All but one species

Ship out to sea

2012-01-27T09:07:00.000-08:00

There are times when working in veterinary medicine makes one feel very low. I, to my luck, am experiencing such a time right now. Brought on by come clients with excessive emotional needs, and worsened by one or two clients whose only goal appears to be making my heart do a little VPC dance, I am wiped out and feeling mildly hostile to the idea of treating any patients in the near future. add in the stresses of a residency, and I am officially burnt out this week.

What makes it still bearable are the nice clients I get and the most adorable puppy I admitted to the hospital the other day. Every time I see him, I want to squeeze him, put him on a cracker and gobble him up. Of course, that wouldn't help with his pneumonia, but damn if his cuteness isn't the best thing I've seen in a while.

In the midst of my ennui morphing to self-berating, I received an email from a client who I'd met the previous week. Her dog had developed acute kidney failure, and she had been referred to me as soon as the regular veterinarian got the scarily high lab values back. I spent a whole 6 hours with the dog and her owner, and my colleague spent another 5 hours, when we ended up diagnosing the dog with anuric renal failure. It was so sad, with the dog being just 4 years old, but the owner was so grateful for the care we gave, that he made sure to write to us about it. Letters like that are so powerful, providing support that we are doing the best job possible, confirming that we are making a difference.

For this past week, that letter has stayed in my pocket for me to read whenever I have a difficult case. I hope it gets me through the next 5 days.

Death midwife

2012-01-19T22:13:00.000-08:00

Seeing either emergency patients or the sickest of the sick in our ICU, I have become nearly immured to death. And that makes me sad. I wish I had the time to truly be with each patient as they dies, pet them for a while afterward, and wish them piece. Or if I could truly be there for the clients, as they realize their beloved pet will not be coming home, helping them start the process of grieving, and ensuring that they have the support they need.

Unfortunately, there are moments where I can only start the process, perform the euthanasia, explain to the owners what they are about to witness, ensure the patient is comfortable and pain free for their last moments. Most times, that is enough. The rare times when death becomes messy leave me broken inside, wishing for a do-over, even though I know that without changing the nature of the disease, the needs of the client, or the time it takes to make a decision to euthanize, that there is nothing that would have changed for the better.

Helping people decide when to euthanize can range between ridiculously easy, or horrifyingly hard. Some clients arrive at my hospital, knowing that their cat is at the end of their life, simply wanting confirmation from me that their decision is appropriate. Other clients, due to extreme love for their pet, lack of medical knowledge, or an inability to admit that their pet is suffering, cannot make the decision to euthanize their terribly ill dog. Helping them come to terms with the fact that their pet will not be able to survive it's current condition, while trying to keep their pet comfortable, is the most difficult task I face.

I would much rather perform CPR, place a chest tube, discuss the allergic reaction, look over blood work results, suture a laceration, monitor a patient on the ventilator, or even treat a terrifying cardiac arrhythmia.

But instead, I find myself using all my energies to ensure that the owner of this sweet, innocent animal who has severe chest injuries and is bleeding out, or cannot breath due to lungs riddled with cancer, or has severe sepsis with a blood pressure which won't respond to three different types of blood pressure medication, or any other horrific illness or injury with an extremely grave prognosis, understands what is going on with their pet. Meaning I take myself off the floor to discuss everything, repeatedly. Many want assurances that their pet is not in pain. Luckily, I'm able to control most animals' pain. But the suffering, that I rarely can fully control. And that is what breaks me.

I see animals suffering, and have tried everything possible to help them them, and still they suffer. My technicians know when I have a patient like this, suffering, with an owner who cannot yet make a decision which would end their suffering, for they see me constantly hovering over the animal, biting my thumb, rocking back and forth on my heals, wanting to do something, anything, and coming up empty handed.

It is those cases, when I am able to guide the owner to the decision, and then perform the actual euthanasia, that I know it to be the true gift which it is. Those are the times when I am most grateful to be able to midwife a patient's death, knowing that I am helping, that I am serving my patients as I swore to do upon graduation, and that I am hopefully providing some peace for my clients.

Sometimes it actually works

2012-01-07T13:53:00.000-08:00

The other week, I did CPR on a puppy twice within 30 minutes. Successfully.

I still feel like a rock star.

Diagnostics

2011-12-29T14:15:00.000-08:00

I know that diagnostics can cost a fair amount of money. $200 for blood work is nothing to sneeze at. But if your cat has been ill for 3 weeks, and all you've let us do is a mini blood panel, a single radiograph, and a physical exam, do not be surprised if we cannot tell you what is wrong. Please bite the bullet and go for a full lab panel, including a urinalysis. I would have liked to have diagnosed your cat with acute kidney injury 2 weeks ago when it had a much better chance of responding to IV fluids quickly. Now that it's BUN is 240, and its creatinine is 8.7, my hopes of getting your kitty healthy and home are relatively low.

Shift work

2011-12-23T03:19:00.000-08:00

Nearly all veterinarians working in emergency medicine have worked overnights. And most of those doctors dream of being able to do their emergency medicine shifts NOT overnight. Of course, there are a few people who flourish at night. I am not one of those people.

I accept that my chosen focus requires me to be up when most sane people are sleeping. I get that I have to make my brain work more at 3 am than most people would dream (why does everything actively dying come in at 3 am, anyway?). But I would give my teeth (which I end up grinding during the day when I'm trying to sleep) to occasionally have a normal job.

Wait, I lie, I'd be boarded with a normal job.I just want normal hours.And by normal, I mean a normal 10-12 hour shift, not the 8 hour shifts found with people who are not doctors, or with people who aren't in the medical field. Or truckers, cops, fire fighters, or even factory workers. And in that last sentence, I am poorly writing how I recognize that those folks have long, shitty hours too (not that they have 8 hour long shifts).

Tonight, I am staying awake in preparation for working the holiday weekend, Friday through Sunday, for 14 hour each night, overnight. Obviously, the sleep drain is already causing me to lose portions of my functioning brain rapidly. In fact, my mentors can easily guess which day of the week it is by the number of vocabulary words that no longer make it to my mouth. (Me: the patient has that wacky heart rate thing where it's going super fast and scares the techs. My poor suffering mentor: you mean tachycardia?) It's scary, and ugly, just how quickly I revert to survival thinking when I'm on overnights: Mara sees cookies brought in by a grateful client whose pet she has never seen, mine! she thinks as she hordes a handful for later.

When I'm actively working (and not prepping like I am tonight, where I allow myself to be a dumbass because no one will die if I think the wrong thing), and busy, I do okay. My brain gets in a pattern of dredging up useful information, I am able to converse appropriately, and I spend what little downtime I have pacing back and forth in front of my patients. But if it's slow, it's as if I'm swimming through molasses. Yes, I can still catch the important stuff for the most part, but it is painful, and there is constant worry that I'm missing something.That worry stays with me when I go home for my 8-10 hour break from work, and manifests itself as horrific dreams where I'm failing my patients, or pissing off my colleagues, or getting myself sued by a client. And then I wake up refreshed (not), and go back to another 14+ hours of just barely keeping up.

Beyond the brain-numbing aspect of shift work, I find the overnights physically destructive as well. I start out the night, relatively warm, my hair combed, with clean scrubs. By the mid point, my hands are like ice, I've got both a jacket and a blanket on me as I huddle in front of the space heater. I develop bags under my eyes, my vision gets blurry, and every joint makes me feel like an arthritic grandmother in the frozen tundra cackling that snow is coming soon. By 4 am, I am shivering and nauseous, with blotchy skin and chapped lips. My skin either reeks of the hand sanitizer, or my cuticles have split and are starting to bleed. I generally have at least one bandaid on some part of my body.It's a wonder that any clients trust me with their pets when I look that beguiling.

What I'm trying to say is that I really, really, really, really, really, REALLY hope that I'll get to work days or swing shifts if I ever make it through this residency

Grief

2011-12-20T11:01:00.000-08:00

I have had, as of last month, 5 cats, 2 dogs, a lizard, 4 foster cats and 2 foster dogs in my home at one time or another. Of the non-foster animals, all but one of my pets have died. Three of them have died in the past 8 months. The most recent one died 3 or 4 weeks ago (it's all a blur in my head), and I am drowning in grief.

To put it bluntly, a large part of my grief is due to the belief (false or not) that I failed my pet. Intellectually, I know that my pet died because he had horrible disease, and developed complication after complication thanks to that disease. But emotionally, I feel like I should have been able to save him. Or at least see his death coming. And maybe some small part of me expected him to die. But my heart was not ready, his death was a shock, and the manner of his death was gut wrenching.

I am glad that my family is able to embrace the new pet we have taken in. She is cute and sweet, and is highly entertaining.

I, however, am keeping her away from my heart. It is far from healed, and the only pet which comforts me right now is Ginger (pictured on the header), who was the companion of our recently deceased pet.

I find that my job as a veterinarian is made more difficult than I expected because the grief barges in, unannounced, just as I am trying to perform a physical exam on a patient, or when I am discussing a treatment plan with a client, or when I am asking my mentor for suggestions regarding a hospitalized patient. I cannot remember words or plans, my ability to multitask has disintegrated, and I question my medical judgement constantly.

I know that time will heal me, and I hope that my clients and colleagues will continue to give me the benefit of the doubt. Eventually I will recognize that I am a good veterinarian. After all, I can still save your pet. Just not my own.

Blinders

2011-12-13T08:34:00.000-08:00

In my training, the most frustrating part of my ability to practice medicine is the rampant opportunities to put on blinders, and my too frequent decision to put them on. Blinders are points in the medical exam where I can make a decision to rule in or rule out a possible diagnosis, always prematurely.

Sometimes blinders are handed to me right at the get go, with a presenting complaint oddly specific or extremely vague. It can be very challenging to ignore that a client brings their dog in for constipation, when he actually hasn't even been trying to defecate. Of the cat that won't eat dinner but did eat breakfast.

Other blinders occur when a physical exam finding pops up, which makes you shut down a line of reasoning prematurely. If a dog comes in for diarrhea, and you find loose feces on rectal exam, don't stop looking at the urinary tract to rule out cystitis or bladder stones which can lead to straining, and sometimes lead to secondary diarrhea.

Diagnostic tests can make you stop in your tracts. Elevated total biliruben may indicate gall bladder disease as an underlying cause of not eating in a cat, but don't discount that it may indicate hepatic lipidosis (fatty liver disease) which is secondary to anorexia.

That niggling voice in the back of your head is not a reason to see slightly abnormal electrolytes and diagnose Addison's Disease in the young male dog obtained from a shelter 4 months ago.

And for the love of god, if your patient has pigmented urine and mild anemia, always keep IMHA on your differential list - do not go down a wild goose chase of urinary infection or bladder stones leading to hematuria as the cause of the anemia.

In every case listed above, I have put on blinders, and missed the diagnosis initially. The constipated dog had a T3-L3 myelopathy. The anorexic cat had a pyothorax. The diarrhea dog was a female dog obstructed by bladder stones. The cat with the high total biliruben had pancreatitis which was leading to partial obstruction of the bile duct as well as early hepatic lipidosis. The young dog had intestinal parasites which were not diagnosed until they were passed after empiric deworming. And I have missed IMHA with the provided description more times than I want to admit.

Every animal was properly diagnosed because I have good colleagues, because I went back and performed the physical exam again, because I asked a question I hadn't planned on asking, and because I am at a teaching facility where we bounce our cases off each other and mine each others' brain for insights which we can't see. I have many opportunities to put on blinders where I chose to leave them where they lay, and those choices are increasing with each month of training. Thank goodness.

You know it'll be good

2011-12-11T23:13:00.000-08:00

Walk into an exam room on the busiest day of the year and have the client state, "don't worry, we know we're crazy." And then request a fine need aspirate of the smallest skin mass ever seen.

At 3 am.

Life's not that bad.

2011-12-09T14:18:00.001-08:00

Doing a residency is not easy. Anyone, physician or veterinarian, can tell you that. I, somehow, lucked out to find one of the kindest residencies that exists in my specialty. Yes, I work at least 50 hours a week with patient care. Yes, I have a minimum of of 200 pages to read each week (book chapters, journal articles, conference proceedings). And yes, when you add in all the other requirements (preparing grand rounds presentations, conducting research, writing journal articles, completing benchmarks), there is a shit ton of work to do. But I still get home every day (or night) and get to see my family. I still get a chance to go out and exercise. I even can squeeze in a chapter or two of a long overdue library book which has nothing whatsoever to do with veterinary medicine or critical care. I get to play with my cat and with my foster kitten. I get to go out to a restaurant (okay, it's Denny's, which has kids eat free on Tuesdays, and we order of the 2-4-6-8 menu. I am a resident after all.) once a week.

I get to live.

And that is a fantastic, amazing, wonderful gift that I can give myself and my family. I may have made them move every year for the past 4 years, ripping them away from new friends and comfortable homes. And I feel guilty for doing this, but not too guilty.

Boy, it's been a while

2011-12-09T01:16:00.001-08:00

Some of you might remember me from this blog I used to have, called All but one species. After a while, I stopped writing there, and changed to 3 AM Veterinarian. And then dumped all of that and changed to The Critical Veterinarian. And then finally cancelled and deleted the whole stinking mess because I couldn't remember why I'd started blogs in the first place, or why I'd changed them so much. By doing so, I deleted years of writing, just in time to start my residency, and it felt rather freeing.

Well, I kind of miss writing more than the 140 spaces I can squeeze into a tweet, so I decided to come back to my starting point.

I don't know how much of this will be veterinary, how much will be home life, how much will be (wished for but rarely accomplished) travel, or if it will all be combined together in one stinking mess punctuated with curse words. But I expect that people I know will find me (even those who may have birthed me), and most of them already know that that I'm a potty-mouthed, passionate person with a wickedly strong sarcasm gland.

Welcome.