Monday, November 26, 2007

The Block of Bad News

As mentioned in my previous post, I will now move onto my first of two Small Animal Internal Medicine rotations (a.k.a. The Block of Bad News). I need to first mention that the nickname is not my own brainchild, but rather that of the head technician with that service. She told us that the block is called that for a reason, and I learned that from the get-go.

On the very first day, I was transferred two cases from students from the rotation prior. One was being discharged at the end of the day, but was diagnosed with having a pheochromocytoma: a potentially nasty tumor of the adrenal glands, but particularly of the cells that produce epinephrine and other similar hormones. The other case was a really sweet Springer Spaniel who had end-stage chronic liver failure. Just looking at the dog gave away that its liver was in trouble. All of its membranes were a yellow color, which you may have heard refered to as being "jaundiced". The reason this happens is that when red blood cells are normally broken down in the body, they release their hemoglobin (the oxygen carrying molecule, picture above) which is converted in the blood to a compound called "bilirubin". Normally, it's the liver's job to take in all the excess bilirubin in the body, process it, and send it to the gall bladder to help make up "bile". However, when the liver has been mostly destroyed, it cannot take in the bilirubin, which builds up in the blood and causes the yellow discoloration throughout the body. In addition, the dog had a tremendously large "pod-bellied" appearance. Another one of the liver's jobs is to create albumin, the most abundant protein in the blood. While it has numerous functions, one of the most important ones is to provide an oncotic pressure gradient to keep water in the blood stream. When the liver is failing and there isn't enough albumin, water leaks out of the blood and into body cavities like the abdomen.

It was a particularly sad case because the dog was only 5 years old and the reason it had the liver failure was from the treatment it was receiving for its epilepsy. The first drug that vets reach for when treating a dog with epileptic seizures is phenobarbital. While it often helps reduce the frequency of the seizures, it can be highly toxic when blood levels reach above a certain threshold. Therefore, dogs chronically receiving the drug need to visit their vet regularly to get their blood level of the drug measured for that reason. This dog was receiving the correct amount of drug and was having his phenobarbital level measured at correct intervals with the level never breaching that threshold. This is a case of an "idiosyncratic" reaction where adverse effects occur even when following set guidelines. While they are very rare, they are devastating for both the veterinarian and the owners.

Needless to say, these two cases left me helpless and confused. While the first case was coming back in a week to get the pheochromocytoma removed, the latter case was basically sent home to die. This was a drastic change of pace for me since my first ever set of cases was on orthopedic surgery where all the patients who come in are otherwise healthy and stable besides their torn ligaments, bad hips, etc (except for the hit-by-cars and fractured bone patients). The liver failure case had the "book thrown at him" in that every possible treatment was attempted in order to help him. Sadly, liver disease is exceptionally frustrating to treat, both in animals and in people. Therefore, if you are reading this, consider this a good reason to treat your liver well and not drink excessively :P.

Stay tuned for next time as I detail the story of my most involved and difficult case I've seen thus far in veterinary school!

Sunday, November 18, 2007

Ready, Set, Go

Hello once again. As previously promised, I will start regularly describing some of my cases that I've seen over the past few months. To finish where I left off, I have one more interesting case from my orthopedic surgery rotation. A Greyhound came in on one of the last few days of the block with a grade IV/IV lameness (i.e. not bearing any weight) on one of its hind limbs. Normally, when trying to localize a lameness in a dog or cat, they cannot tell you where it hurts. Instead, you need to perform a thorough orthopedic examination to localize the source of the pain. In this Greyhound, however, there was not much need to do this because you could look at the dog and see her problem. The toes on one of her hind limbs were all stuck in flexion, nor could he do much to flex or extend her "ankle". If you look at the back of a dogs ankle, you'll see how there is a bone that sticks out to which the Achilles tendon attaches. This is called the Tuber Calcaneus. Just upon looking at the dog, one could see that the tuber was not sticking out hardly at all. We took radiographs to confirm that the bone was broken.

Now, from what I could tell from the history I received from the owner, the dog suffered the injury while racing 10 months prior to presentation to the vet school. The person who brought the dog in was a Greyhound rescuer who said that the dog went through many homes before getting to them. My guess was that each person who had the dog could not afford to have the dog treated, and understandably so. We took the dog to surgery and secured the bone back into place with a plate and screws. The surgery went well, but performing surgery on Greyhounds makes me nervous. The are sensitive to the drugs used in anesthesia, they have very thin skin, and they are very prone to bleeding more and bruising. Nonetheless, these factors should only make one more cautious before moving forward. The dog needed surgical repair in order to use its leg again. Thankfully, the procedure went well and the post-operative radiographs looked ideal, but the dog really swelled and bruised over the next few days.

While the above result sounds gruesome, the surgeon on the case assured me that the dog would likely do well. I had trouble believing that, but he's had decades of experience so I trusted him. Regardless, it could only help since the dog wasn't placing any weight on the leg since its toes were stuck in flexion. The only catch is that it would take weeks to months for the tendons and ligaments in its lower leg to stretch out and return to normal after receiving some physical therapy.

Unfortunately, I do not know how this case turned out because my following block, Small Animal Internal Medicine, left me no time to do follow up on my previous cases. As I will describe in my next couple posts, I practically lived at the vet school for 3 weeks. Till next time...

Wednesday, November 14, 2007

The Die is Cast

Hello once again. As promised, I have returned to the world of blogging. As mentioned before, these past few months have drained me mentally, physically, and emotionally. When I last left off, I was on my orthopedic surgery block which was an interesting block, but the final week of it was rather hectic. Following that was my internal medicine block which was by far and away my most difficult one thus far. I clocked myself in at an average of 95 hours per week while on that service. After that, I had a drastic change of pace and spent three weeks working with horses and alpacas in the large animal hospital in the vet school. Next, I spent three weeks on the vet school's new small animal community practice service which is meant to simulate what real private practice is all about. Lastly, I spent three weeks working with the radiology service looking and evaluating radiographs (X-Rays), MRI's, ultrasounds, and CT scans.

I suppose the more important matter at hand involves the title of the post and what you are likely waiting to hear about......the infamous North American Veterinary Licensing Examination aka the "Boards" exam. Well....all I can really say to you about it is that it's done. I've heard from numerous veterinarians and classmates of mine that everyone feels like they've failed when they come out of the test and that they had many questions on the exam where they were unsure of the answer. If I hadn't heard those remarks from so many people, I would have come out of the 360-question ankle-grabbing haze-fest freaking out. However, I actually went into the exam unstressed and remained calm through the entire six hours. Even afterwards, I just said to myself, "Well....let's just see what happens....". I think this is mostly due in part to my use of the program on I used this website for about 90% of my preparation. Vetprep is a website with a few thousand practice exam questions and I got through every single one of them multiple times. My belief is that, while I'm unsure as to whether or not it prepared my knowledge base well enough, it most certainly prepared me emotionally. Once I started plowing through those questions, I didn't take a break until after the 240th question.

I've heard that many of the people who fail get an uneven distribution of questions related to a species where we all get little education, such as pigs or chickens. No two tests are the same, and each exam for each person has questions taken from a large pool to formulate their test. Overall, my species distribution was fair, but I received alot more equine questions than I anticpated. What really caught me off-guard, however, was how there were a number of business management and ethical questions on the exam. I can understand why there were some business questions on the test because there are a number of vet schools in the US that have extensive courses on the subject. My school unfortunately has a two-day course that really isn't worth much, to be entirely honest. The ethical questions really bugged me though since they were really subjective and could've had more than one right answer. Anywhos, I'll let you all know how I did sometime in January/February once I find out my results. Till then be prayin' for me....

In regards to my current rotation, I am back in my home state of MD working at a shelter/spay&neuter clinic getting some fantastic surgical experience. The people at the facility are very friendly and they have been supremely hospitable towards me. Its only been my second day there and I've already personally performed five surgeries, all spays and neuters. Tomorrow, however, I will get to perform my first ever enucleation....i.e. I'll be taking a cat's eye out. It, of course, will be under the supervision of a doctor and with consent. We believe the cat, which is a stray, got into a fight and took a shot to the eye. All that remains is an infected, disgusting husk of what was once an eye. In addition to that, I heard that next week I might get to do my first ever leg amputation.

Thank you all again for reading my blog and for your support. Since this rotation will probably be repetitive except for the aforementioned procedures, I will use these next couple weeks to tell some stories about the cases presented to me over the past few months. Some come with good endings, some with bad, but regardless, I look forward to telling them!

Wednesday, November 7, 2007

Stay Tuned....

Hello again!

My most sincerest apologies for my extended abscence from the world of blogging. These past couple of months have been...well...trying, to say the least. With what little free time I have had away from the school, I have only been able to study and prepare for the National American Veterinary Licensing Examination (aka Boards).

This coming Monday (the 12th), I will be taking the 360 multiple-choice question exam. Afterwards, I will require much imbibing to make my hands stop shaking and calm my nerves. With that behind me, I should be able to gain some semblance of a normal life again and start blogging again. I look forward to sharing some stories with you all because I have many that need telling. Wish me luck on the exam!!!