“To Cut is to Cure”

We had a 1 week surgery rotation at the university hospital. The university is a referral center with specialist surgeries being performed so we didn’t get to do much ourselves. We scrubbed into as many surgeries as possible and held tissues or passed instruments or operated the suction for the surgeon.  We worked long days; coming in early each day to check on surgery patients from the day before. We also called patients a couple days after their surgeries to check on them and see how they were doing post-op. We wrote discharge notes and surgical reports. Surgical reports are different than a normal medical history. We made sure to include all the instruments used, the type of scalpel and suture, the pattern of closures, exact dimensions of any incisions, and carefully explained each procedure. Each evening we had rounds where we talked about the surgical cases for the day and looked at the pre- and post-operative imaging (x-rays, or CT scans or MRIs).

One of my first patients this week was a beautiful dog who had a significantly sized mass removed from his soft palate (roof of his mouth). Once the surgeon took the mass out there was a very large fistula which needed to be repaired with a skin graft. I was reading some of the articles the surgeon had with him to assist the procedure. It was very complicated, and the anatomy went over my head…that’s the thing about the field of veterinary medicine & surgery… there is always so much more to learn and do and practice! He stayed in hospital for a few days and had to be stomach tubed his meals (who wants to eat when you have a skin graft in your mouth anyways?!). When we went out for walks I had to stop him from trying to pick up sticks with his mouth! Unfortunately, after a couple days one side of his skin graft had failed and he needed a repeat surgery to close the fistula in the roof of his mouth again. After freshening the edges and making another mini-graft the fistula was closed. As far as I know, this patient recovered really well after his revision surgery!

I watched a couple of other mass removal surgeries this week, they were not quite as cool as the soft palate resection + graft. One poor dog had a mass in her rectum that was very uncomfortable. Another dog was very prone to developing lumps all over her body and needed those removed!

One girl in my group watched four splenectomies or something crazy like that this week. I managed to watch one!  The university has this very cool surgical tool which makes splenectomies a lot easier; it basically cauterizes all the vessels and stops all the bleeding so the surgery is much faster and cleaner.

 

One day there was a cria (baby alpaca) that had come in for surgery. He was too big to stay in the small animal hospital so he stayed with his mum in the horse barn and then came to our small animal surgery team to have his bony sequestrum removed from his leg.  A sequestrum is basically a dead piece of bone sitting within the limb; they can be associated with infections and sometimes draining tracts will form. The CT scan of his leg was particularly impressive!

If any spays or neuters were scheduled my group members and I were meant to do them. I watched one of my friends do a spay and a couple of my other friends did castrations. I was very unlucky all week and my cases kept cancelling or no-showing on me! I didn’t get to do any surgeries this week.

 

Towards the end of the rotation I had a very complicated surgical case! The patient was in the ICU.  I completed my rotation in the ICU earlier this year. The ICU team determined that the patient had a septic abdomen. Which meant that he had a bacterial infection in his abdomen—this is really not ideal! We learned that this dog had previously been diagnosed with severe hydrocephalus and had previous brain surgery to put in a ventriculoperitoneal shunt (VP shunt). Very simply —this is a tube that goes from the brain (and tracks under the skin) to the abdomen where it drains the cerebrospinal fluid that builds up in the brain. The excess fluid cannot be in the brain and if it is drained to the abdomen it can be reabsorbed into the body there.

Image result for dog with hydrocephalus

Please enjoy this Google image of a puppy with hydrocephalus. His head is abnormally enlarged and domed. http://www.dogscatspets.org/hydrocephalus-in-dogs/hydrocephalus-dogs/

Unfortunately, the presence of this shunt complicated matters. We didn’t know if the bacterial infection in his abdomen had started in his brain or if it has started in his abdomen and then had tracked up to his brain. The surgery team spoke with the ICU team and then the surgery team liaised with the neurology team. Eventually we decided that it was in our patient’s best interests to complete his abdominal surgery first and then bring in the neurology team to remove his shunt. Then, if he recovered well in ICU he would require another brain surgery in a couple weeks to replace the VP shunt in his brain (this patient cannot live without the shunt). Both surgeries went really well! I helped put in the esophageal feeding tube at the end of surgery.  I’ve been trying to keep up on how this patient was doing by asking my friends who were on their ECC rotation in the ICU room.

Advertisements

The First Cat and Dog Rotation!

I feel like there is a significant lack of cat and dog jokes around to make into a quirky title for this blog…

After my group finished our equine rotations we needed to switch our brains into ‘smallies’ mode because we had 3 weeks of Emergency and Critical Care (ECC) and Small Animal Medicine rotation ahead of us.

The Intensive Care Unit (ICU) room is located in the middle of the university hospital and all the most sick or critical patients get transferred there. Often the team is so busy they don’t leave the room and have no idea whats going on in the other departments!  We either worked day shifts or evening shifts–which were the ones I preferred.  This meant that after normal day time hours most of the other hospital departments had gone home–so if a patient needed a special procedure or diagnostic test we did it ourselves instead of transferring to another department.

Again, as a student we were meant to take a case and be “in-charge” of the treatment and monitoring of that animal while it was in hospital. If an animal presented to the hospital it was called over the loudspeaker and we went to the reception area to triage the patient and consult with the owners.

The first patient I saw ended up being the most complicated case we had all week! The cat was initially suspected to have hepatopathy (a fancy way of saying liver disease) and renal (kidney) disease. After further treatment and diagnostics we discovered both an intussusception and a gastric foreign body with bi-cavitary effusions, hypothermia, hypovolemia, and hypotension…which is a real fancy way of saying that this cat was very very sick!  Each day we had rounds where we could sit outside in the gardens and discuss emergency topics. This patient was a great patient to initiate discussions on identification of shock and management of critically ill patients.

On our next shift we had a blocked cat, which is something I had seen a lot of at my previous job! It is not an un-common problem in male cats.  My housemate went to a conference last year and listened to a lecture about sacroiliac blocks (epidurals) for cats during this procedure. We use epidurals quite commonly in cattle but less so in our small animal patients. One night we were lucky enough to have a cadaver cat to practice epidurals on as well as other emergency skills like jugular catheters, tracheotomies, thoracocentesis, and urethral catheterization.

Another evening, there must have been something in the water in Werribee because we had multiple patients present after they feasted on the laundry room products!! One dog ate everything in site—detergent, soap, wine, bleach, smashed glass, etc. One cat ate lily laundry detergent and lilies are particularity toxic to cats!!

In Australia it is quite common to see snake bite cases! The university is currently working on SnakeMap which is this cool project that collects GPS coordinates of where snake bites occur which will help veterinarians manage the cases more efficiently. We had a few patients present to us in different stages of the course of the disease. It was fun being involved in these cases and I will miss them when I practice in Canada one day.

In the true spirit of emergency we had a couple cases which were rushed directly to the ICU room.  My group stood back in awe and watched the well-oiled ECC team perform CPR on a ferret who was involved in a dog attack.  Within minutes we had experts from the anesthesia team and the exotic specialist vet at the ICU room to assist with the uncommon patient.  Another patient in the ICU needed a pericardiocentesis preformed.   This is a procedure where the vet will stick a special needle through the body wall into the sac surrounding the heart (without poking the heart) to remove fluid—often blood–which is preventing the patient from breathing and pumping blood around their body properly.  This is a really cool technique because it is both diagnostic & therapeutic. This means that by performing a pericardiocentesis we can often get a diagnosis of the disease we are dealing with and we can also TREAT that condition at the same time.

WhatsApp Image 2018-04-22 at 10.06.35 PM

Practicing CPR on stuffed animals during our tutorial. But with that hair-do…. I’m not sure if its CPR or headbanging 😛

My group then transitioned into the Small Animal Medicine Department for a slower paced and more detailed rotation. We had tutorials on nutrition for cats and dogs and discussed diets required for different medical conditions and how to best formulate that into a treatment management plan. We also talked about antibiotics and prudent use.  Lastly, we had a CPR tutorial where we practiced our technique on life-sized stuffed animal patients.  We had a ton of fun practicing because we searched up YouTube and played “Stayin’ Alive” on loud to help us keep on time (compressions should be done at a tempo of 120 beats/min)!

I was in charge of another critically ill patient this week that was transferred back and forth from Medicine, ECC, and Surgery. This cat initially presented with blood in his urine. However, he was very anemic as well. Over the course of the week he ended up needing at least 2 blood transfusions. At one point we were considering giving him dog blood (xenotransfusion) because we didn’t have any feline donors.  Personally, I didn’t know that you could even do that without an animal dying and was completely mind blown! The cat continued to get sicker during the week as we tried to figure out an explanation for his many problems. We performed x-rays, ultrasounds, multiple blood tests, and even an exploratory laparotomy (surgery).  This cat had a very guarded prognosis and I was amazed and delighted at the end of the week when he was pacing around the ward and meowing at me for more food in his bowl (and not through his stomach tube!).

Wednesday was cardiology day! We shadowed the specialist cardiologist that comes to the university. My group sat in on all his morning appointments to watch echocardiograms (an ultrasound of the heart) and ECGs. I had a patient that had come in earlier in the week for something unrelated and when I did my physical exam I heard an abnormally low heart rate, a few tests later and an appointment booked in with the cardiologist and we had diagnosed her with a serious heart condition requiring surgical implantation of a pacemaker.

20180313_114208

Sometimes you need several ECG pages to read in order to diagnose the heart condition your patient has…

And on Thursday we had extra training with the specialist oncologist. She was really lovely and spent some time helping us to better feel lymph nodes in dogs and cats. This is something that I have always struggled to find in normal patients who do not have enlarged nodes.  Several of the patients I saw this week were cancer patients in various stages of diagnosis, staging, and treatment.  I now have a better understanding of chemotherapy drugs, what to do when you think you may have found cancer in a patient, how to treat and diagnose cancer.

These 3 weeks provided tons of opportunities for reviewing multiple different diseases and we had a lovely time in the hospital!

‘Watch me snip snip, watch me neuter’

I’m on my way back to Australia right now; sitting in LAX (my least favorite airport) and killing 9 hours.

Yesterday I finished off a 2 week placement at Tri-Municipal and Meridian vet clinics. They are a mixed animal practice–with the majority being small animal work.

Throughout the week I followed doctors into dog and cat consults. Often I would just listen but sometimes I was involved in the discussion of the case. I  also did my own physical exams and administered vaccines and dewormer to the patient.

Early in the first week I got a chance to try my hand at a cat neuter.  This is a relatively ‘easy’ surgery in small animal medicine—you still have to go to school for a lot of years to get to do it though!  There is a few different techniques and I wanted to try them all.

20180125_125935

I made sure to practice on this string with a knot in the end… I probably castrated it about 18 times. #poorstring

We diagnosed a textbook case of demodicosis.   This is a skin disease caused by a little mite that lives in the skin and can cause a dog to be itchy and lose patches of hair. You can find the mite by looking at a sample under the microscope. This was interesting for me because it is not an overly common disease. As well, quite often you can diagnose a patient with the disease without ever finding the little bug! This particular case presented an interesting opportunity for research to determine if this animal was safe to breed. There is a concern that this could be passed on to future puppies.

My favourite calls this week were the cattle calls. The first one turned out to be a bit of an emergency— we were called to a farm who had a cow with an episiotomy. Unfortunately the cow was bleeding out and the vet had to rush in and suture her up! I hear she is doing great!

We also went to a couple of small hobby farms to do some preg-checking. Yes, this is one of the times where vets stick their arm up cow butts to see what they can feel. It was nice to be on a small farm for these appointments because it allowed us to go a bit slower.  I palpated each cow after the vet and gave my own diagnosis of pregnant vs open (not pregnant).  You can diagnose this based on what the uterus feels like. I need more practice before I can really start being specific about weeks of gestation.

We went to a dairy and examined 4 sick cows. Two of them likely had pneumonia. This was interesting for me to see after my last placement where we did lots of post mortems on cows that had died of pneumonia. This week I got the chance to examine and observe clinical signs of pneumonia in live cows.

Abscess are pretty common in cows. And if you are one of those people that love ‘Dr. Pimple Popper’ then you will love cattle abscesses. So when we got a call about a ‘cow with a lump on it’ that is what we suspected. But, that was not quite the case….

20180118_153943

This is not an abscess, not an abscess at all.

Instead we were presented with a really weird tumor hanging off the cow. It had appeared to have burst open then sealed and re-grown. We determined that it would be best to sedate the heifer for the removal procedure. We attempted IV sedation via the tail vein. Either we under-dosed or the heifer was just not having it—she got a bit loopy and angry but never sleepy enough for us to cast her. She paced at the end of her rope on the non-ideal side of the squeeze.  A bit of a rodeo ensued but eventually she was safely inside the squeeze again, and we infused the stalk of the tumor with a local anesthetic before removing it. The sun was going down and it felt like a bit of a race against time. When we finally had the tumor off I cut it open to see what it looked like inside (classic vet student… because this thing was gross!!).

20180118_165825_001

It was swollen and dark red inside. When you pressed on it a black liquid came off in my hand

The inside was really weird looking and my best guess is a hemangioma? Any other vet field friends have guesses as to what it could be?

 

I had been crossing my fingers and saying little prayers that we would get a calving call on one of my placements. It is a bit too early for lots of calving in Canada right now.  But we got a call for a c-section! Surgery was preformed in a fantastic and heated (yay) barn! with warm water and facilities—like a table! Everything went great and we had a live (large) calf at the end of it! We did a 2 layer closure on the uterus and a 3 muscle layer closure, then sub-cutaneous tissue, then skin. I definitely got my practice in with cattle sutures!

We had a few other interesting cases this week. One of them was a dog who could not pee. He is an adult dog but we suspect that he was born with an abnormality that prevents him from urinating. We took x-rays and he had a huge bladder! I catheterized it and drained a lot of urine for him! You could tell that he started feeling better by the minute. We hadn’t got to the bottom of the problem by the time my placement was over.

I also observed tail docking of some rottweiler puppies. This is quite the ethical/moral debate in the veterinary world.

Another interesting house call was to do puppy exams on German Shepherds (one of my favourite breeds!) at a breeder’s facility. This was a particularily cute….and wiggly exam day.

One morning we arrived to a severely sick scouring calf. We monitored vitals (heart rate, breathing rate, and temperature) and ran in warm IV fluids for a short while before heading off on a farm call. There was an older bull calf castration on the schedule that I wanted to watch.  The bull calf was a bilateral cryptorchid (inguinal crypts).  This means that his testicles were not fully descended and castrating him was not going to be as easy as we wanted it to be.  After putting in an epidural we got the job done on not 1, but 2 bull calves.

By the end of the second week I was lucky enough to have done a few feline spays, a couple of canine castrations, and a bunch of cat neuters on my own. I feel much more confident doing these surgeries by myself. I have yet to determine my own specific favorite method though—hopefully that will come during my de-sexing rotation in a few weeks time.

Snapchat-1788010203

So much focus and brain energy used. I also need to focus on not tensing up my shoulders during surgery.

 

 

After the last day of placement I said goodbye, and drove home in a beautiful snowfall to finish off my packing. Some of my friends stopped in to say goodbye which was lovely as well.

Thanks again to all the staff at Tri-Municipal and Meridian Vet Clinics! I had a great time!

 

Cats and Dogs at My First Clinical Placement!

First week of clinical placement done and dusted! The small animal clinic was a bit smaller and slower than the places I’ve worked in; but you can always learn no matter where you are. This pace of appointments was perfect for asking lots of questions. I took the time to try and have some interesting discussions with the vets including their rationale behind drug protocols, unusual points they’ve learned from specialists or conferences, and how to deal with colorful clients as a new grad.

The clinic had 2 senior vets and 1 new grad vet. I loved this because the new grad vet chatted to me about lots of practical advice on how to navigate (instead of struggle) through my first year in practice. Speaking to the senior vets was fantastic for further expertise on cases and discussion of more complicated surgeries and techniques. This was helpful because after discussing multiple techniques on how to repair ruptured cranial cruciate ligaments we saw a couple of patients with the disease —one dog with a suspected tear, and another dog for a post-op assessment.

One of my favorite parts of this placement was the opportunity to see a flank spay. We’ve been taught that they are generally an older surgery and it is more typical to do abdominal spays now. However, this particular patient was contraindicated for an abdominal incision. I also enjoyed one morning when I spent some time monitoring a critically ill patient who had been brought into the clinic with an acute onset of heart disease and pulmonary edema (fluid in her lungs).

We also performed an enema and an ear clean under general anesthetic and admitted a patient with a fractured pelvis. I enjoyed listening in on consults regarding a seizing patient and a patient with behavioral issues.

Once the vets learned that I knew how to put in intravenous catheters I was allowed to put them in on all the patients that needed one. Practicing my hands on skills was the best part of this week.

A huge thank you goes out to the vets and staff at Greenvale Animal Hospital who are now part of my journey to becoming a veterinarian!

 

WP_20150525_006 (2)