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Posted in Anecdotes, Contemplative, Discussion, Internship, Veterinary Medicine

*NEW BLOG* Life of an Ambo Vet

After completing a year long internship, I accepted my first job as an associate veterinarian in an equine ambulatory private practice. 

To follow my new vet blog, Ambo Vet, click the image below. 

 

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#veterinarian #vet #vetmed #vetlife #equine #horse #equinevet #ambulatory #mobilevet #veterinarypractice #dayinthelife #doctor #ambovet

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Posted in Contemplative, Internship, Veterinary Medicine

Vet students

​See one. Do one. Teach one.

As an intern at an equine hospital closely affiliated with a university, we have hosted a steady trickle of fourth year vet school students since March. Knowing full well that interactions with students would be a part of the internship, I didn’t quite grasp how much interactions would take place. Of course, all hospitals and universities are different, but this hospital has a notorious reputation with students. As one of the lowest scored, poorest reviewed rotations in fourth year, it’s no surprise students show up apprehensive, nervous and gun-shy. Previous student reviews by our faculty and staff live on in infamous legends passed down from each generation of the vet school graduating classes.

Not long into my internship, I became acutely aware of the hospital’s notoriety at the vet school. Some of the students who rotated through in my early months, had already served half of their mandatory time at the Equine hospital. Having had my own painful, brutal vet school rotation experience over a year ago, I’d be damned if I became the same antagonist I had once faced. 

I made it a personal goal to do the following:

1. listen to the stories (half of being aware, is being aware of the other half…problems exist in universities, students, faculty, management, administration…knowledge is power, even if in the form of legends)

2. Encourage. Without fail, support students…both in affirming their strengths, and recognizing areas needing improvement. Positive feedback is the health balance to constructive criticism. The very nature of students means they are inevitably somewhat vulnerable at this stage of learning, especially so close to the vet school finish line.

3. Invest. Even though an emergency might not be the best time to talk things through, I invest time in each student. What are their career goals, previous experience, specific skills they want to work on, areas of weakness, area of practice they are most passionate about, best way that they learn. How can you teach the most efficiently if you don’t know the most efficient way that an individual learns? Introvert, extrovert, raised on a horse farm, never owned a horse…ultimately, it doesn’t matter. Every student is here to learn, and I make the special effort to coordinate extra time for learning, extra time for practicing hand-ties, placing catheters. It’s this investment of time, energy and focus that bring out the rewarding side of teaching.

4. Basic skills. Unless a dangerous situation, I try to get students to do all the hands-on things they can. Blood-draws, catheter placement, ultrasound, art lines, calculating anesthesia drugs, monitoring anesthesia, writing orders… When I heard a common complaint of feeling “lost” and not included in cases, the best way I can prevent future students from feeling that way, is to make sure they are in the middle of everything.

Although I have received so much positive feedback and great reviews, there is a dark side to the review process. Almost every single student I’ve worked with has opened up during the rotation. They feel comfortable asking questions, even if they think their question might be stupid. They are willing to try new things without the fear of strict judgment coming down on them…they overall, express how the experience is nothing like they had imagined it would be. 

Then, faculty and staff sit down to review students. And they review students that they spend a handful of hours around. Students on my rotation spend all day with me. From patient care early in the morning, to rounds to appointments, to emergencies to clean-up. I’m talking 10-20 hours straught. And then to have these individuals evaluated based on first impressions, or an answer they got wrong one time in rounds…it kills me. It is actually a painful and disappointing process. And my weight in reviewing students is minimal. And gender bias, I can’t even get started on that right now.

I only hope students have learned as much from me as I have from them. I hope these ill-equipped reviews don’t strike deep, and that somehow the time one intern spends working with them outweighs writing on paper from faculty that couldn’t even learn their names. 

And, if you’re a vet student who gets one bad review…don’t let it stop you, slow you down and never let it scare you. The reviews are done by people, and all people have bias, flaws and a unique perspective. Take feedback in stride, and as information…and always in context. It natural to remember the scars as lessons, but maybe the real lesson isn’t always the obvious, concrete one.

Posted in Anecdotes, Cases, Contemplative, Internship, surgery

the Demand for Ovariectomy

The desire to tone down the behavioral unpleasantries in mares is nothing new…especially when that time of the month lands on a show. For those high performing equine athletes, estrus can make or break a show season with a swish of the tail. It’s no surprise that the idea of eradicating the hormonal fluctuations has brought many owners to our hospital seeking a permanent, surgical solution to their badly behaving mares. 

And this last week, we had such a case. A 6 year old mare was presented to us for ovariectomy upon both owner request and vet referrals (yes, both of the owner’s veterinarians). The mare’s personality was said to be unpredictable and flighty. During some of her 50-100 mile endurance races, the mare would be performing great then suddenly put the brakes on. Literally, she stopped and refused to continue with the race…forcing a scratch from the race. And after repeated examinations, Trans rectal ultrasounds, hormone surveillance panels and trials of Regumate (the usual go-to treatment for estrus-associated behavior), nothing jumped out as the potential cause for the mare to just stop mid-race. Unless, of course, it was that the mare just didn’t want to continue.

She presented to us nervous, alert and in good body condition. A small mare of only 800 pounds, she was quite skittish of people and we all took our time working with her, talking to her. After a couple days in hospital, she seemed to settle down. Our physical exam findings detected no abnormalities, palpation of the ovaries found them normal is size and consistency, and ultrasound of the ovaries should multiple small follicles on both. And with the owner and rDVMs’ insistence, we decided there wasn’t a legitimate contraindications to not go through were surgery.

When it comes to removing the ovaries, there are a multitude of options…starting with type of surgery to perform…standing vs. general anesthesia. Under standing sedation, common procedures include flank laparotomy and colpotomy. Under general anesthesia, with the mare in dorsal recumbency, the options include a flank laparotomy,  midline  celiotomy, ventral laparoscopy on midline and and diagonal  paramedian  celiotomy. With the rise in availability of laparoscopic equipment and trained surgeons, most ovariectomy procedures are done laparoscopic ally these days. Benefits of this technique include improved  visualization  of ovaries and their associated pedicles  as well as tension-free exposure and transection of the pedicles, thereby reducing the risk of intra-operative hemorrhage. Also, incision size plays a big role in reducing complications, as only a single small midline incision is required for exteriorizing the ovaries. With this smaller incision, less invasive technique, recovery time is also reduced especially when performed with the mare standing.

Taking into consideration her personality, behavior and size (small flank), we elected for the laparoscopic technique under general anesthesia in dorsal  recumbency. Compared to the standing horse, the recumbent position helps to  minimize soft tissue  dissection  and avoids cutting through the flank musculature. In preparation for surgery, the mare was fed pellet ration only for 24 hours then fasted for 24 hours to ensure decreased Iniesta was present in the large colon and thereby increasing visibility in the abdomen during surgery. On the day of surgery, she got pre-op antibiotics, Nsaid and had pre-op bloodwork ran. After getting the green light, she was anesthetized, placed in dorsal recumbency and then elevated to the Trendelenberg position (hind end 30 degrees tilted upwards above the level of the head). Incisions were made for the laparoscope and instruments, five portals in total. 

The surgery itself was pretty routine, with visualization of each ovary and then transection of the pedicles using a Ligature tool. After both ovaries were transected and gripped with instruments, The laparoscope portal incision was extended a couple inches and the ovaries were removed through the incision. Incisions were closed up with 3 layers each and the mare recovered from anesthesia uneventfully. 

She remained on antibiotics and Nsaid for a couple days, and upon discharge from the hospital she seemed comfortable and the portal sites looked good. Upon return home, she gave specific exercise restrictions that involved hand-walking  with otherwise stall confinement for the next 2 weeks. Her return to exercise would be gradual, and continue only as her comfort allowed. As of today, we have not heard back about her status…and assume she is recovering well. 

After thoughts

This case posed several questions, one being the indication for ovariectomy itself. Her stopping during a race is the only behavior the owner attributed to estrus, and after reading through all the current literature and studies…”stopping” is not among the list of heavily studied estrus behaviors. Also, a typical justification for the surgery is when a mare does improve with Regumate, as this associates the improved behavior with the timely changes in hormones (specifically the drop in progesterone more so than the increase in estrogen). Also, having normal ovaries and no identifiable disease of the ovaries, was it enough to take the anesthetic risk that exists with any general anesthetic procedure?

So, did we really just do the ovariectomy at the owner and rDVMs’ requests and not because of our professional assessment? Is it justifiable to simply perform procedures and treat patients based on a non-veterinarian’s demand? It boils down to the clinician, I guess. What they are comfortable with, what they are confident in and how active of a role they want to play in the diagnostic and treatment process. 

And the truth is, not all mares that undergo ovariectomy procedures have their estrus-associated behaviors eliminated. A recent student found 95% of owners saw improvement after the surgery, but less than 30% said that all behaviors and signs were eliminated. Half of these owners reported that the improvement seen after the ovariectomy was equal to the improvement seen when using Regumate. But, in some cases, I guess it boils down to convenience.

Posted in Contemplative, Internship

​Steps in the right direction

The meager salary of interns is nothing new, to either the world or this blog. It can be dealt with. However, the absence of healthcare and other financial benefits exacerbates the financial burden. It goes without saying that CE is critical to the development and advancement of all professionals. While day dreaming about the AAEP 2016 annual convention, I had to accept the fact that there is no way I could afford to attend…even the registration fee alone is vastly out of my monetary reach. I thought back to my hiring contract, which specifically stated there was no money allocation/reimbersement or funding for attendance of CE events, conventions or Association memberships. Coming up with the funding for attending the annual AAEP convention in Orlando would be like winning the CE equine practitioner lottery.
And a thought popped into my head. You can’t win the lottery if you don’t play the game.

I decided to make a formal proposal to the hospital and affiliated university to explore the possibility of intern funding. But, before cranking out some serious hours on the written proposal, I met with the hospital director to test the waters. I ran the idea by some of my fellow interns, which were immediately on board even if pessimistic.

So, we set up the meeting with the director…which lasted a total of 20 minutes (mostly small talk). Then I came right out and asked about options for funding, the possibility of multiple interns attending, and how we can use this experience to not only benefit ourselves…but also bring back the experience in the form of organized presentations to the hospital faculty and staff.

The response to this? “A great idea, and I’ll look into it.”

Less that 24 hours later, the director stopped me in the hall and gave a big thumbs up. I didn’t get it, but smiled…quickly making my way back to the lameness work-up. “We have set up an intern CE fund with money allocated to each intern. $1200.”

I was frozen, surprised then had my lottery winner display of emotion (maybe a little toned down from that). 
“$1200 is great! Every little bit helps.” I said a million thank yous. And the director only grinned. “$1200 each.”

Repeat lottery winner display of emotion (not so toned down).

I am beyond excited about attendance of the AAEP convention being a possibility now. And with no hours poured over a document, no submission and resubmission of documents, waiting with status pending. Straight up, director made it happen. What I’m most excited about? How much this will do for the internship program, and for the benefit of all the interns to follow after us.

It feels good to make a difference. It’s so fulfilling to work in the veterinarian capacity, but equally rewarding to work towards the improvement of the profession through investing in internship learning experience. I’m still shocked…and also very content with the idea that I helped contribute to shaping the internship into a stronger program in the future.

Good news on a good day!

Posted in Internship, Tips, tricks & tools of the trade, Veterinary Medicine

The Drug Genie

I frequently use the Hagyard, Plumbs and Wickliffe android apps to look up drug dosaging and pharmaceutical information. The problem is, I am constantly alternating between the three different apps and this has left me proficient at navigating none of them. Every time I open the apps, I feel like I have to take a 30 minute refresher course. I am left to trial and error in my attempt to remember which of the three apps actually had minocycline doses, or which one has the doses for Ken that each particular clinician likes. I’ll tell you what this looks like…it looks like a combination of a looking for car keys that you misplaced somewhere in the house, and as if the whole concept of smart phone apps is new…while simulatenously late for work. I dislike it so much, I came up with a solution…

The main issue? Need to look up drug doses for patient and calculate their treatment protocol based on their weight…on the fly! Like any normal person, I don’t have them all memorized and don’t always have my big ol’ Plumb’s book on me. Over the last 6 months, particular drugs are becoming more familiar in their use but are still used infrequently enough that I end up relearning the dose 2 months later. I need a bit more time for repetition in order to memorize the doses, but I can at least come up with a decent number of drugs that I should always be able to quickly reference. And that’s where I started, with a list of drugs.

I created a custom drug dose calculator cheat sheet, affectionately called the Drug Genie. And I let excel do what excel does best. Functions.

At the top of the sheet is a place to enter in the patient’s weight in pounds of kgs. If pounds are entered first, the weight in kg will be calculated automatically. All the dosages on the sheet are then automatically generated off a function of the kg bodyweight and the corresponding therapeutic drug dose. Below is a screenshot of the current version. I do have 6-8 new medications to add, and I usually add one or two per week. Obviously the sheet is no formulary, and it’s not intended to me. I just want a quick, efficient source on my phone or tablet that involves minimal scrolling.  

Another great thing is that I’ve tailored the doses to particular clinicians. As some drugs have wide therapeutic dose windows, it has been difficult to re-train myself from standard doses I memorized in vet school. It is customized to the hospital and current clinicians, but might be the same protocol I use once I go out into the field.

In case anyone is interested in test-driving it, I’ll make the excel vesion available for download. Be forewarned, this isn’t bullet-proof and I am human (there could be erorrs)…so if something doesn’t seem right, it’s worth double checking. I’ve been using it for a couple weeks now and I’m pretty happy with it. There a shortcut to the file on my homescreen, so I also don’t have to be navigating through folders and files. My goals are to eventually have three proficient sources divided up into three sheets:

  • Adult drug doses
  • Foal drug doses, CRIs, parenteral nutrition
  • CRIs (adults)

If you have any suggestions or find anything that doesn’t seem right, let me know! Always looking for feedback.

#veterinary #vetstudent #vetschool #veterinarian #vetintern #vetmed #veterinarymedicine #equine #intern #internship #horse #vet #vethospital #equinehospital #horsevet #career #newgrad #vetblog

Posted in Contemplative, Discussion, Internship, Veterinary Medicine

Doing the Internship Math

 

1 year of internship experience is worth 5 in the field


My parents like to remind me wisdom comes from experience, which is procured by time. The only way to get 5 years of experience is to have 5 years of experience. This concept seems to contradict the main selling point of Equine internships…the whole get 5 years for the price of one deal. Internship math. However, there’s no short cut or cheat in taking the 5 for 1 deal…it comes down to hours. The concentration of experience is greater over the course of the 1 year internship, compared to 1 year of private practice. But I can also say this, it certainly FEELS like 5 years crammed into 1. Like my toxicology professor always emphasized, it’s about the dose. Everything can be toxic, it’s the dose that matters.


LOGS, LOGS, LOGS

I got onto this subject of hours after working on my internship logs over the weekend. With how busy it’s been, I’ve gotten behind on both my hours and my case logs. And I didn’t have to do the math to know that I accumulated a massive amount of hours in the month of June. For my internship hours log, I organize the exel sheet based on daily line items. Each day’s hours are categorized as either service, ER or other. Service hours include the normal business hours worked (8-5pm), as well as all the inpatient care and associated tasks (usually done before 8 am and sometimes after 5 pm). ER hours are acquired outside of normal business hours and are the hours worked when I’ve been called in for emergencies. The last category, other, are the hours spent on nursing shifts (minimum one weekend a month, and as needed) or in a teaching setting (lectures to vet students).

paper_sheet_png7233_20160813164221056.jpg
An image of my completed June Internship Hours Log

 

In June, the most hours I worked consecutively (from the time I arrived at the hospital to the time I left the hospital) was 38 hours. 2 hours were deducted from that “shift” because they were spent passed out on the couch in the lounge. Usually interns get one weekend “off.” It is intended for interns to be able to break away (and stay away) from the hospital in order to preserve sanity and avoid compassion fatigue. However, if you have in hospital patients and cannot transfer them to another intern, you come in to the hospital each morning (and as needed throughout the day) to provide in-patient care. In June, I was unable to transfer my patients for my weekend off, and came in…so 30/30 days, I worked at the hospital.

I’m getting exhausted just writing about hours. When talking to friends and family, I tend to subjectively describe my work schedule. “Long day” and “long weekend.” One, because who wants to hear the exact number of hours? And two, context. A 10 hour day doesn’t sound too bad, unless it was following an all nighter or three 16 hour days.

My log is really just the hours spent at the hospital (minus the ones spent sleeping at the hospital). The log doesn’t factor in all the phone calls (sometimes I receive no phone calls about patients overnight, but otherwise I’ll receive more than 3 phone calls in one hour about 3 different patients…every hour from 10 pm to 6 am). But the logs weren’t created for the primary purpose of down-to-the-minute accuracy. I keep them as a general idea of hours spent doing what, on what days for myself, future job opportunities and very importantly – to help define and describe the internship at the hospital as it stands now. Because at this point, I don’t think the hospital faculty and administrative personnel have an accurate portrait of the interns or the internship. In fact, saying they have a portrait at all is quite the overstatement.

But, that a whole other can of worms to open up in a different blog entry.


#veterinary #vetstudent #vetschool #veterinarian #vetintern #vetmed #veterinarymedicine #equine #intern #internship #horse #vet #vethospital #equinehospital #horsevet #career #newgrad #vetblog

Posted in Anecdotes, Contemplative, Discussion, Internship, Veterinary Medicine

It’s not if you get hurt, it’s WHEN

During my gap year between undergrad and vet school, I worked full time at a small animal clinic. Aside from gaining more small animal veterinary experience, the other profound thing I learned was that indoor, general small animal practice is not for me. Any ideas I was entertaining about possibly going into small animal were put to rest. Enjoyed working with the clients, dogs and cats…but an exam room/office job environment is not what I wake up looking forward to doing. I’ll take the pick-up, traffic and McGuever-style work environment any day. 

Interestingly enough, the owner and head veterinarian had originally nestled to do equine work. He actually loved working with horses through vet school. When I asked why he ended up in small animal, his response was simply “it’s not a matter of if you get hurt, it’s a matter of when.” He went on to explain his odds are better against the 80 pound German Shepherd bite than the 1200 horse kick. And that was that, equine practice was not in the cards for him.

What he said was logical, although serious injuries and fatalities occur in both small animal and equine work environments…but you’ve got a better chance at surviving the cat scratch fever than you do the horse that double-barrels. However, it wasn’t until the last couple years that his rational has had more of an impact on me, because since then, I’ve seen various incidences of owners, technicians and veterinarians injured by horses.

The first serious incident I witnessed was my veterinarian performing an emergency examination on a horse that was down. The horse has fallen over a jump, and was refusing to get up. In his examination of the laterally recumbent horse, he moved to palpate the hind limb. The mare did not resist movement of the limb. As as my vet continued through range of motion of the distal limb, the horse suddenly recoiled her leg and then gave him a rebound kick to the face (horse shoe and all).

My vet was blown to the ground instantaneously. Think back to the YouTube we’ve all seen of the horse getting branded. One second the guy is in the camera shot, the next he’s vanished. If you haven’t seen it, searching YouTube for “horse kick” will produce it without fail.

My feet steadily got off the ground and stood up. He was profusely bleeding from a  significant laceration across his jaw. He remained composed, and calmly said “She’ll be fine.” His Technician was scrambling for her phone to call 911. My vet looked at the horse’s owner and said, “I think my jaw is broken, so I’m going to head over to the hospital.” His jaw had been fractured, required surgery and wears the Battlestar across his jaw line. The horse, on the otherhand, stood up within 20 minutes of my vet’s departure. No lameness or injuries were ever seen.

 


Occupation Injuries of Veterinarians

“You’re not a real horse person until you’ve been bucked off, stepped on, bitten and kicked. Spend enough time around horses, and it’s guaranteed to happen.” Is what one of my equestrian mentors told me years ago. I have yet to meet a serious equestrian or equine vet that has not acquired all of those badges.

The occupational dangers equine vets face has gained attention in the recent years. An article discussing Grear Britain’s study of Equine veterinarian injuries starts off with:

“You think riding horses is dangerous, try being an equine veterinarian.”

The results of BEVA’s first survery-based study were profound, with statistical data pointing to England’s equine veterinarians as the occupation carrying the highest risk of injury of any civilian occupation in the country. The study was based on surveys from 620 equine vets completed between September and November 2013. Additional key points of the study:

  • – equine vets could expect to sustain between seven and eight work-related injuries that impeded them from practicing, during a 30-year working life. 
  • – most common “serious” injuries reported:  bruising, fracture and laceration
  • – most common sites of injury: leg (29%), head (23%)
  • – main cause/action that resulted in injury: kick with hind limb (49%), strike with fore limb (11%), crush injury (5%)
  • – almost 25% of these reported injuries required hospitalization
  • – 7% of injuries resulted in loss of consciousness (!!!)
  • – head injuries were most often sustained during endoscopy of the URT, during wound management and bandage-changes
  • – almost 40% of worst injuries, vet was working on a ‘pleasure’ horse
  • – almost 50% of the time, the horse handler was the client or owner at the time of injury

the Near Miss

You can probably guess what event(s) happened today at the internship that would spark this topic of veterinarian injuries. Today, I had a near near miss…and had I been an inch more within range, I could join the ranks of traumatic head injuries, maybe even fatalities. While performing an FR abaxial nerve block, the talented mare managed to kick at my face with her hind right leg. Her hoof came so close to my head, that she brushed my bangs out of my eyes and a strand or two of my hair got caught in her shoe.

“That was a close one.” The nursing assistant said.

“Yeah.” Was all I could say as I finished the lateral abaxial. As I went to do the medial, I felt her tense and thought she was going for my head again…even though I was not position much more toward her head. Instead, she ripped her foot out from my grip. As she did so, an exposed nail head seized the opportunity to lacerated the full length of my pinky finger. I went to put on a fresh pair of gloves and the owner asked why I put the fresh glove on.

“Just so I’m not dripping blood around the hospital.” She hadn’t seen the laceration (I guess I was stoic). When I took the glove off, I could feel the pooled blood in the fingers. The owner took one look at my hand and looked horrified, but sounded impressed “You’re a tough cookie. You may lose all your blood out of your finger, but you were going to get that foot numb first!”

A Day later and the laceration looks like a contender for biggest papercut on a guniess book of world records scale. But considering how things could’ve turned out had she been 1 inch closer to my head, I’ll take the oversized papercut.


#veterinary #vetstudent #vetschool #veterinarian #vetintern #vetmed #veterinarymedicine #equine #intern #internship #horse #vet #vethospital #equinehospital #horsevet #career #newgrad #vetblog

Posted in Anecdotes, Internship, Veterinary Medicine

AbdomiNOcentensis

Although I use the AAEP post-internship competency list as a guide for establishing my clinical goals during the year long internship, it really is what I consider the “bare minimum” of acquired skills. To avoid sounding like a broken record, I’ll try to not to repeat myself too much. While I want to accomplish everything on my list, there are a few things items on the list that I’m itching to do (wish list) and some items that are critical (must have). 

I’m proficient at my PDN and abaxial blocks, but have yet to perform blocks proximal to this. Of particular interest are the low 4 point, 6 point, high four point and deep SL branch. I can take on more proximal blocks once I’m in practice, but for my internship I’m focused on the most commonly injected nerves. I have done one coffin joint injection, but have yet to do fetlock and hocks….especially hocks. I’ve also done one ultrasound guided SI joint injection. Having residents on surgery, the service that primarily sees lameness examination, means I’ve got some compete with them for hands-on experience or else get their left-overs.

Also on the “must have” skills list is the abdominocentesis. I’ve been here 5 months now, and have not been permitted to attempt them on the medicine service. Unfornately, the clinician on medicine has the philosophy that I must have done one in order to do one. And abdominocentesis opportunities have come up dry. Until this past weekend, the weekend of the emergency colics. Luckily, the resident working up the colics with me is all about teaching and helping me hone up my skillset. I have attempted an abdominocentesis once, with a horse in lateral recumbency…not at all the ideal situation for collecting peritoneal fluid. Unconventional, but yet I was successful. However, I’m not going to count that.


AbdomiNOcentesis Attempt 1

My first real effort to perform the standard abdominocentesis was this past weekend. Having not done one standing (normal), I was nervous for a good reason…there is inherent risk and the potential for complications whenever penetrating a body cavity with a needle. So, after visualizing the free peritoneal fluid (the target) to the right of midline where the abdomen extended most ventrally, a sterile prep was performed. I blocked the subcutaneous tissues and muscle at my site (far from the spleen). Then, I used a scalpel blade to make the “small abdominocentesis hole ever” which ended up being neither wide enough or deep enough. The result was extending the penetration with the scalpel and then using the teat canula to puncture through the peritoneal into the abdomen. However, I grew nervous after feeling “steady tension” but no “pop” into the abdomen. The resident lent a hand, which was literally just being more brave about applying force to the canula through the tissue. We obtained an adequate sample of normal appearing abdominal fluid. It was a good dry run, and helped establish a baseline for how much pressure to apply and how to choke up on the scalpel and the canula…a good dry run that I was not at all discouraged about.


AbdomiNOcentesis Attempt 2

Less than 24 hours later, the Colic special at the hospital was still going on. We were working on our four colic, when the resident suggested I do an abdominocentesis. This time, more rehearsed, I got my supplies out. While getting things together, the resident scanned the abdomen to confirm the ideal site where free peritoneal fluid had accumulated…and also, where the large spleen happened to be precariously placed. The resident clipped the site for me and administered the local block while I retrieved sample collection tubes and gloved up. All set.

The resident pointed out the site to me, and I repeated the routine. This time, more confident in the size of the skin incision and depth of scalpel blade insertion. So far, so good. Then, I prepared to pass the two car through the skin incision. I felt resistance and gradually applied more and more pressure until there was a very faint give or “pop.” At first, there was a drop or two of blood. “Reposition, spin the trochar…just see if you can reorient yourself.” I did this carefully, gave a subtle spin to the canula. Frank blood streamed out of the canula and pooled in front of my feet. I looked at the resident, who caught a drop of blood on her finger. “I suspect we’ve hit the spleen. It looks like frank blood. Go ahead and pull out, the abdominal fluid won’t be diagnostic anymore.”

Well shit, is what I was thinking…but not long before the overseeing owner asked. “So if it’s not going to tell us anything, do I have to pay for that?” I let the resident do the talking, and continued to bask in my second unsuccessful solo abdominocentesis attempt. Then, the worry set in about hemoabdomens and peritonitis and I wondered about doing prophylactic broad spectrum antibiotics and if I had just changed the prognosis for this horse’s recovery from colic.

So, what was supposed to be an abdominocentesis turned into a splenocentesis, which ultimately the client was not charged for. 9 pm that night, I couldn’t stop worrying about the possibility of a hemoabdomen. Instead of a sleepless night, I headed to the hospital to repeat an abdominal ultrasound.

In the end, everything turned out okay. No hemoabdomen, no septic peritonitis…and the horse ended up being discharged a couple days later with no resulting complications or incidences for the remainder of hospitalization. And perhaps the icing on top, was when the owner came to pick up the horse and comforted me with 

“Don’t worry, that’s why you’re a student.”

It was a millisecond of being offended before I had a paradigm shift. Even after I finish this internship and am no longer an intern… so long as I am a doctor, I am also a student. The learning never ends.

 


ABDOMINOCENTESIS IN THE COLIC WORK-UP

Why perform the abdominocentesis? Based on the characteristics of the peritoneal fluid, the results can be a good indicator for the necessity of surgical rather than medical intervention.

Examples of colic scenarios that would demonstrate significant changes to peritoneal fluid include:

1.  Displaced or strangulated bowel:  the peritoneal fluid can increase in volume and protein content due to lymphatic or venous obstruction.

2.  Necrotic bowel:  red cells and hemoglobin are present in the fluid due to vascular occlusion.

3.  Strangulation:  increased numbers of rbcs plus increased wbc count of the fluid.

4.  Iatrogenic, abdominal abscesses or thromboembolism:  increase in wbc and protein content without and increase in rbc/Hb.

5.  Obstruction of bowel without vascular strangulation or necrosis:  No changes in peritoneal fluid.

6.  Ruptured bowel:  increased wbcs, protein and fecal material.




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Posted in Discussion, Internship, Veterinary Medicine

The Intern Checklist

AAEP created competency lists that serve as unofficial guidelines for new graduates and interns. AAEP’s lists serve as fundamental backbones for the knowledge base and skillset proficiency expected both upon graduation from vet school and upon completion of a year long internship. By no means are the lists all-encompassing, but they have helped me develop my own list of goals and expectations I aim to achieve during the remainder of my internship. The versions of the core competency lists I found may be outdated, but they were the only ones I could get my hands on. Below, is the new graduate core competency list.

I’m close to halfway through my internship, and I just recently scanned through the internship competency list. Having been so busy with the internship, I have failed to check in with myself and assess my progress toward achieving my list of goals. While I feel like I’ve learned a lot since I started, I felt even more accomplished as I went down the list checking off each fulfilled competency. It’s the type A side of me that got the most satisfaction. Certain tasks, like performing a TTW, I have seen over 10 times but have not had the opportunity to do it myself. I’ve fulfilled a role during the procedure, but haven’t actually orchestrated it solo…so for now, those items I have not done solo and don’t feel proficient at, will remain unchecked.

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Posted in Cases, Internal Medicine, Veterinary Medicine

When Potomac Horse Fever Comes Rolling In

Having come from the other side of the country, our vet school curriculum gave  Potomac Horse Fever a fleeting glance of attention. The first case of the season presented last week, and throughout the work-up, I had that feeling of curiosity like when when you visit a place for the first time that you’ve only seen on TV or read about. It the combination of having knowledge and actually applying it in clinical context…academia meets practice. It was an exciting change from the ‘usual’ cases…the typical medicine caseload has resembled a constant trickle of RAO, gastric ulceration and corneal ulcers. 

 


 

the 1st PHF Case

My first PHF patient was a 12 year old QH mare that presented to the hospital with a 3 day history of mild colic, lethargy, fever, increasing soft manure and bilateral front limb soreness. The referring veterinarian had run a CBC that revealed a mild leukopenia of 4,600 cells. The mare had all the red flags (leukopenia, fever, diarrhea) that necessitate adherence to a stricter level of bio-security protocols and restrictions. We bypassed the hospital and went straight for the isolation ward.

On arrival, she was in good body condition and ambulated well, although bilateral front end lameness was apparent (Grade 2/5). Abnormalities found during her initial physical examination included clinical dehydration of 8% and digital pulses increased in the front when compared to the hind (although not bounding). Her vitals were normal, although she had received Flunixin within the last 3 hours. Aside from a mild leukopenia of 4,500 cells, the rest of her work-up included normal rectal palpation, normal ultrasound findings and no other clinic pathology abnormalities.

She was started on a bolus of plasmalyte (10 liters), followed by 1.5x maintenance  fluid rate (1.5 liters/hour). She was also started on oxytetracycline at 10 mg/kg as the robust initial 3 day dose. This was given in 1 liter NaCl over the course of an hour. She remained comfortable overnight, maintained a normal appetite and normal manure production.

The next morning, I palpated bounding digital pulses bilaterally on her front feet. Hoof heat was increased and with the next few hours she began shifting her weight and was very reluctant to navigate around the stall. At this point, she was started on cryotherapy (ice boots) and continued to receive the anti-endotoxic dose of Flunixin twice daily. DMSO and a butorphanol CRI were started. Even on the butorphanol CRI, she became more progressively painful with an horse Grimace score of 10/12.

Radiographs revealed no evidence of laminitis changes and we’re used to establish her baseline. It took over an hour to get radiographs of all four feet because of her extreme pain and reluctance to bare weight. Without her willing to stand on blocks to radiographs the distal phalanx, we resorted to piling up shavings so that she was 4 inches elevate from the stall floor. She would absolutely not tolerate standing on any 3 limbs, so holding each foot for radiographs wasn’t an option. Hindsight being what it is, I will perform nerve blocks in the future to help facilitate the radiographs.

The mare spiked a couple 103 fevers in the first 48 hours after presentation, but afterwards remained afebrile. Although afebrile, the concern about impending laminitis led us to continue with the ice boots on all four feet at all times. I’ve used “ice-bracelets” in the past, but this hospital utilized two empty 5 liter plasma late bags and does a “double-bag” technique. The outer bag contains the ice and is finest rated to facilitate drainage while the inner bag is intimately against the foot and sealed to prevent the foot from endless soaking. Although the double-bag technique is used hospital-wide, there exists some controversy over the method of securing the bag. Some clinician’s prefer to use 2 inch white tape around the top of the bag (at the level of the distal metacarpal/metatarsal) while others insist on creating a purse-string with umbilical tape passing through holes (similar concept to tying shoes with shoelace holes and shoelaces).

Over the next couple days, the mare deteriorated systemically and repeat radiographs revealed sinking and rotation. Due to concerns about quality of life, the euthanasia was elected. The mare had recently come from the Midwest and was not vaccinated for PHF.


 

the PHF Dam

Within  a couple hours have euthanizing my first patient, I heard the pager sounds echoing through the hospital in sequence. My pager eventually went off (it awkwardly goes off 45-60 seconds after everyone elses’).

ER PHF to arrive in 1 hour.

The second PHF case arrived in stable condition, with no foot soreness and having already been on Oxytetracycline for 3 days. As a precaution, the trainer wanted the horse medically managed in hospital. It was during the middle of this workup that we received another hospital alert

Adult horse with suspect PHF ETA 5PM.

And as if the dam holding back PHF had broken, we had 5 more PHF cases present to the hospital over the course of 3 days. Fevers of unknown origin, foot soreness with colicky signs…everything was starting to look like PHF. It also happened to be the summer storm-a-thon. Like a torrential downpour, or the monsoons in Arizona, we received a whiplash in the form of PHF. As the PHF novelty gradually wore off, the idea of a RAO work-up, gastroscopy appointment or corneal ulcer assessment gradually gain appeal.

 

For those interested, below is the abstract of a peer-reviewed article about the use of cryotherapy in an attempt to reduce clinical development and presentation of laminitis.

 


Prophylactic digital cryotherapy is associated with decreased incidence of laminitis in horses diagnosed with colitis

A. Kullmann1, S. J. Holcombe1,*, S. D. Hurcombe3, H. A. Roessner1, J. G. Hauptman2, R. J. Geor1 andJ. Belknap3. DOI: 10.1111/evj.12156

Summary: Recent research suggested that prophylactic digital cryotherapy (ICE) improved lameness scores, diminished histological changes and early laminar inflammatory signalling in horses following oligofructose administration. In clinical practice, horses at risk for sepsis-associated laminitis receive ICE. Evidence to support this practice is lacking.

Methods: Medical records for horses admitted to 2 university hospitals diagnosed with colitis with evidence of systemic inflammatory response from 2002 to 2012 were reviewed. Horses were excluded if they exhibited signs of laminitis at admission, were ponies, miniature or draught breeds, or <2 years old. Data were analysed using univariate and multivariate logistic regression.

Results: Twenty-seven of 130 horses (21%) developed laminitis. Seven of 69 (10%) horses treated with ICE developed laminitis compared with 20/61 (33%) horses that developed laminitis but did not receive ICE. Factors associated with laminitis included site of hospitalisation, admission respiratory rate and blood L-lactate, and ICE, P<0.05. Horses treated with ICE had 10 times less odds of developing laminitis compared with horses treated without ICE (odds ratio 0.11, 95% confidence limit 0.03–0.44). Sixteen horses (16/130, 12%) were subjected to euthanasia in hospital. Fourteen of these horses had laminitis and 2 did not develop laminitis. Survival for horses with colitis that developed laminitis was 13/27 (48%) compared with survival for horses with colitis that did not develop laminitis, 101/103 (98%).

Conclusion: Laminitis occurred in more clinically compromised horses. Use of ICE reduced the incidence of clinical laminitis in the study population suggesting that digital cryotherapy is an effective prophylactic strategy for the prevention of laminitis in horses with colitis.


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