Wednesday, November 30, 2011

1 week left

My maternity leave ends on Wednesday, Dec 7, and I descend into the fray of veterinary emergency medicine once again. Currently, I am having very mixed feelings about this.

During my 3rd trimester, I was absolutely positive that I wanted to become a stay-at-home mother. The thought made me inexpressibly happy. Now, almost 9 weeks on the other side of my time at home, I realize that I would probably go mad without the challenge of my job. I love what I do quite sincerely. I also love being domestic - cleaning the house, fixing dinner, and the like. It is quite satisfying. I also cherish being home with my beautiful, sweet daughter.

Since I enjoy both things so much, I think being a working mom will be the best option for me.

ER medicine is a mixed bag for motherhood. While offering intense, long hours - ER medicine also offers long stretches of time off to enjoy with my family. I make more money than my GP counterparts, leading to less stress related to financial burdens. Further, despite some shortcomings that I have elucidated here, I have a great job in a bad economy. I'm thankful for that every day.

It's going to be a big adjustment. I know I'm probably going to miss things with my daughter. On the other hand, I hope to be a strong role model for her. I want her to grow up knowing that she can be anything she wants to be and still make time for a family. I also want her to grow up financially secure and to never have to worry about our finances. Growing up with 5 siblings, money was always tight for us, and early on, I worried a great deal about my parents' financial situation. I have carried this stress with me ever since childhood, and I will likely die with it. Hopefully, careful planning and saving will prevent Evaline (and our future children) from facing these worries.

T minus 7 days!

Saturday, November 26, 2011

How we differ from Dr Pol

So, I thought since Dr Pol is setting the perception of veterinary medicine back about 50+ years, I would explain how I am a different sort of veterinarian and how the clinic where I work is progressive instead of backwards.

Patients during surgery are availed of the following:

1) An IV catheter and IV fluids to help control and maintain blood pressure, as well as to administer pain medications, blood or plasma transfusions, and life-saving medications such as atropine and epinephrine.

2) Full anesthetic monitoring including oxygen saturation measurements, end-tidal carbon dioxide (very important), heart rate and rhythm, and blood pressure. Patients are monitored by expensive equipment but also by a technician that is making sure that the machine readings are believable. The technician assesses pulse quality, gum color, and heart rate and rhythm periodically by actually laying hands on the patient. This ensures that we know how are patient is REALLY doing - at all times.

3) Our surgery table is heated to ensure that patients do not lose too much heat during surgery. Anesthestic gases causes vasodilation and a drop in blood pressure. As a result, body temperature drops. Opening up the body cavities exacerbates this. The technician monitors body temperature and measures are taken when necessary to keep the patient warm.

4)Sterile technique is always observed. All surgical instruments are cleaned and steam autoclaved (sterilized) between patients. All patients are fully draped, and the surgeon wears a cap over the hair, a face mask, booties, and a sterile surgical gown. The technician wears a mask, cap, and booties unless assisting. The surgical room is used for NO other reason than invasive surgery (opening the thoracic or abdominal cavities).

5) All patients are intubated and hooked up to an anesthetic machine and ventilator. This way, respiration can be closely monitored and supplemented as needed.

These are just some of the ways we protect our patients surgically. Outside of surgery, we are just as meticulous. Patients receiving IV fluids are on IV pumps that control fluid rate. These are in turn monitored by the technicians to ensure that they are working correctly. That way no patient receives an overload of fluids, which can be fatal.

Patients with infectious diseases such as parvovirus or feline respiratory tract disease are isolated from the ICU in a separate ward. This is to prevent nosocomial infection, as well as to protect animals with compromised immune systems (as in parvovirus).

If a patient presents injured and in shock, permission to administer (cheap!) pain medications is obtained right away. Pain medications indicated for severe trauma and shock, such as a mauling, are opioids. NSAIDs or steroids are not proper medication for a patien in this condition. They are not potent enough, quick acting enough, and have side effects that can be greatly worsened by shock. Patients are also started immediately on IV fluids to stabilize blood pressure. Oxygen is administered as needed either via face mask or incubator/oxygen cage.

If a patient comes in with severe neurological deficits or other problems that cannot be addressed at our clinic, referral to the nearby specialty practice is immediately offered. If referral is declined, discussion of the options is initiated, and an informed decision made with the client's help.

Patients are never sent home in a state of heavy sedation or anesthesia. All patients are fully recovered and monitored before they are sent home with their owners.

There are a thousand ways I could compare us to show that we practice up-to-date, forward thinking medication. We use constant rate infusions of narcotics to keep our post-operative patients and very sick, painful patients comfortable. We utilize the most recently recommended treatments for a variety of conditions - including choosing our antibiotics wisely and carefully rather than placing all patients on them. Steroids are avoided in cases of shock and head trauma and used judiciously where indicated. We have an ultrasound machine, digital radiology (many human clinics do not even possess this technology), and a radiologist on call who can review difficult to interpret xrays. Our technicians are highly skilled and dedicated to patient care.

As a clinic, we work hard to offer our clients the most current and best diagnostics and treatments we can. We do not cut corners to save money. Yes, we're in it because we love animals. We're also in it because we want a job that matters, and we care about what we do on every level.

We're not all Dr Pol.

Monday, November 21, 2011

The Incredible (?) Dr Pol

Since I haven't seen a patient in weeks, I have no exciting stories to relay. On the other hand, I am curious as to how many of you guys are watching this National Geographic show? It is causing an uproar in the veterinary community.

If you follow my blog at all, you know I have a passion for high quality medicine, staying updated on current diagnostics and treatments, and generally practicing with compassion and integrity. I am passionate about being the best vet I can possibly be. I am also passionate about spreading the word regarding what veterinarians really do, how much training we undergo, how expensive our education is, and how important GOOD, competent health care is for your pets.

Thus, I am a little dismayed by the way the new National Geographic show portrays veterinarians. Don't get me wrong - Dr Pol seems like a compassionate, good man. He has been doing his job a long time. I am not bad-mouthing him. What bothers me is that he is very outdated in his methods.

Granted, this is a reality TV show. It is being twisted to portray things exactly as NatGeo wants them portrayed. I understand that. But when I see Dr Pol doing an orthopedic surgery (in this case, a femoral head osteotomy) without a cap, mask, or gown on, and minimal sterile surgical technique, I cringe inside. This is a major surgery in which the head of the femur is cut off. Infection is a very, very big concern. Further, this dog - undergoing painful, major surgery - was not even intubated or on anesthesia of any sort. Had this dog arrested during surgery, saving him would have been difficult to impossible without control of his airway and an IV catheter. There was also no evidence of any pain medication being administered.

This way of doing things is very, very out-dated and considered well below the standard of care.

So far, the show presents veterinarians in a very dismal light. In our clinic, patients undergoing surgery are on IV fluids, intubated so that we can breathe for them as necessary, provided with adequate analgesia, and absolute sterile technique is maintained at all times. Yet, Joe Average Pet Owner is unaware of this. Many owners see all veterinary care as equal. Dr Pol's show reinforces the idea that veterinary medicine hasn't advanced since the days of James Herriot and that we all do things in this "old school" fashion. The opposite is true.

Further, it reinforces the idea that all vets are in veterinary medicine strictly for the love of animals, that we practice substandard medicine that puts patients at risk, and that there have been no improvements in veterinary anesthesia and analgesia in the last dedcade. It's setting the perception of veterinary medicine back 50 years or more. There is no discussion of proper sterile technique, referral for complex cases, chemotherapy, digital xray, constant rate infusions (CRIs) for pain control, or any of the many, many advancements that have been made in all areas. We can do amazing things for animals, yet this show reflects none of that. For Pete's sake, I watched in amazement as he amputated a dog's tail in an exam room with minimal pain medication, no anesthesia, and NO sterile technique.

It's disheartening. Everyone loves "Good 'ole Doc." He's cheap, he's quick, and he's "old school." Unfortunately, old school doesn't usually benefit critically ill or injured animals. This was evidenced when he gave a nauled puppy a shot of steroid (absolutely NOT indicated in trauma anymore - in human or animal medicine) and left it in a cage. He described the dog as "in shock" - yet he provided no pain medications, IV fluids, or oxygen to stabilize the shock. He placed the puppy in a cage where it died. I treat this kind of thing on a daily basis, and a shot of steroids isn't going to fix a badly mauled animal. It was heartbreaking.

Anyone watching it? What do you think?

Friday, November 18, 2011

Important points

I thought this was a thoughtful article highlighting some of the things good veterinarians do.

Thursday, November 17, 2011

We're all still alive!

Being a new mom is exhausting, I'm not going to lie. Our daughter is going through a high need stage right now; she needs to be held constantly. She won't even sleep unless she is being held by me or beside me in the bed. The other option is being carried by my husband in our Moby wrap.

T minus 20 days until I return to work. I have some apprehensions about it, I won't lie. Thankfully, my husband will be home for the next few months. Hopefully that will make this transition easier. We shall see. Pumping breast milk at work is going to be interesting - given that my job is a lot of feast or famine.

In the meantime, I have Thanksgiving to look forward to - lots of family time with our new addition. The definite upside is that her grandparents always want to hold her, giving me a much needed break!

Friday, November 4, 2011

The skinny on chocolate (toxicity)

This is my favorite time of year, hands down. I love the holidays - especially Thanksgiving and Christmas. For the first time in more than 5 years, I have both major holidays off of work and will be spending them with my family! I am very excited about this. It will be unlikely to occur again for many years. Well, unless I get pregnant again soon and go on maternity leave that happens to correspond with the holidays.

One of the small things I love about the holidays is the abundance of candy. Starting at Halloween and continuing through the end of the year, chocolate treats abound. I'm trying to be **more** careful about these sweet treats due to my gestational diabetes and predisposition for Type 2 diabetes, but it's hard. Imagine then how hard it must be for a dog! They have no sense of "good idea or bad idea" - they only know that chocolate smells (and tastes) delicious.

Chocolate ingestion is something I see all the time in the ER. The numbers certainly go up around the major fall holidays. Thus, I thought we could talk frankly about chocolate toxicity here.

My take on it? Chocolate toxicity does not exist.

I say that slightly tongue in cheek. But not really. Let's first talk about why chocolate causes problems for dogs (and people who eat too much of it). Chocolate contains 2 important substances : theobromine and caffeine.

Theobromine is an alkaloid found in chocolate. It is a fascinating compound that has medicinal effects. One of these is the treatment of asthma, as it relaxes the smooth muscles in the bronchi, allowing bronchodilation. Caffeine is actually metabolized into theobromide within the human body. Theobromide leads to increased heart rate and vasodilation leading to decreased blood pressure. It can also lead to tremors, nervousness/excitability, and seizures at higher amounts.

In small quantities, theobromide is not toxic. This is why we can all enjoy chocolate deliciousness. However, in large quantities in people and in dogs (who metabolize chocolate more slowly), toxicity CAN occur.

The early signs of chocolate OD in dogs are vomiting, diarrhea, and increased urination (diuresis). As the amount of exposure increases, the clinical signs worsen leading to tremoring and possibly seizures. Death can occur.

Still, I have only seen a couple of severe cases - dogs with heart rates of 190-250. They responded well to fluid diuresis, mild sedation, and beta blockers to slow the heart rate. And I have seen one dog that presented for chocolate intoxication die. His death was sudden and inexplicable. It was a small chihuahua. His heart rate was very high, but he was alert and active. He had no other health problems. He was in his kennel, receiving fluids, barking his head off, and about to be sedated, when he suddenly and unexpectedly dropped dead. Resuscitation was not successful. I still have no idea to this day if this was really a chocolate related death or some other problem (underlying heart disease).

The vast majority of the dogs that eat chocolate do just fine with no treatment. It is massive ingestion that is worrisome. Also, the darker the chocolate, the more concerning. Pure cocoa is bad! Milk and white chocolates are barely worth concerning oneself over.

Rule of thumb? Apply common sense. If your 70 pound Labrador ate 1 snack size KitKat, he is not going to die. If your 70 pound Lab ate an entire bag of dark baking chocolate, a trip to the ER is warranted. The reason I say that chocolate toxicity "does not exist" is because it is very, very, very rare to see serious consequences as a result of chocolate ingestion. Most dogs just don't eat enough or the right kind (dark) of chocolate to have any problems other than mild hyperexcitability.

When in doubt, call your local veterinary ER - we are happy to talk to owners about quantity and toxicity. We do it ALL the time.