Why I am Pursuing a Residency...

I feel like I should explain myself and my career goals...I think perhaps not everyone understands what exactly I am doing. I know there are people out there who think I am still in school...I am not...I have my license and I could go anywhere and work. What I have chosen to do is pursue further, higher training. I am in an internship now, yes, but this is still a job! I am working, getting paid, my patients are mine and I make the decisions on them. And after this year, yes I could just go work in a small vet clinic, but I do not want to do that kind of work. Vaccinations, broken toenails, spays, declaws are just not my life's goals...I want to specialize and so that is the reason for me pursuing a residency. It is still going to be a job...I will be working every day...it is just different kind of work, specialized...like when you go to the doctor for surgery you do not go to your regular practioner, or for GI issues they send you to the gastroenterologist...the same thing holds true for veterinary medicine. Human doctors have to go on and do internships and residencies as part of their training...veterinarians do not, but there are the select few of us who wish to do that and want to specialize in a certain aspect of veterinary medicine. That is me. I like internal medicine. What that means is that when you take your pet in to your local veterinarian and they diagnose it with thyroid disease or adrenal disease or it is losing weight and you can't figure out why or the treatment is not working and the pet is getting worse...they will refer you to someone like me...for further diagnostics, and treatments that are out of their capability both mentally and physically. Once I am done, I will never do vaccines or spay/neuters or broken toenails...I won't work in a small little practice with one vet and one technician...I hope to be in a specialty practice somewhere with other specialties like oncology, surgery, dermatoloy, exotics, pathology....why?...because I do not ever wish to do surgery or deal with dermatologic issues...and I never want to see rabbits/ferrets/birds/reptiles again...so you see...I have a special interest....internal medicine, and so that is why I wish to pursue higher training...so that I can be Board-certified in that specialty and deal with only internal medicine issues. If I went into regular practice I would be miserable...I would find it remedial and boring. So yes, this training is long and it may take me far away from family and friends....for a little while...but afterwards I will be happy with my career choice and I will be able to move anywhere and get a job...and then I can think about starting a family. I know it seems weird and people are skeptical about why I think I need to go all over the place and why can't I just get a job...but it doesn't work like that...not yet anyway... So, if you all care, here are the states I am applying to: Minnesota, North Carolina, Boston MA, California, Georgia, Texas, Tennessee, Michigan, Ohio, Alabama, Colorado, New York.,..in no particular order - I have not decided my rank order yet. So, I am really excited and I hope that I get a spot. This is a very competitive residency...there are hundreds of us applying for ONE SINGLE SPOT at a particular place!! Yes, that is crazy and I am scared that I will not get chosen...so I know that there are those who don't understand why I am going to be moving all over - but if you could just be happy for me and send up some prayers for me between now and March (when I find out)...I would appreciate it....I need your support now and throughout the training...even if that means I head somewhere else for 3 years...don't count me out of the family because at the end of it all hopefully my smiles will be well worth it.

I'm Betty Crocker!!

So I still have a lot of the apples left from home and I didn't want them to waste so I was tyring to think of things I could make with them that I will actually eat. I don't really eat pie or apple crisp...so I got out my cookbook and decided to make apple cinnamon muffins, from scratch -- the turned out quite good actually...I was pretty proud of myself. Yes as you can see...I lead a very exciting life outside of the clinic!!! Now I am just watching tv..the shoe scrubs...I never used to really watch the show but a friend from Vet school that I used to hang out with would watch it all the time and I sorta got hooked on the show. I heard on the news that it is supposed to snow on Thanksgiving...actually some accumulation possible...good - hopefully it will keep people away from the ER on Thanksgiving so that I get off early!!! Of course unless your pet is dying them come in for sure, but a torn toenail is probably not an emergency!!! Well, I am going to finish my glass of wine and head to bed because I am on call in a few hours. Smiles.

Back on the Triage floor...

God how much do I hate the triage floor!! Although...I did see some pretty interesting cases this past four days and it is true..winter does bring some relief. I saw a little dog the other day that had the clip from another dogs rabies tag pierced through his lower eyelid!! - yes and so his eye was wearing this other dogs collar - ouch!!! So I sedated him and threaded it back out, stained his eye - no corneal ulcer - woke him up, and sent him home with pain meds and antibiotics. Satsifying case I guess. I also saw a bird that had dipped its beak into nail polish and then was acting all drowsy and tipsy on its perch. That would be from the butyl alcohol in the product - causes drowsiness, seizures, pulmonary edema - bird was fine once at hospital and lungs sounded fine - sent him home for them to monitor him over the next 12 hours as it can take that long for the pulmonary edema to develop. Had a pitbull with a neck laceration due to being tied out on a cable. Anesthetized him and fixed it, had to be carefull of jugulars and trachea in that region but I think I did a good job. The gross thing about this case, while under, tape worms start coming out of his butt - so the tech started to pull them and she got a huge hand full that looked like spaghetti and would not come out so we had to cut them!!!! It was so gross!!!! Yeah- he got dewormer also. Ich!! What else did I see - urinary tract infections, broken toenail, hot spots, pesiticide ingestion, ... the list goes on, I forget as the days go on. Oh yeah - saw a very sad heart failure case, 10 yo dog, came in in respiratory distress, couging up bloody froth, mucous membranes blue - gave her injection of lasix, torb to calm her down, and nitro on her gums and placed her in oxygen. Talked to owners about this being heart failure as she has history of heart disease. Said we need to get her out of the episode of failure - if we do she has progosis for survival of 9-12 months, every episode after decreases about 5 months. Said to do that we may need to place her on ventilator - she needs CRI of heart meds, echo. Talked about the fact that if she ruptured one of her chordae tendinae (ligamentous part of heart valves) then there is really nothing we can do. Well, after crying for a long while and talking on the phone to her husband they decide they will euthanize and wife wants to sit with her while husband gets there. So I bring her back to ICU to the oxygen cage and let her sit there - meanwhile the dog has not improved and still has pink fluid dripping from it mouth and nose. I walk out to go grab the forms I need them to fill out and all of a sudden they are calling me back - the dog is now laying on its side in the oxygen cage, pink fluid just pouring out of its mouth and nose, struggling for each breath. I say we cannot wait for her husband we have to euthanize now - so we do and of course the owenr is just bawling, what a mess of a case!!!! Poor dog and poor owner. Ok, enough work talk. I am applying to 13 residency programs...13!!!! I hate this, I probably will spend all this time and money and not get a residency. I hope I do. I have the three clinicians from AEC writing me letters....I know they know a lot of people!! We will see.

Chinchilla??...what do I do with it?

Where to start...my past 4 days in the ICU were...interesting...and quite sad as well...the one day when I came in to take over there was the cutest 4yo white bulldog/boxer mix with one ear that just stood straight up on its own and the other that flopped over. He had previously had surgery at his vet to remove a very invasive mast cell tumor from his left hind limb...apparently they had to remove half of the cranial tibial leg muscle...so the dog had went home and then continued to bleed from the leg, went back to his vet who took one look and said yeah go to AEC. Let me tell you about the mast cell tumor...compare it to an anaphylactic shock reaction in humans severely allergic to bees/peanuts...and that is what this tumor does in the dog....and when you go in surgically and muck around...it releases all the histamines, sets off the SIRS (systemic inflammatory respons sydrome) and basically affects all aspects of the dogs body...we transfused the dog two times and he was still dripping blood from the leg...so I talked with the owners and we decided to take the dog back into surgery to see if there was a vessel that needed to be ligated...when placing the dog under anesthesia he stopped breathing, but we got him intubated and then things were ok....however I called owners at that time to touch base and let them know he wasn't doing well...I get off the phone and all of a sudden I hear "code to the surgery suite"...so I run in there and see one of the residents up on top of the surgery table doing chest compressions!!!...oh great!!!...he is not responding, I get to make the phone call and owners elect to stop CPR efforts...sad...meanwhile, the owners of my other pet in ICU are visiting...this is a dog with presumed pancreatitis who was just not responding to treatment...he was taken into surgery for biopsies and explore...and now was severely hypotensive and not responsive...I had him on a dopamine CRI and still could not get a blood pressure reading...owners had elected to euthanize finally after 8 days and $6000...and as I was getting the solution I hear once again..."code to icu"...it was him, trying to die before we euthanized...so I helped him out...it was a sad night. Then Bubba the chinchilla walked in the door at about 2AM...I didn't evenknow what a chinchilla was going to look like before I walked in the room...he was really...cute?...but sick, lethargic, not eating x 2wks...so I took him in the back and it turns out he has really bad teeth that are malaligned and have sharp points on them which are cutting into his cheeks...ouchy no wonder he doesn't want to eat...so I got him admitted and we gave him pain meds, sq fluids, syringe feedings...and he turned into a little piggy...eating everything we gave him!! The other night I had a cat come in that had been straining so the owners thought it was constipated and administered a fleet enema....NEVER DO THIS....fleet enemas are toxic to cats because they contain phosphates which cause hyperphosphatemia and then hypocalcemia in cats...end up with a cat with seizures, trembling, cardiac issues....so I ran bloodwork and no abnormalities and since it had been 6hrs since the enema was administered the cat was lucky and probably the owner grabbed the one enema with no phosphates..crisis averted...ok but why the straining? Took rads because owner convinced of constipation even though on rectal nothing was in colon...rads showed no stool at all in colon....but of course if you go looking you are going to find something...GI tract was suspiciously knot-looking...could have been because of the large amount of intra-abdominal fat or dehydration...but hey not constipated...so instructed owners to go to their vet in am to re-take rads...then I did a UA because I really think the cat had a urinary tract infection...so I put him on some antibiotics and we will see. Then I have 45minutes let on my shift and in walks a pyometra dog (uterine infection) I know before I even put my hands on the dog...took rads, didn't see anything, placed ultrasound probe on belly - yup two large fluid filled uterine horns....talking with owner about surgery...he wants to try antibiotics and I say she is very sick, likely already septic...it is either surgery or euthanasia...surprisingly...he signs the estimate for...surgery...its a go...I say she won't go until later in the morning becuase she needs to be more stable first...so I walk back to fill out her treatment sheets and low and behold she is laying on her side...won't get up....start fluids and blood pressure is....unreadable....great she is now in decomensated shock....so I start bolusing both HES and crystalloids...finally get her up to 110 blood pressure and heartrate down from 180 to 130....ok....also started her on pain meds and antibiotics...so then I transferred her to the next icu doctor and that was that....treat and street!!! Now I am sitting around in my apartment obviously not studying like I should be...trying to think about things to write in my letter of intent and trying to figure out what residency I want to rank...

I think there's something in her eye...

So I ended up getting called in last night around 8PM to help out on the floor because one of the other Dr's had to go help out the surgeon in surgery...didn't get out of there until 1am. Saw some cool cases though. One was a torn toenail - that's not so cool, just sedation, rip it off, and then bandage it. Easy. Ok, second case was a weak cat...breath smells like renal disease...I get him admitted, run some bloodwork, and surprise...acute renal failure just like the cat I talked about in the last blog...BUN 387, Creat >13.7, Phos >16.1. Ahh yes, same story different cat. Call owners and say we should place a central line, urinary catheter, do abdominal ultrasound, urinalysis plus culture - and increase estimate to 2500-3500. They seem a little taken aback by the price (who wouldn't be!!!!) so I say that we can also keep as we are, rehydrate him, recheck his blood values after he's hydrated, and see if he is responding...if he is, then we probably should go ahead and do the above, if he isn't he probably needs dialysis...either way, gives them time to think and also allows us to see if he is going to respond before they invest all that money. So they decide to do the latter....I wish I could have stayed to take care of him...that is the worst thing about the triage floor...it's just "surf and turf"...you stabilize it and then boot it to ICU for the doctor there to take care of...I really don't like that...I like seeing my cases through, making the decisions on what to do next...oh well, someday. So my last case then was a dog that was squinting a lot, her eye was watering....I suspected either an ulcer or a foreign body in the eye...so I sedate and take a look and yep...little sliver of wood stuck right in her cornea...so I give a little more sedation, numb the eye with drops, and removed the little stick...then sent her home with topical antibiotics and oral antibiotics...oh yeah, and a referral to see the ophthalmologist the next day...I am not taking that chance!!! So that was my on-call shift..got out of there at 1am. But hey at least I get an extra $50 for getting called in....whoopee!!!

Hard Lessons Learned

Hi...first have to apologize because my computer crashed last week and so the 'Geek Squad' has been fixing it for me and luckily it is back and functional and have not lost anything that was saved....which is awesome because my paper info was all on there, pictures (which are non-replaceable). So work has been..weird..messed up...so I've come up with some lessons that I have learned these past 4 days while I was working in the ICU (which I love by the way...reinforced how much I hate the triage floor!!!). LESSON #1 : Life IS hard - deal with it...and if you must quit...don't burn bridges!!! So, we are down one intern starting next Monday...yep she is actually throwing in the towel and quitting. To be fair, she does have a couple health problems she is dealing with, however for the most part the main reason is because this internship is hard as hell, it was never what she wanted...so it seems weird that she would take it in the first place...but also, people are mean to her at the clinic, I have noticed this and it makes me really mad...she is a good friend of mine and I hate that people are always talking so bad about her...I think they are realizing now that we are friends because they say a lot less around me now about her...which is good because I don't want to hear their mean comments anyhow. I WILL still stay friends with her because she is so nice and we have a fun time when we go out. She is staying in Milwaukee to work, her boyfriend is finishing vet school at UW. BUT...despite that...I am irritated becuase the schedule is out thru Feb...and now it needs to be re-done...what that means is the rest of us will lose days off and end up working more, more on-calls....that makes me really irritated!! The schedule I have now was going to be perfect for allowing me to travel to different places to interview for residencies...oh well though...life goes on... LESSON #2: Do NOT drink and drive with your dog!!! Yeah, this is a very sad story. On my Sat. night shift in ICU, around 2:30AM we got a call from the Milwaukee Police Dept. saying they were bringing a dog in that had been involved in a car accident...hmmm...it of course was called as a stat triage...it comes back on the stretcher and it is this big, beautiful brindled bull dog...with no pulses, no heart beat, not breathing...DOA. So, I go out to talk to the Police officer...apparantly when they arrived at the scene the dog was found pinned between the front seat and the dashboard...he was breathing at that time but had blood running from his mouth, he started agonal breathing on the way to AEC and was dead by the time they arrived here. The worst part was the it was a mom's dog and her son had been driving drunk...who knows why at 2AM with a dog in the car...and crashed into a light pole. So the son was in critical condition, they did not know if he would make it...and I had to call the mom and tell her her dog was dead. That was a sad phone call - one of the hardest I have ever made... The thing that makes me cry is that the dog was probably so happy to be going for a ride in the car...and then he died because his owner that he trusts to take care of him was driving drunk!! Bad decisions, hopefully if the son makes it this will wake him up a bit... Please...don't drive drunk with your pets, and if you take them in the care...seat belt them up because they are no different than people... LESSON #3: When you leave for vacation - Hug and Kiss your pets as if you will never see them again...because you might not!! Two really bad, sad cases I have now had of owners that left on vacation and returned to find their cats dying. One was the blocked cat I discussed in an earlier blog. The other,another cute little girl kitty who the pet-watcher described as hiding alot and so she never really saw the cat alot. When the owners returned, the cat was under the bed, severely dehydrated, not eating, laying on it's side. She brought it to her vet who did some preliminary bloodwork and found severe renal elevations and so it was transferred over to AEC. My ternmate admitted the case and I inherited the disaster later that night when I came on shift in the ICU. The cat had acute renal failure...was more than 10% dehydrated (this is raisin-like for those who don't know), and had renal BUN of 386 (normal is less than ~27), Creatinine of 14 (normal less than 2.0) and Phosphorus of 27!!! (yes I kid you not!!! normal is usu less than 4-5). Oh my god...wait...it gets worse. The sodium was 190 (normal is around 140-150), chloride was 170 (normal around 120), potassium was 5 (this is high end of normal). The cat was started on rehydration fluids to try to both rehydrate and also to flush out the toxic high levels described above. It gets worse...with sodium and chloride that high, this means the blood is hyperosmolar (think of it as really salty) - what this means is that the fluid in tissues is then going to tend to go into the blood to dilute it....this is especially bad in the brain...so what the brain does (because the brain is oh so smart and really only cares about its own survival) it creates substances that make it hyperosmolar as well so that is does not lose fluid and still can get the blood supply it needs. OK, go brain...however enter me with my fluids....with a cat like this I want to push as many fluids as I can obviously because I want to flush out the toxins...but now I can't because I am adding fluids which will dilute the blood (which on one hand is good) but for the brain...now it has produced these substances that will stick around and it is matching the blood, the fluids I add then will tend to leak out in to the brain causing cerebral edema...shoot!!!...so now I have this cat who desperately needs high rate fluids, but I have to push my fluids slow because you must only lower the sodium and chloride by so much per hour to avoid fluid in the brain. So, I push fluids over ten hours, normally I would push over 4-6hrs...and recheck bloodwork shows the values are not dropping, they are in fact rising. Now I know I am not pushing fluids as fast as I would like but this cat is still on about 4x maint which is a lot...and which should still be working to bring values down. So something else is going on. I reassess the cat and find that after being on fluids now for 7hrs, the bladder is no bigger then when I first met the cat, and it has not urinate...uh oh...I told you it gets worse. The cat is not making urine. So not only does it have acute renal failure, it has anuric acute renal failure....this is bad, it means the kidneys are not working at all. There are medications we can give to see if they cause the kidneys to produce urine (diuretics) however in this severely dehydrated cat, that is not a good option at this time. We do ultrasound and kidneys have some fluid around them and some minor abnormalities, but otherwise nothing huge...the rads also show nephroliths, but this could be an insignificant find. So, I get on the phone with the owners and say that the cat is most likely going to be one that needs dialysis - thousands of dollars - owners say they will not do that... I say then we at least need to place a central line (catheter) so we can monitor pressure which will allow us to push fluids faster, and she needs a urinary catheter in so that we can monitor if she is making urine. I give them a really poor prognosis, they fight over the phone with each other and then decided to try this first and see if we can get values down. So that gets placed and another 4 hours go by and I am in with the cat as the techs have just drawn blood...I notice cat is panting so I am listening to it and HR is 110 (normal for cat is 180) so I have techs hook up an ECG and there are huge abnormalities...before bloodwork is even back I know that values have increased again just from my PE and my ECG....I am suspecting that potassium is now at such dangerous levels that it is causing abnormalities in the heart....bloodwork comes back and confirms my fears so I get on the phone with the owners and they finally decide to euthanize, they get out of bed and come in. And, that was one of the saddest euthanasias I have ever done...the woman was just bawling and wouldn't stop...sad. OK - lessons done, dont think I learned any more. Work was super busy this weekend..and of course Saturday I had the pleasure of an extra hour at work because of the time change...I ended up doing 18hrs on both Saturday and Sunday...so needless to say I just came home and crawled into bed and slept half of my first day off...now today I am on call...I try to ignore the mess in my apartment when I get home..by mess I mean things knocked off of every table and counter, napkins shredded, mail shredded, any other paper shredded...this would be courtesy of my cats who do not appreciate it when I am gone for 18 hrs in a row and they are very 'vocal' about telling me this. If not for them however, coming home wouldn't be half as great. They love me ( or at least this is how I interpret it!!!)...it is like a huge train in the house from the minute I walk in the door...me and then my two little shadows following close behind...they sit on the edge of the tub while I shower, watch me brush me teeth...webster even sits on my lap while I go to the bathroom!!! and then we all go to bed...Webster gets the left armpit and Patches the right. The funny thing is Webster has always cuddled in my arm, underneath the blanket with his head on my pillow. Now however, patchie is doing the same thing.... and they love to sit on the couch...webster will help me send emails...throwing in an occasional line of jibberish which I don't understand but which I am sure he is trying to say something important.!! OK, well, sorry I have been a way for a while as I have not had my computer. Hope everything is going well for everyone...hopefully no one has any snow yet!!! Can't believe winter is so close....smiles