The new job

I went to my first staff meeting at my new job on Saturday morning. I was thisclose to not going due to the flu bug that I seem to be carrying. I find this HIGHLY unfair. Jim and I were sick not a month ago. Jim's dad thinks it's the flu, based on a phone conversation.

At any rate, the staff meeting got me really excited to start work. Wednesday, by the way, is my first day. I have mixed feelings. If I was well and had been able to unpack my house fully, I would be thrilled. Unfortunately, I'm sick and have only unpacked about 40% of the boxes. Not my usual style, and it's driving me crazy. I also need to buy 2 bookshelves, 2 dressers, a desk, and a cat drinking fountain. Illness has rendered me incapable of making purchasing decisions, so mostly, I just sit at the computer and stare at Crate and Barrel's website without being able to do anything about it.

Ahhh...the flu.

1) Driving
1) Cleaning
2) Painting
3) Painting
4) Cleaning
5) Washing paint off self and husband
6) Being extra super crabby
7) Taking my North Carolina State board exam (yesterday, went fine)
8) Fretting about decorating a house that feels too nice for us.
9) Breaking up unhappy cat fracases...fraci?
10) Having a sore throat and wondering if I've got the swine flu!

That's what I've been doing.

The sound of echoing

The loan has been approved, the title is clear, and on Monday, we will own our first house. Wow.

Our last rental house is bare and echoing. My best friend from vet school is here and helping clean and organize. The semi is almost completely packed and will be shipped out Monday. It shall arrive (hopefully) Wednesday or Thursday. Till then, we will be sleeping on an air mattress...in our NEW HOME.

The cats and birds are completely freaked out about the absence of furniture. Despite moving 11 times in 11 years, they have never adjusted to the hullaballoo.

We go home for a family reunion on Friday/Saturday, then return to Chattanooga on Sunday to pick up the traveling zoo, and then to North Carolina and our new home! It's going to be a long and exhausting journey with 9 animals, but at the end waits our house. OUR house! It's a very, very fine house.

Moving

We're in the process of moving. The semi arrives tomorrow. In the midst, I feel sick. Not sure why. Periods of lightheadedness/weakness/no appetite/exhaustion. I want to sleep all the time. It's great! Reminds me of the time I found out (belatedly) that I had mono while we were moving. It explained a lot. Of course, I am uninsured at the moment, since I opted not to COBRA my insurance.

We close on the house Monday (if no wrenches are thrown into the works...which is a big IF). Alright, no more procrastination.

Photo Essay: Tyrolean Traverse DeSoto Falls

We had a fabulous day. My husband and I joined my aunt, uncle, and children at DeSoto Falls in Alabama for the annual Tyrolean Traverse day. Click on the pictures to see bigger versions.

Not Superman, not demi-gods, just people...

First off, let me apologize for this post. This is a subject very near and dear to my heart. I've been trying to put this post together for several days, and it keeps evading me. I finally just sat down and wrote it. It's not very good, and it jumps all over the place. Perhaps after a few days, I will attempt to re-write it into something more coherent. Until then...

I've been reading several books lately (the latest is Overtreated, others I've read include Better: A Surgeon's Notes on Performance, Complications: A Surgeon's Notes on an Imperfect Science, and How Doctors Think). They have led me to a topic very important: medicine (human and animal) and its limitations. Ever since I started actually being a veterinarian, I have been undergoing a slow and painful awakening to my misconceptions about medicine. Growing up, I invested fully in the idea that doctors are semi-gods, capable of bringing disease to its knees and helping us all. I viewed medical technology and medical research as hallowed institutions - ones not subject to market forces and the whims of the pharmaceutical industry.

Then I became a doctor myself.

Now, I see medicine for what it truly is: a wonderful but limited ART form. Medicine has created many wonder drugs and done many amazing things, BUT medicine does not cure all. Medications are not the panacea for every disease (not what the pharmaceutical companies would have you believe).

Medical journals - once the bastion of ivory tower research - have now become largely written by researchers that are funded by pharmaceutical companies. One recent estimate put the number of researchers WITH CONFLICTING FINANCIAL INTERESTS doing research and writing literature for the Journal of the American Medical Association at 80-90%! Yes, you read that right. The great majority of the medical literature that doctors rely on to make medical judgments is funded by pharmaceutical companies that want to sell a drug. Veterinary literature is NO better.

On another, completely separate subject: how many of you think that every drug we use in life has undergone rigorous, controlled, randomized, blinded clinical studies before being put on the market? How many believe that these drugs are safe because the FDA says they are? Further, who believes that they all work as they are supposed to and that each new drug is a huge advance on an older drug that does the same thing?

If you answered yes to any of those questions, check out a brief rundown of the Vioxx debacle. I realize this is a Wiki article, but this information is verifiable through the AMA. I have read several of the studies myself.

How many of you believe that if your doctor recommended high dose chemotherapy followed by bone marrow transplant for breast cancer than it must work? That this treatment would only be recommended after extensive and rigorous studies?

If you answered yes: read this brief blurb about high dose chemo and autologous bone marrow transplants. Since that blurb was published by the NCI (in 2001) - this type of chemotherapy has been discredited as being no more successful for treating breast cancer than standard chemo. It was a horrible experience in the early days - with women being isolated for up to 3 weeks while they waited for their bone marrow to recover. During this time, they were sicker than you or I could probably ever imagine. Many women died from the treatment (although this can be true of any chemotherapy).

Other examples? There are a million...but it would take pages and pages to write them all.

Ahh. To delve into this topic with any amount of clarity and determination would take hours and hours.

My message: doctors and veterinarians are humans. We are subject to the same bias as the regular public. We are ordinary people who may or may not be able to read the published literature regularly and with a very studious eye. We are not gods, and medicine doesn't fix everything. Whenever your doctor or veterinarian recommends something - TALK to them about it, ask questions, do research, and figure out for yourself (with the help of professionals) whether that recommendation is a tried and true diagnostic/therapy.

Be an informed patient/owner. Know the medications you or your pet receive. Make sure your doctor/veterinarian is aware of them.

Remember: medicine is only as good as human beings themselves can be. We're all fallible, we all make mistakes, and most importantly: MORE medicine does NOT equal good medicine. Sometimes more is just more.

As a doctor, I am rapidly learning to view treatments and diagnostics with a discriminating eye. I try to keep up on the literature, to read it with discernment (although it's difficult to read 10 article, pick them apart, then go look up the researchers and find out WHO funded them). It is something I take very seriously. Just because a new technology or new drug or new test is available doesn't mean I should or need to use it on a patient. Just because I CAN order a CT scan on a patient with suspected cranial bleeding doesn't mean I SHOULD - especially if the owner is not interested in pursuing a craniotomy.

Just one more thing that makes being a doctor such a damned challenge!

If you take nothing else from this post, take these 2 things: the pharmaceutical companies are spending millions of dollars supporting doctors that in turn do research and publish articles in respected medical journals (JAMA, JAVMA, New England Journal, JAVIM). And second: often more medicine isn't better medicine, it's just MORE.

(As a sidenote: while Overtreated is riveting reading, full of spectacular examples, it is a poorly referenced book that seems rather sensational. It does - however - point out some ideas that are important to think about in regards to the sky-rocketing cost of human medical insurance/medical care and the medicalization of the American people.)

Interesting case numero dos

So, on my last night of relief, after deciding to head to surgery on my liver laceration dog, the scene as follows:

I'm sitting up front, typing notes frantically and talking a mile a minute to 2 women about their dog that managed to ingest a large quantity of chocolate. Mid-sentence, the code alarm goes off. I bolt from my chair, leaving them staring after me.

As I barrel into ICU, I'm faced with this picture: a 120lb Bernese mountain dog, laterally recumbent, non-responsive on a gurney. Techs are scuttling in every direction, gathering monitoring equipment, a laryngoscope, and drugs.

I check for a heartbeat and find a rate of about 180 (extremely rapid for a dog this large). Her gums are tacky and bright red with a slow capillary refill time (significant dehydration/shock). Blood pressure is low at 70/40 (normal should be around 120/60). Blood glucose is also low at 45 (normal 70-100).

The owner meanwhile is rattling off the story. On Sunday, this dog was seen at our clinic. The ER doctor suspected a foreign body in the intestines. A contrast study revealed a possible obstruction. The owners wanted to wait till Monday to take the dog to their vet for surgery. On Monday, the dog transferred. For some reason, surgery was delayed until Tuesday. When the surgeon went in, she found a corn cob lodged in the intestines. After 6 hours of surgery, it was out. The intestines LOOKED viable and nothing was removed. Now, it was Tuesday night/very early Wednesday morning -and the dog was non-responsive.

With a low blood glucose, low blood pressure, and significant dehydration, I suspected that the intestines were dying post-operatively (as happened to me recently with a linear foreign body surgery). I checked a lactate (a measure of tissues being deprived of oxygen). It was 4.8 (normal up to 3). This is elevated but not terribly.

I explained all this to the owner, and she understood. We talked about intestinal necrosis (death) and sepsis (overwhelming systemic bacterial infection as a result of the dying GI tract). I explained that I suspected this was going on and that - in all likelihood - a second surgery would be required.

The owner understood, signed the hefty estimate I gave her, and left her dog in my care.

For the next few hours, I worked on stabilizing the dog. I got her blood pressure and blood glucose up, as well as her heart rate down. Her hydration status improved. I was on the fence - go to surgery now or wait? As the only doctor in the building, I had no one to bounce my question off of...so I went back and forth, back and forth. Finally, I called the big wig ER doc and asked her opinion. She told me to wait until the dog was more stable. So I waited.

The following morning, her lactate continued to climb, and her shock returned. Surgery revealed death of the great majority of her small intestine. The surgeon removed 5 FEET of her intestines. Sadly, she died later that day.

I doubt had I taken her to surgery a few hours earlier, anything would have been gained. Sometimes the intestines are insulted too much to ever recover.

With my time, with my time...

What have I been doing with my time? So, I was going to work on the 4th of July, and then again tomorrow. That was until it suddenly occurred to me that I retired my Tennessee state license. Yup, as of June 30, I am no longer licensed to practice veterinary medicine in the state of Tennessee. So my days of working relief at RIVER are over. I am officially free as a bird until I start the new job (whenever that might be).

We're in a holding pattern house-wise. We'll know about our latest offer tomorrow at 10am. If it doesn't go through, then we'll go to Plan B. Okay, forget Plan B. I think we're officially to Plan Q, at this point. Whoever said this is a "buyer's market" is severely deluded. Yes, dear readers, you sense frustration.

I can't start setting up change of address forms, calling the electric company, water company, and Comcast until I have some idea of WHERE we're moving. We're in a complete and total holding pattern, and it's starting to drive my husband and myself up a wall.

I did have a lovely 4th of July. I ended up at the lake with my husband and internmate. We swam, bathed in the sun, and engaged in generally sloth-like behavior. Afterwards, we had dinner, saw Up, and then enjoyed the fireworks show downtown. For a day with no plan other than work, it turned out great.

Also, on the bright side, my husband is finished teaching his month long summer class, so he is free as a bird for the next year. He can work on his PhD thesis and actually have something of a life. He's been so relaxed the last few days, and it's been amazing spending unfettered time together. I'm sure in 6 months, he'll wind up finding a job - but at the moment, he's all mine.

As a sidenote to prove my nerdiness, I spent several hours today perusing my new Kirk's Current Veterinary Therapy. For those of you who don't know - it's a big fat book (costing over $100) that covers current recommended therapies for just about everything. It was a gift from the head of our hospital as a thank you for our hardwork as interns. It's a great book, and I'm in love with it. How's that for nerdom??

Up

I just wanted to pop in and recommend Pixar's new movie "Up" to anyone that hasn't seen it. I'm not generally a Disney fan, but I've really enjoyed every Pixar movie I've ever seen. "Up" however was beyond anything I've seen. It was beautiful, poignant, hilarious, stunning to watch (the animators outdid themselves), with a sweet, heartwarming (and heartbreaking) message. I cried several times. Given that I weep when lettuce wilts, that's not saying much. My husband on the other hand, who has cried exactly 3 times in the 16 years I've known him, had to bite back sobs. It's a tender movie with a lovely, haunting score. I cannot recommend it enough. I've seen in twice in 3 days. The previews do not really do the film justice, and they certainly give no real hint to the underlying premise. Go see it go see it go see it go see it. I PROMISE that if you hate it, I will personally mail you the $6-15 your ticket cost you. Scout's honor!

Ode

Yesterday was mine and my husband's 10th wedding anniversary. We spent a low key day together - a movie (Pixar's Up, which I can't recommend enough) and dinner at a pricey restaurant. Gift exchange followed and was lovely for all involved.

Mostly, my blog is about myself and my exploits as an ER veterinarian. This post is about him.

We met when I was 14. We started dating when I was 17, he was 20. We married 1 week after I turned 20. After 13 years together, 10 married, I have to say that I can't imagine loving anyone more than I love my husband. The following are some of the reasons why:

He still makes me laugh - even with corny jokes.
He has an enormous soft spot for tiny kittens.
He treats me like a princess, even if I don't always act like one.
He takes his teaching position very seriously and has a staggering work ethic.
He believes it is his responsibility to take care of me and has done so for the past 10 years (as a sidenote: I'm excited about my new fancy job allowing him to take a year off to work on his PhD thesis. I can take care of him for a change!)
He spoils me rotten.
He's intelligent, interested in the world around him, and loves a good discussion.
I never get bored with him.
He's the first person I want to tell any news - good or bad.
He makes me feel beautiful.
He always drives, even though he hates driving, because I hate it more.
He puts up with the 3 parrots that take up space, poop on him, and yell at inappropriate hours.
He loves children and will be an amazing father.
He is truly the best person I know and my best friend.
Our sex life is still amazing.
I fit against his side perfectly, so sleeping together is perfect.
He always lets me pick the side of the bed I want to sleep on and takes the other.
He does dishes without complaining (and I hate dishes).
He loves his family and my family.
He doesn't criticize me, is slow to judge, and quick to forgive.
He sees the best in people.
He is my family.

To you, husband...all my love, for all time.

Not with a whimper, but a bang

My "last" night at RIVER was exactly as I imagined it would be...crazy.

I say "last" because I might be picking up relief shifts here and there during July to pad the old bank account. On the other hand, I might just decide I'm finished and give myself 2 weeks off before the moving (?) fun commences. We'll see. I have a sneaking suspicion I'll be working.

Last night was unbridled chaos. Case of the night is as follows:

A cute, 1 year old female spayed dachshund/corgi/bassett mix presents for a 1 hour history of ADR. The owners reported that she was unusually lethargic. She was outside, in a fenced yard for several hours, and when she came in, she just wasn't herself.

When I saw her, she was quiet but responsive. Her gums were pale, and her belly was mildly distended. Otherwise, she was normal. Her abdominal xrays were strange. She had a loss of detail on xray (usually meaning free fluid in the abdomen), as well as a collection of gas bubbles up near the liver/head of the spleen/stomach. The radiologist's best guess was a liver abscess. I ultrasounded her to find a moderate amount of hemorrhage in her belly but no clear source.

I was perplexed. Why was a 1 year old dog with no history of trauma bleeding into her abdomen? Clotting times were normal, so rat poison was out. I gave the owners the options: wait and monitor, if PCV starts to drop/hemorrhage worsens, go to surgery or go to surgery now. We chose the wait and see approach.

At 4am, after fluids to stabilize her and rehydrate her, as well as injectable opioids and acepromazine...her heart rate was still 180 (very high). On a whim, I checked a lactate. I was stunned to find it was 10 (normal up to 3). Lactate is an indication of anaerobic metabolism (no oxygen). When elevated, it often indicates that somewhere in the body, some unlucky organ is suffering hypoxia (lack of oxygen) and switching to anaerobic metabolism to produce energy. I called the owners and told them I was going to surgery to find out exactly what was going on in their dog's belly.

To my surprise and displeasure...my patient had somehow managed to lacerate one of her liver lobes. An enormous blood clot was sitting on top of it. After examining it, I decided a partial liver lobectomy was in order. Terror set in. I'd never done one of these before, and OF COURSE, it was the hardest liver lobe to access, as well as being closest to the vena cava. Two and a half hours later, and a massive amount of sweat, adrenaline, and near wetting myself terror later, the lobe was out, and my patient was recovering.

Today, her lactate is 1.4. She is eating, drinking, and urinating. In another 48 hours, I can call this surgery a success. Until then, I will not relax.

And I'm left with this question: how, precisely, does a dog manage to lacerate JUST its caudate liver lobe without a single bit of evidence for external trauma?

Second interesting case of the night to come later!