Tuesday, December 16, 2008

Brownie Points

I frequently give out "brownie points" to my technicians (and sometimes my fellow doctors) at work. These aren't anything that I keep track of, much less remember from day to day who I've even given them too.

Sometimes it comes in the form of, "brownie points to whoever can tell me where I left this chart", or "brownie points if you come up with a good treatment plan for this patient".

Other times I give them out more as recognition that someone took the initiative to do something less than pleasant. Someone was going to have to do it anyways, but it's nice when someone does it cheerfully and quickly. For example, "you gave him a bath after he danced in diarrhea?!?! glad it wasn't me, you get brownie points!!"

Yesterday I made a big batch of oatmeal chocolate chip cookies, and today I brought them into work to share. I told everyone that if they needed an excuse to eat cookies (as many of us generally do), they could tell themselves that they were redeeming their brownie points!

Maybe next time I'll make real brownies - I even have a recipe bookmarked for one that includes ingredients I have in the house!

Monday, December 15, 2008

My First CCL

First time for everything - and today it was an cranial cruciate ligament tear in a 90-pound 5-year-old yellow Labrador Retriever.

She was the perfect candidate for the tear, and I had diagnosed her after seeing her for a mere 5 or 10 seconds in the lobby. She bounced towards me, completely non-weight bearing on her left hind leg. I asked her to sit for me like a good girl, and when she did she flipped that knee right out, refusing to put it where it belonged. Classic. I informed her that her daddy and I had a very expensive discussion to have, and invited him into the exam room.

She had all the right history, she was out hunting (her collar read "forever pheasants") on Friday, and she came up lame all of the sudden. She wanted to keep hunting. Dad kept her quiet for the weekend, but she just didn't spring back by this morning. Her knee was lax and swollen, but everything else about her looked great.

We took x-rays, I checked with my boss (the TPLO guy), and went in to deliver the damage to the poor owner. $200 for today's visit. ~$2000 to do the surgery here. ~$2800-3100 to do it at the U. He's gonna call me back to let me know where he wants to do the surgery - all he wants is for her to be able to hunt again.

I think they would both be devastated if she couldn't.

Saturday, December 13, 2008

The pyo that took a month

I first saw her, S, for drinking more water. She was a 9 year old Chow crossbreed dog. She had never been spayed, but otherwise was kept well by a young man without too much money to spare. After careful interrogation, I determined that there was really nothing at all wrong with her other than she had quadrupled her water intake in the past week or so.

As any good new grad would, I looked in my brain for the most obvious things. An older intact female who was at the very least PD (polydypsic) - obviously it was a pyometra, or an infected pus-filled uterus. Other options for polydypsia included kidney disease, urinary tract infection and kidney disease. X-rays at our clinic are $150, a CBC and chemistry profile is $110, and a urinalysis plus culture is about $120. Due to the financial constraints of this situation, I had to go with the most likely causes of disease. She was acting totally normally, and her temperature was normal. She had no pain in her abdomen, no vaginal discharge and I had no reason other than instinct to order abdominal radiographs.

Her urinalysis was normal, although her specific gravity was a little lower than I would have hoped. Her urine culture was negative. I did manage to convince her owner to run bloodwork when she was just not acting well a couple of days later. Because I was still curious about pyometra, I did a vaginal swab (negative) and an abdominal tap (negative). The bloodwork came back with a mild mature neutrophilia, a mild non-regenerative anemia (anemia of chronic disease), and a completely normal profile.

I didn't treat S with anything at that time. I explained the symptoms of pyometra as a surgical emergency, gave him directions to the e-clinic and sent him on his way. I didn't hear back from him for almost a month.

She appeared back on my schedule about a month later, unexpectedly. The appointment book said that she was not eating and that she had lost some weight. When she came in, I immediately noticed a couple of things. First, she had obviously lost a significant amount of weight, about 10 pounds. Second, she smelled awful! I lifted her tail to take her temperature, and asked if she had been having any diarrhea. Her hind end was coated in fetid material. Her owner denied any abnormal stools.

I pretty much didn't give the owner a choice at this point, we were going to do some x-rays (the last thing on my original 'want list'). We took her in the back and gave her a butt bath, and clipped some of the matted fur. X-rays were pretty clear - a grossly distended uterus. I again did an abdominal tap - this time easily acquiring 3cc of bloody purulent fluid. It then clicked on what the "diarrhea" was - it was pus, resulting from an open pyometra.

An open pyo was definately preferred, as it was about 5pm and the last thing I wanted was emergency surgery. I gave him the estimate and prepped her by giving a shot of antibiotics and a liter of fluids subcutaneously. He was scheduled the next morning to drop her off for surgery.

Surgery, like almost nothing else in this case, went textbook perfect. I had a vet student with me, and she had fun scrubbing in and helping me out. She was bright, alert and eating the next morning. More than she'd eaten in a long time. She went home that afternoon on antibiotics.

A week later her owner was pleased to report that she was bright, alert and eating normally again. Success! Score one for intuition. :)

Friday, December 12, 2008

New Directions

This blog needs to change direction I guess. I graduated from vet school this past spring and am now working at a 3.5 doctor practice in a moderately affluent neighborhood.

To sum up: I received my masters in public health in september of 2007 and my doctors of veterinary medicine in may of 2008. I took 3 weeks off and started full time at this small animal practice. Another new grad started with me at the same time, and the last full-time doctor has been practicing for about 15 years. The clinic owner has been in practice for about 10 years, and splits his time pretty evenly between the two practices that he owns.

Once the first 8 or 10 weeks had passed, I started seeing very few new things. I quickly became proficient at the everyday things: vaccinations, ear infections, acute and chronic vomiting and diarrhea, kidney disease, food allergies, etc. Even the things that I have come to think of as routine can be unique and interesting depending on the client and patient. Seeing these things frequently means that I have become more adept at diagnosing them and have perfected my "speil" that I give while explaining the diagnosis and treatment process it has also enabled me to better explain to clients the specific challences and difficulties that they may face while following through with the course of treatment.

But, as usual, it's the new and different things that keeps things fun and interesting for me. Last week I did two surgeries that I had never done before, both reproductive. The first was a pyometra (infected uterus) which has a story that almost deserves its own post. The second was a cryptorchid (retained testicle) cat. Both went off without a hitch, and I'm very proud of myself.

In the meantime, I'll try to keep my eye out for fun and interesting cases and post about them more often. Also, some housekeeping around the website to update some of the blogs that I follow.