depressing week

i think the emotional weight is starting to burden me already. that's a little bad, right? i guess i'll post more later, it's been too emotional lately to talk about it now. i need to get through this week and to my next rotation, then i can post ...

week 1 of neuro over and done with

week 1 of neuro over and done with
i thought neuro would be a scary rotation - just because it is -- well, brain surgery and all. at any rate, it's been a busy week. i had 2 interesting patients - one was really sad, the other has a good prognosis. i guess i'll talk about the sad one first.

on thursday, a lady came in with her 12 year old dog. big guy - oddly light for his substantial size. only weighed 60lbs, but he came up to my hip. some sort of chow/greyhound mix. he was a really, really nice dog - sweet-natured. at any rate, she came to see us because the dog recently had 2 seizures. no other clinical signs, just the seizures. the bad news was evident as soon as i heard the dog's history. 12 years old, no previous history of illness, sudden onset of seizures. no metabolic issues like hypoglycemia that could be causing seizures. there's 1 thing you think of immediately and that's brain tumor. typically a meningioma - as that's the most common brain tumor in older dogs. the woman was crying from the minute she started to explain the dog's problems to me - she barely got through 'he's been having seizures' before the tears started. she's really been struggling with this.

so a seizure is caused by a single neuron or a group of neurons in the forebrain that - for whatever reason - become overstimulated and start to fire. there are different types of seizures, ranging from brief absence spells, in which an animal or person just spaces out, to what used to be called grand mal seizures - but are actually tonic-clonic seizures. those are the biggies in which the animals are rigid, unresponsive, cry out, lose bowel and bladder control, and usually have post-ictal symptoms like disorientation, ravenous appetite, and maybe transient blindness.

so with that said, our biggest recommendation for diagnosis was first what's called a met check - 3 radiographs of the chest to look for metastatic cancer. for some reason, cancer in dogs loves to go to the lungs. if we suspect cancer, any type, we always look in the chest first. so we did our rads - and they were normal - yay! the next step in this case was CT scan of the brain. i was sure what we'd find. and sure enough - there it was - a big tumor, sitting in the olfactory lobe of the brain. probably a meningioma- although without doing histology, there's no way to be 100% sure that's the type. but it's definitely a tumor, and it's definitely big.

the owner was distraught, but i think she was prepared for it. the options for treatment are multiple - surgery followed by radiation, surgery alone, radiation alone, or palliative treatment (treating the symptoms without treating the tumor - steroids and phenobarb for the seizures). the owner is mulling over the options, but i don't think she has decided yet what to do. it's been an emotional couple of days for her. she came down from about 2 hours away and stayed in a hotel here while her dog was with us for 2 days. she was alone - and it made me feel bad. i can see why veterinarians get compassion fatigue. i felt so bad for her that i wanted to do something to help her - but there wasn't anything i could really do - except try to recommend a good hotel for her. it made me really sad for her.

i wasn't there when her dog was discharged and went home today. i had to be at school from 6:30-12pm, taking care of my patients. that patient wasn't going home till 3pm. i actually came back to be there, but the owner was running an hour late. i wound up going home and crashing into bed for 6 hours...wasn't the plan, but that's how it happened. it sucked, but i have to get away from that place sometime - as jim says, i'll burn myself out if i don't. i have to be back tomorrow at 7am to take care of my one patient left in ICU. that's my happy story - but i'll save that for later...

i had multiple other cases throughout the week - but my brain tumor patient and my little back dog have been the most interesting.

still kickin'

and tons to talk about - but it's 12:18 am. i got to school yesterday at 6:30am. now, 17.5 hours later, i am finally home. i have to go BACK to school in 6 hours. i was on my feet for 17 hours straight with cases - and i only have 5 hours to sleep before i have to return and care for my 2 high maintenance ICU cases...and 1 non-ICU non-high maintenance case...

hold tight, interesting stuff to come tomorrow - on my honor...

( i just realized how many numbers there were in that short short paragraph...here's another number -- 54, no - 36 - no 48...OK BEDTIME FOR ME)....

i'm suffering from acute idiopathic polyradiculoneuritis

not really, else i'd be paralyzed and very unhappy. that syndrome is also known as coonhound paralysis. it's a disease of dogs (particularly coonhounds - surprising i know) that is caused by some unknown toxin in raccoon saliva. it causes a rapid ascending motor paralysis. the end result of this is that the animal is totally paralyzed - respiratory muscles included. if supported on a ventilator through the crisis, they can recover. it takes a while, though. i'm just hoping one doesn't come in this week, because i'm on neuro emergency duty from 12am-8am on friday night, and if there is a ventilator case, i get to sit with it and monitor everything for 8 hours straight. yeah. i'm serious.

i'm totally serious.

my final grades:
LA ortho: A
SA ortho: B
SA ultrasound: A
Adv Imaging: A
Derm: A
SA Soft Tissue Sx: A

still left to find out is oncology... not that it matters, but if it weren't for SA ortho, i would have made straight As. i was a little surprised, i thought i did poorly on LA ortho and went down to a B. i was never concerned about small animal ortho. oh well...

anisocoria (that's pronounced 'gawd, aren't i stupid?')

we had an emergency surgery come in yesterday at 4:15pm. sucks, eh? on a friday afternoon. i didn't leave school until 7pm (and i got there at 8am, of course). at any rate, it was a dog with an iris perforation (or prolapse). this occurs usually when the dog has a really bad ulcer that eats all the way down through the cornea. the iris muscle can then pop out of the ulcer and hang around. not good, obviously. we went to surgery immediately to fix it. after it was over, dr m asked me to place some atropine in the dog's eye. atropine is a mydriatic/parasympatholytic. see, your pupils are under sympathetic nervous system and parasympathetic nervous system control both. when your sympathetic nervous system (from now on SNS) kicks in you have a fight or flight response. your heart rate skyrockets, you start to breathe fast, your muscles get more blood flow, and your pupils maximally dilate to let in more light for better vision. when you're relaxed, your PNS is running, and your pupils are constricted and small. well, atropine is a parasympatho-lytic drug, which means that it 'lyses' the PNS response. one result of this is that your pupil dilates. anyway, i put drops in the dog's bad eye, and went about my business. when i came home, jim and i had dinner, watched a movie. then i went to take my contacts out and was given quite a start. my left pupil was huge. my right was small and normal. it took me a minute, but it occurred to me almost immediately that i must have inadvertently touched my own eye after giving the drops.

i feel stupid because they warned us that this might happen and to be careful. and yeah, i wasn't obviously. last year, a student did the same thing. only she didn't come to the realization of what must've happened. instead, she saw a doctor and went through a score of tests before - midway through the testing, she realized what had happened. she was so embarrassed that she let the doctors finish the tests rather than tell them.

oh yes, unequal pupil size is anisocoria.

so i promised to talk about the dog with diaphragmatic hernia. but i'll start another post because alison has complained that mine are currently too long.

can we all say OW?

diaphragmatic hernia (can anyone say ow?)
so, 2 wednesdays ago - i was on emergency duty from 5pm-11pm. this entails hanging around the vet school, fielding calls from concerned owners, and taking emergency cases as they present. around 8pm, we were informed that a dog was coming in that the owner said was hit by a car (HBC, as vets refer to it). the owner said that the dog was stable.

when he came in, the dog was panting heavily but otherwise ok. no obvious trauma, broken bones, hemorrhage, the like. we took it back to ICU, and the panting steadily got worse. the dog was obviously in shock. it was pale, breathing rapidly, and weak. the internist tapped the chest for fear that the dog had a pneumothorax (breach of the chest cavity leading to air in the chest, loss of negative pressure, and lung collapse - called atelectasis). the chest taps were negative. we were exceedingly puzzled, as the dog was obviously in respiratory distress. pneumothorax is quite common after HBC. we tapped again, and the chest tap was still negative - on both sides. we should have known what was wrong immediately after listening to the heart. in a dog, the heart sounds are loudest on the left side and much more muted on the right. when we ausculted, the heart was on the right side, and nothing was heard on the left at all. we stabilized him as best we could and prepared to take him to radiology. as we were wheeling him down there a tech suggested diaphragmatic hernia. it was like a light went on - duh! of course.

xrays confirmed it, there was indeed a DH - and a bad one. DH is exactly what it sounds like. the sudden increased pressure in the abdomen (as a result of the car hitting the dog) leads to an explosive rupture of the diaphragm. this hole in the diaphragm allows things that should stay in the abdomen to rush into the chest like there's a party goin' on and hang out there. and that's what had happened. the stomach was all the way up to the heart and had displaced it to the right side of the chest. the spleen was up there too - whoopin' it up with the stomach. the xrays were impressive, to say the least. the stomach was filled with gas and bloated, so it was easy to see.

the dog, meanwhile, was rapidly going into respiratory arrest. he was most comfortable and could breathe most when he was held upright with his front legs in the air. we're guessing that the stomach fell lower when we did that, allowing him to breathe. my rotation mate, thomas, held the dog in this position for 45 minutes, while the owner decided whether to euthanize or precede with surgery. at one point, the dog stopped breathing completely, and we had to intubate him and bag him. very ER, i know.

the emergency surgery team was called in to work on the dog, and the surgery went pretty well. however, DHs have a very high complication rate - the highest mortality is within the first 24 hours after surgery. our dog was still kicking a day later, and we had high hopes for survival. unfortunately, he died 2 days later. the heart and lungs just aren't meant to withstand that kind of trauma. barotrauma and traumatic pericarditis are 2 reasons that DHs have such a piss-poor prognosis. the abdominal contents smash up against the heart and lungs, which are just not meant to handle pressure.

interestingly enough, dogs can be born with a congenital DH, in which intestines and organs slide in and out of not just the chest but the actual sac around the heart (called a peritoneal-pericardial DH). they can live years and years before some other problem necessitates xrays and someone notices the irregular silhouette of the heart and diaphragm. the traumatic ones are the baddies...

ps - avian species lack a diaphragm and rely entirely on their pectoral muscles to breathe. thus, when restraining a bird, it is crucial to not press down on their chests, else they cannot breathe.

so yeah, that's about all here for now. i'm going to look in the mirror at my normal sized pupils and enjoy feeling not weird.

what i've learned in 2 weeks

as my first 2 week rotation draws to an end, i'd like to take this moment to reflect on what small store of knowledge i've accumulated in that time. so here are my thoughts on the ophthalmology rotation:

1) eyes rock!

2) a properly prepared vet student should ALWAYS have the following on hand at any given moment:
-a pencil - because for SOME reason, clin path likes the order numbers for cytologies written on the slides with pencil only - everybody else looks at you like you're crazy for owning one
-a ball point pen - because you're writing crap down constantly
-a Sharpie - for all those blood tubes for which a pencil OR pen won't suffice
-a calculator for quick drug calculations
-a small reference card with all drug information written on it so that you're actually capable of calculating said drugs
-the small animal nerdbook - which while small - is surprisingly heavy - and if not properly counterbalanced will cause a definite tilt toward the side of the pocket where it is located
-a hemostat, because you just never know when you're going to need to pinch an animal's toes (for deep pain perception, not because pinching animal toes is particularly amusing)
-a leash - or two - which are worth more at the vet school than a million dollars - lay one down, and you will NEVER see it again. EVER. and if you do - around another vet student's neck, you'd better have DNA evidence to prove it was once yours
-a stethoscope - for taking rectal temperatures. doh. i'd hope you'd know what a stethoscope was for without me telling you
-bandage scissors - because what good hospital doesn't bandage it's patients? getting an eye exam? here - have a bandage! and somebody has to cut those bad boys off!
-post-it notes to stick all over everything, including your forehead so that you don't forget the 15,941 things you have to do in the next hour and a half before fluffy's owner shows up 3 hours early to take fluffy home
-your picture vet ID and your student ID so that you don't find yourself on emergency duty at 10pm, banging on the door leading to the courtyard, hoping desperately someone hears you and you DON'T have to scale the chain link fence, walk through the construction site (of the new vet school addition), and climb the other chain link fence to again reach humanity (or alternately, sleep outside for the night until the doors unlock at 7am)
-the mental fortitude of a triathlete. because - my god - you'll be in one treatment area with 15 other vet students, 7 vet techs, 2 vet assistants, 8 doctors, and 43 animal - all exhibiting some sort of neurological and/or dermatological and/or ophthalmological and/or critical emergency type problem (and i'm not just referring to the animals here). and god help you if you can't a) move fast b) think fast and c) locate things when you had no prior knowledge of either their existence or whereabouts. as in 'yes dr vick, i know exactly what an Oppenheimer-Weizelsteffen micrometer is - and i'll get it right to you' - and finally, do all
this with a smile so that you don't piss of a) your classmates b) the techs c) the doctors d) the techs e) the techs f) the techs - and of course, you have to do it while the building shakes because these last few weeks have been the weeks during which pile driving of huge, 100 foot foundation spikes are being driven into the ground, a mere 13 feet from the hospital and further, these weeks have been marked by 2 power outages - one lasting 7 hours (how exactly do we run a hospital without central power? you'd be surprised - you don't really need much light for ophtho exams).

SOOOO. anyway. it's been a great rotation, in all seriousness. and in all seriousness, i do carry all of that stuff with me everywhere i go. i think if i were to weigh myself, i'd be at least 5 lbs heavier with all my gear. it's pretty funny. especially seeing myself in the mirror.

3) i DO NOT like being the 'low-man' on the totem pole, so to speak. the outgoing 4th years (tomorrow is their last day) are still with us currently, helping us adjust to the clinics and learn how to do paperwork. and we have 3 especially nice 4th years with us - who obviously know more than we do about everything - and yet, i have a huge chip on my shoulder about anyone trying to tell me anything. i tend to get short and snippy when i feel like someone is explaining something to me that i already know how to do or find. and it's a really unattractive character trait. even though tomorrow is their last day, i'm going to try really hard to keep that chip hidden for the day. i really don't like it about myself.

4) i feel really comfortable in clinics - but that might change with rotations.
so my week - overall - was fairly interesting. i had 3 great cases, one very sad, one interesting and mystifying (i had a bunch of other cases, too - but none hospitalized - and more run of the mill cataracts and glaucomas and ulcers 0h my!).

on tuesday, we saw a jack russell terrier - 10 years old. his owner complained that he'd had a sudden onset of cloudiness and redness in his right eye. he came in on emergency, and i stayed to help dr m deal with it. interestingly enough, it was another anterior lens luxation -in which the lens in the eye comes forward and hangs out under the cornea. this lens had a mild cataract, so it was much more obvious than smoky's (see previous post). what made this case interesting is that first, the JRT was 10 years old. this is an inherited problem in these dogs, and they often have lens luxations. however, it's typically at a young age - and this dog was pretty old for it. but what made it really exciting was that the owner elected to have surgery to remove the lens. however, when we went to prep the dog the morning - we found a curious thing. the lens was gone from the front of the eye. when we looked in with a transilluminator, it became apparent that the lens had fallen back into the posterior segment of the eye. it wasn't "fixed" - it was just in a different location -one not amenable to surgery. we were quite surprised, as this is a little unusual (though not unheard of). we could see the lens moving around back there. it was pretty nifty to see. it's not the greatest thing, as its presence in the back of the eye could lead to retinal detachment, so the owner is watching the eye and is prepared to come back at a moment's notice so that we can constrict the pupil - in an attempt to keep the lens forward - and do surgery.

my next case that stayed in the hospital was really sad. we saw a young black lab (4.5 years old). he was massively fat and had difficulty breathing because of his weight. but no matter, that's fixable, right? when i did my eye exam on him, i saw a disease called anterior uveitis. this is a really impressive eye disease to see because it can make the eye really pretty and visually appealing. however, it is almost always indicative of systemic disease. around here, blastomycosis (a fungal infection dogs get by inhaling spores) is a known culprit. we were fairly confident that in a dog this age with the signalment (mild fever, feeling ok otherwise, anterior uveitis) that blasto would be our underlying cause. the dog was very sweet natured, but he did NOT like having his eye examined. AU is really painful - it's basically inflammation of 2 structures deep in the eye - called the ciliary body and the iris. all kinds of secondary changes occur in the eye, including something with the flashy name of iris bombe (pronounced bombay) - in which the lens and the iris stick together, making the pupil all funky looking. (See the picture). one of our first diagnostics was chest xrays, as these can locate fungal granulomas - since blasto likes to hang out in the eye and lungs. xrays obviously can find lung metastatic cancer too. but we expected blasto. we also aspirated the two GIANT prescapular lymph nodes that dr m found on palpation (that i missed because the dog was a spaz). guess what this sweet, only 4 year old black lab had? yeah. no blasto. cancer. everywhere. not only was it cancer, but the cytology on those lymph nodes came back saying that it was some kind of crazy cancer that the cytologist, who has been a cytologist for 30 years, did not recognize. they said it much more medical jargon-y than that, but that was the gist...

so that blew. a 4.5 year old dog.

my other case was ANOTHER lab with AU. but i'll fill you in on that one later.... right now, i have to study. as usual.