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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Out of the Woods – Creepy Farm Call #1

In the spirit of Halloween, I was thinking back to some of the more creepy farm calls I’ve been on in the two years. I definitely place this one in the top 5, but certainly isn’t the scariest or eeriest story by far. Saving that story for a future post.


Last June, I was sent out on a very remote farm call…almost an hour into the middle of the woods. Our appointments in google calendar were also linked with Google maps, so that navigating to the next call was automatic. I rarely entered in or checked a destination address. I passed through a couple neighboring towns, and then through small “ghost towns” …old wooden buildings with the planking peeling away and paint long gone, old decrepid cars with all the tires flat. If listed, town population signs never sported a number over 300.

Cell service became intermittent, and then non-existent once I turned off the highway onto a paved road. After 15 minutes, the paved road turned to gravel, and after passing a ntional forest sign, I started passing foresty service roads. After 30 minutes, I still hadn’t passed a single house as I wound down through a valley along a wide, fast-paced river.

The appointment was for a feral, lame horse. The horse had already received 2 tubes of dorm gel prior to my arrival. I had tried to find this place before, but after an hour of searching, called it quits. We arranged for one of the owners to meet me today, the spot I quickly approached (a Y in the gravel road with a tree inbetween the forked paths). He waiting there in a weathered mid 80’s ford truck. He had already turned around to servce as the pilot car, and a plume of exhaust fumes serged up from where the exhaust pipe would’ve been.

We didn’t pass a single house, driveway or other sign of residence. Gated and overgrown logging roads intersected the gravel road, which wound deeper and deeper into what I presume, was still national foret land. The gravel road faded to dirt road, and as we came around a sharp corner, his truck suddenly disappeared from sight. I hit my breaks to see his exhaust plum leading my like an obnoxious bread crumb trail. He veered down a dirt path, certainly no road. An assortment of dust-laden vegetation crept far enough over the path to make it invisible. I remember thinking they didn’t have a mailbox, and that I was probably coming up on a squatter compound…but squatters or not, they had a horse that was severely lame.


The truck stopped at a widening of the dirt path, and then pulled away to park amongst an assortment of rusty, scrapped and stripped cars, trucks and vans. Dispersed beyond the cars, amongst heavy tree trunks with low lying branches, were 5 large tents. Picture safari-style hunting tents…aged, mossy, holed and sagging canvas between the frames. Beyond the tents, a small paddock was built with an assortment of scrap metal, poles, logs and other makeshift materials. The guy said nothing and disappeared into a tent. All the tents had ventilation through welded pipes, the canvas material cut to give the steaming pipes a wide bearth.

An older woman was standing with the horse, and motioned for me to come over. I got out the basic tote, head lamp and wandered through the brush to the coral. The horse’s hooves were overgrown to the point of making 6 inch long skis, with the toes almost curling back like elf shoes. With the horse sedated, I could complete my exam and figured the lameness was a result of the unmanaged toe length and laminitis. It was while I was discussing this with the owner that I motion caught my eye. From all directions in the woods, coming around and between massive tree trunks, people slowly emerged. Men and women, ranging from (my guess) early 30s to mid 60s, silently made their way out of the woods. Some of them didn’t seem to notice I was there, others shot furtive glances. One by one they disappeared into various tents. If any of them spoke a word, I certainly didn’t hear it.

My heart was racing at this point, and I felt vulnerable and exposed. The only thing I could think to say was that I was going to grab my phone from the truck (not that it had cell service or would do any good). I got to the cab and grabbed the only real defense weapon I had. It was a can of mace my friend had gotten me after I was attacked by a farm dog a couple months earlir. As I was returning, one of the flaps to the tent was flapped back. Inside, there were large burn-barrel with lids…5 or six with pipping going towards what I assume isthe main pipe coming out the top of the tent. I glanced to make sure the vet bed was closed, ie locked. It was.

As I finished discussing my recommendations, the various tatter-clothed people emerged from the tents one by one. They randomly accumulated around the bed of the vet truck, looking it over curiously. They were 5-10 feet away from the truck, inspecting it and ocassionally me. I confirmed no cell service, and never wanted a distress beacon so badly in my life.

The owner went to retrieve her checkbook while I settled into the truck. Like every time your heart is pounding, pulse bounding, adrenaline serging…minutes in panicked reality feel like hours. This situation, no different. I sat there, on the verge of fleeing but forcing myself to wait. No one said a word amongst the six or seven scraggly, barefoot men that lingered around the truck. Women arrived, check in hand, and and said the guy who brought me here was just turning his truck around to show me the way back.

$%@$ that, I thought. No people or cars were behind me, and all I could manage to say cooly through the cracked window was “I’m good.”

I didn’t know that little ford vet truck could go so fast in reverse, and I’ve certainly never driven in reverse that fast for that long in my life.


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Logistics Behind Ambulatory Work, Part II: Drive Time

I receive quite a few questions from ride alongs, job shadows, students and clients about the ambulatory component of work as a mobile equine vet. I decided to share some of my experiences and insight by answering some of the most common questions I get. In Part I, I discussed some of the logistics behind scheduling, navigating and billing for our practice.

The next series of questions I am frequently asked include:

  • How much time do you spend in the car on average per day?
  • What is the longest you’ve ever driven to one place?
  • What do you do in the car all day?

 

Drive Time

Google Map’s timeline is an invaluable resource for tracking how much time we spending getting from point A to point B, tracking mileage, tracking the time spent at each farm call and overall time spent driving per day. All this data is arranged in a calendar mode, meaning I can pick any day of the month and retrace my route.
The season and whether or not I am on call are large factors in the amount of time I spend in the car. I went back and reviewed my timelines from different months to get an idea of variation between seasons.

Our slow season is November-March, so I chose to review the month of January. For the month of January, drive time was 2-3 hours per day with 2-3 farm calls (1-2 hours were spent at each farm call). My on-call days with emergencies increased the average number of hours to 4, with 1-2 farm calls per day. The average appointment time for these emergencies was 2-3 hours.

From March-June, business starts to amp up. For May, drive time per day averaged 4-5 hours with an average of 4 farm calls a day. On days with emergencies, drive time was 5 hours with 2-3 farm calls per day.

Our peak busy season is from the end of June to the beginning of September. When I reviewed my timeline data for July and August, my jaw dropped. I knew I spent a lot of time on the road…but was still shocked to find that the average amount of time I spent in the truck was 8 hours per day with 4-6 farm calls per day.

And the longest we ever spent driving in one day? 10 hours!! This was for a day with 4 farm calls appointments and 3 emergencies. And the longest drive I’ve made in one direction was 2.5 hours, from the northern part of the Realm to the western part of our Realm with closure of a major highway due to an accident.


Making the Most of It

When not in conversation or on the phone with clients, the first thing I do during the drive between barns is complete my medical records and invoices. This is, by far, the biggest advantage to having my assistant drive. At my previous job, when I did not have an assistant, I would have to do invoicing and notes at the end of the day…often times adding another 2-4 hours to my work day. Not only was this exhausting, but increased my errors on invoices and reduced the quality of my medical records.

Once medical records and invoices are done, other work-related tasks I do are review lab results, go over my follow-up list, and review the appointments for the next day. When that is all said and done, I move on to entertainment. I have a wide variety of music tastes, but spend enough time in the car and all types of music wear on you after awhile.

So, I discovered podcasts…a wide variety of podcasts that range from veterinary education, to psychology, crime, current events, controversial topics, history and so on. Some of my favorites include:

Favorite Podcasts from Pocketcast

Logistics behind Ambulatory Work

Occasionally, we have ride-alongs or people doing job shadows, usually students ranging from high school to vet school. For those considering a career in veterinary medicine or future ambulatory vets, it is an interactive, uncensored day-in-the-life experience. The types of questions I did not really expect to get were regarding commuting and driving. The questions I get asked most often include:

  • How big of an area do you serve? What are the logistics behind scheduling appointments? Who determines the route? How do you know how much to charge for a farm call?
  • How much time do you spend in the car on average per day? What is the longest you’ve ever driven to one place? What do you do in the car all day?
  • Does getting car sick mean you can’t be an ambulatory vet?
  • Does the truck ever break down? Have you ever gotten in an accident with the work truck?

I’ve received these questions often enough that I decided to write a couple posts about this side of the profession from my personal experience.


The Realm

Our service area (which I refer to as the realm) is vast, one of the largest I’ve seen. From where our office is located, we service up to an hour and a half in every direction…meaning our call radius is 1.5 hours, not factoring in traffic. The realm ends up being a large part of the western side of our state. While the majority of our work is North, an emergency an hour South of our office could mean a 2.5 hour drive from one end of our range to the other. Most practices I’ve spent time with service a 40 minute radius around their hub.

As for navigating the realm? I have to give a shout out to navigation apps. All of this would be a lot more difficult without today’s smart phones, GPS etc. I consider myself very fortunate to practice in a time when this technology is easily available. Not afraid to admit that I cannot imagine the farm call experience before Google maps existed. For the vast majority of our navigation, we use Google maps and Waze, which do a great job 95% of the time.


Scheduling

Luckily, our front office staff are all locals with an excellent knowledge of the cities/towns and road system. Equally important is knowledge about traffic. The commute to a particular barn in the morning could be well over an hour, while the same route could take 30 minutes if its around lunch time.

Efficiency requires concise, well-planned routes, the front desk carries the heavy burden of scheduling. And they are phenomenal at avoiding the big scheduling mistakes, which off the time of my head are:

  • Return trips (same barn more than once in a day)
  • Same stops (different doctors to the same barn in a day)
  • To-and-fro (alternating near and far locations like North  South  North  South …vs. starting north and working south throughout the day)
  • Localizing (keeping all farms in a particular direction, vs having calls at complete opposite ends of the service radius)

I have full respect and appreciation for the skills of the front desk staff, because I dabbled in scheduling at my previous job and found it to be a pain-staking, hair-pulling mess.


The Financial Side

Minimizing drive time is essential, as our farm call fees (ranging from $80-140) over times barely cover the overhead and wages one way…not to mention if the next call is equally far at the other end of our range. Often times, the company actually loses money as the basic, rough example below shows:

Farm call 40 miles from office, 1 hour drive time

  • Farm call fee charged to client: $100
  • Gas: $10
  • Vehicle wear and tear, mileage, licensing, insurance: $25
  • Assistant’s time (company cost): $25
  • Doctor’s time (company cost): $60
  • Total cost to company for farm call (one direction): $120

Not a precise or perfect example, but easy to see why scheduling and routes are so important. And after all the effort is made into tactfully planning an efficient day, there comes an emergency call that changes it all…and even if the call is at the other side of the realm, traveling in peak traffic hours, those facts don’t register because the focus shifts to getting there safely and as soon as possible, so that we can do what we joined this profession to do- care for our equine patients and the clients attached to them.

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!

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.

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