The Case of the Upper Airway Obstruction

Hello once again from the land of veterinary medicine. When I last left off, I detailed my entrance into the infamous block of bad news and promised to tell of my most challenging case yet. Towards the end of the first week in the rotation, I was informed that an emergency case was on its way and that I was selected to take the case (every other service in the hospital lets students decide which cases they want). Being but a newbie student and new to the profession, I like to see what cases I have coming in advance so that I have ample time to prepare. All that I knew about the incoming case was that it was a dog that couldn't breathe.

When the patient arrived, the technician said, "Your patient has arrived, but she went directly to the intensive care unit because it apparently had a seizure while on the way here." Oh goodie.... The doctor and I went and took a look at the dog and found that it was panting heavily, but still had a normal pink color and was otherwise ok. The dog was placed in an oxygen cage, but trouble would arise whenever we took the dog out of the cage to examine it. We couldn't do much without causing the dog to squirm and struggle because of it's personality. When this occurred, the dog would close its mouth and shortly thereafter tilt its head back, feint, and turn blue. We would immediately treat the dog with oxygen therapy and it would recover, but we used this opportunity to realize that there was no air passing through either nasal passages. Thankfully, our evaluation of the lungs found them to be normal. Because the dog had no prior history of neurologic disease, we quickly deduced that the "seizure" that the clients claimed had occurred was likely one of these feinting episodes.

After our initial evaluation of the dog, we went and spoke to the owners about what we found and the dog's prognosis. The dog was a miniature poodle and a really cool dog overall. She also had a really cute name which I wish I could say, but I need to maintain confidentiality. The dog was only 7 years old and the owners were really attached to it, so they said to do whatever was needed to help her out. Rule-outs for such a condition include and abscess at the root of a tooth that has swollen terribly, a foreign body (dogs get the craziest things up there nose), a reaction to some foreign substance, and sadly...neoplasia. The latter is the official term for a tumor and I try my very best to avoid using the dreaded "C-word" around clients because even the slightest mention of that word strikes dread in their hearts, even when the possibility is unlikely and your only mentioning it to cover your ground. We explained to the owners that she would have to stay in the hospital for likely an extended period and would require intense and detailed diagnostics to figure out what was going on with their pet.

With the official go-ahead from the owners, we admitted the patient and went forth with her work-up. We initially placed her on an antibiotic and a steroid in the hopes of removing any secondary infection and to reduce any swelling occuring in her nasal cavities. This poor dog had to endure through bloodwork, x-rays, a CT scan (aka a CAT scan), two rhinoscopies (where a camera is placed into the nasal cavities) with biopsies taken, and surgical entrance through the roof of the mouth into the nasal cavities to the area where the camera can't reach. Thankfully, all of those diagnostics showed how there was not a tooth-root abscess or foreign body. The most frustrating aspect of the diagnostics were that the biopsy samples both came back as "inflammation". That answer can be a double-edged sword however because while it means there was no tumor tissue in the samples, tumors can still have an inflammatory coating around them (i.e. we missed).

Two weeks of hospitalization and diagnostics later, the patient gradually improved in her condition and began breathing air out of her nostrils. While I was very happy that the dog improved, a few thousand dollars were spent on this dog only to fix it with monitoring, antibiotics, and steroids. I personally have never been a big fan of the so-called "foo-foo" dogs, but this lil' poodle really grew on me and won a place in my heart. I'm a relatively tall and stocky guy, and many of my classmates and doctors who saw me taking care of her and walking her made many "Aww, how cute..." and "You're the perfect match" comments that would make me sick :). In addition, because of how long she was hospitalized, she became a local celebrity who saddened everyone when she left.

As frustrating as this case was, I am very glad it had a happy ending. What caused the airway obstruction, you ask? I have no f***ing idea and it irks me to this day. The client owned a hair salon and would allow the dog to walk around and mingle with her customers, so our hypothesis was that the dog was reacting to the hairsprays and other chemicals. I hope you enjoyed the story, and be sure to tune-in for my next post which will be about the end of my internal medicine rotation where I had a wave of kitty-cases....some of which had yellow skin!

**The above image is from "Care Beyond Cure: Diagnostic Secrets and the Cancer Patient for 2005!" and can be found here

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!

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...

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 www.vetprep.com. 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!

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!!!

The Crucial Cruciate

(Picture to be inserted later)

Two weeks down, one to go for the remainder of my orthopedic surgery block and my oh my has it flown by quickly. A fellow classmate of mine pointed out to me how my class is already 1/4 of the way through our final year, which I find amazing since every morning it feels to me like we've all just begun. This past week was a bit less hectic for me since I've started getting a hang of all the nuts and bolts of the inner-workings of the teaching hospital, but I was still super-busy nonetheless. Thankfully, of all the appointments I saw this week, only two stayed for surgery; i.e. the rest were outpatient visits (rechecks, hip evaluations, etc). The two that stayed at the hospital both had the same problem and received the same surgery: ruptured cranial cruciate ligament.

In people, this is known as tearing one's ACL, which stands for "anterior cruciate ligament". These are the same thing, except the first word refers to a direction. The semantics are different between animals and people because of how we are biped and animals are quadriped. Anterior in people means in the direction of the front of your body, and cranial in animals means towards the head. That aside, there are two cruciate ligaments and they are both inside of your knee joint. They have a number of vital purposes: preventing your knee from over-extending (yeah...ouch), preventing your knee from twisting, and preventing what's called the "cranial drawer". This is where the femur (your thigh bone) slides backwards off your tibia (your calf bone). There is a cranial and caudal cruciate ligament, but the cranial one is what tears most often because it receives more stress than the caudal one (caudal meaning towards the back end of the body). Initially, the tearing of the ligament hurts like hell, but the pain quickly goes away. However, in the long run, this ends up being catastrophic because osteoarthritis and degenerative joint disease develop within the joint to a severe degree because of abnormal loading of weight on the joint.

There are a number of ways of treating this problem, but unfortunately surgery is really the only way to go. The degenerative joint changes will be inevitable, but having surgery will greatly help to delay the disease. Both of my patients this week had a procedure called a "Tibial Plateau Leveling Osteotomy" or TPLO. I won't go into great detail, but I first need to point out a crucial anatomic point about the tibia. The top of it is relatively flat as one would hope, so that the femur and tibia can have two flat smooth surfaces which interact. What happens in the TPLO is that we make a semi-circular cut to the top of the tibia and rotate it backwards so that (when looking from the front of the tibia to the back), the top of the tibia, or plateau, slopes upwards. This, in essence, prevents the femur from sliding off the back of the tibia and causing the drawer I mentioned above. Because we are intentionally fracturing the tibia, we then place a plate on it with some screws to secure it in place. I completely understand if all of this comes off as gibberish to you. To be completely honest, I had the greatest difficulty in understanding what went on with this procedure until I saw it. The best part of all was how the surgeon allowed me to drill and place one of the screws into the plate (under his very close and scrutinizing supervision of course).

While this whole description may come off as horrifying or gross to some, please take into account the patient here. If left alone, the dog (and very rarely cat) will not be able to walk on the affected limb within 6 months to a year, leading to either amputation or euthanasia depending on the client. By doing this barbaric (I supppose) procedure, these dogs will get multiple years of healthy ambulation out of the limb assuming it is diagnosed quickly enough and the dog isn't already ancient. In fact, every one of my patients thus far this block who have received the TPLO are already back to using their affected limb to full function. More often than not, the cruciate rupture occurs to larger breeds of dog, but it can also happen to small/toy breeds as well. In regards to the cause of the rupture, all we know is that the ligament slowly degenerates on a microscopic level for some time, resulting in an overall weakness and increased fragility. Unfortunately, noone knows exactly why this is happens, and both athletic dogs and dogs that are indoor couch-potatoes get it all the time. If you or anyone else you know has a dog that ruptures its cruciate ligament, please keep in mind that 60% of dogs that rupture one, will rupture it in the opposite limb within a year or two.

One last point I'd like to make before logging off is that you shouldn't let this make you frightened or concerned about letting your dog get the exercise it needs or desires. This only happens to a very small fraction of dogs. If anyone would like more details on this process or the procedure, I'll gladly dig up or draw out a picture to help enlighten you. Take care!

The Nuts and Bolts of It All

Hello again, and thank you for your patience with my well-spaced apart blog posts. As mentioned in my previous post, I have begun my first primary care block: orthopedic surgery. Needless to say, I was completely overwhelmed last week since I had to learn all the paperwork and other inner-workings of the hospital as I went. On average I was at the school 14 hours/day last week, with one day clocking in at 17 hours. Much to my relief, I have a moderate grasp on how things are run and should not have to spend so much time at the school with the piles of paperwork. In all honesty though, I don't think I've been so stressed out in my entire life, and I know it's just the beginning. While learning all those inner-workings, I'm still in charge of the care of my patients. On top of all of this, I need to spend time reading selected topics for when we have rounds with the doctors. While the surgeon I'm working with on this block is a great teacher, he can really come off as intimidating sometimes, especially when in surgery and he points to some structure and says, " What's that?". Now I can move on to talking about what I've seen thus far.

My first case was a bit of a complicated one unfortunately. A small dog was presented to the teaching hospital because of getting hit by not one, but two cars. Amazingly enough, the dog appeared at first to only come out of the incident with multiple fractures of his pelvis; i.e. he had no pulmonary contusions, no broken back, no internal bleeding, etc. However, after the first day of taking care of him, I was convinced that there was just something not right about his mentation, so I insisted on having a consult with a neurologist. After the neurologist took a look at the dog, he discovered the dog suffered some damage to his right forebrain, causing him to be partially blind in the left eye and had some deficits in the function of his left front limb (probably the left hind limb, but they were evaluated because of his fractured pelvis). One thing that is of immediate concern with trauma to the hips is nerve damage to the urinary and gastrointestinal system leading to urinary and fecal incontinence, and thankfully this dog had neither.

To make a long story short, we took him to surgery and placed a plate on one side and used a large screw in another area of trauma. After surgery, we took some post-operative radiographs and the surgeon was very pleased with the results. The next couple of days were all about evaluating the dog's level of pain, ensuring no nerve damage during the surgery, continued evaluation of the dog's mentation, and the return to use of the hind limbs. Thankfully, by the end of the week, the dog was standing up, taking very short strides, started wagging it's tail, and did not seem as painful when handling his hips. While it was certainly pleasing to help the dog out, the client was the factor that made this case so pleasing and reminded me of why I chose this profession amongst all of my stress and paperwork. The client was a really nice elderly gentleman who's wife has lived in a nursing home for years. It was absolutely gratifying knowing that I helped his lil' buddy who's there to keep him company when he can't be around his wife. He was so happy when he picked up his buddy seeing how well he has begun to improve already.

That's all for now, stay tuned for my next post about the most common orthopedic problem in dogs...the rupted cruciate ligament (aka "tearing an ACL" in people). Oh....I didn't have time to take any pictures this week (and I need to be careful about confidentiality) so I've included a picture of my bulldog. :)