Thomas

There are certain patients and clients you know you’ll never forget. Some cases that almost haunt you, arising from the subconcious on a whim. Little reminders seem to be hidden in tiny corners and crevaces of every day life. Whether its meeting a person or horse with the same name, diagnosing another patient with the same disease, or even sitting at AAEP lectures with the topic being similar in nature…a horse with a similar disposition, or sometimes just a single word on a billboard. It seems just as time has gone by, there is a reminder somewhere that brings the memories trickling (sometimes flooding) back.

This is the story of Thomas, one of the cases that for many reasons, I will not forget.

I first met Thomas in January for a routine dental and vaccines. His owner, Emma, had been referred to me by the practice that performed his pre-purchase exam only a month prior. His PPE had gone smoothly with no significant abnormalities found during the extensive work-up. The owner wasn’t able to attend this first appointment, but the trainer was present. She lead the handsome young gelding into the washrack. Just watching him walk into the washrack, I could see incoordination and exagerated gate in the hind end. His hind feet were parked oddly out from under his body, with his front feet almost ontop of one another. He stumbled and stepped on himself multiple times in the 5 minutes I spent observing. He had a slight head tilt to the left and the left side of his lower lip drooped. The nature of the appointment instantly changed, with the focus turning to neurological examination instead of a routine dental.

The findings of the neurological exam revealed cranial nerve deficits, especially noteable on the left side. Facial nerve paralysis, the head tild and decreased pupillary reflex times were the most significant CN abnormalities. On dynamic assessment, he had a grade III hindend ataxia and grade II bilateral forelimb ataxia. He had assymetrical muscling of his gluteal muscles, with the right being much more extreme than the left. He had marked weakness during the tail-pull to the right, at one point he almost fell over. Given the cranial nerve deficits and generalized ataxia, we decided to rule out a top differential of EPM. He had neck radiographs taken at the PPE, which after second review, were normal. No traumatic events were in his history.

His EPM titer results came a week later. The titer levels were high, indicating a 95% likelihood that his signs were attributed to EPM. We moved forward with a standard treatment protocol of daily Ponazuril and Vitamin E. In a month, we would return for a recheck neurological exam.

We continued the Ponazuril another month, during which his imrovement plateaued. Emma, opting to give him every fighting chance, elected to try another EPM medication called Protazil. After a month on the protazil, his recheck exam found significant improvement. His neurological signs had improved enough that now a right hind limb lameness became apparent.


5 months later

Now 5 months after diagnosing the EPM, with most of his facial nerve and ataxia signs resolved, we moved forward with his routine care. His vaccines and dental went without complications and he continued to receive his bodywork and acupuncture. I’ve held some skepticism in thepast, but the bodywork and acupuncture had a profound effect on his physical and mental state. He looked brighter, moved easier and the right hindlimb lameness was resolved.

A month later, I received a text that he had relapsed. The same day, I went out to exam him,. He was dull, quiet and his neurologic abnormalities at returned worse than before. After heavy consideration, Emma made the difficult decision to let him go. Unfortunately, for insurance to cover the costly treatments and reimberse for all the money spent, a necropsy at a certified facility had to be performed. I won’t name the insurance company, but I will say that how all the details were handled was grotesque. The insurance company required that Thomas’ necropsy be performed with 8 hours of his euthanasia. Since the only lab near by was 6 hours away, and since Thomas was not safe to transport, it took detailed coordination between all of us to meet the time constraints. In the veterinary field, you develop a way of talking about these things in a tactful, professional manner. I have never had a client involved in the details of this process, and honestly, I had never been involved in planning such intricate, time senstive logistics. The whole process was heartbreaking and gruesome for Emma, a nightmare for anyone whose beloved companion becomes an object, entity or commodity to company policies. I admire her and all of the strength she clearly showed through this painful process.

To meet the time constraints and laboratory hours, we had to euthanize Thomas in the middle of the night. After working that day, I set my alarm for 12am so that I could make it to the barn by 1 am. His transportation (provided by my assistant) would deliver him to the lab between 7 and 8 am. I set the alarm, just in case…but I definitely did not sleep. I had discussed his case with multiple internists, researched novel treatments so extensively that anytime I went onto google, it asked if I wanted to search new research in EPM. Although I was confident in my diagnosis and that the treatments we had done were the present gold standard, there was still that little voice whispering “but maybe…”

We arrived at the barn just before 1am. We placed the catheter, sedated Thomas and lead him out of the barn. Fog had crept in and it was starting to rain. Then, it started to pour. I remember the syringes being slippery, and all of us squinting through the beams of the headlamps as we laid him down under using anesthetics. He went down gently onto his side, deep in a sleep state, before Emma gave the gesture to give the final injection. Within minutes, Thomas was gone.


Answers

It was 2 weeks before the necropsy results came back. The trouble with EPM, is a definitive diagnosis is not always possible even with necropsy and microscopes. The chances of identifying the organism, especially after months of treatment, becomes slim. My fear was that the necropsy would not identify the organism anywhere, and determine the cause of his neurological disease indeterminant. When I read the results, my heart sank. No EPM organisms had been identified on necropsy and histopathology. But down, at the very bottom of the extensive report, a note said that the abnormalities found in the spinal cord were consistent with those seen in EPM.

We had all reached a point where we wanted answered. We wouldn’t get the answers as to why he suddenly relapsed, or why he didn’t respond to treatments like some horses. EPM, the heartbreaking disease that it is, can do anything at any time…making it a challenge and yet another disease warranting further research.

We did not get the answers we wanted, but we did get the answer we needed.

At a horse show a couple weeks ago, I ran into Emma. We small-talked a little, and she hugged me before we parted ways. She expresed sincere gratitude for my efforts. She said one day she might look at bringing another horse into her life, but that she isn’t ready. I returned the hug. Sometimes, at the end of it all, that’s all you can do.


Click here for information on Equine protozoal myeloencephalitis (EPM)


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When we cannot save them all, but we can save some

Like many rescues in the area,”Starfish Rescue” used to rotate through all the local vets. Almost as if going through phases. Before I eve stepped foot on the property, I was warned ahead of time. One, their bill is outstanding at over $5,000 owed. Two, overcrowding. Three, don’t be surprised if compliance is low. Four, don’t get sucked in.

My first time arriving at the rescue was in response to a horse that was down and seizing. We never determined the cause, and he never seized again. My second visit, months later, was to recheck a laminitis case that my colleague had seen a couple of weeks prior. The mare had recently had her feet trimmed, and Maureen (owner of the rescue)reported the mare was still having difficulties walking. It was difficult to focus on the laminitis over the glaring neurological deficits. After a full neurological work-up, EPM was at the top of our differential list. With titers returning at >3500 with two subspecies, we felt comfortable with the confirmed diagnosis and began treatment.

Over the next couple months, I attended several more emergencies at the rescue. Sick foals, colicking mares, face wounds, terrible leg wounds, even a sweet gelding hit by a car…cases I will never forget for both good and sorrowful reasons. And trying to make a difference, while balancing financial constraints with high quality diagnostics/treatments means a lot of advanced diagnostics went under the radar. With a limited budget composed of donations, it is a different challenge all of its own trying to negotiate and prioritize which horses to treat and which horses could not be saved…especially when the rescue’s conviction stands behind saving them all.

Early on, my recommendations based on poor prognosis (septic joints, fractured joints) was unheeded. It would take weeks for the rescue to come to the same conclusion, with the euthanasia being performed by the same person who picks up the horses afterwards. A bullet to the skull can be an effective form of euthanasia, but when it goes terribly wrong, it can be one of the most inhumane ways.

6 months in, and I have earned their trust. Early on, I would have to defend every diagnostic, medication, treatment protocol and justify quality of life concern. Now, not only am I greeted with open arms, but their compliance with my instructions and view of my professional opinion, does not waver. It is amazing what time (on and off the clock), patience and a whole lot of energy can do for a relationship, especially a professional veterinary one.

There have been cases that tugged my heartstrings, and cases that I spent night after night attending. We have lost some horses and saved some horses, but with every horse, we have always tried our best. It was some of these strange cases that I further expanded on my skill set, performing joint lavages and regional limb perfusions. With money a constant wall we are up against, I’ve put in many calls to specialists and board certified surgeons/internists. I am thankful for both their time and energy, and the helpful advice that has led me to treating cases in unconventional, yet successful manners.

So, although I didn’t know it when I showed up at Starfish Rescue the first time, it would come to be one of those places with some of the most sincerely compassionate people I have ever met…and something I have wholeheartedly become thankful for this year. And it reminds me of medicine in general, that we cannot save them all, but we can certainly save some.

Case of the Mondays

Like most things in life, do something long enough and often enough, and it gets easier. Drawing blood, placing catheters, passing a nasogastric tube, suturing…do it often, with a goal of doing it well. Then, there comes the added benefit of confidence. And there’s no better way to appreciate a skill, than to have acquired it and then lost it. About halfway through a “typical” day, I was made aware of those skills I take for granted.


BAL Gone [every kind of] Wrong

It started with performing a bronchoalveolar lavage on a gelding with intermittent coughing over the past year which fluctuated with weather, exercise and environment. With non-specific findings on ultrasound, we proceeded in our diagnostic plan to determine the nature of the cough. We elected to retrieve a non sterile sample from the lower airways to evaluate for RAO and IAD. I’ve passed an endoscope countless times, and performed it successfully and easily enough that I consider it at acquired, reliable skill.

By the conclusion of the BAL, I felt like I had rehearsed for a performance demonstrating everything that could not go right. The highlights of this performance included:

  1. BAL tubing hit the ethymoids, causing a profound nosebleed
  2. Projectile, unrelenting spraying of clots across self, assistant, owner, trainer and three innocent onlookers
  3. BAL tube entered the esophagus, rather than the trachea
  4. BAL tube retroflexed and came out the oral cavity
  5. BAL tube severed by teeth when traveling through the oral cavity
  6. BAL tube #1 ruined, retrieved BAL tube #2
  7. BAL tube positioned correctly in trachea, cuff would not inflate
  8. BAL tube #2 leaky cuff confirmed
  9. Continuation of #2 problem (Projectile, unrelenting spraying of clots across self, assistant, owner, trainer and onlookers)
  10. BAL tube in position, cuff inflated, saline injected in…unable to collect any saline
  11. Added more saline through tubing, retrieved <40 ml

I was relieved when the whole thing was done. After all the above complications, at least the sample was collected and submitted. What else could go wrong? Then, I got the lab report stating:

Sample has insufficient cells, inconclusive. Recommend collect second sample for analysis.

This was just the first appointment of the day.


Miscommunications, mistakes, mishaps and misfortune

When not a soul could be found at our second appointment, I called the owner. Turns out, the appointment had been rescheduled to the following week…news of which, didn’t happen to make it to today’s day schedule.
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Our third appointment canceled.

Our fourth and fifth appointments had the wrong addresses (showed up at a neighbor developement and then mistakenly went to the owner’s house instead of the boarding facility).

Collected the wrong blood tubes, forgot to dispense a medication refill, double-charged on an invoice, made at least 12 U-turns…

And the cherry on top? At 6pm, as we’re wrapping up at the last appointment and about to begin our 90 minute drive home through late rush hour traffic…my assistant hesitantly asks,

“Hey, have you been having problems with the gas gauge?”

I hadn’t. No one had. About 4 minutes later, the thing we were dreading came to fruition. We ran out of gas.


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Newest Vet on the Totem Pole

Whenever I become frustrated while learning and improving upon particular skillsets or techniques, especially when my progress isn’t meeting my expectations, I think of a specific phrase to provide perspective. Every vet was a new vet at some point. The only way to get 10 years of experience, is to spend the 10 years gaining experience. It goes without saying that no vet was born with a doctorate straight out of the woom. Any expert, instructor, teacher, trainer, mentor etc…was at some point, a beginner themselves.
While sometimes I feel TOO aware of where my inherient new grad weaknesses are, itwwould not be safe for me to assume my boss and more seasoned colleagues are just as aware. There have been times when I have had appointments put on my scheudle that I had absolutely no or an insecure amount) aof experience performing or even interpretting. For this reason, the seasoned and invested colleagues of the practice are worth their weight in gold.
I’ve been an associate at my first “serious” multi-doctor practice for a little under a year. Soon, my one year employment contract will be over and I am already looking ahead to negotiating the contract for the second year. To be hoenst, I was in sucha pinch to find a new job after leaving my first private practice job, I did absolutely no contract negotating. I will say this is “new vet” lesson #1. Coming in as the new vet does not mean you “Take what you can get” and certainly doesn’t mean that you’ll have to tough it out with a “pay your dues” themed contract. To any “new vet,” my first recommendation is to negoatiate and not just settle for the minimum.

The lessons learned over the past year are countless, but I put together a list of the more prominent lessons, surprises, realizations and adversity I faced in this first year, in the context of a new graduate and new hire. Every practice is different, and maybe some of my list is unique to my practice…but worth sharing regardless
  • Desire to “prove” yourself is natural. But proving your worth does not mean you have an inherent labor or favor debt to other associates.
  • Case-pushing and dodging. You’ll get the bottom of the barrel for cases and clients. There were clients and patients that other vets refused to see once I was around. Clients that wer rude, inappropriate, didn’t pay their bills, used other vet practices interchangeably and sometimes even notorious patients (mean, dangerous, feral). Whatever cases other doctors wished they did not have on their schedule, would end up on mine.
  • Opposite of case-pushing, is case-nabbing. These tend to be new clients that would contribute to a strong clientel of an already established vet. On multiple occasions I had new clients who were put on my schedule for gastroscopies (or other advanced diagnostics/treatments) but several days later suddenly appeared on a different doctor’s schedule…for no reason, with no discussion.
  • New grad and new vet double wammy. I have lost count of the number of times I arrived at an appointment and the first thing clients commented on was my age. Most commonly something along the lines of “Aren’t you a little young to be a doctor?” or “You must be the assistant. When does the doctor arrive?” There are also the demeaning references based on the gender and age included calling me girl, missy, little lady, youngin, gal, or refusing to address me as doctor.
  • Skepticism. Yeah, you may be absolutely right on your diagnosis and treatment recommendations…but for it to be legit, you’ll need the backing of another associate that you’re doing the right thing
  • The interpersonal dynamics of the practice alone have been difficult. The biggest difficulties have been when staff refuses to show the same amount of respect to the new doctor (especially if they are outgoing, kind and amiable) as they do the senior vets that are hard on staff.
  • Favors. That can become a slippery slope when the staff finds out the new vet will not be so protective of their time and feel too guilty about charging for services. I did a dental for a staff member who had one horse, and I did not charge for my time. Another vet in our practice would’ve charged 300 compared to my 75. Word got around and suddenly I was at the beckoning call of every staff member who owned a horse. This is a great way to fill your schedule and prevent you from getting actual cleints. This is also another way to end up getting called for emergencies for staff animals when you aren’t even on call that night!
  • Establish your professional and personal boundaries. A favor is simply that, and no one is entitled to favors.
  • You’ll do things different. You’ll get called out on it by non-vets. I had an assistant argue with me about passing a NG tube up the wrong nostril. I always pass on the left so I can see the tube go through the esophagus for visual confirmation. Apparently all the other doctors tube on the right. The assistant telling me I was doing it different, and not like all the other vets, seeded an unnecesary amount of anxienty and fear in the client…while also undermining my professional knwoeledge and abilities.
  • Don’t take it personally when you meet a colleague’s client, establish a great rapport, save their horse from a critical emergency….then see months later that they insist on sticking with your colleague for upcoming dentals, vaccines etc. Don’t assume that this is because you did something wrong. Don’t underestimate the bonds between your colleagues and their clients.
  • The learning curve is steep but you don’t have to do it alone.

the Vet’s Assistant

The idea of having a vet assistant in the field was obscene to my first employer. She viewed them as an unnecessary (and even impossible) expense and liability for any solo practitioner. Whether it’s for the similar reasons, most vets in the area do not have assistants. I remember reading an AAEP article back in vet school, which discussed a multitude of reasons and scenarios in which it does pay off for a solo practitioner to hire a field assistant. I remember reading the article, never having seen an equine vet with an assistant, and thinking what a luxury it would be.

Then I hit that job lottery, the place I work now. It’s not that assistants are merely an option, but that taking assistants in encouraged…and there is the obvious list of reasons. There is also the not-so-obvious list of benefits and rewards that come with having a comrade out in the field.


Teamwork Makes the Dream Work

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DVM 360 has a recent article about this very topic, called Equine vet techs deserve a seat.

Our assistants are wonderful, and with individualized training, their potential is endless. The basic responsibilities in our practice include managing daily truck inventory and restocking, manage truck maintenance/repairs/cleaning, cleaning/maintenance/trouble shooting of all equipment (xrays, ultrasound, endoscope, dental equipment etc), cleaning/organizing/packing up for all appointments, horse handling (some vaccinate and draw blood), processing in-house lab work, uploading all digital imaging/lab results, help manage schedule, driving (allowing plenty o time to SOAP and invoice for the doctor) and so forth. With the help of the assistant, I can do 3 dentals in the time it took me to do one alone. I easily see three times the number of appointments in a day with how our team works.


Unsung Heroes in the Field

But aside from the logistics, there’s the other advantages…company. It’s a lot of hours in a truck most days (2-3 hours of driving usually, sometimes up to 6 for a day with ERs and appointments). You can’t put a dollar amount on good company, especially on long exhausting or stressful days, where you have someone who was with you for every moment of it. It’s both a professional and a personal bond. Comic relief, podcast discussions, small talk, singing along with the radio, reviewing cases we saw that day, an ear to listen, or even just the feeling that you’re not alone taking on the world of equine medicine. Not to mention the safety…unfortunately, not all owners are as skilled at handling their horses as we would hope. There has been many a time (and more often than not) that the situation becomes significantly safer by having the assistant handle the horse with special restrain techniques, or even just positioning for exams/flexions/nerve blocks. I remember coming back from an ER at 3AM, after a full day of work, and rolling down the windows singing at the top of my lungs trying to stay awake on a windy back-country road….I came close to falling asleep at the wheel multiple times, and am very thankful I haven’t had to do that again.

And for everything they do, the things doctors expect, appreciate and need….there is an endless list of all the unseen, unmentioned ways that they support us on a daily basis. Being a veterinarian, you face challenging, humbling, heartbreaking and gut wrenching experiences…and experience equally rewarding, uplifting and inspiring moments. It’s those rewarding experiences that give me the feeling of happiness…and the only thing that makes that happiness even greater, is when it’s shared with a teammate.


Thank you to all the veterinary assistants and technicians who remain unsung heroes in the veterinary field. Whether you’re in the exam room, surgery suite or field, the wonderful aspects of vetmed would not be nearly as wonderful (or even possible) without you!

Luckiest vet in the world


The hostile work environment, professional sabotage and unethical veterinary practices I faced at my first job as an equine practitioner in private practice made the first 6 months a living hell. After working over 100 hours per week, my boss’s vengeful decision to “punish” me by withholding my paycheck, brought me to the breaking point. Against the advice from my family, and with the support of my friends and colleagues, I quit my first job without a 2 week notice. If having profane names yelled at me wasn’t enough, my boss then told me “I know all the vets in this area. You’re never going to be an equine vet in this state.”  My assertive response was “Not you, or anyone, will ever stop me from being an equine vet.”


2 months later

By October, I was hired as an associate at a multi-doctor equine private practice that not only has a phenomenal reputation and rapport with the equine community, but also has a “work family” atmosphere. Although I knew my previous job was horrendous, I didn’t realize how terrible it was until I started at my new job. Better hours, better pay, respect, benefits (health, retirement), mentors, the opportunity to be my own doctor, strong support staff, emphasis on the highest standard of care, safe/reliable work truck…for the first couple months I felt like it was too good to be true. I was waiting for the facade to come down, but now 6 months into my new job, and this is sincerely, genuinely the wonderful place I work.

 

The only negative/downside? My goal was to spend 3-4 years at my first job before moving to Colorado for a “dream/forever” job…and there is a little part of me that thinks darn, I found my dream job already and it happens to be in the wrong state.

 

And if that’s my only complaint…I may be the luckiest vet in the world.

Facing the Repercussions

To really understand this post in context, you’ll need to understand the backstory. If you haven’t already read the predecessor to this entry, I highly recommend it.

In order to make an employee’s last two weeks a “living hell,” Dr. Cray gave the office staff and myself her decree to engage in work-place warfare. My last post left off at a pivotal moment. I accepted the reality of the work-place situation and the brutal truth about my boss’s nature. Then, I did the thing I should have done months ago. I spoke up. I refuse to make someone’s life a living hell. And from that point on, the work-place is becoming my living a hell.


My Redefined Role and Responsibilities

Everything but a Veterinarian

Unable to hire new employees, the office was severely understaffed. Now, instead of seeing appointments in the afternoons, I was assigned to the front desk as a receptionist. This is when I began to struggle, both personally and professionally. And the troubles didn’t stay at work. With only two other employees, Dr. Cray’s started singling me out. She became uncharacteristically kind to the other two office personell, bringing them gifts each morning and asking about their weekend. When she turned to face me, she snap at me to go clean her instrument tray from the ER last night or go count the vaccines in her truck. Everything became a test or barrage of rapid-firing questions (to which some of the questions were about patients I never saw, prescriptions I was never involved in, or billing accounts that were from 5 years ago). She seemed content if I did not know an answer, and became vicious when I did. She took to devaluing me in front of clients and other employees.

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Within a couple weeks, she allowed me to see appointments only 1 day a week. When clients requested appointments with me, she told the office to tell them I wasn’t available…little by little, I watched the only benefit to my job dissipate. Veterinary experience, the only thing worth staying for, was slowly replaced by my new duties which included:

  • Restocking supplies, tracking orders,
  • Create and maintain inventory system
  • Truck inventory, maintenance
  • Manage all social media accounts
  • IT for all office equipment (phones, computer, scanners, fax, internet)
  • Invoicing
  • Equipment maintenance
  • Barn tasks (feeding, stall cleaning, turn-out)
  • Yard upkeep

Veterinarian turned Receptionist turned Detective

All those hours I put in at the front desk paid off. In an attempt to fully analyze the situation, and come up with a plan…I started gathering intel. When the UPS guy saw me up front, he said he wouldn’t bother learning anyone’s name because no one sticks around long enough for it to be worthwhile. Thanks to the UPS guy, I started looking for more information about the previous associates. I remembered she didn’t order me business cards for the first 2 months in case I was going to quit. She said she’d spent too much money on wasted cards. After looking into the business card order history, what I found was startling.

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Over the past 10 years, 9 associates were hired, and of the nine associates not a single one worked for Dr. Cray longer than a month. No surprise there! I also had mixed emotions about what this said about me. Obviously someone with a healthy amount of self respect would not put up with or stay in this type of environment. I don’t like to quit, and I will endure, endure, endure. Although I gave myself credit for getting through the last four months, I also had to change my way of thinking. I’m not here to endure. My goal and aspirations are not to endure life, endure each day. What is the sense in being in the profession I love, if every day I dread and resent going to work? I suffer, my relationships suffer, and it doesn’t do the profession any good.


If someone doesn’t know whats wrong, how can they fix it? I’m a believer in that concept, and I had been silent for too long. If we were going to make this work, we were going to have to make some changes. It was time to sit down and have a chat with Dr. Cray. I worked the meeting into our schedules, and gave her a heads up that there were some items I wanted to discuss with her.

And in 2 days, that’s exactly what we’ll do.

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That moment when you’re really glad you did…

Having never performed field castrations completely on my own, I served as the anesthetist while my boss performed the routine surgeries in barn pastures and backyards. Although her castration tool-of-choice is the Henderson drill, she took to demonstrating the different surgical techniques (open vs. closed) and cycled through the different types of emasculators with each castration. After watching five or six castrations, the opportunity for me to perform my first castration presented itself in the form of a laid-back, confident client and healthy six month old Thoroughbred colt. My boss kept a watchful eye from her position at the neck of the horse, while I talked my way through each and every step of the procedure. For the entire 20 minutes that it took me to perform the castration, my heart felt like it would pound right out of the chest. My hands trembled the entire time, and it wasn’t until I was done that the client said I did a thorough job. She said she knew I did a thorough job because apparently I narrated step-by-step the entire surgery. I was so focused, I wasn’t even aware that I’d done that. My first castration went well, and was without complication. Now, it was just a matter of getting a few more castrations under my belt before I’d be performing them solo in the field.

Unfortunately, starting out as a young doctor and being new to ambulatory practice, I ran into some difficulty getting consent from owners. On multiple occasions we hit this roadblock, when clients were not on board for allowing a “fledging doc” cut their colt…regardless of the well-seasoned and experienced veterinarian watching my every move over my shoulder. Each time the plan changed, the itch for experience got stronger and stronger. After 3 months, and having watched over 15 castreations, I was chomping at the bit.
When we showed up on the small mom-and-pop farm, the plan was for me to make another notch in my castration belt. The horse was a 5 year old Arabian stallion, recently purchased and barely halter-broke. He was so high strung and wire, that just the act of sedating him alone, was quite the feat for my boss and I. This ordeal was enough to change the minds of the clients, who recanted their original offer for me to perform the castration. I settled into my role as assistant and anesthetist, and tried to push the itch out of my mind.

Several rounds of sedation later, the colt was sedated enough to anesthetized with my boss’s ketamine protocol. He dropped quickly to his side, and we got to work positioning and scrubbing the incision site. Within a few minutes, he was starting to wake up from the anesthetic. My boss is one fast lady, and it takes her less than 5 minutes to castrate a horse. She placed the Henderson drill and spun each testicle off, she checked from hemorrhage and then gave him a rinse. About the time he was getting his antibiotic injection, the gelding was strong enough to push me off his neck and stand to his wobbly feet. My boss took his halter, and I helped balance his staggering hind end as we made our way toward the barn.
As he took several steps, a normal amount of blood slowly dripped onto the gravel..leaving a breadcrumb trail of red droplets. By the time we’d gone 150 feet, the slow drip became a fast drip…which then became a weak trickle of blood. In the stall, I called my boss’s attention to the steady stream of bright red blood coming from the incision site. I rounded up some gauze and fed it along as she packed it into the incision and simultaneously dodged his attempts to kick her. As she packed more gauze, the amount of bleeding increased. The gauze was drenched, and after packing three rolls in there, the bleeding was not improved. He was more awake at this point, and took to slamming us against the stall wall.
After several minutes, it was apparent the packing wasn’t going to be enough to stop the bleeding. A large blood of blood had accumulated, and the rate of hemorrhage was even greater. We made the decision to anesthetize him again in order to explore the incision and locate the source of the hemorrhage. The boss drew up the drugs, and we didn’t waste any time laying him down again. The amount of blood and the fact that he was only lightly anesthetized made identifying the bleeding structure difficult. Without good visualization, we worked somewhat blindly. The boss clamped some hemostats down on the part of the cord she could find and left them while she packed around the instruments with gauze. No sooner had she gotten the gauze mostly into the incision, did the gelding try to jump up onto his feet. I struggled to hold him down while the boss unclaimed the hemostats and packed the rest of the gauze. He nearly launched me over his shoulder as he made several attempts to stand. When he finally stood, the bleeding appeared to have ceased. Everyone breathed a sigh of relief, and the owners, my boss and I guided the horse to his stall for a second time.

I was in the middle of cleaning instruments when I heard a commotion from the barn. The owners went running past me towards the barn, and I could hear someone yelling help. “We’ll just euthanize him” the owners was saying as we all ran towards the barn. I had obviously missed something, and didn’t know who or what was being euthanized. “He’s going down!” The owners sounded panicked, and I arrived at the stall to see the gelding buckling his knees. “Just euthanize him on the lawn.” The husband said decidedly. My boss was helping to hold the horse against the wall of the stall. She looked mostly confused but there was a hint of some other emotion I couldn’t recognize. From between the gelding’s legs, blood was gushing down and into the shavings between his feet.

“What option do we have? We can’t put any more money into this.” The clients kept saying. My boss was now looking concerned, a look I haven’t seen too often. She usually exudes confidence, but definitely didn’t exude that when she was studying the profuse amount of blood coming from the incision site. The hemorrhage was significant enough that now I felt the real weight of the situations urgency.

“Your options? The referral hospital for surgery. Or we can euthanize him. Or we lay him down again?” The owners quickly shot down the hospital option due to finances and said to just euthanize him…and quickly before he collapsed in the stall and further complicated the situation. “Euthanize him?” There was no hiding the surprise in my voice. “We’ll just lay him down again.” I said. “I’ll draw up the drugs.”

“A third time?” The wife asked me.

“I’d lay him down 5 more times before going the euthanasia route. After I give him the drugs, he’s going to be out for awhile. He’ll be in a very deep sleep so we’ll have time to really get in there and find the bleed.” A Drew up my anesthetic protocol, a combination of ketamine and diazepam that put the gelding on the ground again, this time in a very deep slumber. After performing over 200 anesthesia at the internship, I developed a dependable anesthetic protocol and I have complete confidence in both my drugs and their dosages. My go to IV pre-mads are butorphanol and xylazine, and my induction drugs are a combination of diazepam and ketamine. A small bump of ketamine extended the anesthesia time, and kept the gelding out for the entire time that was necessary. My boss explored the incision site, welding handfuls of clotted blood and searching for the source of the hemorrhage. At one point, the gelding was so still my boss asked if he was still alive. As if right on cue, the gelding took a slow deep breath. I rinsed the area as my boss explored the cavity, feeling around blindly. When her gloved hand emerged, it was holding the end of a large bleeding vessel and shredded wisps of soft tissue. The testicular cord had been torn, which had resulted in the hemorrhage. My boss placed three transfixating ligatures, and afterwards we both studied it for bleeding. When no bleeding occured, she let the cord recede back into the incision.

“In 20 years, I’ve never had this happen.” My boss admitted. You bet we high-fived right then and there, bloody gloves and all. I was mostly just relieved. Hemorrhage is a real potential complication of castration, and it was the first real “bleeder” I had seen. While he slept off the drugs, we placed an IV catheter and started him on fluids. As the gelding recovered from his third round of anesthesia, we walked him back to his stall.

“Well, that’s one way to get to know the new vet.” One of the clients said as we packed up. “We were ready to euthanize him right here.”

“Well, not with Dr. Morgan here you weren’t.” My boss said as she gave me an appreciative look. Both clients gave us hugs, followed by a series of thank yous.

“Can tell you’ve done the whole anesthesia thing once or twice.”
I had to laugh when the client said this. All the hours spent running anesthesia during my internship, wishing I was doing anything but anesthesia. Counting down the days til I could turn in my anesthesia badge and never set foot in the anesthesia room again. And here I am, 5 months later, having one of those moments when despite all the weaknesses, hardships and trials that surrounded the internship experience, I’m really glad I did it.

#veterianrian #vet #vetmed #vetlife #equine #horse #equinevet #ambulatory #mobilevet #veterinarypractice #dayinthelife #doctor #profession #equineveterinarian

A whole ‘nother species

Even though I was hired on as a predominantly equine vet, and have concentrated my efforts, time, professional endeavors and life to equine medicine, I accrued a decent amount of experience with small ruminants both before and throughout vet school. I’d like to place the emphasis on the descriptor ‘small’ ruminants. I’ll ride along with my boss on any call, no matter the species. There is one species (well, excluding camelids and pigs) that I absolutely don’t feel confident in. Cows.

On my treasured Saturday off after a rough week of colics and lacerations, I knew something was up when my boss rang. She sounded optimistic, “Whatcha doin’?” I was honest, and she knew my sleeping habits by then. On any Saturday I have off, at 9 am you can bet I’m sleeping. She informed me she had three emergencies that had simultaneously called and were all in different directions. She was nearly to one, and the next one was a horse with a laceration of unknown proportion. She didn’t have to ask because I knew why she was calling. “What ER would you like me to take?”1500039069095-542038303

Three words over the phone and I was wide awake.

Sick.

Down.

Calf.

The other calf they recently acquired had died in the night, and my boss suspected this farm call was more in the direction of euthanasia than heroics. I headed out with the address plugged into the GPS and an ETA of 30 minutes. Highways to streets to gravel road and the numbering on possible driveways became scarce. Luckily, I had discovered the Google Maps’ satellite view and this helped tremendously with locating barns and houses. But, satellite imaging via Google Maps was nothing without mobile data. This ran out with about 4 miles to go and I ended up taking a long gravel road that zigzagged past caved in barns, abandoned double-wides and the occasional deserted house. The road ended at a picnic shelter camped out in front of a lake…I hadn’t passed anything matching the physical address of the house I was looking for.

Out across the open pasture, I spotted an old, tiny run-down cabin. (I might have overlooked it as a storage shed, but after a couple months of farm calls in this area, I never underestimate what structures serve as someone’s home). I heard the lawn mower first, then spotted the red riding lawn mower as it rounded the shack. It’s rider was a shirtless man in his 60s or 70s, with tattered suspender straps over his shoulders and a wide brimmed straw hat. He sported a cigarette from one corner of his mouth, and a long piece of straw out the other. His jack Russell sounded the alarm. I waved as he slowly made his way over to the truck. Over the barking dog, I asked if he happened to have a sick calf. He left the lawn mower idling as I got out of the truck. He gave me a once over look and shook his head. He looked disinterested and slightly annoyed and motioned over his shoulders “My neighbors have a calf.” Then he gave directions that sounded as helpful as google map’s “no network” message.

I started to get into he truck when he hollered. “Are you the animal doc?” And I answered yes.

After I answered yes, he gave a mischievous grin and winked. “If you’re the doc, I’m an animal. You want to work on me?”

I shook my head and put some effort into a laugh, one of those ha-ha very funny laughs. Then I got in the truck and performed a 7 or 8 point turn as the self-proclaimed animal on the riding lawnmower made cat calls.

The truck’s diesel engine is loud, but wasn’t loud enough to drown out the series of howls he let out from under his wide-brim hat.

#veterianrian #vet #vetmed #vetlife #equine #horse #equinevet #ambulatory #mobilevet #veterinarypractice #dayinthelife #doctor #profession

VET LIFE STEP BY STEP – HOW TO LOSE A CLIENT

I unintentionally discovered one method for ensuring you will not have repeat business from a client. And for the sake of showing my humility, while sharing my mishaps, I created a simple step-by-step guide on how to lose a client.


HOW TO LOSE A CLIENT IN 5 SIMPLE STEPS

1. Ask client if they would be willing to move their appointment up to an earlier time, preferably if it will involve them rushing or canceling previously made plans. Schedule them for this earlier appointment time.

2. Show up 1 hour late.

3. Promise you can accomplish all the appointment goals by a particular time.

4. While they are helping hold your patient in preparation for a dental float, spray them directly in the face using a dosing syringe full of dirty water from the horse’s water bucket.

5. Finish the appointment 30 minutes later than you promised so that it interferes with the plans they had to rearrange in order to meet you at the time you requested.

 


When my boss couldn’t make it to her appointment at a nearby barn, I offered to step in and help carry some of the appointment load. Not only was this my first time meeting the client, but it was also the same barn that I had visited earlier in the morning for an emergency colic appointment. This client had one horse scheduled for a dental and two horses scheduled for vaccines. Having been on emergency calls all night, and reporting to the Colic first thing in the morning, I never had time to get vaccines. When I agreed to take the appointment (Since I was already at the barn), I also realized I was out of tetanus, West Nile and flu/rhino vaccines. While my office staff arranged for the client to come to the barn at 11 am instead of 2pm, I embarked on what I thought was going to be a quick trip to the office for more vaccines. But phone calls, questions, client drop-in and various other events resulted in my taking an hour longer than I had hoped.

By the time I showed up at 12pm, the client had already called my boss to see what the deal was. She let me know what her wait time had been, and I apologized profusely. With a riding lesson scheduled at 1, she was skeptical I could get everything done in an hour. Determined to regain her trust and confidence, I promised I’d have it done.

I set up my dental equipment, vaccinated the horses and got ready to sedate the gelding for his dental. “Oh yeah, he doesn’t sedate well just so you know. He’ll look like he’s about to fall over asleep, but as soon as you start working on him he’s wide awake.” Let’s just say she knew exactly what she was talking about. And after I felt confident in his sedation level, I filled a large dosing syringe full of water from his dirty bucket. I put the tip of the syringe in his mouth, and as I shoved with all my might on the plunger…he almost reared up. It was perfectly coordinated and timed, and instead of the water going into his mouth…the water shot full-force straight into the client’s face.

Basically, she got a power-wash to the face and was soaked. She did not laugh. She looked absolutely pissed and annoyed. I told her I was mortified, and that I was sorry. To which she responded, “I’ve had much dirtier and nastier things on my face.” I laughed, and went to work.

What would’ve normally been a 15 minute dental float was a 45 minute struggle between a horse’s buckling knees and his frantic swinging head. By the time I was done, the client had her own client waiting to begin the riding lesson. Embarassed, mortified and disappointed by the multi-modal failure, I left one more apology with her before I drove off to the next appointment.

As soon as a left the barn driveway, I was dialing the office to give them the step-by-step account, and share my new found method to ensure that I’ll never be the vet she requests to work on her animals. We all had a good laugh before the office manager said, “Well, I doubt it cost us any money. She’s had an outstanding balance of over 3 grand for the past couple years and refuses to put a dime toward it.” She paused. “Maybe after spaying her point blank in the face, she’ll get the hint that we kinda want to be paid for our previous services.”

Despite her account delinquency and bad attitude in general, I still felt horribly unprofessional and foolish…though after talking with the Office manager, I felt a little less guilty.
#veterianrian #vet #vetmed #vetlife #equine #horse #equinevet #ambulatory #mobilevet #veterinarypractice #dayinthelife #doctor #profession #equineveterinarian