Monday, November 28, 2011

More Nicknames...

You know how many people have the habit of calling people "Big" and "Little" whatever their name is when referring to a father and son or something of the sort? It struck me this weekend that I have a couple of Big-Little pairs in my household.

First is Big Stubborn, aka Sam.

Then Little Stubborn, aka Peanut.

And we have Big Chicken, aka Flower.

And Little Chicken, aka Scout.

Fits all too well...

Wednesday, November 23, 2011

Complaints Again

Apologies, folks. I've had plenty of good fodder for the blog but have been kinda blah and just a bit stressed so have not taken the time to write lately. Can't Spell has been properly threatened but has failed to respond. Alas, I guess I'll have to pull out the good ol' super glue, vaseline, balloons, etc. next time we're in contact and come up with some horrid practical joke for her...

What to talk about amongst the craziness that has been life lately? First I think I'll tell about my funnest ever surgery from last week. I love reconstructive stuff. That and exploratories are my all-time favorites. We had a young pit bull puppy that was brought in by a local rescue group for a wound on his leg that they had been told was caused by accidentally spilling liquid Draino on the leg. The wound was about the size of my hand (6.5 surgery glove) on the lateral aspect of the thigh. It was actually granulating in nicely at the first visit then the scar tissue contracted to a point that it was significantly restricting the range of motion. I started out with hopes of doing a simple Z-plasty on the caudal stifle area to free up the motion then discovered that the scar tissue was so extensive that it involved all of the underlying fascia and much of the muscle bellies. I wound up resecting the entire wound and approximately 3/4 inch thick scar tissue beneath it in order to restore range of motion to near normal. Then I used multiple flap grafts and relaxing incisions to close the defect. It turned out so pretty and I had a blast. Not surprisingly, a small portion in the middle has dehisced but the range of motion is great and I would rather maintain that and sacrifice the skin. I've had them working him pretty hard already and will see him back in one more week for a second surgery to repair the remaining defect. I can't wait!! That's the fun part...

Today, Dr. C struck again. Ancient old poodle with an abscessed upper fourth pre-molar. I anesthetized her and did an almost full mouth extraction only to discover a disturbing black mass associated with the abscessed tooth. Ten to one it's melanoma. Bad, bad, bad.

And there was the depressing dog fight. Two dogs jumped the third dog and chewed her up pretty good although the wounds were all relatively superficial. We first saw her a week ago from last Friday. She was shocky and we treated her with IV fluids, antibiotics, debrided the wounds and partially closed the worst / deepest one. By Tuesday, she was doing great, eating, drinking, wagging her tail and all perky. By Friday, she was kinda dumpy and not eating well. Saw her back and performed blood work which showed that she was moderately dehydrated and had a low protein level. Big shocker there with those wounds. Debrided some more dead tissue, gave her some fluids and something for nausea (in case antibiotics were bothering her stomach) then allowed her to go home. The owner's husband had a prostatic biopsy that day then subsequently had to return to the hospital after collapsing. He required a blood transfusion and an ICU stay through the night... Spoke to the owner repeatedly on Saturday; dog was still kinda dumpy and not eating but hadn't really changed much. Offered hospitalization or to continue at home; they opted to wait and bring her on Sunday due to some difficulties with the husband, etc. I advised that I was on my way out of town and they needed to talk to my boss. Later the dog suddenly started breathing heavily then collapsed with clear fluid coming from her mouth. My guess is that she must have thrown a clot to her lungs. It happened very quickly. Even if she had been in the hospital, really nothing I could have done. It doesn't stop me from being self-critical about the situation, though.

Mom is up to the usual mess right now. We heard from my crazy druggie brother and sister-in-law the other day. I'm constantly amazed that someone can be nearly 70 years old and still so naive. Mom listens to his story and immediately realizes the sister-in-law is back on something but fails to spot it in my brother although to me it was equally obvious. They, of course, wanted money. Like that's a new thing. And they, of course, are still unwilling to go into a rehab program. And mom is still adamantly refusing to go to the doctor for her issues. She gets angry when I suggest it for any reason and believes that any medication that might be available would cause worse side-effects than any help it could provide.

She was particularly challenging over the past couple of weeks. She's in the process of finally retiring at the end of the month and most of her sick leave has been rolled over to add to retirement time. The few remaining days she has been trying to use up. We had been planning for months to go to Huntsville and hear David Jeremiah speak so I had suggested she take that day off which she agreed was a good idea. She then randomly took a different day off and worked on that one. The following week, I had suggested taking a Thursday off for a day trip which she agreed to do then did not then got mad that I did not want to leave at noon for a 2.5 hour one way trip... That was also the day that she got mad because I didn't immediately fix tuna salad for her to eat and went to bed without eating like a pouting child. I ask you this, how hard is it to open a can of tuna? Lately, though, if I don't cook or fix something healthy, all she will eat is sweets and candy.

I visited a friend of mine this past weekend that I've not seen in a long time and she pointed out something that I've lost sight of (you know, can't see the forest for the trees). If I want to do something more with my career, I probably should try to figure out which direction to take now rather than waiting because mom's only going to get worse with time and it's only going to get harder to go further. Now I just need to assess things a little more objectively and decide what I want to do because I'm really not happy with where I am at right now.

That's a hard thing to say. I really like my boss as a person but I hate the quality of medicine I'm stuck practicing. He refuses to move out of the dark ages although I have managed to get him to think a little more about things. He has become really money motivated; he wasn't that bad when I knew him previously. I got really PO'd at him about the stray animals he took in then wouldn't discount much at all for the spays / neuters. My confession is that I spayed and neutered all of them over the weekend while he was out of town. Ever since I feel somewhat guilty because I hate lies and am always criticizing him for his untruths and now I've been untruthful and deceived him... Do I have the right to continue to criticize when I've also not been honest?

And I really wish he would at least listen! I never realized quite how controlling he is until now. I guess the different capacity has changed my perspective. For instance, the fun surgery I told about while ago came in Monday and he saw it for the dehiscence. He told them that the wound had so much tension that it was not surprising it dehisced. No, it was not surprising but it was not under tension; it was because we chose to exercise and preserve range of motion. Or the other day he told an owner that tramadol would do nothing for arthritis pain (I had started the dog on tramadol for its arthritis and avoided NSAID's because of age and the fact that the owner had been giving Motrin (!) so I figured a good washout would be indicated before adding a different (safer!) NSAID.) Since I'm managing no less than 5 of my personal dogs' arthritis issues on a daily basis primarily with tramadol I think I probably have a greater grasp of its capabilities. And further, since he comes from the generation of "let them hurt a little so they don't move too much" I think I have a greater grasp of pain control in general. He scares me with the way he'll randomly give steroids and NSAID's, especially to older patients with no blood work. Or just pop a little dose of gentamicin here and there... The sad thing is that he doesn't really mean to throw me under the bus or do bad medicine; he just hasn't bothered to stay updated or to think about the fact that he is no longer the only doctor in the practice.

I have to admit that there is a part of me that still longs for the residency but I don't think it is really feasible. So, time to try to be really objective and make some decisions about life. For now, I think I'll end my complaint session because I'm bushed. Hope everyone has a wonderful Thanksgiving. Will try to post again sooner and will definitely work on Can't Spell. Hope she's prepared for our next visit even if it doesn't happen until April...

Thursday, November 3, 2011

Still Alive, Not in Jail - But it was a close call...

Oh my. What a day was yesterday. I'm not sure if I can tell everything without this becoming a book but I'm gonna try...

I woke up all dizzy and vestibular because of the weather changes and had not slept well due to fever and chills related to my recurrent ear issues. Needless to say, this started the day out wrong. Had to take some Meclizine to function thus adding another factor for less than normal function of the brain which feels as if it is already deteriorating. I walked in to a patient of mine having arrested. It was an older dog that I had seen recently who seemed to be doing well other than having a urinary tract infection. Because of her age, I had recommended routine blood work be performed. It came back with moderately elevated liver enzymes and total bilirubin therefore I recommended an ultrasound to look for tumors, etc. The owner had planned to schedule that next week. The dog then developed respiratory distress early Wednesday morning and arrested shortly after arriving at the clinic while the boss was working on her. She had severe pleural effusion and on necropsy I'd bet it was lymphoma in the liver that metastasized to the lungs. Not a good way to start the day at work.

There wasn't all that much scheduled in the surgery area, only 5, and mostly "routine stuff."
That being said, y'all know how non-routine routine stuff can go on a bad day. The cat spay, which I can usually be done with in 10-15 minutes was like trying to bleed a turnip for pre-anesthetic blood work as well as induction plus the cat was freaking out and hard to hold. One of my talents is that I'm really good at handling cats. Unfortunately, I'm the only person in the clinic who is. Had there been someone else available to do the venipuncture, I would have readily swapped places and restrained the cat. The spay, of course, did not go smoothly either. The hemostat holding the ovarian pedicle was crap and almost caused a dropped pedicle, the uterine body tried to tear, the needle pulled off the suture, etc. You get the picture. The two dog spays kind of went in the same direction. I really want to perform a scientific study to prove that white dogs truly bleed more. The white Boxer was a bloody mess and there was no logical reason that I could offer; no dropped pedicles, no torn vessels other than normal, nothing, but she looked as if I bathed her abdomen in blood.

Then there was the preputial surgery. Little dog whose penis protrudes and gets stuck to the haired skin causing it to roll inward and trap the penis. This is the second time I've worked on it with the first procedure helping but not quite eliminating the problem. Relatively speaking, this one went smoothly but with the number of penis / preputial procedures I've been doing lately I'm thinking I should "specialize." The other procedure was to removed a wire from the mandible of a dog who had an old fracture and the wire had developed a draining tract. Unfortunately, the bone had not fused but it was already unstable with the wire in place. Of course, that turned into a lengthy, bloody mess because the wire had apparently broken at some point. I'm pretty positive I did not break it since it pulled easily but there was a piece left that I had to dig out. I don't like wiring mandibles; I like using acrylic much better. It's probably very expensive though, which is likely one reason most private practitioners don't use it.

I put off the last surgery for just a little bit and ran over the hill to the grocery store and to pick up lunch for a change. Wish I hadn't. I know to be really careful about eating out with all of my crazy food allergies and thought I had picked something safe. Didn't turn out that way. Unfortunately, I had not brought lunch because I was feeling yuck and running late; I didn't even have cheese to nibble...

I had planned to do the last sneak in procedure during lunch. I say sneak procedure because it is a little dog that we have inherited and one of the kids fell in love with, planning to adopt. Maybe I'm wrong in my views, but I do not think that it is right to charge employees for our time. For drugs used, food, materials, etc. at a discount, sure, but not for our time. There should be some perks to working at a vet clinic; especially where the pay is not good. Because my boss does not agree, I admit that I'm deceptive and sometimes slip things like that in while he's out of the office. With my craziness, I feel guilty about it all at the same time of being convinced it's important. Problem is that I criticize him all the time for "little white lies" that I disagree with so I have to self-criticize that I'm doing the same thing. Rabbit trail alert! Am I expecting too much from him to be more truthful? I hate the way he (like many others) goes to CE meetings, takes full credit, but didn't actually attend all the lectures he claims. Or his willingness to alter numbers on the drug log when there is an entry that he forgot to write down. Or the way he sometimes just lets things slide when talking to clients; not an outright lie but a lie of omission. But I'm doing the same thing to him, aren't I? It's hard having a strict conscience.

Back to the sneak procedure. We weren't sure if the dog was spayed and she really needed a dental. Unfortunately, the crazies started showing up early and it was one demand on my time after another. People who the boss had talked to or left phone messages for came to pick up their pets but, of course, had 1001 questions that needed to be answered by me. Decided to pre-med since there was a break that should be long enough to get things done. Saw the first afternoon appointment. I felt like I was back in New York. The first thing out of the lady's mouth was where is Dr. --? I explained that he was out and who I was. She barely consented to allow me to cut her dog's nails. After that, I quickly explored the other little dog; she was spayed (thanks to one of my teachers for showing me how to find out fast without a lot of mucking around as I've seen some vets do which makes determining a dog is already spayed take longer than actually spaying it) and we did her dental. I also pushed the new owner into a microchip while she was snoozing since the dog hates needles so much.

After that, the one appointment on the books became something like 15. It was a day characterized by minor crap that took 5 times as long as it should. Cat with miliary eczema; owner was nice but full of questions and was the second most sane person I saw all afternoon. A dog who might need a nail trim but, oh by the way, if you want to listen to his heart feel free. A chicken rushed in as an emergency broken leg; I had talked to the pseudo-owner ("It's my neighbor's chicken!") the day before. The lady who I've known for years with 45 minutes plus of conversation trying to decide if it is time to euthanize her dog. Please don't misunderstand on this one; I have no problem taking that much time to discuss an important decision but the problem with this lady is that she cannot decide anything for herself. My interpretation is that she is tired of the care needed for a geriatric pet but feels guilty euthanizing for that reason alone therefore wants me to decide for her that it is the best thing for the pet (not her, mind you.) I can't make that decision for her and, knowing how I feel about geriatrics, I'm sure y'all understand why I'm not going to advise her to euthanize unless the dog really deteriorates.

Then there was the cat who needed sutures removed from her entropion repair. That would have been quick and easy and I like her owners, they are very nice. What made it time consuming was that they are the same people who owned the dog that started the day... Needless to say, they had questions.

Even a simple rabies only with exam took way longer than it should have. The owners all wanted to chit chat yesterday. I felt like the psychiatrist role that we often have to play was taken to the extreme, all the while I was walking in a daze myself with the medications, allergic reaction, and already feeling yuck.

Between appointments, I talked to a lady who couldn't understand that her account ages the unpaid balance and applies any payment to the oldest charges. She sees it as picking up medication, paying for it that day, and it should not show up on her bill. I tried explaining every way I could and she only got more upset. Then when I had to excuse myself to see patients, she got more upset. Guess the boss will enjoy that one today...

I have yet another febrile cat with elevated liver enzymes. What is up with that?? It's like a rash outbreak and I still have had no one willing to let me go far enough for an actual diagnosis. That owner called over and over during the craziness and, of course, my help can't seem to handle telling her that I'll call her back after-hours because we were so busy. And the help contributed to the stress level. The one worker who usually does the best job made me crazy yesterday. She wouldn't restrain appropriately no matter what I said. The aforementioned cat was dehydrated and trying to place an IV catheter plus pull blood turned into a joke. The catheter happened; blood was very difficult to obtain and I only got a tiny sample. I handed it off to her and she promptly used all that was there to run the wrong test; not what I had asked for at all. At the end of the day, I tried one more time to get blood with the same results. Hopefully, the boss can get some more today for the rest of the testing. The girl also spent most of her time going into the rooms ahead of me on things that she really couldn't do much with then chatting with the owners. Every time I needed a set of hands, they were nowhere to be found. I wasted so much time looking for someone to restrain or take pets to the front, etc. yesterday it's not even funny.

Still I have not managed to get the girl up front to understand that I need a chart, a patient record for each individual, and something actually written on the chart to tell me who I'm seeing and why on EVERY SINGLE PATIENT. I'm about ready to strangle her. At the end of the day, I discovered (this was not the only one, just the final straw) that there was no chart pulled for the chicken. I guess since it's only a chicken it doesn't count.

The last appointment was a very large German Shepherd who has had infrequent, mild seizures for a couple of years. He has not been on medication and, like most of our clients, had no desire to go for an MRI to confirm there was nothing else present. He had a long, severe seizure overnight and was still showing significant post-ictal signs including blindness and the inability to ambulate, eat, or drink. I hospitalized the dog and was attempting to place and IV catheter and get blood. With two people holding, he still managed to kick and go crazy with us winding up with blood all over us, the room, and the dog. At least I also got some in the tube. I also got an IV catheter in place. Then I discovered we had no more fluids and our order had not arrived. It was too late to arrange a loan from another clinic. Wonderful.

By that time, I was so frustrated and aggravated with the whole day and with my help that when they wanted to know if there was anything else they should do and could they go home I just felt like yelling "Get the hell out of my hair NOW!!!" They left and did not do some of the things that they should have but I just didn't have the ability to calmly find and point out what they could do. Good grief; they are adults, can't they look around and figure out what is left to do?

I wound up being at the clinic until almost 8 finishing up all the stuff that was left over both by me and them. While I realize it's not necessarily a good thing, it was easier to just do it myself. Yet another reason I don't need kids. That I did not yell at anyone or pull out some weapon and just go ballistic is a miracle in and of itself. I have rarely been so happy to leave a place at the end of the day and so glad to have a day off. Hopefully I can recuperate enough to face it again tomorrow.