Friday, December 16, 2011

Weird finals dreams #2

This dream was all about food.

I dreamed that I was at a store trying to buy salted caramel gelato. I was really pumped about the salted caramel gelato, just as I would be in waking life. I opened up the freezer case and poked my head inside. I rifled around. There was no salted caramel gelato! I was heartbroken!

Moving my hand a few inches away though, I came upon some bar cookies. They were like fudge, with a layer of green minty stuff, and a layer of crushed nuts. I drowned my sorrows in them, and they were delicious. I also noticed some strawberry ones, but in my opinion the mint ones were much better.

Cut to a scene of me in a lawn chair. I am spooning and eating an enormous coke slushy. I don't even really like coke. Or slushies. But in my dream, the texture was amazing, and I was sad when it melted.

Weird finals dreams #1

I never feel stressed around finals. It's more like a marathon, compared to the sprint that is a regular exam. I have no real obligations other than to study . . . and keep on studying. I'm not usually sleep-deprived because I have all the daylight hours to study without juggling other activities like class and work. The stress must be there somewhere, though, because I frequently am visited by strange, vivid dreams during finals.

Last week I dreamed that one of my classmates had a swollen head, and I had to come up with a list of differential diagnoses as to why. I came up with:
Infectious: viral
Infectious: bacterial

Maybe he had turkey rhinotracheitis virus?

Wednesday, October 12, 2011

Slainte, Universe

Last Friday, a friend and I spent the afternoon working the vet school booth at a large dairy cow expo. We students are required to do a few outreach things in the community to qualify for our educational funds to use for externships and conferences. Neither of us was thrilled that we'd signed up; we'd just finished an exam and would have preferred to spend the afternoon napping. But there we were.

Nobody came to talk to us for an hour. Being two chatty people, we passed the time chatting. I was in the middle of animatedly making a point, when out of my peripheral vision I saw a large figure approach. The table at which I was seated moved three inches into my abdomen as a giant man leaned his bulk on it. This man was actually ruddy-faced. I don't think I have ever had occasion to describe a real person that way. But his round cheeks were so red beneath his close-set blue eyes that I could almost hear the wind whistling over the moors as I puzzled over the fact that this man was bent at the waist with his face five inches from mine.

Now, the Dairy Expo is evidently a big deal, diplomacy-wise. During our uneventful hour, I had noticed people walking by wearing little red ribbons, indicating that they were visitors from abroad. The red ribbon pinned to the ruddy-faced man's cotton plaid shirt read "Ireland."

"I think I'm going to faint," he gasped. Well, actually, he lilted it, adding to the absurdity of the situation.

My friend and I looked at each other. "Do you need water?" she asked. "Do you want to sit down?" I tried.

"No," he gasped as we ran through all the treatment options we could think of.

"Do you need to eat something?"


"Are you too warm?"


"Well, I hope you don't faint!" I cried, letting panic creep into my voice. I imagined him falling, limp, across our spindly table. I pictured my friend and me pinned by the table between a giant Irishman and the concrete wall behind us.

"I hope I do!" he cried. This was not the response I expected, since this man was clearly having a heart attack. I was in the middle of one of those split-second reveries, in which I visualized extricating myself from the twisted tablecloth and trying to remember CPR.

"You do?" I struggled to think of a medical reason why fainting might help his condition.

"Yes, I do, because then a pretty lady might kiss me and wake me up." I swear that, as he said it, his eyes actually twinkled.

I uttered a few incoherent syllables. I blushed. I abandoned my search for the nearest AED. My friend, who is better-adjusted than I am, burst out laughing.

He stayed a few more minutes, chatting about Ireland and and the U.S., until his smaller and less-twinkly traveling companion came to retrieve him. As he left, he took my entire hand in his rough red palm and shook it.

"Come and visit my country any time!"

So for the price of my Friday afternoon nap, I got to encounter a real, live cultural stereotype. One that caused me panic, and then flattered me. Perhaps the universe sent him to our booth, since neither panic nor flattery from giant friendly strangers is compatible with being in a slump. Slainte, Universe.

Tuesday, September 27, 2011

Sophomore Slump

It's here. It seems I am not immune to the downward trend in vet-school opinion ratings following the euphoria of first year. Lately I have been short on patience with people I normally like, stressed about an exam load that is actually much lighter than last semester's, and anxious about social dynamics within my class.

I can attribute my blah-ness to many things. First, I have not figured out my workout routine. Last semester, I was running three times a week. I am a fairly terrible runner, so I was not running far, but boy did it do wonders for my mood. I was on a runners's high all semester; my focus was awesome and my grades rocked. It turns out I'm one of those people, the kind who get a little nutty when they don't get their run in.

Second, as I predicted, school is one big kvetch-fest. My god, people, don't you know we feed off of each other? Every minor inconvenience is the end of the world. And the worst part is, I take part in it, just to connect with people. Being the lone Pollyanna in a group of Eeyores doesn't make you any friends. But it brings me down. The worst is talking about people. Most of what is said is not mean-spirited, but almost all of it could be taken that way out of context. The worst part is, I take part, because it's the way of communicating. I know that to excuse myself from this kind of talk would be to excuse myself from a large part of the social life of the school. But what other choice do I have when I find myself repugnant for joining in, ad stress out about who might have overheard me saying what?

Third, I am entirely overcommitted. I thrive on being productively busy, and the desire to avoid boredom is one of the things that led to me veterinary medicine in the first place. But three officer positions, even though one is in a fairly inconsequential club, is spreading me thin, on top of my weekly overnight on-call shifts in the hospital.

Fourth, my schedule is such this semester that I have no mornings free, which translates to no horse time. I didn't realize how much I relied on it until a resident asked me to hold a horse for him while he discussed it with a group of students. With the lead rope in my hand, giving the horse's ear a good scratch, I put a name to a missing piece.

Fifth, there is a project that I'm working on. It's quite close to my heart, and the possibility of failure is very real. If I am successful, it will be a stressful sort of success; but if I am unsuccessful, I will be heartbroken.

I am feeling that creative pull again. Perhaps that will translate to more writing. I am also going to make a point of running this week, no matter what else I have going on. I've got to shake this funk.

Tuesday, August 30, 2011

My stethoscope

I will start second year this week. I am ready to go back. I am excited to learn about bacteria, viruses, toxins, and all the other abnormal stuff that this year will introduce. And yet, lately I have been contemplating my stethoscope.

My stethoscope is a Littmann Cardio III with the double bells, in color navy. Fairly standard for a vet student to buy during his or her first year. So standard, in fact, that I have a little name tag attached to distinguish it from the other navy Littmann Cardio III stethoscopes that various of my classmates own. The reason this piece of medical equipment has been in my thoughts, I imagine, is that when I hold it, I re-experience the excitement of starting first year.

Our stethoscopes arrived during the first week of school. Along with my classmates, I opened the boxes like I was opening the Ark of the Covenant. Inside, nestled into its foam padding, was the physical metaphor for the profession I was undertaking. I took it home with me that night because I wanted to explore it, and did not want to seem too excited in front of classmates who were still strangers to me. I bicycled to the library that sunny late-summer afternoon, feeling the corner of the box digging into my back through my bookbag, and feeling the more important for it. "I have a stethoscope!" I texted to one of my friends. What I meant was, "I am really going to become a doctor!"

Other sensations can evoke in me, to a lesser extent, the fresh excitement that my stethoscope conjures. Going to the library in the medical school on Friday afternoons, secretly loving that I was studying instead of hanging out or napping. The smell of the teaching hospital, which morphs from antiseptic, to hay, and back again as you walk through the wards. Two rounds of finals have worn some of the polish off my memories of sunny afternoons by the windows in the library, and a summer of working on-call shifts in the teaching hospital has tinged that smell with top notes of exhaustion and annoyance. But my stethoscope remains pure.

So when I go back to school this week, I will tune out the complaints of my classmates. I don't want to hear about how not ready they are to be back at school, or how they wish it was still summer. Because, a year in, I am still lucky to be there. What's more, I am excited to start something new. When the readings pile up, and the on-call schedule becomes ridiculous, and the days seem too short to accommodate the work I need to accomplish, I will think about my stethoscope, and I will be excited.

Saturday, July 23, 2011

I go to the barn because I like the horses

Blue sky. Green Hay. Chestnut horses. Red berries. It is the colors of summer Mondays that leave the lasting impression.

We trot the first edge of the property. I squeeze with my calves, and feel my mount move infinitesimally faster. I squeeze again, and he pushes off with his hind quarters. He is not a hot horse, but I know how he can move when given the right encouragement. I post slightly faster, rising and falling in my stirrups just out of time with the beat of his trot. He gets the message, and falls into rhythm with me.

As we round the first corner our ride really begins. A mile stretches in front of us, with green hayfield to the left and white fence to the right. My horse sees this and picks up his front feet, showing me his big, bold trot that can keep up with the canter of some of his companions. It is a hot day, and I am glad of the breeze that our increased speed creates. We coast along. I lay my head along his neck as we go under the low hanging branches of the walnut trees across the fence, smelling his sweet, dusty mane.

Past the trees I straighten up. I touch my horse's flank with my right calf, and kiss at him with my lips. In a single beat his gait changes, from the up-and-down of a carousel horse to the back-and-forth of a rocking horse. I settle into his canter, reminding myself to sit up straight, point my toes up, and breathe. Now we really fly. I let a laugh escape my mouth. I am no adrenaline junkie, nor do I have any kind of need for speed. Horseback riding is the one exception. Little snorts escape my mount's nose in time to his canter, and I use these to keep time, keeping my position in the saddle.

We near the end of the long straightaway. I tighten the fingers of my left hand into a fist, and apply pressure with my right leg. My horse's velvet nose bends to the left, becoming visible to the side of the curve of his chestnut neck. I coax him into a circle, then a smaller one, then a smaller one; soon we are moving no faster than a trot, but at a beautiful, smooth canter. Collection, or something like it. My abs protest as I force myself to work on these precision exercises; it's so much easier just to loosen his reins and fly.

We halt in the middle of our former circle. Despite all of the kinesthetic sensations I am experiencing, it is the colors of the day that threaten to overwhelm me. The sky is so blue. The hay is so green, a green that I never would have believed existed in my former life in which I did not frequent hay fields. My horse, my wonderful mount, is such a shiny gold-red in the sun that I can't resist leaning down to hug his neck. His chestnut-tufted ears swivel back at me quizically.

The third edge of the property is uphill; ideal for going fast. This is my favorite part of the ride, but I can't let my horse know that. We trot toward the hill, then canter a bit, and then trot again. I know he wants to run, but it needs to be me who tells his when to begin. As the incline increases, I take my reins in my left hand. With my right hand, I grab the red saddle pad that is peeking out over his withers. I give him the smallest kiss, and he picks up a lovely left lead. We climb, and we fly.

When our ride is over, and my horse is brushed and picked and kissed and put back out to pasture, where he plunges his nose into the water trough, I clean the barn at a leisurely pace. Catching sight of a plastic bowl, I rinse it out and tote it to the property line. There, in patches between the trees, are the largest red raspberries I have ever seen. I hum to myself as I pick,eating one berry for every three that go into the bowl. It is quiet here. I move slowly, and listen to my own breathing. I can smell horses and sweat on my person, but there is nobody here to smell me. I pick for hours, until the 'plunk' of a berry into my bowl disappears into silence as the bottom of the bowl becomes obscured, and finally, disappears.

Sore muscles. Sunburnt skin. Juice-stained fingers. Relaxation. These are the impressions that summer Mondays leave me with, long after my memories of what I said or read or did have faded.

Sunday, June 19, 2011

They liked me, they really liked me!

Exernship #1 complete. I learned tons about equine practice, but most surprisingly, I learned many things about how I feel about veterinary medicine, equine practice, and this practice in particular. I record them here to guide me when selecting future externships.

Things I learned:
Veterinary medicine is 100% the profession for me. I don't know how I ever thought I could do anything different. It is creative and cerebral, with little down time. It encourages and requires continued learning.
I love equine practice. More importantly, I am convinced that I could do it. The fact that I have never competed in eventing or high-school dressage does not need to stand in the way of my becoming an equine vet it it is what I want to do.
I like ambulatory practice a surprising amount. My revelation is that ambulatory practitioners in California, as compared to the Midwest, do not have to drive in the snow. Those double-lined insulated coveralls I have had my eye on would not be necessary. Hopefully, my net externship will be at a clinic with a larger inpatient population so I can compare the lifestyles of hospitalists and ambulatory practitioners. Although I am leaning towards internal medicine, the idea of having a truck of my own with a fully-stocked vet box in the back is exciting.
I am a know-it-all, but sometimes this is okay. I think 24 years into my life I have finally learned how to not be obnoxious about it, because that just doesn't make you any friends. I was lucky in that several of the vets at the practice were academically-minded, and enjoyed discussing arcana of anatomy, parasitology, and other subjects with which I have just been acquainted. This is reassuring, because I have met other vets who have an "I don't remember that crap" attitude about vet school. This is demoralizing when the majority of your time is spent learning and being tested on that "crap." At this practice, I met vets of the sort that I want to be.
I crave to be told I am doing a good job. This is not a good thing, because someday I will be in a situation where I need the conviction that I am practicing good medicine whether or not someone tells me so.
Wherever I end up interning, I want to make sure there is good mentorship. Nothing builds my confidence as much as performing a procedure with someone there to watch and correct me if necessary. I also believe that at times, you have to drive your own experience as regards mentorship. Looking at the two different interns and my perceptions of their experiences, I suspect that the extent to which you feel comfortable asking for what you need determines what you get. I need to remember to be clear about requesting to be taught things and to ask or assistance often.
Getting along with the techs and clinicians is paramount to one's happiness in a workplace. A little friendliness and a lot of humility go a long way. This practice had almost exclusively wonderful people.

To pack next time:
Chapstick with SPF: I fear my lips lost out on my fastidious sun-protection regimen
Electrolyte water: boy was it hard to stay hydrated jogging horses in the midday sun. I thought I would be alright with plain water, since the weather is much less humid than I am used to. Instead, I was just dehydrated the whole time and now I feel really hungover.
Polos: kind of the extern uniform. I hate polos, so I did not shell out the money to buy them just for this externship. But I think next time I will.
Twice as many homemade granola bars: little rectangles of peanut buttery, almondy, dried fruit-y, chocolate chip-y joy. Good for breakfast, lunch or dinner. One of these has enough energy to keep you going for hours at a time. That's probably why I ran out one week in.
A camera: well, actually, an iPhone. Once I have one. Good for taking pictures of cool cases, using as a watch for TPRs, making notes, setting timers, looking up drug info, calculating drug doses- I need one of these. Really.

Things to not pack next time:
A sundress: wishful thinking. It was not really warm enough by the time I got off work, anyway.

When I left, the clinic was effusive in their praise of me, which made me blush. They encouraged me to come back, which I would love to do. I will actually miss all the people there, and I will definitely miss the daily routine, which I was just getting down. I scheduled this externship as kind of a "throwaway" externship to get my feet wet in equine practice, since I am not a fourth year and am therefore not a candidate for internship next year. I ended up loving it. I thrived. I eventually felt like part of a team. Although I need to visit as many clinics as possible, I will definitely try to come back to this clinic in future years.

Thursday, June 16, 2011

Recovering the Dragon

Today was surgery day. The surgeries were interesting, and I started to understand anesthesia. But what blew my mind was induction and recovery.

Induction and recovery, simply put, are the acts of knocking a horse down and then getting it back up again. It sounds simple, but it is actually quite dangerous, both to the patient and to the team of people assisting the patient. To go smoothly, induction and recovery require choreography and communication. A little muscle does not hurt, either.

The day's first surgery was a large black gelding who was on the nervous side. After being premedicated and sedated he was led into a room with padded mats on walls and floor. I climbed thorough a trap door in the ceiling of the hallway next door to take my place in the loft overlooking the induction room.

Four people stand at the side of the horse. One, who is the vet acting as anesthetist, administers the injectable anesthetic. Nothing happens for a while, and people above and below chat.Without warning, the horse pitches to the side. All four people in the padded room brace backwards with their right leg and push with both hands on the horse. The absolute synchrony with which this occurred floors me. I see four sets of forearm muscles form cords.

The horse is lowered onto its side, and its legs are hobbled. Large hooks attach the hobbles to a track in the ceiling. The door into the surgery room is opened, and the horse is guided, feet up, onto the table where it remains in dorsal recumbency. Pads are placed to mitigate the crushing of its own body weight on the horse's nerves. Finally, the horse hooked up to the ventilator and the anesthetic gas begins to flow.

Recovery is no less dramatic. The scene in the surgery room occurs in reverse; the anesthesia machine is disconnected, the pads are removed, the door to the padded room is opened, and the horse is guided back inside, where it lies in lateral recumbency. The anesthetist stays by the head, monitoring the anesthetic depth by looking for nystagmus, the strength of the palpebral reflex, and other signs. The horse has standing wraps placed on all of its legs to prevent it from injuring itself as it gets up. From my vantage point up top, I admire that two legs are red, one green, and one blue.

This time I am not alone up in my crow's nest. Someone climbs up and grabs hold of a rope attached to a pulley. Another person down below attaches this rope into the horse's halter. This person ties a second rope around the horse's tail; this rope attaches to a pulley in the opposite corner of the room from the head rope. Yet another person climbs a ladder and takes hold of that rope.

Recovery is relatively long. This is preferable; a horse that pops up from general anesthesia is disoriented and dysphoric and poses a threat to itself and the people helping recover it. Two techs and the anesthetist remain in the padded room. They kneel with their hands on the horse to discourage the horse from getting up immediately upon awakening. This is when the atmosphere becomes festive. Dr. C up holding the tail rope chats with Dr. I, the anesthetist, and L the tech, who is basically running the show. The conversation meanders, and we laugh freely.

As quickly as it went down in induction, the large black beast on the floor gasps. Two gasps, later, the horse is extubated, and the three individuals in the padded room hold him onto the floor. The anesthetist, her job done, makes a hasty exit. The horse is disoriented, a dark shape on the floor and gasps and snorts, resembling nothing so much as a waking dragon. I am reminded forcibly of the sheer animal-ness of this beast. He is frightened and confused with every pound of his considerable body weight, and we have no way to reassure him that our restraint is only to help him.

When he brings his head up, it is the job of the head rope person in the loft to heave upward. The trick to holding the head rope, however, is the rope must follow the head. The horse uses its head for balance, so when the head goes up, the rope must go up, and vice versa. The tail rope, on the other hand, is more of a brute strength operation. As soon as the hindquarters come off the ground the tail rope person must pull and tighten and pull some more. This is because the horse is unsteady on his hindlimbs, and the rope acts as support.

This horse's first few attempts at recovery are abortive. He ends up in a corner, gasping, back on his side. After much encouragement by the people on the ground, he stands shakily. I almost can't help looking away, because this 16 hand animal is teetering like a poplar in a windstorm. Added to his general unsteadiness is the fact that, on account of his surgery, one of his forefeet is completely numb to him. I hope the adage about the three-legged stool being stable is true in the case of horses. He does not fall, and he calms as a regular lead rope is snapped back onto his halter.

This was the first equine induction and recovery I have every witnessed, and I was amazed, not by the process itself, but by how magical it seemed to me. Both the human and the animal were displayed at their most archetypal: the human planning, choreographing and executing; the animal displaying 1500+ pounds of flight mechanism. I am certain this is a dance I will witness several more times. I am sure that at times I will witness it when I would rather be somewhere else, like in the middle of the night, perhaps. But today it was magical.

Nephrosplenic Entrapment

No, it is not a legal term. Nor is it an exotic food. Rather, it is a type of colic where the horse's left colon gets hooked over the ligament connecting the spleen and left kidney and causes the horse pain due to mesenteric pull and gas distention.

Yesterday a referral came in about a horse with a suspected colic. We didn't get much information besides that "Louie" was looking a little off, and a warning that he was kind of pushy. I was excited to see something medical rather than surgical, so I jumped in the car with Dr. Intern and we headed down the road.

Louie turned out to be a good sized paint horse, who did indeed look uncomfortable. We had his owner, an earnest teenage girl, lead him out of the relentless sun into a covered area for examination. Louie just appeared restless and painful, hanging his head while he shifted his weight and pawed the ground. His owner informed us that he had passed only a small volume of feces today (unusual for a horse, which is an eating machine, and therefore a pooping machine). Dr. I performed a physical, focusing in particular on his heart rate (a possible indication of pain) and his gastrointestinal sounds. I watched as she listened to his upper and lower abdomen on the right and left sides. Next, she did something that I had only encountered in the context of cattle: she "pinged" the horse on its upper left abdomen.

"Pinging" is the process of listening to the abdomen while flicking the area around the stethoscope with your fingers. If there is any gas trapped there, you will hear a high "ping," like the noise you make when you tap on an inflated basketball. Dr. I told me to have a listen to the abdomen. She told me there was one abnormality, but not what it was. I was quite proud when I identified that gas-filled upper left abdomen, especially since I never really understood what a ping sounded like in a cow. On top of this, Louie also had almost no GI sounds in the other quadrants of his abdomen, indicating that his gut was not moving.

Dr. I administered a dose of pain medication and a sedative, noting the time. The rate at which the pain breaks through the drugs, she explained to me, can be an indicator of the severity of the colic.

To get an idea of what we were working with, Dr. I donned a rectal sleeve and lubed it up. Standing carefully to the side of Louie's back legs, she performed a rectal exam. This confirmed a large, gas-filled structure on the left side, which she suspected was left colon.

Even though this colic was most likely a hindgut issue, she decided to attempt passing a nasogastric tube to reflux and stomach contents. Louie, however, was not up for that, and we gave up when it became clear that we did not have the manpower to hold even a sedated Louie still enough to shove a piece of plastic tubing into his nostril, down his choana, into his pharynx, down his throat (avoiding the trachea) and into his stomach. Louie's teenage owner and I were both nearly lifted off the ground trying to hold his head.

The decision was made to trailer Louie to the clinic; that way if Louie's abdomen turned surgical, we would waste no time, and even if it remained medical, we would be better equipped to support the gelding. Louie's pain seemed to be controlled for the time being, so we loaded him into a trailer and headed for the clinic. Some cases. Dr. I told me, actually will resolve themselves over the course of a trailer ride because of the motion of the vehicle. We crossed our fingers that Louie would be one of those lucky horses.

When he arrived at the clinic, Louie was becoming painful again. We hustled him into the stocks and gave him another dose of pain meds and sedation. The next step was an ultrasound of the abdomen, which confirmed the nephrosplenic entrapment that Dr. I had suspected. I admit that while I can recognize structures on tendon and musculoskeletal ultrasound with some facility, the abdomen looked completely unfamiliar to me. I gathered that not being able to see a distinct spleen and left kidney indicated that they were hidden behind gas-distended colon.

In the stocks, and with more hands restraining him, we were able to pass an NG tube on the second try. I stood on the left and held his ear, trying to convince him not to throw his head. At last we smelled stomach gas at our end of the tube, and Dr. I pumped clean water into his stomach, and then collected whatever came out. We refluxed a small amount of fluid and some gas. Clearly, this was not the source of Louie's pain.

The next step was to get intravenous fluids into Louie. It was a hot day, the horse was agitated and sweating, and since he had been feeling poorly, had not been drinking. To combat possible dehydration and electrolyte imbalance, we placed a catheter and began to bolus plasmalyte once Louie was safely in a stall.

Dr. I decided to administer a peripheral vasodilator in the hopes that it would shrink Louie's spleen and allow the loops of colon to slip off and back into their normal orientation. Since this drug causes peripheral vasodilation, a concomitant increase in the volume of blood in the heart occurs. This increase is sensed by baroreceptors in the great vessels, and sets off a decrease in heart rate. Obviously, a heart rate that drops too low can result in syncope, or fainting, and with a 1500 pound horse, this is a big problem, both for the horse and for any hapless humans in the area. As a result, I was given the job of monitoring his heart rate during the twenty minutes over which the dose was administered. This may have been the best part of the whole experience, because now I have no doubt that I can both locate the heartbeat and calculate the rate correctly. I smiled to myself, recalling my equine physical exam labs where I just pretended to avoid the scrutiny of an overbearing instructor.

Twenty minutes later, my ears were numb from the stethoscope earpieces, but Louie remained on his feet. All we could do was wait, and hope that Louie's spleen would politely move out of the way of his displaced colon.

Louie continued to look uncomfortable, pawing and the ground and hanging his head. Murmurs began among the techs, and Dr. I contacted the surgeon on call to let him know that there might be an abdomen to cut.

Luck was on Louie's side, however, and after around 45 minutes, the left abdomen ping was gone. In its place was a reassuring dull thud. Louie stopped pawing the shavings in his stall, picked his head up, and started engaging with his owners who were standing outside his stall. Ultrasound confirmed that the distended, gassy mass was no longer where it had been. Score one for medical colics. Dr. I called the surgeon back to put him off guard, and the techs breathed a sigh of relief.

Since Louie's colon could technically displace again, we needed to monitor him every few hours until the morning. We wouldn't feel really confident until we saw real, formed manure. I pulled the 4 AM shift. When my alarm went off, I heaved myself out of bed, reflecting on how much worse this would be either not in California, or not in June.

In Louie's stall, I found a different animal than the dumpy horse of that afternoon. He even looked bigger, holding his head up and greeting me at the stall door. Soon after I haltered him, it became clear that Louie was hungry, and he had just about had it with my not feeding him. As I listened to his heart, he pawed the ground in a way that was more threatening and less pathetic than his previous leg movements. As I performed the important auscultation of his GI quadrants, he raised each hind foot in warning, one for each side I ausculted. Although this was no way to treat a person at 4 AM, I was just glad that he showed no signs of pain. Best of all, by 7 AM he had passed two piles of manure, to hallelujahs that only veterinarians can hear.

Louie just got better from that point. By better, I mean pushier. In fact, Louie and I had several disagreements today, over whether I was allowed to examine him, who would exit the stall door first, how fast we were going at the hand walk, which direction we were going at the hand walk, and whether it was okay to drag me over to a patch of grass so he could stuff his face. I remembered a trick from my dog training days; whenever Louie started going faster than I wanted him to, I turned around and we went the other direction. It worked somewhat, but by the end of his brief walk-and graze, Louie and I were glaring at each other pretty hard.

What I got out of this experience, aside from confidence in taking heart rates, is reassurance that I like the pace of an urgent problem. This is not how I would have described myself previously, but I do. I like being able to see a problem and work out what is going wrong and what has to happen to make it right. Perhaps most obvious, I hate being bored, and an emergency is the opposite of a slow day at work. I learned that I like medicine, and that I have only just scratched it's surface. I also learned that I can often rely on my knowledge, even though it is only the knowledge of a first-year veterinary student. I identified the nephrosplenic entrapment immediately when it was described to me, and I heard that ping. This is a very small deal, but it is a very big reassurance that my work will have tangible returns.

Tomorrow Louie will return home, and I will not be sad when it is not my job to walk him and haul his nose out of the buckets of hay, potted plants, and grassy patches. He will be glad to return to his life jumping fences with his teenager and never again letting me touch his abdomen with that cold metal thing. Maybe we'll glare at each other a little bit as his trailer pulls away.

Saturday, June 11, 2011

No foot, no horse

Yesterday's theme was lameness. Lameness is a huge part of equine practice, particularly sporthorse practices. The term "no foot, no horse" describes the fact that whether on the trail, on the flat, over jumps, or in front of a cart, a horse's purpose in life is to perambulate in some way.

Not having grown up on the back of a horse, lameness is mysterious to me, and an area in which I am honestly not sure I will ever be comfortable. In referral practice (like at the vet school) it is the realm of the surgeon, whereas my nascent interests tend toward internal medicine. Nevertheless, I was in the presence of an expert yesterday and within the context of lameness I had a revelation about systematically approaching a problem.

A lameness exam, put simply, consists of watching a horse move through all of its gaits, palpating tendons and joints, performing flexions, and watching it go some more. Depending on the character of the lameness and the resources of the owner, it may involve nerve blocks, radiographs, or ultrasound. To the inexperienced observer, abnormalities in the horse's gait are almost impossible to see unless they are extraordinarily severe.

Dr. C's first exam was a flea-bitten gray (think red-freckled) Hanovarian-type gelding. The horses in my life seem to be getting bigger; I remember my grandma's Morgans being much smaller than the thoroughbreds I ride now, and the Hanovarian was bigger still, with withers that were level with the top of my head. I had the job of jogging him up and down while Dr. C evaluated his gait both going and coming. The horse may have been jogging, but I was definitely sprinting. Dr. C flexed each of the horses joints as hard as he could, and then watched him trot more to see if he could elicit a lameness that way. After he had formed preliminary opinions based on these flexions, and his palpation of all of the major tendons in each leg, Dr. C requested to watch him go on a longe line. I was deemed too inexperienced to longe the horse, which hurt my pride. The outcome was positive, however, since Dr. C did what nobody ever had before, and explained to me what he was looking for as the exam took place.

Even most horse owners watching a lameness exam would see only this picture: a horse moves in a large circle around a handler holding the line and walking in a smaller circle to keep the horse moving forward. The vet stands and watches, occasionally requesting changes of pace to the walk, trot, or canter, and changes of direction. After twenty minutes or so, he will describe what he saw and how that bears on the horse's soundness. He may perform more flexions or watch the horse go in a straight line again. He may block certain nerves in the legs to try and localize where the pain is coming from.

Leaning on the paddock fence, Dr. C described to me what he was looking at. On some rounds he looks at the head for any bobbing. He looks at how far each hind leg moves cranially during the canter, and compares it with the length of the stride on the other lead. He evaluates whether they canter comfortably in either direction, or whether they tend to break from the canter due to discomfort. I will not describe the exam in any more detail because I know I could not do it justice. I will need to be coached through dozens more lameness exams if I am ever to really understand it. What was a revelation to me, however, was the systematic approach. When Dr. C described his approach, it dispelled one layer of the mystery of lameness for me. I saw that, with practice, it was not so much different than learning to read a radiograph; you have a set series of steps to go through to ensure you evaluate everything and don't miss any abnormalities. I believe that there is a true art to lameness evaluation, but yesterday's experience convinced me that perhaps it is a skill that can be learned.

The idea of systematic approaches to diagnostic problems has been a theme of my veterinary education so far. Before starting school, I was daunted by the prospect of cramming enough knowledge into my head to ever successfully diagnose an animal. To my mind, not terribly systematic naturally, it appeared that veterinarians were walking compendiums of animal disease who could look at an animal, lay hands on it, and know how to treat it. I now realize that only a savant could function this way. In reality, an animal is examined, a list of differential diagnoses is created, and this list is sorted and refined systematically. After years in practice, one gets used to clinical signs that are most often correlated with certain disease processes, and this can give the impression of encyclopedic knowledge. Systems, however, help prevent diagnostic mistakes.

After so much jogging I fear I have come up lame. I think I'll spend my weekend afternoon reading and resting my feet in preparation for tomorrow's jaunt up to the East Bay!

Wednesday, June 8, 2011

Intro to stallions

Today I handled my first stallion. The price of this experience was one carsick tech and an attempted poultry jailbreak, but in the end everyone survived. The further I get from the experience, the less realistic it seems, so I will record it here.

I began the day apprehensive. Scanning the appointment board this morning, I saw that not only was I riding with a different doctor today, but I would also be attending a dental on "Boris" this afternoon. Boris is a stallion. My only contact with stallions has been in clinics where they spend the day tethered to the wall in a padded stall, squealing while they wait for their turn with the dummy mare. I had never been faced with holding the lead rope of one of those muscular beings, let alone restraining one while a vet rasps the sharp points off of his teeth. As the the tech "L" and I head down the highway I have trouble paying attention to his polite conversation, staring instead at the dry hills with their spreading oak trees, and praying that this is not the day I get trampled.

Our first call is not to Boris, but to an ultrasound of an old gelding with a kind face who had been kicked in the pasture. This is where we meet up with the doctor, whom I will call Dr. C. C for cool, because this guy exudes it. This makes me nervous, because cool is a department in which I show serious deficits. My fears are soon assuaged, however, when Dr. C impresses me with his painstakingly thorough ultrasonagraphic examination of this gelding's shoulder. Though not a man of a thousand words, when prompted, Dr. C will explain in detail what he is doing and why, and my confidence grew as I was able to recognize not only the structures in fuzzy black and white, but also the abnormality.

The drive back to the clinic with Dr. C was long and I was able to pick his brain about many things, including the increased trend toward hyperspecialization in veterinary medicine.
"You've kind of got to know something about everything, and everything about something, right?" I ask, using what is evidently my current favorite quip.
"Exactly. For example, my specialty is lameness. I want to know everything I can about lameness. I think internal medicine is interesting, but there is not enough time to really delve into it."
"It's like how mixed animal practice is not really feasible anymore, unless you have different practitioners for each category."
"That's right," he laughs. "Sometimes people ask me to look at their dogs or cats. Or goats. I don't even open that door. I just say I'm the wrong person to ask."
I laugh, unable to imagine Dr. C's coolness, which serves him well when he is absorbed in an appraisal of a jogging horse, allowing him to kneel in a barnyard to examine a bleating goat.

Boris lives about an hour south, along the coast. The fog has burned off and the sky is a cloudless blue, so I look forward to a scenic drive. Dr. C and L (his tech for the day) are less enthusiastic.
"I hope nobody gets carsick," says Dr. C, by way of response.

I see what he means. The highway is one of those uniquely Californian roads carved out of the side of a foothill. Whoever first planned it never dreamed of anything as massive as a truck with a fully-stocked vet box in the back. I try not to look at the precipitous drops that peek out where the eucalyptus thins in places, as Dr. C roars around each curve at interstate speeds. This is just the sort of highway that once made my five-year-old sister proclaim tearfully, "It's too wiggly!"

The road spits us out several hundred yards from the ocean, and I indulge in a personal nostalgia fest at my first glimpse of the Pacific in months. In short order, however we turn onto a road even wigglier, and much narrower, than before. There is no eucalyptus now, just that green grass that looks like little wheat stalks and ripples appealingly, like velvet.
"What happens if someone comes the other way?" I ask, looking down the rock face to my right?"
"You're screwed!" Dr C laughs. It occurs to me that someone had to drive a horse trailer here at some point. The winding road didn't make me queasy, but this thought does.
After half an hour more of winding through nowhereland, we arrive. There is a large house with a gate and a simple barn at the end of the driveway. I see no horses, only several paddocks of that same ripply green grass. It is silent, and with the pattern from the moving ocean clouds on the grass, I have to admit that the property is breathtaking. We are here, however, to float the teeth on a stallion, and so far see neither man nor beast.

A sign on the gate instructs us to ring the bell. We look around for a doorbell, and find none. Suddenly, I realize that the bell in question is right in front of us; it is one of those temple bells formed from an old compressed air canister. I point out a rock balanced on a fence post, ostensibly for the purpose of ringing the bell. Dr. C looks at the rock for a few seconds before banging it against the bell. Nobody comes.

As we are deciding to go in search of the horse ourselves, a woman manifests onto the driveway. She is of a sort that I recognize; white hair left au naturel atop an ensemble of a shapeless blue work shirt and jeans. Something about her gaze suggests a certain detachment from reality.
"The stallion moved next door, I'm afraid."
"Next door?" D. C scratches his head.
"Actually, one canyon over. He's helping to stage the ranch that's for sale."
I see Dr. C and L exchange a glance.
"You can follow me in my car. It's too complicated to give directions, but I can take you right there."

We pile back into the truck and take off after the woman as she roars out of the driveway. It seems that the large ranch-become-artist community in the area is up for sale, and its sellers believed that Boris's presence would help move the property. We drive on, unsurprisingly, another winding road, watching the woman almost collide with a mail truck rounding a blind curve. I catch sight of L's green face in the rearview mirror, and offer him the front seat, but he waves away the offer.

We arrive at the ranch by way of a wrought iron gate with the emblem of a llama. It's actually quite spectacular, and I would not have minded taking a picture of it. I make no mention of it, however, remembering Dr. C's opinions about the non-equine species. I do smile to myself, however, when we pass the emblem's flesh and blood inspiration cushed in a field, tufted ears held high.

The road eventually ends in a circle surrounded by gigantic oak trees. The parking lot abuts an old-fashioned circular paddock in which a black and white tobiano paint grazes.
"Is that our guy?" I ask doubtfully. He must be, since there are no other horses around, but this smallish creature grazing blissfully, surrounded by a few dozen chickens is not quite the stallion I was expecting.
"This is Boris. Boris loves carrots." The woman shakes a black bucket toward us to underline her point. "But I will warn you. Boris hates vets." She glares at us, as if by potentially offending Boris, we had already offended her. The woman coos and fusses over Boris while L and I spend a chunk of time trying to address the fact that there are no electrical outlets present into which to plug the dental tools. The woman is unconcerned about this fact, choosing instead to tell us about Boris's lovely natural life.
"He's a lucky horse, getting to stay a stallion and live up here. His teeth are good because he's eaten grass all his life."
Dr. C mumbles some assent while throwing the rope of the dental speculum over the ceiling beam in the parking garage where L has located an outlet.

The woman coaxes Boris over. As L slips the dental speculum over his head and Dr. C injects the sedative into his vein, I concede that there is something undeniably appealing about him, but he his far nothing like the stallions I have seen at horse fairs, who are, frankly, living embodiments of sex. I begin to feel a fondness toward Boris, perhaps born out of my relief that he is not the snorting, flaring dragon of my fantasy. He doesn't even seem to bear any animosity towards us, despite our being veterinary types.

"Oh no, the chickens! Could you, can you-" the woman has left the paddock gate open and the chickens have started to expand their foraging radius to include the area outside the paddock. The woman gesticulates wildly at me, entreating me to catch the runaway chickens. I glance at Dr. C and L, but they are already hitching Boris's head up, as the sedative takes its effect. I walk toward the chickens in an arc, trying to channel Temple Grandin and herd them back into the paddock, praying they don't scatter. Luck is on my side, and the runaway fowl shamble back into the paddock with a few irritated looks at me.

Teeth floating in horses in the modern day is a power-tool operation. Whereas until recently a large rasp, called a float, would be used to smooth off the rough points that horses develop on their teeth from constant chewing, motorized floats are now the standard of the industry.

Dr. C allows me to feel the inside of Boris's mouth after the bits of chewed grass have been flushed out. I feel points along the outside of the upper arcade that are causing ulcers on the inside of his cheeks. This is normal for a horse, since their molars do not occlude completely with one another as they erupt continuously throughout adult life.

Boris turns out to be a lightweight as far as the sedative is concerned, and I take a new post at his rear as he sways off balance. I push his hind quarters to the side to encourage him to square up his feet and lock his knees. Instead, Boris takes this as a cue to lean his entire weight against my outstretched arm. After an eternity of rasping by Dr. C at the front end, I gingerly take my hand from the wobbly stallion and venture to back to the mouth. This time, where there used to be points is a smooth arcade.

L and I pack up the truck while the woman flutters around, talking about a trip she is going to take to track wild mustangs. While she is fluttering, a lanky man with a dark, oily braid down to the waistband of his paint-stained jeans sidles up. He carries a bag made from a different pair of paint stained jeans. Everything about him screams "artist."
"Ah, Joseph," cries the woman. "Dr. C, this is Joseph. He is the ranch manager." I slide my eyes back over him, surprised by my misinterpretation of his profession.
"I just got back from milking the goats," he announces. I read the subtext in this statement, and it says, "I am so in touch with the land." Learning that Dr. C is a veterinarian, his eyes light up.
"Would you look at one of the goats?"

I catch Dr. C's eye for a split second, and then turn away. I take Boris by the lead rope and coax him back toward the pasture. Boris is still wobbly and unwilling to move his feet, so I smile as I listen to Dr. C's hasty dissembling. I thank Boris for being a good first stallion for me, and take in the effect of Boris in the paddock with his chicken harem. I have to admit, the effect is good. As the three of us finally pile into the car, Dr. C and L shake their heads in exhaustion. I just smile. It's good to be back in the land of my birth. I wonder who is going to see the goat.

Monday, June 6, 2011

Hocks, blocks, and emergency call

Day 1 of my externship ended much better than it started. I settled into my tiny extern room last night feeling much like I did the day I graduated from college and moved into a room in a house on my own; uncomfortable, lonely, and a little bored. I woke up at 5:30 AM due to a combination of jet lag and the intern in the room adjacent to mine ripping pieces of packing tape off a roll. This made me paranoid that I was going to miss morning treatments, which woke me up further, which made me realize how little sleep I got, which made me paranoid that I would not get my coffee, which eventually got me to get up and make coffee. I then sat around in my garrett and read a book for the next 2 hours or so until someone came to find me.

I hate the first day of new jobs. I hate feeling incompetent, even though I know I cannot be expected to know where the doctor keeps his ultrasound equipment, or how he likes his injection sites wrapped. I try to watch and learn and absorb as much as I can, but this takes up a lot of my attention and I end up feeling clumsy and slow witted.

It was emphasized to me how much getting along with a person can affect your happiness and even your ability to excel at a clinic. On the first call I rode along on this morning, the tech and I did not click. I felt that she was unfriendly and taciturn and she probably thought that I was a moron. As a result, I worried more about how my actions reflected on my competence than on what I was learning. I was miserable during this call, hastily concluding that equine practice was not for me because I have so little clinic experience and no idea what to do. This evening, however, I rode along to an emergency with the intern on call. Perhaps it is because she does not seem like she can be much older than me, or perhaps it is because she is bubbly and talkative, but we clicked and we chatted the whole way. At the call (suturing a minor, but bloody, laceration) my actions were more decisive, my help more helpful, and my questions more relevant than they had been at the earlier farm call where I had been preoccupied with feeling awkward.

I can see that this situation holds two important lessons. The first is to take a darn good look at the atmosphere of any hospital I am thinking about interning or working at. I want to end up somewhere where I feel supported at least in personality, because I know that is when I make better, clearer-headed choices instead of reacting in a fit of trying to prove myself. The second lesson is just to learn to practice good medicine whether I am friendly with the people around me or not.

Things I need to review:
Hock injections
Flexion tests
Acupressure points and their relation to lameness

Too sleepy now, though. Must sleep.

Sunday, June 5, 2011

Knowing everything about something, and something about everything

I consider myself a writer. But why? I rarely write anything. Not on paper, anyway. Sure, I compose essays and dialogues in my head almost daily. I have dreamt up characters who are constant enough companions to me that I have trouble believing that nobody else knows they exist. I have a memory full of half-baked story ideas and a hard drive full of sketchy narratives.

I have considered myself a writer since I was a child. I knew I was a writer like a knew I liked swimming and hated raisins. Unquestionably, a foregone conclusion. But writing is hard. How do I know if I have anything worthwhile to say? Crafting a cohesive story is work, and takes mental effort. I have school, or work, or I should really go running.

And then there is blogging. I am an avid blog reader. I know what I like in a blog, and I read blogs for different reasons. Some are voyeuristic: I like to see old classmates of mine swell with pregnancy and then pop out squishy infants who develop into children in what to my perspective seems to be time-lapse photography. Some are informative: I like a good cooking blog, and cannot stand a bad one. Some served a purpose at one point and now have just become habit: these are the veterinary student blogs that I read before I started vet school, hanging onto every description of a daily routine which is now familiar to me. Some are inspiring: I have a friend or two who either through pictures or words beautifully frame a place in time, or a concept in space.

The blogs I prefer are thematic, rather than narrative. A stream-of-consciousness description of a day in the life or an event generally does not hold my interest. The blogs I prefer do not read like diaries, since I can't help feeling that the public forum of the internet is not the place for raw introspection.

After graduating from college, I had a few lame jobs that used a fraction of my mental capacity and held almost none of my interest. If I was still working this sort of job, I could probably consider myself a writer, first and foremost. But in a few short years, I will be a veterinarian. This is an intense profession, in terms of time commitment, mental and physical energy, and effort spent in preparation. I cannot wait to be a veterinarian, and I love pushing myself to learn as much as I can in the knowledge that it will help me be an awesome doctor. I know that I would not be happy in a profession that did not challenge me. I want to know everything about my chosen career.

At the same time, an equal and opposite force makes me want to do something creative for every hour I spend working or studying. I want to read, write, knit, garden, and play music. I want to know something about everything. Mostly, I want to write, like I always knew I would.
And so I will start writing here, merely for the sake of writing. I want to create a writing habit. I will write something every day. I will find something to write about. I will break my own rules, probably. I will sometimes write in a narrative style, even though I find that style difficult to read. I will let this blog take and shift shape. Other people may get something out of it, or they may not. It is, after all, for me.

I will begin by writing something each day of my first-ever equine externship, for which I am traveling to California right now.