Hard Day

Didja ever have one of "those days"?  Of course you have.  And one of mine was yesterday.

The morning was fairly busy, but I was trucking through and doing okay.  By lunch time I had only a couple of drop-offs left to be seen, and even with a full afternoon schedule I was comfortable we'd get things done.  Then we had several sick pets drop off during lunch.  And then the afternoon went all to heck.

A good mix of appointments has routine annual exams and vaccines mixed with puppy/kitten boosters and some sick pets.  The sick cases usually take longer but you can make up for that with the quicker and easier vaccinations.  Things get backed up when everything has a problem, and that's what happened to me.  Each case had a minor or major illness, even the ones that came in just for immunizations.  Like a traffic jam, each case backed us up further and further, until clients were waiting around an hour just for me to get to see them.  This kind of wait is very unusual in my practice.

I'm a fast and efficient vet, if I do say so myself.  I can get through cases quickly and efficiently and have seen 40 pets in a day without leaving late.  Most days I leave within 15 minutes of closing, if not right at closing.  Every once in a while I'll have sick cases up until the end and may leave 30 minutes late, though this is uncommon. Yesterday I had a dog that dropped off around 1:00 that I didn't even look at until 7:10 (we close at 7pm).  I finally left around 8:20, which hasn't happened to me in years.  It was an insane afternoon!  I really hated the clients having to wait so long, as I stress client service to my staff and wait times of over an hour isn't something I can easily accept.  At the same time my staff and I were moving as fast as we could and had to give each pet our best care.  I was wasted and drained by the time I got in my car, but we made it through.

But the worst part is also the reason for talking about this (and a bit of a vent).  I worked my hiney off yesterday and had less than expected to show for it.  My job isn't all about the money, but we also need to be profitable in order to stay in business.  And if someone works really hard, they get frustrated if that work doesn't pay off.  As busy as I was, I had a lot of clients who declined the recommended care, work-up, or medications.  So I spent a lot of time on some cases for very little revenue.  Again, I'm not all about the money, but as a business leader I do have to keep an eye on it, and just want to feel like my work pays off.  I ended up doing about 75% of what I had expected based on how busy it felt.  In fact, today I saw seven fewer pets but did almost 20% more than I did yesterday!

So for anyone planning a career in veterinary medicine, be aware that some days are worse than others, and sometimes you do a lot of work for little reward.  Them's the breaks, and are a part of the job.

A Tumor Or An Alien?

My technology detox went well (though my son complained daily about being bored because he didn't have TV or video games), so it's back to blogging.

Today I wanted to share a case I had from a few months ago.  Really the case was pretty straight-forward, but the images are cool.  The dog had a mass on it's back that had been there for a year or two but had recently begun growing larger.  I've seen a lot of things in my career, but this one actually impressed me.

Fair warning...some of these images are graphic to the faint of heart, but certainly aren't the worse ones I've shown.  Proceed at your own risk.

These pictures are from the beginning of the surgical removal.  The dog is anesthetized and the area shaved and prepped for surgery.  Notice how long the dog's hair is.  Now imagine this ulcerative, oozing mass covered with matted hair!  Yep, that's what I saw on the initial exam.

That's a pretty impressive mass.  I half-jokingly wondered if there was an alien somewhere in there, ready to pop out like the "chest burster" in the Alien movies.  Sadly, such was not the case.

The mass was pretty routine to remove, though there were a lot of large blood vessels going into it and I kept having problems with bleeders.  Nothing that vets don't face almost daily, though, and all vessels were easy to clamp and tie off.  As bloody as this may seem to some people, the actual loss to the patient is minimal and doesn't require a tranfusion.

Many people aren't aware, but skin is constantly under slight tension.  When you cut through skin that tension is relieved, causing a gap.  When you remove part of the skin (including a tumor) the gap becomes even more prominent.  When you have a large mass and want to get 2cm margins around it (to make sure it's all removed) you can end up with a pretty large defect, and closing such a large wound can be challenging.  Thankfully, we are trained in doing so!  There are actually several neat tricks and techniques you can do to get the edges touching each other so that healing is faster.

And here are the "after" pictures!  A bit tight, but considering how much I had to remove I was very happy with the results.

So what the heck was the tumor?  I'm glad you asked!  We sent it off for pathology and it came back as a hair follicle tumor.  It was benign, just locally aggressive, so the outcome was really good.  The patient did well and the incision completely healed.

And no alien in the center...drat!

Technology Detox

It's amazing how much our lives are involved in technology.  I remember rotary dial phones and not having an answering machine.  If you weren't home to pick up the phone, nobody knew where you were and they couldn't get in touch with you.  And we were okay with that!  I remember being able to only watch TV stations that we could get with our antenna and how big of a deal it was when we got cable.  I remember when the Internet was Usenet newsgroups and simple email.  Now we have multiple laptops in our home, several cell phones that stay glued to our sides where ever we go, broadband wi-fi, and satellite, DVRs, and DVD players for the two TVs.

It's time to take a break.

Lately I've been missing my creative side.  I used to write short stories and poetry.  I have written some amazing and often twisted adventures for table-top role-playing games.  Yet I seem to be having problems tapping into that side of me.  I feel the press of age and banality.  I don't take much time out to just have fun and be a child again.

I miss that, and I'm doing something about it.  For the upcoming week I'm doing a detox and having my whole family do it with me.  For the next five days the TV will be off, no video games will be played, and the only purpose of the computers will be for checking email (I teach online classes and do other important things via computer, so I can't go that long without email).  I'm going to spend time thinking, playing, and writing, and hope to reconnect with that spark that I used to have.  My goal is to eliminate the distractions of the modern world and find that part of myself that used to thrive on the creative process.

See you on the other side!

Living With A Hernia

Yes, another Weird Al reference, which for regular readers should be no surprise.  For the uninitiated...

Of course, a case brought this up and I thought it would be a good educational opportunity.  Today I spayed a puppy with an inguinal hernia, one of the less common ones.  Many clients will have been faced with hernias in their pets and most of the time it's not a serious issue.  So Let's talk about exactly what a hernia is, a few common kinds, and why you need to treat them.

Essentially a hernia is a hole or defect in the muscle of a cavity, usually the abdominal cavity, with resulting escaping of some contents through the hernia.  The hernia is usually named based on the location.  In some cases the hernia is the result of a type of birth defect or developmental abnormality where the muscle never closes properly.  Sometimes a hernia can be the result of trauma, such as being hit by a car, or a severe muscle tear from stretching or straining.  In all cases the defect should be treated as potentially serious and be evaluated immediately.

Why are we so concerned about hernias?  Because abdominal contents can migrate through the hole and under the skin or into the chest cavity.  If that organ becomes entrapped and the blood supply is cut off, the tissue will start to die and you have a suddenly life-threatening emergency on your hands.  Most hernias won't reach this point but that risk is enough to have a vet determine when and if surgery needs to be done.

So what are some common hernias?

Umbilical:  This is the single most common hernia most vets see, and is something I diagnose just about every month.  The place on the abdomen where the umbilical cord attaches has a small hole in the abdominal wall that allows blood vessels to pass between the placenta and the inside of the body.  The hole should start to close immediately after the cord falls off, but this does not happen in some cases.  Normally you will notice a swelling or bump at the "belly button" that may come and go.  This is typically simply abdominal fat that is passing through the small opening.  In some cases the opening will persist longer than normal and then close up, trapping abdominal fat outside of the body.  The vet will be easily able to detect this hernia and tell you if it needs to be repaired.  In most cases it's not large enough to be highly concerned about and we'll wait until time to spay or neuter and do it while the pet is under anesthesia.  I've had two cases in my career that had frighteningly huge hernias and I got them into surgery by 10 weeks old because of the risk of intestinal loops passing through.  But most cases are "NGS" ("No Great Shakes" as my old pathology professor used to say).

Inguinal: This is what I fixed today.  The hernia is down in the groin where the abdomen meets the leg, at what is called the inguinal ring.  This is a normal small opening in the abdomen through which blood vessels pass.  In some cases the ring is too large and we have to go in and close the defect.  This is a much trickier surgery because it's in a narrower and deeper area, as well as having large blood vessels that we need to avoid and not tie off.  It's a delicate, slow surgery, but not highly complicated for a good surgeon.  These are uncommon and I'll usually see one every couple of years.

Abdominal:  This hernia is most commonly due to trauma and is a tear in the muscle of the abdominal wall, normally somewhere away from the inguinal or umbilical regions.  It can be potentially more serious due to the fact that there is often trauma involved and the tear can be large.

Diaphragmatic:  This kind of hernia is probably one of the scariest I've dealt with and the most life-threatening.  The huge majority of the time this happens after receiving a sudden blow to the abdomen, usually when hit by a car.  The sudden force causes a tear in the diphragm.  Abdominal contents can start to move through the hernia and into the chest cavity.  I've dealt with cases where intestines, liver, and spleen are all sitting in the chest.  Not only is this a concern for strangulation of the organs passing through, but the abnormal contents puts pressure on the heart and lungs and can cause problems with proper air flow and blood pumping.  Surgery for this kind of hernia carries considerable risk since you are opening the abdomen and chest and have to deal with the consequences of chest surgery as well as abdominal surgery.  So far I've not lost any patients when I've done this surgery, but I know many vets who would refer the case to a specialist rather than tackling it themselves.

Of course there are many other kinds of hernias, but you start to get the idea.  Muscle is torn, something moves through the hole, and problems happen.  Always talk to your vet about any unusual swellings on your pets and pay attention if the start using "hernia" and "surgery". 

You Get Used To It

One of my earliest appointments today was a pair of puppies for routine booster vaccines.  The boy was sweet and playful but the girl was very shy and skittish.  I had barely begun my exam when she suddenly started freaking out, trying to bite me and urinating all over the floor.  I was trying to keep her out of her own urine and she managed to graze me with her teeth.  It's not the first time I've handled such things, so it didn't phase me much (though certainly frustrated me).  I covered my wounds well, went to the back to get an assistant and a muzzle, washed my slightly bleeding scrapes and then went back to finish the exam and vaccines.  After we were done the client seemed to notice the long scratches and bit of blood and asked me if the puppy had bit me.  I told her that it was nothing serious and happens almost every day.  I had scrapes and a small puncture as well as urine on my pants, and I was brushing it off as routine.

And the thing is, I wasn't lying.

There are many things you get used to in the veterinary profession.  It's a daily occurrence to get urine, feces, pus, or blood on us.  Pretty quickly you realize that it all washes off and you can't be grossed out by it.  Multiple times per day I have a pet that needs to be muzzled or is otherwise a bit aggressive, including some who need to be fully sedated before doing even the most simple service.  If you got bothered and scared by this, you couldn't last long in the field.  We see dying pets, stupid clients, difficult decisions, and numerous other things that your average pet owner would be upset by or become nauseous over.  You get used to it.

One of my other cases today was a small hot spot near a golden retriever's ear.  The owner was pretty worried about it but in my estimation it was actually pretty mild.  This was only a couple of inches across and was scabbing over.  I've seen them where it's the entire side of the face and is oozing blood, pus, and other unmentionable things.  I was able to explain to the client that we could easily treat the case and it wasn't as bad as the thought.  I might have been a little jaded, but I've gotten used to so many worse situations that I couldn't be worried about this.

Many people have asked me over the years how I deal with the things I see and do.  When I first started being around vets I would indeed get sick at the sight of certain things and actually did pass out a couple of times.  So what changed?  How did I learn to handle these sights, smells, and experiences?  I hate to say that there really isn't any magic trick.

I just got used to it.

Attack Cat

Here's an email from Barbara...

I was wondering if you ever heard or witnessed acts cat like ours. I have been around cats my entire life, and have never came close to meeting a cat quite like ours including feral cats. First when she came into heat  ( my mom lost her job and we had to wait for a low coast clinic to have space ) she literately stalked me, hollowing at me and "other" things. When I would leave the house she would calm down and be fine, after we had her spayed she stopped that however she now attacks strangers whom come to our door. Picture a cat attacking UPS instead of a dog!!! If guests come into our home we have to lock her in another room or she will bite, hiss and claw them. She is obsessed with socks, she carries them in her mouth making mothering sound of cat with kittens would. If we take them away and do not put them behind a closed door she will go to great length to get to the sock. She is obsessed with water including taking showers with us, she will sit in the tub or sink meowing until we turn on a faucet to drink out of. Then the oddest one is she gets obsessed with something she will not leave it alone no matter how much you redirect her, you literately have to put her in another room for a period of time before she unfixate on the object. She runs up and bites my 4 year old sister for no reason besides she thinks it's funny. If my mom is away from home for a night this cat will be up all night into things, meowing and running crazy, if my mom is home she sleeps thru the night. The scariest part is this cat isn't a year old yet, and luckily she is a small framed athletic cat because if she was a bigger build she would have already made a nasty wound. 

Believe it or not I have indeed seen several cats like this.  Fist of all, howling like she's demon-possessed is actually very normal when a cat is in heat.  In fact, it's one of the key behavioral indicators that I look for since they don't drip blood like a dog would.  The other behaviors are uncommon, but not unheard of.

One of the first things to realize is that animals think very differently than humans.  For example, she's not attacking your sister because "she thinks it's funny."  Animals don't have a sense of humor and don't mentally process behaviors in this way.  She is doing these behaviors for many reasons, such as natural instinct, overstimulation, anxiety, and some sort of reward (such as a sense of having caught prey).  

Cats are carnivores and predators so many of the behaviors we seen in them are related to hunting.  Even the play of kittens is more along the lines of practicing for when they can hunt real prey.  A cat can't anticipate the future like we can, so they don't know that they won't be in the wild bringing down mice and birds.  Their instinct is to get ready in case that ever happens.  Since kittens are learning and practicing for adulthood we often see them do it more frequently than adults.  There are ways to redirect or discourage such behavior and your vet may be able to help in this area.

I will be honest in saying that some cats (and dogs) simply have a screw loose.  Seriously!  Psychotic behavior happens in all species, and I've known plenty of pets that have worsening aggression as they get older.  These cases can be difficult to deal with as they require significant special attention by the owners and will need at least behavioral therapy if not actual medications.  Hopefully your cat isn't one of these animals, because I've had to euthanize pets for severely aggressive behavior, especially when the attack unprovoked.

Don't ignore the behavior merely because she is small.  Even a minor cat bite or scratch can become severely infected and size doesn't matter.  I've received some pretty bad bites from small, young pets and those can be just as dangerous as from larger ones.  If she isn't a year old yet she still has some growing to do and may cause more serious harm once she is older.

I would definitely recommend finding a vet who is skilled with behavioral issues and talk to them about what you can do to help with these problems.

Is College Necessary?

My father and I were discussing this last week and I thought it was a good subject to bring up.  As someone with a BS, MS, and DVM I may surprise people with my viewpoint.  I don't think that a college degree is necessary for success or happiness, and I don't think everyone should seek one.

Let me give a little background.  Neither of my parents received a Bachelor's degree or did much advanced schooling after high school.  Yet both of them were very intelligent, well-read, and had a desire to learn.  My mother worked in the business world before I was born and then became a housewife. My father became a regional sales manager for Volvo, responsible for sales in dealerships over a multi-state territory. Both of them were quite successful in their respective careers.  I learned from them that a college diploma doesn't mean that you're more intelligent and the lack of one doesn't mean that you're less so.

I also think that a general college education is often overrated.  Fifty years ago a college degree virtually assured a high-paying, quality job.  Nowadays that isn't true, as many people graduate and have no good job prospects.  College degrees are becoming the norm, not the exception, and this dilutes their significance.  There are also many people who choose majors with limited real-world application, finding themselves holding a diploma that really doesn't mean much.

I am a big proponent of vocational education and find it unfortunate that community college educations are often looked down upon.  A high quality mechanic can actually make more money than I can!  We need people in these fields that don't require a traditional college degree, and they can be highly successful.

But what about education and expansion of knowledge?  Yes, the general education requirements in most colleges help broaden the experience and knowledge of students.  However, I think we can achieve the same results by properly instilling and encouraging a desire to learn.  People need to be more self-motivated and rely less on spoon-fed education.  As parents and teachers we need to help children want to learn.

Now I do realize that certain careers (such as my own) do require extensive college, and that's okay.  I am glad for everything I learned through my education.  I also think that if someone really wants to go to college that they should.  However, they should do so with an eye to what they're going to do to support themselves and their family after graduation.  And they shouldn't be encouraged or forced to attend if their career goals don't require it or they don't have the aptitude.

With my own children I'll certainly help them go to college if that's what they want and need.  But I will also encourage them to follow their desires, even if it doesn't take them past a high school diploma and some job training.