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 Unexpected Problem #2 (ER case, part 1)

After seeing a couple of routine appointments, we started receiving back-to-back emergencies. Our emergency calls included a colic, a foot abscess, a case of cellulitis and a minor laceration. Around 9pm, right as we parked the work truck in the garage, my work phone rang. On the other end of the line, was a panick stricken owner who thought her horse had fractured its leg after getting kicked by another horse in turn-out. We regrouped, and made the short 25 minute drive to the ER.


The Presenting Complaint and (Most) Obvious Problem

When we arrived, we spotted the mare in the beam of our headlamps. She stood in the pasture, trembling, painful and unable to bear weight on her hind leg. Aside from a <1 inch long laceration through the skin located in front of her hip, there were no real significant findings on my physical exam. I could not palpate a fragment, fracture or instability in the limb. After ruling out a foot abscess, fracture of the distal phalanx, we confirmed no fracture from the stifle down. Our radiograph equipment in the field is not capable of shooting images of the hips or pelvis, and with no ultrasound, ruling out a pelvic fracture wasn’t going to be an option. Leaving her in the pasture, without water or shelter, was not an acceptable option. After giving pain meds and sedation, we inched our way slowly and steadily to the barn.

Discovering the (Less) Obvious, but Equally Serious Problem

In the barn, I turned my attention to the wound over the hip while I next steps for the painful leg. After clipping around the wound, I was both shocked and disturbed to find out the extent of the wound. What looked like a superficial, small tear in the skin, was actually a dime-sized penetrating wound. With a flashlight, I looked into the wound and probed the extent. Beyond layers of muscle, fascia, fat and connective tissue…I found myself looking through a tiny viewing window right into the mare’s abdomen. I saw the glisten of light off what I presumed to be the right dorsal colon.

Bad Gets Worse

A penetrating wound into the abdomen doesn’t carry a favorable prognosis, especially when managed in the field. The client’s financial constraints meant referral for hospitalization was not an option. Abdominocentesis (belly tap), bloodwork, ultrasound, SAA…also not within the financial realm. Dedicated to trying, and wanting to give the mare a chance, the client asked for the most aggressive approach we could take to treating in the field within set limitations.

Antibiotics, anti-inflammatories, suturing the wound and monitoring comprised the mainstay of our treatment protocol. To be honest, I was expecting these efforts to serve mainly as a comfort and reassurance that we had tried something. I’ve seen horses succumb to far less serious ailments with intensive treatments and hospitalization. We placed an IV catheter so we could start a robust course of antibiotics (kpen and gentamicin) and banamine.

Where it gets interesting

By 1am, we had discussed catheter care, administer meds, given extensive instructions on what to watch for…and when we left, the entire ride back was filled discussions on everyone’s thoughts, ideas, speculations …wondering about the source of the lameness as well as the surprising penetrating hole. The hole was clean through the side of the horse, with defined edges and minimal surrounding trauma…almost like it had been made intentionally, by someone blessed with the art of careful dissection. Without knowing the systemic status of the horse, I could hardly sleep with thoughts of the undiagnosed fracture, the possibility of punctured bowel, the chance that whatever punctured her side could be floating around in the abdomen, the imminent danger of sepsis and endotoxemia…this, combined with group speculation as to what caused the wound.

A stick?

A nail?

Fencing?

Tree branch?

What about a bullet? The client asked, explaining that the family dog had sustained a similar injury a year ago when he had been shot with a small-caliber gun (pellet gun or 22?) by a disgruntled neighbor. With so many unknowns, possible complications and serious risks associated with this emergency case… I was not optimistic about the outcome of our next visit, which I expected would in the very, very near future.