Saturday, September 19, 2009

And Then There Were Five

It's been a rough couple of weeks for the interns at Metropolitan Veterinary Hospital. Early last week, we found out that one of our internmates, Jon Pierce, was leaving the program for personal reasons. It was a considerable shock to our collective system; Jon is a good guy and showed a lot of promise as a budding veterinarian and surgeon. Jon will be fine: It sounded like he would go to work for his father, a general practitioner in the area. Aside from the obvious loss of us not having Jon around, this will likely also mean a 1/6th increase in each of the remaining interns' workloads. We're still waiting to hear exactly how the schedule will change, but the assumption is there will be a marked increase in emergency shifts, plus or minus a concurrent decrease in other clinical rotations.

If that wasn't enough, another one of the interns was involved in a serious traffic accident a couple of days ago. It sounds like she will be okay, but it seems like we Metro interns might very well be an endangered species. It is unclear as to how long she will be out of action, but I believe she starts back tomorrow sometime.

And then there was the Ohio State-USC game. Ugh. That's all I'm saying. Ugh. Moving on...

As for me, no terribleness has befallen me so far. I'm finishing up a 2 week stint on specialty surgery, this last week in Neurology. I find that I'm attracted to disciplines that are hard and no one else likes. Ophthalmology for one, Neurology for another. I freely admit I'm not smart enough to be good at Neuro, but I find it fascinating that the neurologists are able to (correctly) identify a problem to the specific disk space or tiny spot in the brain with a name I can't pronounce by how severe a tremble is or which side of the body it is on. MRI's, also, are very, very cool. Once one has some idea of what you're looking at, it is an invaluable tool for visualizing neurologic structures and they're pretty to look at, to boot.

Next, I go back to daytime emergency doctor, what we call the DOD. That means a I've made it through a full cycle of rotations and am starting over. It is hard to believe I've been here that long, but it's good that things are going rapidly. I'm approximately 25% through my internship already. That also means that it's getting to be time to be looking for residencies again. So far, the only one posted is at Missouri University. It's early and there will be several more residencies posted over the coming weeks, but the odds are daunting that I will be fortunate enough to be picked to fill one. Any and all positive, good thoughts will be gratefully accepted.

As for now, it's about time to watch Ohio State stumble through another football game...signing off.

P.S. The veterinary profession lost a good man and a great teacher earlier this week when Dr. Cliff Monahan died unexpectedly at home. He was the Class of 2004's class advisor, our parasitology professor, and a caring, thoughtful, intelligent, self-less person who was always available and willing to help in any way he could. I am sad for his friends and family, but also for the next generation of veterinarians who won't be lucky enough to have Dr. Monahan teach them.

Wednesday, August 26, 2009

I'm Going Back to Dayton

I'm going back to Dayton,
I'm going back to Dayton...ay, yo, I don't think so

Actually, I will be going back to Dayton, as I get this weekend off! Having finished the two week overnight ER rotation, I've been assigned to the General Surgery rotation. To quote from the Metropolitan Veterinary Hospital Intern Handbook, this rotation is designed to "provide the interns with practical surgical experience and allow them to learn variations on surgical techniques by spending time with several general practitioners in surgery." In other words, it's a rotation set up to help me learn what it's like to be a general practitioner and to be able to do some spays, neuters, and maybe even a declaw. I didn't realize it at the time, but I was assigned to this rotation for approximately 5 years...just at an external location.

A couple of good things about this rotation: 1. The member doctors don't do a ton of surgery everyday, meaning I'm pretty much done by 2 or 2:30 p.m. at the latest. 2. No inpatients means no weekend responsibility. That adds up to me getting the heck out of Akron this Friday for a few days of R & R in a lovely destination known as West Carrollton. I am greatly looking forward to hanging out with my wife, seeing my dogs, cat, and fish, and eating some good food at our favorite restaurants. I'm also hoping to be able to stop by Twin Maples to say "hey" to everybody.

The hardest part about this week has been the transition from overnights back to days. I woke up Saturday evening around 6 p.m., went to work at 8 p.m., got home on Sunday around 11 a.m. (the 3-5 crew was brutal), and then stayed awake until around 9 p.m. Sunday night in an attempt to start the switch and be able to sleep through the night. If you're keeping score at home, that's about 27 hours straight with no sleep. It sorta felt like I was watching myself on TV as opposed to experiencing things in the 1st person. Monday and Tuesday were both sort of blurs as well. Tuesday night, I went to bed at 8 p.m. and that seems to have allowed me to catch up enough on my sleep to be mostly functional.

It is also a little akward being taught by other general practitioners, some of which have been out of school a shorter period of time than me. Not that I am the world's authority on any aspect of veterinary medicine, but I am reasonably comfortable performing routine elective surgeries. I remember when I was a fourth year student, the idea of doing a spay by myself was sort of exciting and scary at the same time. Now, it's just another task to be acomplished. I don't mind doing the surgeries, though, as it makes the day go faster, it's not terribly taxing, and it seems the member doctors appreciate being able to delegate some of their surgeries without having to worry that the intern is going to mess things up too terribly.

Another nice thing about this week is I have enough free time that I'm able to hang out in ophthalmology some. Dr. Belknap mentioned today that she has an idea for a research project for me, so one more thing to stay busy with and, hopefully, build up my residency resume.

So, things are still going pretty well, and I'll see you soon, Dayton.

The August Installment of the Val Petry Musical Awareness Project:
I feel a little bad that I'm unable to continue to introduce Val to new music in surgery, so I wanted to take this chance to throw a couple of new names out there:
1. Matt Hires: a singer-songwriter out of Florida. His album is called "Take us to the Start" and his songs are pop-y with catchy choruses. Cindy and I first heard of this guy last year as an opening act for Eric Hutchinson in Columbus and his first CD recently came out. It's available on iTunes and a couple other places if you search for it online.

2. Bryon Friedman: If you like Jack Johnson, you'll like Bryon Friedman. His back story is even pretty similar. He's a professional downhill skier on the U.S. ski team and has recently started playing music. His music is laid back and mellow, similar in sound to Jack, and has a little bit of a country sound as well. He has two CD's, one called "Road Sodas" and the new one titled "Matchstick Memories." It's the new CD that I've heard and it is pretty good. Again, available on iTunes and , I think, from his website if you Google him. Happy listening!

Nothing Good Happens Between 3 and 5

Over the past couple of weeks, I've come to a realization as absolute and undeniable as any accepted natural law:

Nothing good happens between 3 a.m. and 5 a.m.

You would think, actually, just plain old nothing happens between 3 a.m. and 5 a.m. You would think 99% of the world would be sleeping during these hours or, at the very least, barely waking up and starting their day. You might even be right on that second statement, but oh, that 1%. That 1% is a special bunch. That 1% thinks, "Hey, I've got nothing else going on, why don't I obsessively observe my pet and decide that it needs immediate medical attention." Or, maybe it's more like "My pet has been dying for 2 or 3 days, but NOW it's an emergency." Either way, they descend upon Metropolitan Veterinary Hospital in droves to ensure that the unfortunate intern asigned to overnight ER duty has a crappy shift.

Also, I believe there must be some sort of organization, a club or social network, perhaps, these people belong to, because they show up at the exact same time, often with little or no funds, and at a time when the computer system shuts down to back up its files. Maybe it's not that organized; Maybe the switching off of the computers creates a shockwave (I think of the scene from Pirates of the Caribbean were the medallion lands in the ocean and alerts the ghost-pirates to its location) that only tardos can detect. I don't know what it is, but I know it is not any fun.

Frequently, I would sit around from 8 pm until 3 or 4 a.m. and see 1, maybe 2, cases only to then be bombarded by the wave of marching morons with complaints ranging from "My dog vomited once or twice" to "My dog hasn't moved in a week or so." Here's the thing I can't get around: If my dog was vomiting at 3 a.m., I would have no idea. None. At best, I might partially rouse from my slumber long enough to think "I'd better turn on the light before I go pee so I don't get throw-up on my tootsies" before rolling over and falling back to sleep. I absolutely woudn't know that my dog was lethargic at that hour of the night/morning. Lethargic? Really? A dog is supposed to be lethargic at 3's supposed to be, actually, lethargic, non-responsive, and apparently comatose. We call that, in complex medical terms, SLEEPING! Oh well. I've said it before, and I'll say it again, if people were smart or used common sense, I'd probably be out of a job.

Actually, aside from the 3-5 crew, the overnight shifts weren't that bad. I find it takes about 3 days for one's internal clock to flip by 12 hours. Once that happens, one's daily routine is not that different from being on a day shift. You wake up, you eat a meal (in this case dinner), you go to work. Once your shift is done, you go home, you eat a meal (I killed a lot of cereal), maybe watch a little TV, then go to bed. Thank God, though, for dark curtains. I found sleeping enough to be a bit of a challenge, at least initially. I would wake up at 3 or 4 in the afternoon, wide awake, and struggle and sleep a little longer. If it weren't for the curtains, it would have been WAY too bright to sleep long enough to be functional.

One nice thing about the overnight shift is how un-busy the hospital is. During the day, there are around 6 specially practices, 8 or 10 general practices, and all the support staff/daytime emergency personnel around. Rarely can you walk 3 feet without having to side-step someone. At night, however, there are all kinds of quiet places to be and, being the only doctor in the hospital, usually you're not looking around for support staff if something needs done.

Overall, the night shift has probably been my least favorite rotation so far, but it is an infrequent rotation and it is still very doable. I'm glad to be finished living like a vampire for awhile and, should I wake up between 3 a.m. and 5 a.m., I'll shudder slightly and try to block out visions of the 3-5 crew. Wait...was that my dog vomiting????

Saturday, August 8, 2009

I've Been Up All Night, I Might Sleep All Day...

Let the fun begin.

Tomorrow evening, I begin a two week block of overnight ER shifts. That means from 8 pm until (theoretically) 8 am I will be in the hospital watching over in-patients and seeing emergencies. The rumor is that this is a better rotation than daytime emergency (which I've already survived once) but 15 hour days are not uncommon and no days off. The strangest part, I think, will be adjusting to the 12 hour flip of my daily clock. I haven't had to man an overnight shift since clinics in vet school and I'm a little worried it will take me a long time to make the adjustment. With that in mind, I'm going to try to begin the switch today. The goal is to sleep for many hours this afternoon and try to stay up as long as I can tonight. Hopefully, that will allow me to sleep most of tomorrow as well and be "up and at'em" by 8 pm tomorrow.

For the past 2 weeks, I have been on the surgery service's rotation. I spent the first week with the neurology department and, once again, I am flabbergasted by how frequently owners submit to advanced imaging such as MRI and CT. On average, we performed 2-3 MRI studies per day! I think, during my five years in general practice, I convinced--maybe--3 clients to be seen by a neurologist for that procedure. But, I must say, MRI studies are friggin' cool. Being able to see within the brain and spinal cord and not just be guessing about what might, maybe, likely, probably could be there almost feels like cheating. Of course, it helps when you have an exceedingly brilliant neurologist and a well-trained resident pointing out the things that are wrong.

This past week, I was with the soft tissue surgeon. It ended up, through luck of the draw, to be just me and him...All the residents were out of town and the surgery intern was assigned to the orthopedic service. This is both good and bad. Good, because I was scrubbed in on everything, bad because we had 9 or 10 patients in the hospital for several days and I was the only one examining, writing up paperwork, and calling the owners on all of them.

From a strictly surgical standpoint, I got to see and participate in the full spectrum of outcomes. The first day on service, we were to correct a patent ductus arteriosis (PDA) on a very adorable, 16-week old, Springer Spaniel puppy. A PDA is a communication between the aorta and the main pulmonary artery that is supposed to close within the first few days of life and must be ligated if it doesn't. The reason behind this is simple: the PDA creates a circuit for blood flow which negatively affects systemic blood pressure and greatly increases the stress and workload of the heart. If uncorrected, most patients will die from heart failure within12-18 months. The good news is that the prognosis is excellent. Most of these surgeries go off without a hitch, despite dealing with LARGE vessels very near the heart through which the entire blood-volume of the patient flows, and the surgery is immediately curative.

On Monday, however, the surgery did not go off without a hitch. We were nearly finished when the PDA tore resulting in massive--I don't have a strong enough adjective, really--hemorrhage. It was one of the most gut-wrenching and stressful experiences of my veterinary career. We worked for nearly 45 minutes trying to staunch the flow of blood and repair the tear while transfusing blood as fast as was possible. Despite an amazing effort by the surgeon and the technical staff, though, we watched as the patient's heart rate became slower and slower, then the heart shivered and just stopped. I thought I had become pretty jaded over the past few years, but this one bothered me and has stuck with me.

Luckily, the rest of the week's surgeries went well--even the second PDA surgery. I am in awe of the ability of the surgeon to have a short memory and knock that surgery out of the park. It was a good thing I had a mask on otherwise everyone could have made fun of the mouth-agape-in-shock-and-horror look I had while he was dissecting through the fat overlying the monstrous vessels. Other fun, new things I did that I've never done: biopsied 3 livers this week and none of them bled afterwards, operated a "Ligasure" (a wicked-cool cautery device that seals vessels as wide as 8 mm) resulting in (intentional) splenectomy of 2 patients, ligated portal vessels the size of my pinkie finger, operated the camera for a laparoscopic and and arthroscopic procedure, and assisted on a tibial tuberosity advancement surgery to correct a torn ACL. All of which was very cool. Oh, and I got to neuter a dog, you know, for old times sake.

So, now off I go to try to fool my body into believing night is day and day is night. I've often wondered what it would be like to be a vampire...

Thursday, July 23, 2009

Internal Medicine, or a Crash Course in Ultrasound Interpretation

I've been released from the DOD rotation (daytime emergencies) and have spent the last 10 days or so with one of the internal medicine services. This one is called Akron Veterinary Internal Medicine and Oncology Practice (shortened to AVIMP for obvious reasons) and it has been a positive experience so far. The doctors (one oncologist, one boarded internist, two "practice limted to internal medicine" vets, and a resident) are very easy and fun to work with. They all seem to have a well-developed sense of humor, so I'm fitting in pretty well. That said, they are very, very good at what they do and I'm amazed on a daily basis at how much they know and how thorough their understanding of physiology and disease processes is.

Most of my time is spent assisting (read: holding the patients) for ultrasounds. Abdominal ultrasonography is performed on almost every patient and, seeing the changes, both subtle and not so, in all of these pets is both fascinating and a little scary because I worry about what all I was missing by not ultrasounding this much. Routinely, definitive diagnoses are reached in patients that, in general practice, I'd have been left guessing on. I find this to be highly rewarding and satisfying. Again, it helps that most of the clients don't balk at the $600-$800 work ups, but medicine is a little easier when one is allowed to gather all the information at hand.

The other nice thing about the AVIMP rotation is slightly better hours than before. I tend to get to work earlier, because part of my responsibilities is "TPRing" the patients and walking them in the morning before rounds; however, we are usually done and leaving by 6 pm, as opposed to 9 or 10 like a couple of weeks ago. The weekends, as well, are a little better. This is a welcome change as it allows more opportunity to spend some time with Cindy. The distance is wearing on me a little bit, especially if something is amiss at home and I can't do anything to help. Luckily, Cindy has been great and our friends have been extremely helpful in maintaining my peace of mind.

Unfortunately, due to the way my internship is scheduled, I'll be moving to a new service (specialty surgery) on Monday. The upside is there's always something new to look forward to, the bad part is I move on just as I'm getting into the groove of the routine. Oh well, just the nature of the beast, I suppose.

So, one month down, 11 to go and, so far, it has been pretty much what I expected. I'm tired, but dealing okay, and I really think I'll look back on this as a positive experience. Stay tuned for more updates.

Everyday is a day at the zoo

One very interesting aspect of working at Metropolitan Veterinary Hospital is one of the member doctors is a big-time exotics vet and is the vet for the Akron zoo. What that means for me is we see all comers, whether that is dog, cat, bunny, ferrets, tortoises, etc. I also "get" to see wildlife to a certain extent. Technically, we're not supposed to treat owned wildlife, but we routinely receive "Good Samaritan" drop offs. In the past couple of weeks, we've had 10 or 11 "orphaned" baby bunnies (I put orphaned in quotes because they're not really orphaned, but momma wild rabbits don't sit on the nest like people think they do so people assume the babies have been abandoned), 3 wood peckers, a weasel, and a double crested cormorant (a big, blue bird that looks like a crane only with duck feet.) By far, though, the coolest wildlife has been the two raptors that have come in. We received a Peregrine falcon from the local police...he was found in a garage and seemed disoriented, but was fine, and a Barred Owl who sat in his cage and clicked at me everytime I walked by. Birds like that are unbelievably impressive up close and, although I didn't do much but get them checked in and call the exotics folks, it's cool to think that I was part of rehabbing them.

I wouldn't begin to pretend that I've become even marginally competent in treating exotics, but I'm slowly getting, at least, comfortable with examining them and having an idea of what needs to be done. Sadly, most of the exotics don't do well...generally, by the time a bird or other prey animal shows that it is sick, it is REALLY sick and there's not much that can be done. Occasionally, though, we make a difference and it is definitely a learning experience.

If nothing else, I enjoy walking through the exotics ward and checking out all the animals I wouldn't get to see otherwise.

Saturday, July 11, 2009

(Almost) 2 Weeks Down...

Wow. I knew the internship was going to be a lot of work but, by a rough estimation, I've spent 170 hours at the hospital over the past 13 days. The rotation I'm on now is called "DOD" or "Doctor on Days" or "Doctor on Duty" or something like that. What this entails is me being at the hospital at 7:45 am to round with the overnight intern on all the hospitalised cases then taking over care of those cases as well as seeing any emergencies that come in between 8 am and 8 pm (or so). Basically, my job is to keep an eye on the patients and notify the primary doctors' on the case if something goes awry. I also have to see patients and either treat and release them, or route them to the appropriate specialty service. This last part often becomes a game of hot potato for the services depending on how bad the case is and how annoying the owners are, with me in the middle playing the go between. Even more frustrating is when there are, essentially, no cases all day until 6 o'clock, then (like happened Thursday) a dog is admitted in status epilepticus with a 107.9 fever, and 10 minutes later a Lab puppy with a front limb de-gloving hit-by-car injury shows up 5 minutes before a hit-by-car Bichon with a large tissue defect wound on its right hip. On days like that, the 8 pm end time is mythical and I get home closer to 10 pm or 10:30 pm...just in time to throw food in the general direction of my mouth, collapse into bed, and start the whole thing over again.

What's even stranger than the schedule, though, is...I'm having a good time. I'm tired but, for the most part, I feel like I'm actually getting to participate in practicing medicine. I definitely still have "money cases" and whacko's to deal with, but at least 50% of the clients I see are willing to see a specialist and try to identify a problem, even if it is not a positive outcome. For example: Monday morning a 6 year old Rottweiler scheduled for bilateral total hip replacement later in the week came in unable to use it's rear legs. In general practice, I would have discussed a transfer to a neurologist, the owners would have declined, I would have given the dog steroids and euthanized it a few days later without knowing if anything could have been done. On this dog, the neurologist went over the exam with me and confirmed my findings, took the dog to MRI and I got to see the previously silent spinal tumor in the images. Still not a great outcome for the patient, admittedly, but the process of making decisions based on evidence gleaned from diagnostics was allowed to take place. How novel.

It helps, as well, that the vast majority of the specialists LOVE what they do. They are excited and enjoy working up the cases and helping you see it the way they do. I've yet to get the feeling that I'm annoying the surgeons or the internists when I bug them about a case I saw and admitted to their service. Maybe this is still all the "honeymoon" period with the new interns, but I'm hoping it stays this way...with maybe a few less hours, though.