up as they recover or wait to stabilize enough to go to surgery. The Internal Medicine service often has ICU patients, like when a pet who comes in to be assessed for increased frequency of urination gets diagnosed with diabetes and needs time to get stabilized and started on insulin. The animals in the ICU are usually not far from some sort of impending crisis, which is why they need to be monitored so closely and need to be close to lots of people who can act quickly if something bad happens.

In the past week, I saw my first grand mal seizure in a dog (terrifying). I've learned how to take blood pressures using a Doppler, learned how to set up a CRI (constant rate infusion), watched a classmate remove fluid from a dog's abdomen, and saw my first case of pericardial effusion. I saw a dog who got put on a ventilator to breathe for her after meningitis caused his brain to swell to the point that he lost control of his respirations. We made a lot of sad diagnoses (cancers mostly, or poor outcomes following surgery), but also got to send a lot of our patients home after they made it out of the woods. I helped take care of a litter of kittens post-C-section, and got to send a tiny puppy patient home after he recovered from a pretty major head trauma.

Critical Care is a place where the swing between hopelessness and miracles occurs 10 or 20 times a day. Sometimes all the monitors, tubes, medications, and blood tests seem so invasive and pointless... but then there are cases where your patient looks a hundred times better after receiving a liter of fluids, or that one EKG tells you that your patient is turning the corner, and it all suddenly makes sense.

I'm still not sure that I'm built to handle the wild swings between elation and sadness that come with Critical Care, but I will say that the feeling of getting a hug from a client who gets to take their dog home after five long days in the ICU is worth a million bucks.