Tuesday, July 24, 2007

In a Deep Sleep

Greetings and salutations, I hope all is well for everyone. My block of performing anesthesia is coming to an end. Overall, the block has been a fantastic review of previous material and a great beginning to see what we learned about drugs in effect. In just a short three weeks, I've seen a great selection of cases, many of which were orthopedic procedures. I've done anesthesia on dogs getting hip replacements, cruciate repairs (the equivalent to when people tear their "ACL"), luxating kneecap repairs, and more. One case in particular was very unique. A dog was brought in as an emergency because it was hit by a boat. To explain in more detail, the dog was riding on its owners boat at one of the many lakes near here and jumped off the front of the boat while it was in motion, went under the boat, and got caught in the propellers. It was quite a horrifying site to see the dog so mangled when it came to the vet school. After the dog was systemically stabilized, it was taken to surgery. It had to first have some skin damage along its chest treated, then have one of its hind limbs entirely amputated (no joking, the leg was hanging by a thread), and the other hind limb was horribly broken, so it had an external fixator placed. This is where you place pins through the limb and bones so that they come out each side of the leg by a few inches, then secure the pins on each end to a metal piece going perpendicular to them (i.e. in the direction of the limb), so that in the end it kinda looks like a ladder, if that makes any sense. The dog is actually recovering well, but needless to say, it's not going to be able to walk for another couple of weeks.

Another fascinating case assigned to me was that of a small mixed breed dog that required a "balloon valvoplasty" procedure. This is the exact same procedure that is done in people where a very long catheter is placed into the jugular vein and/or up through the femoral vein (in the leg) all the way into the heart. Animals (and people) who need this procedure have a heart valve that is not opening up enough to allow proper flow through the heart, therefore, the end of the long catheter has a balloon on it which is inflated to allow stretching of that narrow passageway. While this may sound fascinating, it is an extremely dangerous procedure. I was told prior to inducing my patient that its likely for the dog to just die on the table and there's nothing I could do about it (i.e. it's a dog with heart disease to begin with, and if the balloon is inflated even slightly too much, the valve can tear, leading to almost instant death. The good news about this case was that the dog did fine with the procedure and anesthesia, the bad news is that they couldn't fix the dogs problem. Not all hearts are amenable to these procedures and you can only hope that you can resolve the issue.

Sadly, I must tell of my case from yesterday, as I had my very first ever anesthetic death :(. My case was a 15 year old dog that was presented for an anal sacculectomy....and yes, its as gross as it sounds. The dog was going to have an anal gland removed because there was a tumor growing in it. Geriatric dogs like this one are always a challenge for anesthesia for a lot of reasons that I can explain in detail if you'd like, but this one also had diabetes, and while undiagnosed, we felt it had the beginnings of Cushing's disease (where your body makes too many steroids). I induced the dog and for the most part his induction went smoothly. At the beginning, he was having trouble getting enough oxygen, but we realized that because this dog was really, really, obese, it had difficulty expanding its chest enough to inflate all of its lungs. I caught onto this quickly enough and began to breath for him with big breaths and he maintained oxygen levels perfectly. The techicians then began to prep the dog for surgery (clipping hair, sterilizing the surgery site, etc) and about 30 minutes later I noticed his heart rate going 120......110....100....95.....90..... I then proceeded to ask the anesthesiologist on duty for some glycopyrrolate, a drug that can stimulate a low heart rate. She said ok, and came over with some to draw up into a syringe. Next, I said to the technicians, "Ummm......can you guys check to see if his ECG leads were on correctly?" because there was a flatline. The anesthesiologist saw this and immediately listened to his chest, then shouted out "We have an arrest! Someone get me the crash cart!" Thankfully, people came from everywhere and immediately we had around 15 people there to help out. Since I was already giving him breaths before going into cardiac arrest, I was in charge for breathing for him while the doctors performed CPR and gave drugs like epinephrine. Much to our surprise, we brought him back to life within a minute; he was breathing on his own, he started to get reflexes back, etc. We all stayed with him to the point where he sat up and practically kicked out his endotracheal tube.

The doctors wanted to get some blood gas values on him, so they started to pull some blood, then he started doing what they call "the kick of death" which is a spasmodic twitching of the limbs before going to arrest, then fell over, and went back into cardiac and respiratory arrest. Again, thanks to all of the help, we resuscitated him back to life. Unfortunately, I don't think his heart fully recovered and would repeatedly go back into arrest whenever the epinephrine we gave him wore off. We were going to put him on a constant epinephrine drip, but by that point the owners of the dog arrived and awaited their decision whie we had him stable.

My classmates today pointed out to me how amazed they are at how unphasable I am in the face of stressful situations such as that. However, I told them about how that was the case until the clients arrived. Just as I explained in my previous post about performing euthanasia for the first time, the dealing with the dog itself should not get to me, in fact, it would hinder my ability to save the dog. However, when those owners arrived bawling their eyes out, calling to the dog even though by that point he was likely brain dead, it became very difficult for me to do anything. That is by far and away the hardest aspect of the job, not performing euthanasia, or rectal palpation of cattle. What made matters much, much worse was that the dog went into arrest while the owners were in the room with the dog. We had to be sympathetic to the owners and escorted them out of the room while we performed CPR again.

In the end, we resuscitated the dog 7 times before the owners decided to call it quits and I completely felt their pain. Noone should have to go through such pain, but its an inevitability when one decides to own a pet. The amount of love and companionship they give us more than outweighs having to deal with such pain. We discussed the case and I was told I did everything perfectly, gave the dog much smaller doses of anesthetic than a young, healthy dog, kept breathing for him etc, but anesthesia is always a risk for patients like this one. The owners made the right decision when they decided to stop performing CPR and I completely feel for their loss.

Sorry for the sad news, but my next block starts on Monday and I get to go to the other end of the surgery table as my next block is on orthopedic surgery, which I find super fascinating. Thanks to all for reading!

Sunday, July 15, 2007

Warning: Cute Animal Picture Alert

Greetings again. I am now back indoors and back to working with companion animals. As mentioned previously, I am now on my block of anesthesia, but before I get into that, here are a couple of finals pictures from my large animal ambulatory medicine block.
The picture above is one of me holding a lamb (duh) where we were called to treat a single ewe in the flock for anemia. The interesting thing about this farm was how the owners had a total of 200 sheep, but didn't market any of them (i.e. they were all pets) and had a name for every one of them. The ewe that was anemic was 12 years old and had this lamb just recently. Because this was going to be her last lamb, the lamb was fittingly named "Finale".
This picture is of me with one of the school's calves. These lil calf houses are absolutely fantastic for keeping the calves happy and preventing transmissible disease during their most vulnerable time in life. Have no fear, there was nothing wrong with this calf :).
Here, my group and I are doing some assemly line-style vaccinations of calves owned by the school. To the left are two of the food animal professors from the school. I want to note that I was not looking because I didn't hear the photographer wanted us to look at the camera. :P

That's all for now, I'm exhausted from my day at beautiful Smith Mountain Lake, a resort area snuggled in the Appalachians where my wife and I celebrated our 1-year wedding anniversary canoeing and swimming around the lake. More updates to come, stay tuned!

Sunday, July 8, 2007

Doin' Time

Well, today is the last day of my ambulatory large animal medicine block and I will greatly miss it. I'm on call today so I might have to go out again (which will hopefully lead to some more good stories). The picture here is of yours truly placing a tube down a cow's esophagus. After placing the tube you secure it to the cow's face and then pump a watery mixture of calcium, phosphorus, magnesium, potassium, and other nutrients down into their rumen. Many farmers can't afford real expensive medications or advanced procedures, so you're often left to only provide supportive care as your primary treatment for these animals. This cow in particular was bouncing back from an LDA correction like I described in my previous post.

By far and away the neatest part of my week was going to work prison herds. I thought I was only going to one prison, but I ended up going to two. The first one I went to on Thursday and only worked on about 40 cattle. The second one had about 300 cows.....all of which had to be rectally palpated for pregnancy diagnoses. We had to move the cows through a chute, assembly-style, where at the end of the line a doctor would palpate and ultrasound them, then a student would palpate. The doctor I was working with was nice enough to wait and say what his diagnosis was to the person recording until I palpated and gave an answer. Through the course of the day, I rectally palpated over 150 cows (and I still feel dirty :P). At this time of year, the majority of the herd is kept on pasture at a state park adjacent to the prison, while a small portion of the herd is kept at the prison itself. The primary doctor in charge took me away from the major herd to go with him to the prison itself so we could be efficient. That's where the heat really picked up since he made it so I was palpating down the line from him, and whenever I slowed him down, he'd keep yelling up how we needed to keep moving, hurry etc. For each one I had to check with the prison guard who was assigned to recording what the doctor diagnosed and check my answer with him. Overall for the whole day I was about 75% right which is pretty damn good since I've never done it before.

While at that prison however I had a very frightening moment. I was palpating the cows as the entered the head chute at the end of the line, and before you can palpate, you close a door along the chute: one so you can get to the back of the cow, and two so you can keep a barrier between you and the next cow in line. One cow, however, was not to be deterred by such a barrier and attempted to leap over the door and on top of me. Fortunately for me the cow made a bunch of noise before doing so and I saw it coming; unfortunately for me I noticed as it broke the door open. Therefore I had to climb up on top of the cow I was palpating and leap out and over the head chute to escape being crushed. Needless to say, the rest of the day was spent looking over my shoulder.

One might say that I should've been looking over my shoulder anyway, and that's because the entire day I was working right with a bunch of inmates. There were usually no more than 1-2 guards around while there was somewhere around 15 inmates helping move the herd along our assembly line. They were surprisingly friendly, easy to work with, and flattering (because they kept calling me sir). The guards weren't armed and the inmates could have run away because the herd isn't kept inside tall barbed-wire prison fencing. I asked one of the doctors how this whole system works and why there aren't any issues with escaping, and he explained to me how these inmates have to be on tip-top behavior for an extended period of time to even get the priveledge, plus many of the prisoners had little time left on their sentence. One inmate in particular said how he only had 9 days left on his sentence. The whole bunch of them were rather entertaining because they had to try and stop some escaping calves that needed treatment for various diseases, but it was apparent that none of them had any experience dealing with cattle. Some were terrified of the lil calves running towards them. I laughed the hardest, however, when one of the inmates asked me "Hey man, how you know each of these cows is female?". Now, I was about to say something nice and polite like explaining what we see through the ultrasound, but the other inmates weren't so forgiving. Before I could say something, they others started bursting out in laughter and one said, "Aw hell no!! Tell me you did not just ask that! TELL ME you did NOT just ask that!!!"

I will certainly miss getting to drive around everywhere and get to work out in the nice weather, but I will be getting to work again with dogs and cats. Unfortunately my next block is anesthesia, and while I do feel anesthesia is an absolutely critical aspect to veterinary medicine, it doesn't peak my interest quite like surgery does. I enjoy the concepts of anesthesia, but I dislike sitting around and monitoring a 3-4 hour procedure. I have a couple extra pictures from my large animal block that I will post here in the next couple of days.

Wednesday, July 4, 2007

Happy 4th!

I hope everyone's 4th of July was relaxing, festive, and full of hot dogs and pyrotechnics. Before I go into some more things I've been learning, I wanted to point out how I didn't realize until now how only members of blogger.com could post on my forum threads. I have now changed that so anyone can go ahead and post comments, and I'd really appreciate it if you did. In particular, I'd like feedback about my previous post about my contemplating an internship in food animal medicine.

One other lil tidbit to mention is how I won't be able to post for the next two days because I am going to prison :(. Now before you get all worked up, I am going to one not because of committing a crime, but because all the prisons in VA have adjacent farms where the inmates have to work. There is one vet at the school who is willing to do the herd health management for all these prisons, and he takes students with him. Unfortunately, the prison is four hours away so we'll need to stay overnight at a nearby hotel because we have to spend the whole day at the prison farm. Needless to say, I'm crossing my fingers in hopes that I can come back with some positive stories for you :).

That aside, the picture you see above is of yours truly finishing up a surgery on a cow. The surgery in particular was the correction of a "left displaced abomasum" (LDA). Many people are under the impression that cattle have four stomachs, but in reality it is one stomach with four connected parts. The last part of the stomach before food enters the intestines is called the abomasum: it is functionally and structurally very similar to the stomach that dogs, cat, humans, etc have. The organ normally sits down at the bottom of the cow and on the right side, but without any attachments to the body wall. For a variety of reasons that I won't get into, when a cow gets sick, the abomasum can become atonic and stop contracting, leading to it filling up with gas. This in turn results in the organ moving to the left side of the body and floating up to the top of the cow. Overall, as you can imagine, this can be disastrous for the cow and thankfully farmers have been trained well to identify a cow that is suspicious of having an LDA. The best way to diagnose it however is to place a stethoscope on the upper left side of the cow, along the ribs, and listen while you flick the side of the cow with your finger. If you hear a "thump" sound, the cow is normal, but if you hear a "ping" sound, you have flicked gas and know the abomasum is there. The sound was described best to me by comparing it to the sound a red rubber kickball makes when you would nail it back in grade school. The procedure involves making an opening on the cow's right side, reaching your entire arm across the inside of the cow, grabbing the abomasum, bringing it back over to the right side, and suturing it to the body wall so it can't happen again. In the picture above, we have already done that and have started to close up the body wall. Take note of how the cow is standing for this procedure; all that is done for anesthesia with this is a local block of the muscles and skin that is incised, and somehow the cow really doesn't mind (assuming the block is done correctly).

That's all for now. Wish me luck in prison!!!

Tuesday, July 3, 2007

For Purple Mountain Majesties

Greetings everyone. I wanted to post a story last night, but I was on-call and went out on an emergency right when I was done for the day. While some may complain about having to stay at work until 10 PM, here was my workplace (the picture). This block has really given me an appreciation of the Appalachian mountains. We were called to a beef cattle farm where the owner noticed a cow went into labor Saturday morning, but remained in labor until he called us on Monday night. One might think that the owner was being neglectful, but in reality he wanted to contact us sooner but couldn't catch and wrangle the cow for us to examine her. This was one helluva experience. We restrained her in a head chute and reached into her uterus to palpate the calf....or at least that's what we expected. Instead, we came upon what is referred to as a "fetal monster": a horribly mutated (and dead) calf that cannot come out of the mother because of its horrid disfigurement. There are a few causes for fetal monsters, but in this case it was most likely due to a disease called Bovine Virus Diarrhea (BVD). What made matters worse was the fact that it had become rotten of the past couple days and there was a subsequent infection of her reproductive tract. Needless to say, it was Foul (note the capital F). Our goal was to get the beast out of the cow without having to perform a C-section, which we did, but it took over an hour-and-a-half. The doctor hooked up some chains to its head and limbs and was reaching inside to keep it lubricated as I got to pull on the chains with all of my strength. To put it in perspective, I was still standing while pulling, but at a 15 degree angle with the ground. Because the calf was becoming rotten, whenever we placed a chain on any part of the body, and I pulled, I just fell on my a** because the body part would just tear off (I say body part because only half the time we knew what it was exactly. After much fatigue and loss of patience, I yanked what remained of the monster out of the cow.....only to have it follow with all of the bloody mucus and fluid that built up inside that promptly splashed all over the clinicians lap.

While this has by far and away been the most disgusting thing I've had to deal with, I've been delightfully surprised. In fact, I've enjoyed it so much that I'm thinking about doing an internship in it next year. I feel it would be nice for me to work with dogs and cats most of the week, then driving around to farms a day or two per week. This would work out perfectly for my wife and I since she won't be graduating from her PhD program until a year after I do. I'm still entirely on the fence about this and would love to hear input from other people. What are your thoughts?