Bad news

This post exactly details how to give bad news. I remember one case where I diagnosed a relatively benign form of skin cancer in a French bulldog and the owner went absolutely apeshit crazy. As had as I tried, I was not able to get all 6 steps in, although I tried my hardest. What would you want?

Hello, is the light on?

The new hospital is not yet busy. But in a way that's good, because we are all figuring out the computer system, thinking of ways to promote the business, and writing protocols and discharge instructions like nobody's business. My contribution, no surprise, will likely be to start an educational blog.

No I won't be linking to it here. Then I can't pretend to be semi-anonymous.

We're also thinking of making a facebook page, offer first aid classes, sending in articles to local newspapers, offering to do a radio show for a local station, handing out business magnets at local dog parks, visiting potential referring veterinarians, and talking up the place to pet supply stores.

Any ideas you have to help get our name out there would be much appreciated.

In other news, this weekend I start the dreaded yet exciting residency interview bonanza. Yep, as planned, I will be travelling what feels like everywhere to see if the places I'm applying to are right for me. And I am going to be picky.

Cranky technicians? Not going there.
Criticalists who never step foot on the hospital floor. Never going there.
Schedules which require me to be on call every night for a week. Nuh uh.
Surgery rotations where I don't get to cut because the surgery residents want all the cases. I don't think so.

No, I will only rank a place where I think I'll get the support I need, where I'll have access to the specialists and information necessary to learn all the skills and knowledge inherant to a criticalist, where I'll make enough to get by and where the cost of living isn't sky high.

Some people may say that my pickiness means I'm not dedicated to my goal of being a criticalist. To them I say hogwash. I firmly believe that advanced training in a specialty can occurr without demoralizing hours, without an environment of bitterness, without a belief that I should either sink or swim. People can become great specialists despite those hardships, but why should they have to?

Hebivore, carnivore, onmivore, labrivore...

During my internship, I was on-call for emergency surgeries once a week. Now that doesn't mean that I was the only one to come in when there was a surgery - the boards certified surgeon came in as well. So while I got a fair amount of surgery time, I did very little surgery on my own. Granted, towards the end of the internship, the surgeons did much less and I did more, but I never did a surgery completely on my own. We had surgery labs, where we got to practice certain techniques on cadavers donated by people whose pets had died or were euthanized, so in some sense I have done nearly all the emergency surgeries I would need to know.

But until this week, I have never done a surgery without someone more experienced than I in the hospital at the same time.

Let me say this. It. Totally. Rocked.

OK, now for more specifics. The patient was a Lab puppy. I never think of a Lab as a Labrador but rather as a Labrivore because Labs are notorious for eating anything and everything. This pup had not wanted to eat for 2 days, and had been vomiting for 3 days. X-rays weren't obvious, but the blood work was textbook for an upper GI obstruction (hypochloremic metabolic alkalosis). Happily, the owners were willing to go for an ultrasound which showed a beautiful foreign body in the stomach practically waving hello at the ultrasonographer.

Of course, as soon as I realized that I would be taking this animal to surgery, my hands started to shake. Don't get me wrong, I love surgery. But it has been many months since I was in on one, and the first time you are completely responsible for a patient in a new way, well, it's a little bit terrifying. Happily, my colleague, who has the same level of experience as I do, took one look at my face and ran to get the surgery textbook. A few minutes of repeating the name of the holding layer of the stomach, and I was good to go. One gastrotomy (cut into the stomach) and 4 enterotomies (separate cuts into the intestines) later and I had the better part of someone's Halloween costume. I think it was a Pocahontas costume - lots of tan leather and fringe.

The puppy went home 2 days later, eating like a Lab should, and acting like a puppy.

And I, while still intimidated by the idea of surgery, now know that I'll be ok the next time I do one. Unless, of course, it's for a hemoabdomen. All those damn arteries to tie off. shudder

And the shoemaker's children are always barefoot.

My dog, Annie, has a bum leg. More specifically, her right carpal joint (aka her wrist) is deforming. Dogs' forelimbs (front legs) are supposed to looked stacked directly on top of the toes, when viewed from the front. Annie's right leg does not.


Here, look at her left forelimb, and you'll notice how nice and straight it is with no swelling.

Here's a better view, comparing the two legs. This swelling and incongruency came on acutely in the spring. I've tried to keep her on pain meds to see if that helps, but with the amount of arthritis in her back legs, she needs stable front legs to walk with ease.


The only way to stabilize her joint is surgery. A carpal arthrodesis, to be precise.

Now Annie is 12.5 years old - no spring chicken. And up until her leg started to go wonky, she still acted like a puppy. But for the past 6 months, she's been looking and acting like an old dog. The 6+ month-long wait? Due to first having an intern's wages, then the whole back surgery fiesta, then the moving, and oh yes, not working. So now that I finally have a job, and finally know some of the surgeons in my new city, I'm planning on scheduling her surgery soon.

There's a part of me that worries that Annie is "too old" for orthopedic surgery. Then I smack myself on the head, tell my worries to shut up, because I know this is the only way to stop her pain. As her owner, it is my responsibility to do what's right for her, and as her veterinarian, it is my responsibility to relieve pain and suffering.

Then another part of my brain pipes up that I'm crazy to want to incur a vets bill likely over $1000 for a dog who could die at any time. Again, I smack myself, because her other medical problems will never be life threatening. Nail disease, arthritis, joint issues - those don't kill animals. Intractable pain kills animals, or at least makes us decide to euthanize them. And if I don't do something to fix her pain, I'll be the one to blame.

Her nail disease is currently in remission, now that we have buckled down and are giving her the appropriate medications at the right time, thanks to a spreadsheet I print out each week. Her arthritis would be better served if I was able to take her on walks to keep up her muscle mass - unfortunately her carpal issue makes walking more than a city block nearly impossible. It's a lovely catch-22.

So hopefully next week I'll get her in to the surgeons for their evaluation. My dream is that the surgery goes well, she recovers within the expected time frame, and then I can start more aggressive treatment for her arthritis, possibly including physical therapy.

T minus 18 hours and counting...

Tomorrow, I get to be a veterinarian again. Granted, I've done some relief shifts in the 2.5 months during which I've been unemployed, but that's nothing like working regularly at a practice. I'm excited and terrified and nervous and happy.

I'm trying to figure out how many of my books I should bring with me to contribute to the "library" near the doctor's station, if I should bring 1 meal or 2, how I'll possibly remember anyone's name, and where the hell my list of CPR drugs went to. Of course, with my first shift being overnight, I'm also wondering how I'll readjust to the hours after having so long with a normal sleep cycle.

This is a brand new hospital - just opened this week - squeaky clean and beautiful. We're all new to working with each other in general, and will likely have some bugs to shake out. Everyone I've met so far seems great, and I hope we'll all work well together.

I'm getting my residency interviews set up - can't wait for that first paycheck so I can blow it all on airfare, hotel rooms and car rentals.

preparation or not

Re-reading all my notes and surgery textbook - not happening. Instead, I'm on a cooking craze. Cooking food, especially vegetables, or baking is one of my several stress releasors. Is releasers a word?

In the past 72 hours I've made roasted cauliflower, braised kale with chickpeas, kale stew (yes, I bought a bunch of kale at the farmer's market), roasted beet salad, homemade pizza, volcano muffins, donuts (both powdered sugar and cinnamon and sugar varieties), whole wheat pancakes, gingerbread, and meatballs.

I may not remember the names of the arteries as they branch off from the main trunk, but my fridge is full.

Rather than do something productive ...

I'll be starting work soon (finally!) and hence have been spending the last few days making lists of things to do. Of course, I been procrastinating madly.

Things on my list:

Knit socks
Complete new nerd book (especially drug doses)
Edit differential diagnoses lists
Organize computer files (especially discharge handouts)
Organize and label file folders of journal articles
Do draft #5 of the case study
Write letter of intent for residency
Send questions to interesting residencies
Buy bike helmet
Pick out museums, parks, etc to visit during remaining time off
Contact local veterinarian about purchasing Adequan for my arthritic dog
Contact local animal shelter about volunteering for wildlife medicine and surgery
Make Halloween costumes
Get haircut
Review surgery notes and books
Read through entire 3rd year of vet school notes
Find a dentist
Find a physician
Get flu shots

What I've done from the list:
Get haircut
Attempt to write draft #5 of the case report
Attempt to write my letter of intent

What I've done instead:
Gotten very good at Spore
Drunk gallons of tea
Read books the way a person in the desert drinks water
Listen to all of our albums by The Smiths, Green Day, Jack Johnson, and The Undertones
Recheck VIN and Facebook obsessively
Plant 90 bulbs in the front yard of our rented house
Finally start going to yoga classes nearly 2 years since the last class (thanks 4th year of vet school, internship and back surgery!)
Stare obsessively at my face and wonder why I'm so much hairier since I passed my 35th birthday than I was before it
Grab obsessively at my saggy midsection and wonder when the baby weight can no longer be called baby weight (answer: 2 years post-birth, which means I have 6 years to account for myself)
Re-potted my indoor plants
Thought about cleaning the house
Bought my 2010 pocket calender
Interrupted my working-from-home husband an uncountable number of times

So, excited to be starting work? Yes. Scared shitless that I no longer have the "excuse" of being an intern when I don't know something? Yes.

Good times folks, good times.