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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Mindhunters and Midnight Calls

For my first on-call weekend, I was co-pilot to one of the associates and assistants. Around 11:30pm, as we were wrapping up our 4th emergency of the day, we got an ER call for a horse in respiratory distress. The first address we arrived at was in the middle of a suburban neighborhood, obviously the wrong address. We idled in the couldesac while the associate, Dr. Kepper, struggled to get the correct address. It seemed no one on the phone knew the address for the residence, althought they confirmed the horse was in fact at their residence.

After 25 minutes of wrong turns, u-turns, and sleuthing via google maps, we made it to the right road. We drove quickly down the paved road, passing occasional looming, dimly lit mansions. When the driveway ended, we parked in front of a run-down expansive ranch home. None of us got out at first. We just watched the events unfold infront of us. Our arrival sparked some confusion amongst the obviously enebriated residents. Enebriation, not uncommon for late night calls, usually owners who opened a bottle or two of wine before discovering their horse had a laceration or bit of colic. But it didn’t take long observing this group of random strangers, that enbriation was a little too soft a word. Their movements were, for lack of a better word, tweaky. Their speech was incoherient, thoughts scrambled. I wondered how they had managed to call us, let alone find our practice online.

I am going to preface the remainder of the story with this small tidbit: Earlier today, I had binge-watched the second half of Netflix’s season one of Mindhunters.

One man, in his mid 40s, approached us. To access the back pasture, they had to move a truck which blocked the driveway around the back of the house. We did not think much, until a scrawny young man and man in his mid 70s came wandering through the overgrown hedges of the front lawn. From somewhere in these hedges, they produced jumper cables.

Dr. Kepper wasn’t about to wait for these shenanigans. “We’ll just walk. How far is the horse?”

The central area of the house was mostly windows with a large atrium garden. With every light on inside you could see the entire layout of the home. Dark is dark, I’ll admit. But it wasn’t until I got outside that I realized just how dark the night was. No moon, no stars, just darkness above and around. I grabbed the headlamp and Dr. Kepper carried her laptop as a makeshift light source. The guy lead us around the side of the house, wading into darkness and unknown terrain. In the light of my headlamp, I saw he had his shoes on the wrong feet, the last half of the shoelace strands worn off. He wore one dirty sock. I glanced inside the house in time to see a figure of a woman sitting on the floor rocking back and forth anxiously.

Uneven steps led down the side of the house past windows of the daylight basement. One of the windows in the basement had black, metal bars on the inside of the glass. The room was empty, but I could see a jail-style door on the opposite wall. On the other side of the rod-iron door was a normal door. No one else seemed to notice the homemade “cage.”

This was the point at which Mindhunters triggered my rampant imagination. We continued in silence down behind the house, through the middle of a pasture of unknown proportion. The only noise was the sound of us slushing through damp, tall grass. After several minutes, an old barn loomed ahead in the glow of my headlamp. Dr. Kepper marched on, following a couple yards behind the man. The barn had two big doors, but the first thing I noticed were the many, many locks and bolts and chains on the outside. It as not necessary to count the number of bolts, padlocks and chains to know that it was excessive and albeit, alarming.

The man was heading straight for the barn, Dr. Kepper striding behind. The assistant shot me a “this is #$%@ing sketch look.” I mouthed back “I will not go in there.”

Just as we thought he was going to start unlatching, unlocking the doors, he turned and lead us beyond beyond broken fencing into another expansive field. If possible, this field felt even darker than the first. I couldn’t see the house behind us anymore and I kept looking over my shoulder to see if anyone was following us.

This was when I began to wonder if there even was a sick horse here.

I kept checking behind us as I followed Dr. Kepper’s laptop glow. Just as I was going to ask how much further to the horse, a shadowy figure came into view. I feel kind of ashamed to admit it, but it was a wave of relief that washed over me the moment I saw the down horse. Then that relief vanished, and we all launched into emergency care mode.

The mare, down and unresponsive, had labored breathing, no CRT, a heart rate of 80 and weak peripheral pulse. She was matted, sticky with sweat that had cooled, and her muscles were rigid. It was very apparent she had been suffering for some time. Her body was covered in wounds, the ground around her torn up from her thrashing around. After discussing prognosis and options, the owner elected for euthanasia. Although a sad ending, the ability to bring an end to her drawn out suffering was the most compassionate thing we could do. While the owner disappeared into the darkness, we sat with the mare for a few moments before confirming she had passed.

Silently, under the glow of the dying headlamp and Dr. Keppler’s laptop, we navigated our way back to the truck. After loading up, no one said a word until we had some distance.

“I know no one attacked us or threatened us, but I just have the feeling that we narrowly escaped with our lives.” I said, and a some laughter lightened the heavy mood in the truck…right before Dr. Kepper’ phone rang with the next late night emergency.


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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