Saturday, May 12, 2012

People never cease to amaze me...

Just thought I would offer this update to the previous post. The folks with the diabetic cat came in yesterday about 15 minutes before closing with the complaint that the cat still was not eating. I was pretty pissy until we started talking and I found out that the anti-nausea injection I had given worked wonders and she had only stopped eating again that morning. Then, poof, they dropped the bombshell. Complete turnaround. Now they are willing to try insulin. Go figure. Sometimes allowing people to stew in their own juice is more effective than using a battering ram...

Thursday, May 10, 2012

Shameless Promotional Preview

Just an update on my publication attempts.  I have finished Volume 1 of my cartoons and am in the process of self-publishing.  This is the cover image.  I am still finishing the editing process but hope to have the volume available by mid-July at the latest.  For those of you who have been privy to the cartoons, there are several brand new, never before seen images included with many of the older ones.  This volume primarily deals with the time spent actually in vet school but certainly has forays into my chocolate obsessions and such.  I'll update when it is actually available then begin to shamelessly encourage y'all to spend money...

Ye Day of SNAFU

Yesterday was a day filled with a series of SNAFU’s.  I don’t know why there are days like that on occasion.  You know, those where no matter how hard you try, nothing, not even the “routine procedures” can possibly go right.

I won’t relate every incident but I am going to tell about the ones that stick out in my mind the most.  I feel a little guilty that this post is on the negative side but...such is the way life goes sometimes.

Most surgery days I spend the morning in the OR and my boss sees appointments.  This arrangement just kinda fell into place without much discussion.  We sometimes flip a coin to see who will cut emergency cases and sometimes he decides he wants to cut something but that is not the routine.  Occasionally, I spend all day in the OR if the surgery load is really heavy although we keep one day lighter since my boss typically takes Wednesday afternoons off for golfing, that legal and politically correct four letter word.

Yesterday should have been his afternoon off but between the fact that it was raining and therefore not conducive to golfing and that he had multiple ear trims scheduled (I don’t do that surgery) it was not to be.  I had a spay scheduled that has a mild heart issue that we had already worked up and that was the only surgery scheduled besides the ears.  End result was that I was seeing appointments most of the day while he did the ears.

The first “fun” clients were the couple who, might I say at the start, do NOT have financial constraints that brought in their middle aged obese female cat who stopped eating.  I kept her to perform blood work, etc. rather than trying to speed diagnose in between a very full appointment schedule.  Long story short, the cat is diabetic.  Her glucose levels were far from the worst I’ve ever seen but definitely diabetic.

Diabetic cats are not equivalent to diabetic dogs.  Cats can go into complete remission.  Some cats can be managed on once daily insulin rather than twice daily.  And there are even a few cats that can be managed on diet alone (prescription diets available through Hill’s and Purina) or with the addition of oral hypoglycemics (although dosing can be difficult if you don’t have a compounding pharmacy available).  Dogs, on the other hand, are pretty much universally insulin dependent and rarely can be fully regulated on once daily dosing.  There’s my brief educational rabbit trail for the day without going into crazy pathophysiologic detail:)

I called the owners and explained the diagnosis and that I wanted to start their cat on a prescription diet and insulin.  The owner stated that she was nervous about needles so I explained about the size of the syringe / needle and encouraged her to let me show her when she picked up her cat.  She seemed open to the idea and both she and her husband came by about half an hour later.  I walked into the room with the cat and my demo needle.  Both people stood with their arms crossed and avoided my eyes.  I started by showing the syringe and explaining how the injection was given.  I then uncapped the needle to show them how tiny it is.  During this time, both gave the impression they were ignoring me.  When I uncapped the needle, the husband interrupted my comments to say, “We won’t be doing this.”  They wouldn’t allow any further discussion.  I got very blunt and told them that while we can try food +/- oral hypoglycemics, we very likely will be facing the decision of euthanasia either due to worsening diabetes or fatty liver if the cat doesn’t start eating again.  They really didn’t seem to listen but did take the food and the cat home.  I shudder to think where this will go since I really wanted to keep the cat and start insulin and make sure she would eat before discharge...

By the way, I should add that the owner in the previous post that I discussed the hyperthyroid cat has agreed to try to new Y/D food that Hill’s has developed.  It was the usual awesome conversation though, as he first said he could feed the cat separately but when given details on the food suddenly became reluctant.  You just can’t please people.

Then there is the Lab who is on a rather high dose of prednisone and has been for quite some time for chronic atopy.  She’s an older dog and her owner wanted her checked over because she’s polyuric, polydipsic, polyphagic, and panting a lot.  Oh, by the way, I don’t want blood work or anything.  I recommended that we minimally decrease the pred dose and strongly recommended blood work.  She decided she would prefer to talk to my boss on a day when he was available.

Lately I’ve had a burst of fibrosarcomas in cats.  Unfortunately, one that had dirty margins but was doing very well with no evidence of recurrence came in yesterday with a tiny nodule.  She got added to the surgery list because when the first mass appeared it quadrupled in size in less than a week.  Another random educational rabbit trail...I know that the actual percentage of cats with vaccine related fibrosarcomas is fairly small but the reality is that it occurs and, as a good friend of mine expresses statistical information, when it is your pet, the reality is that it is either 0 or 100%.  Most likely this cat’s fibrosarcoma is due to vaccination several years ago at a different vet.  The owner stated that the vet always gave the vaccines between the shoulder blades.  After surgery yesterday, I simply have no more tissue that can be removed.  The owner can’t afford radiation +/- chemotherapy therefore if the tumor returns again, we can only keep the cat comfortable then euthanize when the time comes.  The standard of care is that vaccines should be given in the base of the tail or very distally on the limbs so that an amputation (therefore hopefully complete excision) can be done if a tumor occurs.  This discourse is NOT  intended to discourage vaccination.  Vaccines are important.  It is just that vaccination, like any other aspect of medicine, needs to be done in an intelligent manner weighing risk to benefit and making it as safe as possible.

I also saw a rather anxious cat for vaccinations who, per the owner, is quite aggressive.  We were discussing behavior issues and how anxiety can be a trigger for aggression and made a plan to treat the cat.  Things were going quite smoothly as I did an examination and trimmed the nails until the dogs in the waiting room let loose and he turned around and almost nailed my hand.  Good thing I have well trained reflexes, he got me a little but nowhere near as badly as he intended.  I had to get help to finish because at that point he was out of kitty minutes and figured anything that touched him might be dangerous.

The rest of the morning appointments I’m sad to say kinda just blur together as primarily skin / allergy issues that all wanted a magic cure as explained in the previous post.  Lunch time arrived and I found that my boss had not finished with his ear trims.  I’m not real sure what he expected but I got the impression he thought I was going to do my two surgeries through my lunch break and then he could come back and do his last ear trim while I saw the rest of the day’s appointments.  I’m learning to take better care of myself.  It’s still a struggle but I’m doing a lot better.  I went ahead and removed the fibrosarcoma then left for my break during which I go to the park and walk.  As I walked out the door, a man came in with a dog; I pretended I did not see.

Apparently, the guy was a “good friend of Doc’s” and called him on his cell phone when he was told there was no doctor in the office to give his dog its “allergy shot” i.e. steroid.  My boss then came in and did it even though it was lunch hour and clearly not a life and death emergency.  He then pre-medicated his ear trim but still hadn’t started on it when I returned 45 minutes later.  I started the afternoon appointments which had a bright spot in the County Drug Task Force dog that came for his vaccines.  I typically enjoy these appointments as long as the handler is good and this dog I particularly like.  He’s just a lot of fun and so easy to deal with plus his handler is super caring and nice.  The afternoon went downhill from there.

Next up was an appointment time set to see some drug reps.  Myself and the tech were there at the beginning and it was actually an interesting dialogue.  About 15-20 minutes in, my boss joined us, having finally finished the last ear trim.  He almost immediately became belligerent which is totally unlike him.  Of course, too, it was about something that he missed in the first few minutes of the spiel.  We finally got finished and I was thinking, at last, I’ll get the spay done (this was nearing 4:00p.m., by the way).

Nothing about the spay went right.  First, her veins were crappy and getting an IV  catheter placed was a huge challenge.  Finally got that done then induced her and intubated her.  This is an example of why so many of us are control freaks and hate to delegate.  Someone else intubated and I don’t know if it just wasn’t in place from the beginning or if it got pulled somehow between prepping and moving to the OR.  In any case, I had entered the abdomen and was about to clamp the first ovary, the dog suddenly did one of those waking up pushes where most of the intestines come out and hit the clamp and tore the pedicle (this was a middle aged dog just coming out of heat with all the implications therein).  So now I’m working with a dog with a heart problem, a bleeding pedicle, trying to wake up and jump off the table, guts all out in my way and a fairly small (typical) spay incision allowing no extra room to search for the bleeding pedicle.  In addition, two of our staff were angry with each other and not helping each other or doing their own jobs therefore trying to pull my technician away...

I’ll relieve the anxiety rather than making you relive the moments with me and state that the dog is fine.  It was very tense for a bit though while she got re-intubated while on her back, given more drugs and finally was actually asleep again.  Yes, this is indeed one of the reasons I’m such a control freak.  At least if I had intubated and the same thing happened, I’d know for sure it was or wasn’t correct at the beginning therefore who or what to blame.

I had a screaming fit and relieved some of my tension at the staff members because their behavior was helping to endanger my patient by causing my technician to be yanked in so many directions.  My hands were shaking very badly at the end which is very typical of me after severe stress.  This makes me dread next Tuesday when someone stupidly added several ear trims on top of an already full surgery schedule...  We rarely do this many, usually they are few and far between, but a breeder is having the whole litter done.

My boss saw the remaining appointments while I spayed the dog which took 2-3 times longer than normal because of all the problems.  He was grumpy about it, too.  He was probably pouting because by then the weather had cleared but he couldn’t leave to golf.

When I finally left yesterday, I was beat.  All I really wanted to do was collapse.  In fact, inertia had set in as I made phone calls and finished paperwork to the point that I almost fell asleep at the desk on the uncomfortable chair.  I probably would have fallen in the floor had that actually happened.  Might have added entertainment to the morning, though.  Thankfully, I have today off to recuperate before the fun begins again tomorrow!