Reflecting on the past year and choosing my three words for next year

Each year, instead of a New Year’s Resolution, I choose three words to help guide my decisions and how I live my life. Last year at this time, I was holding a brand new baby in my arms, and the words I chose to guide the oncoming year reflected my deep sense of commitment to her and my family: Nurture the future.

Now, here I am a year later, and my baby is a year old, and her big brother is 4.5 years old. My sense of commitment to my family is no less, but a lot has happened in the past 12 months, and the coming of a New Year brings with it a special opportunity to reaffirm one’s goals and direction.

So let’s see…here are some of the big changes that have occurred in my life in the past year:

• After 8 years practicing at the only hospital I’ve ever worked as a veterinarian, I parted ways and took a leap of faith into a new practice.
• My good, old dog, Monty, crossed the rainbow bridge. His age was unknown, but I estimated 12-15 years old.
• My working relationship with the veterinary publication, Clinician’s Brief, has molded itself into yet another adventure. I accepted a position as Medical Contributor, which means I help select content to post on their Facebook page and e-newsletters and write some of the copy for those elements.
• I announced my plans to step down as president of a non-profit organization that I started in 2008. It is in a good financial situation and has great leadership in the wings. I hope I’m leaving it in good shape for a great, promising future.

The risks associated with my employment changes has brought some tension in my personal life, and while sparing this blog of the gory details, suffice to say I believe with all my heart that I’m making the right move and I am working really hard to make sure other loved ones in my life will see that these changes will have a positive impact on all of us.

With that in mind, I have given tremendous consideration to the words I chose for 2013. One “challenge” I faced with my previous three words (“Nurture the future”) was my relentless sense of needing to accomplish things—whether it’s the laundry, a blog post, or an agenda for an upcoming board meeting of which I’m president.  So while I want to spend time with my family—and have been spending nearly every night on the couch watching TV with my husband after the kids are tucked in—I need to run the laundry, read and write more, and make impressive contributions to my new practice, where I hope to someday be a partner.  Most nights that I sit on the couch and watch reruns (thanks, Netflix!) of Magnum, P.I. and Mythbusters, I enjoy my time taking it easy, but there is a little voice in my head reminding me that I have obligations, and I’m making things more difficult for myself by putting them off.

In 2013, I want to listen to that little voice. I want to accomplish the things I know I can accomplish, which requires that I take the time to be organized. I want this leap of faith transition to ‘wow’ those around me—because I know I can do it.

Here they are, my three words for 2013:

Listen. Organize. Energize.

 

Friday the 13th

Some days, it feels like nothing goes as planned.  Friday the 13th was one of those days.

My schedule included two prophys, a dog and a cat. I also agreed to radiograph two raptors for Operation Wildlife. I thought I might actually have some time to catch up on some projects.

The phone call from one of our technicians informing us that she was too sick to come in was our first clue that today would present some challenges. Then I was told our in-house blood analyzer was out of diluent and we couldn’t run the CBC on one of my prophys (we require preanesthetic bloodwork). The chemistries weren’t working right either, but someone was “working on it”.

The next surprise was the devastating news that a cat belonging to one of our former employees died suddenly and unexpectedly—he was found that morning under the bed, deceased. A complete mystery, upon which a necropsy shed only a glimmer of light, and hopefully histopathology will be more revealing.

By 9:30am, it was clear that an emergency surgery (gastric foreign body) needed to be worked in. My associate planned to do the surgery. My technician was finishing up taking full-mouth radiographs on my first patient, a 4-year old sheltie undergoing her first prophy. She was missing at least seven teeth, and radiographs proved that they were truly missing. But a surprise finding came up—as they tend to do with full-mouth radiographs—and I found myself looking at an unerupted supernumerary tooth. Removing it was no big deal, but between the extra time on the phone with the client and the extra time performing the extraction, my technician was delayed in getting started on the emergency surgery.  We postponed the second prophy for the afternoon.

While my associate, technician and an assistant were in the surgery suite, I decided I could radiograph one of the raptors waiting for me. I weighed my options between the two—a barn owl used as an education bird that recently seemed to be holding his wing funny, and a Mississippi Kite with a fractured wing. I chose the barn owl, hoping to find something simple that didn’t need surgery.  He was never going to be released to the wild, afterall—what kind of injury could he have that would need surgery? A transverse, displaced proximal ulnar fracture, that’s what. Reluctantly, I rebandaged the wing and made arrangements for the bird to come back next week to surgically stabilize the injury.

Just when I thought I should go to lunch, we had an urgent care exam walk in: a 10 lb Pomeranian that had been picked up (literally) by a much larger dog. I was delighted to see the dog wagging happily and breathing normally. But that wound on her back worried me—how far did the gap between the skin and underlying muscle reach? We agreed to keep her for further evaluation under anesthesia.

A hurried lunch later, we surveyed the path of destruction that appeared to have swept through our treatment area. The blood work for the cat (my second prophy) was done, so my technician predmedicated and began working on her. My associate, eager to help after utilizing the majority of our staff for the last several hours, helped me anesthetize and treat the wounds of my injured Pomeranian. The wounds turned out to be far worse than I expected. Her entire dorsum was separated from the underlying muscle.  I placed two drains, gave her a Convenia injection, a Baytril injection, and a Metacam injection.  She woke up smoothly (still wagging her tail, bless her heart). I sent her home with oral Baytril, Metacam, and tramadol, and I’ll see her back early next week.

The cat prophy was uneventful, and full mouth radiographs revealed no surprises. I wished desperately that I could help my staff clean up, but I would more likely create greater chaos and confusion by putting things in the wrong place. So I headed back to radiology to x-ray the Mississippi Kite, fully prepared to see another injury in need of surgery or worse.

Then I experienced my first good surprise of the day: the figure-8 bandage was doing an excellent job of stabilizing the fractured ulna! Not only did the bird not need surgery, but he stood an excellent chance of making a full recovery and returning to the wild! I shouted the good news to my technician. She shared in my rejoicing, then made a poignant observation as I carefully held the bird waking up from its anesthesia.

“Grace’s surgery went well and she feels a whole lot better now, too. And two pets have better mouths now, thanks to us.”
“And Rosie won’t slough off her entire back now—hopefully,” I added.

We thought the day was chaotic and would never end. But at the end of the day, we realized everything we’d done, including all the mess we’d made, was for a good cause. We were doing our jobs, and doing them well.

We survived Friday the 13^th.

The best laid plans…

Excited to practice my new communication skills (see my recent post about the FRANK Communication Workshop I attended), I picked up the phone to dial my 4:30 consultation about some rabbits. The client lived far away and had questions regarding her “herd” of about 100 rabbits (started as a 4-H project). The staff had warned me this would be a challenging conversation.

An hour later, I sighed as I hung up the phone, having barely used ANY of my newly honed skills. In fact, I barely got a word in edgewise.

Luckily, we pre-arranged payment by credit card at a rate of $25 per 15 minutes, because apparently it was not possible to spend less than 20 minutes on the phone with her. And she had a LOT of questions.

Wisely, I opened a blank Word document to take notes during our call. Trying to keep up with what could most aptly be described as “verbal diarrhea” was nearly impossible. I thought my notes would be helpful for practicing my reflective listening–ha! I could have set the phone down, walked away for 5-10 minutes, come back, and she still would have been talking. I literally had to interrupt numerous times to clarify important details or make what I hoped was a useful contribution to the discussion. I’m pretty sure I never asked an open-ended question and lord knows I never had a chance to pause!!

To my pleasant surprise, I could hear her trying to wrap things up as the clock ticked closer to 60 minutes. I asked if the conversation had been helpful for her, and she said yes.

In fact, she will try to bring a couple of her rabbits to come see me some time. I wonder what that will be like?

FRANK Communication training

A dream of mine came true today: I attended the first day of the Pfizer FRANK Communication workshop!

A little background about FRANK: it’s a veterinarian-client communication workshop designed to help practicing veterinarians and their staff communicate better and more effectively with their clients and team members. I first learned about it when our Pfizer Technical Services veterinarian, Dr. Joe Holzhauer, presented several “pieces” of the workshop at our hospital a few years ago. Ever since then I knew I wanted to take the full workshop, taught by Dr. Jane Shaw and colleagues, based in Fort Collins, Colorado, at the Colorado State University Veterinary Teaching Hospital.

It’s a 1.5 day workshop, and today was Day 1. Somehow, I missed the advance reading assignment, so I was worried I would feel behind. Fortunately, the Frank presentation Dr. Holzhauer had brought to our hospital had prepared me well, and I’m interested enough in this stuff that I had already read one book (Exam Room Communication for Veterinarians by Dr. Jon Klingborg) and started another (Skills for Communicating with Patients by Silverman, Kurtz & Draper) on the subject of communicating effectively with clients.

We spent the first part of the morning learning some of the science behind improved communication skills. Not surprisingly, veterinarians who take the time to listen to their clients’ concerns can enjoy better compliance with their recommendations and achieve better patient care. The clients have an increased sense of satisfaction and have a better understanding of the recommendations being made. Studies in human medicine show that improved communication from the doctor yield improved clinical outcomes and decreases complaints and malpractice litigation.

We also discussed two main approaches to communication: the “shot-put” method and the “Frisbee” approach. As you can imagine, “shot-put” is one-way and can be overwhelming to clients due to the amount of information being dumped on the client. With the “Frisbee” approach, you have a two-way dialog with the client, listening to their needs and concerns, and shaping your recommendations to fit the situation. There has been a paradigm shift in veterinary medicine, getting away from the veterinarian-centered conversation (“I’m the doctor and I know best”) and moving towards “relationship-centered” communication where the dialogue is guided by feedback from the client. An important distinction to make: we do not practice consumerism, where the client says, “This is what I want,” and is not willing to have a back-and-forth dialogue.

In the afternoon, we practiced the communication skills we learned about in what was basically a wet lab setting! CSU has these exam rooms designed for the sole purpose of improving communication skills. A group of students can sit on one side of a one-way mirror, with headphones on, and listen to the conversation occurring in the exam room on the other side of the wall. Wow, how cool is that? There were six people in our group, and we each took turns interacting with a professional actor who portrayed a client in a pre-determined scenario. After our allotted time of 15 minutes, we all discussed how the interview went (what went well, what would be even better).  I have no doubt that we all learned a ton from this!

An added benefit was when Dr. Shaw stopped by our room for a visit. Dr. Shaw is like the guru/goddess of veterinary communication training. Someone asked what are we supposed to do when a client with a sick parvo puppy gets mad at us because she doesn’t have the money to pay for treatment? She skillfully took on the role of an angry client, and I watched one of the members of our group struggle with what to say to her as she got angrier and angrier. Then we paused, discussed what could be done differently, and tried again. I watched with amazement as one of our group members skillfully employed empathy statements and long pauses to let the owner vent her frustrations. Eventually the anger gave way to just sadness, and seeing this transition—although it was really just acting—gave me confidence and peace of mind in knowing that it’s ok to just agree with a client about the sucky situation and just let them talk. You can’t make a bad situation not suck, but you can be there as a human being and listen to them.  Sad, but touching. And instead of making the client angry that you didn’t help them, they will remember your compassion (and hopefully not write nasty reviews about you on Google!).

Tomorrow, we will do more communication lab work. The actors were fantastic, and the scenarios forced us to not worry so much about the medical/technical side of things so much as focus our attention on our communication skills.

I’m already looking forward to bringing these skills back to work with me, as I know I will be able to employ them immediately!!

Treat the patient, not the numbers

Photo Credit: Lewis Cole

I remember in vet school, one of the clinical instructors said, “Treat the patient, not the numbers.” One of our patients was a miniature schnauzer with pure red cell aplasia–her bone marrow wasn’t making red blood cells. Her hematocrit hovered around 8%!! Yet, besides tiring easily, she seemed perky and continued to eat well. We were discussing when to do a blood transfusion, and someone asked how low does the hematocrit have to be before you would transfuse her. But there is no absolute number–it depends on the patient.  Her anemia progressed slowly over time, so her body had time to compensate for the decrease in systemic oxygen delivery. (Side note: this is also the patient I will never forget because–sad part warning–she died mid-venipuncture to collect a tiny sample of blood. She literally couldn’t part with another drop of blood! Her final hematocrit was 5%.)

Another version of this saying goes, “Treat the patient, not the disease.” I can especially see how this rings true in human medicine. You go to the cardiologist for your heart. You see the ear/nose/throat doctor for your sinuses. You talk to a urologist about cystitis. You can end up on so many medications for this and that, with none of the doctors seeing the big picture: the person as a whole.

I try hard to not get too carried away with numbers, but I’m sure there are times when I could do a better job. For example, don’t we get all up in arms about elevated Alk Phos levels? I mean, how many clinically normal patients do you see with an Alk Phos greater than 800 and otherwise normal blood work? For me, it’s probably once a month or so? I do think further testing is warranted, to check for disease that is not yet clinical but may become so.

Going back to my first example of gradual-onset anemia. Take the flip-side. If you were presented with a patient who was white as a sheet and lethargic with a history of possible rat bait exposure, and the hematocrit was 20%, would you recommend a transfusion?

What I Learned This Week

Here’s a sampling of what I learned this week:

• Chameleons can’t convert beta-carotene to vitamin A
• There’s some kind of freeze-dried diet of cactus fruit for tortoises–cool!
• Necropsy on a 5-year old guinea pig revealed a large tumor inside her uterus–never seen something quite like that before
• Necropsy on a 3-year old budgie revealed one of the largest renal adenocarcinomas I’ve seen. The bird had demonstrated the predictable loss of use of its leg, mimicking a broken leg in the owner’s eyes.
• Over the past several weeks, I’ve had a crash-course in Mycoplasma infections in rats. Usually, when I see respiratory problems in rats, they’re on an individual case-by-case basis. A rat-owning client of mine recently acquired two female rats, not knowing they were pregnant, until they delivered 20 babies (between the two of them) three weeks later. All of them have been plagued with respiratory difficulties since then, and two have died. This week, I came across this article, which helped shed some much-needed light on the subject for me: “Mycoplasma pulmonis in Rats,” by Drs. Jennifer Graham and Trenton Schoeb, Journal of Exotic Pet Medicine, Volume 20, Issue 4 , Pages 270-276, October 2011.
• Palpated my first trigger point (see videos in my previous post)–wow, was it painful for the poor dog!!
• Evaluated behavior of a young but socially mature English bulldog with unusual, but severe aggression. He was adopted from an area shelter last November. He doesn’t seem anxious or fearful like most of my aggressive patients, but we’re pretty sure he has hearing loss. His behavior seems totally appropriate, and he’s very social. But if he becomes over-stimulated, it’s like a switch goes off and he gets a “crazed look” in his eyes. He has attacked the owner herself and the owner’s mother, sending the mother to the ER with serious injuries of her arm. The owner realizes that euthanasia is appropriate, and may ultimately be necessary. We are going to try an 8-week course of fluoxetine to see if that helps even out his excitability (in addition to strict environmental management). If it does, he will need to stay on it for life. I’ve never encountered a dog with aggression quite like this before–it will be an interesting road that we walk together.

It was a pretty good week, one in which I was able to help people and beloved animals. I don’t feel like I had any “do-overs” this week.

Videos related to pain management

When I come across an online resource of veterinary information that I find interesting and think others would find useful, I like to share it here! This week, I came across some videos on Vimeo that demonstrate some important concepts in veterinary pain management. Here they are:

1. From Dr. Rick Wall: m. psoas major examination & treatment – As the veterinarian palpates the affected muscle belly (psoas major), you can clearly see from the dog’s reaction that the area is painful and needs treatment. Two patients are demonstrated in this video, a black dog and a boxer with short haircoat/lean figure. Dry-needling is also demonstrated, both with and without sedation. Be sure to watch the whole thing!

2. From Dr. Rick Wall: Feline Hyperesthesia Syndrome – This cat is extremely agitated and uncomfortable due to fleas. You can see by the convulsing that his response is far more intense than one would expect in a typical cat. The veterinarian gave him gabapentin, which modifies how the central nervous system perceives the pain signal, and you can see in the video that his agitation is less severe after receiving it.  [I had trouble embedding the video--click this link to see the video on vimeo.]

3. From Dr. Mark Hocking: Canine pelvic quadrant trigger point examination – Helpful narration explains what is being done and you can clearly see the dog’s response where he’s painful.

If you’re interested in learning more about trigger point examination and pain management in general, I highly recommend you join the IVAPM (International Veterinary Academy of Pain Management)–you will learn so much!!

Another resource I found recently (and it’s free!) is the Yahoo! group: triggerpointvet – you must be a veterinary professional to join, as membership/access is limited.

Do you know of other valuable pain management-related resources others might find helpful? Share them in comments below!

How veterinary medicine is like pediatric medicine…and how it’s not

Almost daily, I hear pet owners justify their behavior towards their beloved pet by saying, “She’s like my child,” or “He’s my baby!” Does this mean the person thinks their four-legged animal is equivalent to a human child?

I can’t answer that–partly because every situation and relationship is a little different. What I do find intriguing is how similar my job is to that of a pediatrician–with some important differences.

Top 5 List of How Veterinary Medicine is Like Pediatric Medicine

1. Our patients can’t talk. Both pediatricians and veterinarians must rely on their history-taking and diagnostic skills to achieve a diagnosis. The parents need to be able to give us the information we’re looking for, and they can’t always answer our questions. (Although a pediatrician probably doesn’t hear, “I don’t know, he goes in the backyard” when asked if a child has been having loose stools!)
2. Our patients don’t understand what we’re saying.  This is hard to accept, but it’s a reality that our patients may be scared out of their mind, and we can’t explain what’s happening to them, or why we have to get a blood sample, or what to expect with a particular test or treatment.
3. Our patients require a caregiver. Unlike an adult human patient, who you can give instructions to, our patients rely on someone else to follow the doctor’s instructions. Some parents follow the doctor’s instructions to a T
4. Parents–of any kind–just want reassurance that their baby will be ok. I was reminded blatantly of this when I took my three-month old daughter to the pediatrician with RSV. The nurse practitioner was talking fast about a bunch of stuff that I didn’t fully understand, and all I really wanted to hear was, “She’ll be ok.” I try to remember this when faced with a similarly-anxious pet parent: talk slow and be reassuring (when possible).
5. As the doctor, be prepared for an interrogation of sorts regarding the why’s, what-if’s, and how-t0′s. Because of all the reasons I just listed above, the parent feels a huge responsibility and wants to be sure he/she understands the situation well enough to do right by their little one.

…and how it’s not:

1. Due to completely different rules regarding insurance, pet parents are required to pay in full, at the time that services are rendered, which can vary from hundreds to thousands of dollars. That is a hard pill to swallow for the average American family that already has their own health care to pay for.
2. Ultimately, pets are NOT humans, so no matter how strong the human-animal bond is, there will be some unavoidable differences between a relationship with a pet and owner versus a child and parent. We know the life expectancy when we bring an animal into our lives–we may want it to live as long as we do, but we know that it won’t. We also can’t take the pet with us everywhere we go (usually), like we would a child.
3. We can’t even begin to compete with the federal assistance programs (social welfare) that are in place to help children in troubled homes. Although many non-profit organizations exist to support the welfare of animals, they are not federally mandated or funded, nor should they be. Animals will always be lower on the totem pole in our society, so it’s an inescapable truth that pets (in a general sense) will never receive the full spectrum of care and support that humans do. But it is thanks to those non-profits that some pets can receive help and support.
4. Veterinarians see patients through the pets’ entire lifespans, not just the pediatric stage, so we see a wide spectrum of age-related illnesses. Pediatric doctors obviously just see people during their early life stage.

Of course, there are many more reasons and ways that veterinary medicine differs from pediatric medicine. Can you list some?

It’s never a good time for an emergency…

Photo credit tamurray5 (flickr)

…but you can make time to prepare for one!

I’m a firm believer that planning for emergencies is one of the most important things anyone can do, for any type of situation! Perhaps I say this because I’m the founder and president of the Johnson County Animal Response Team (JoCART), and have climbed a steep learning curve to understand the ins and outs of disaster preparedness. Or maybe there’s an element of Murphy’s Law at work–if you’re prepared for a worst-case scenario, then it won’t happen!

Regardless, I felt a voice calling me to action this morning after reading a Clinician’s Brief article, Lessons Learned: Breathing Difficulty in a “Well” Cat (April 2012).  (A side note–I really love these Lessons Learned articles that spotlight a case gone wrong and what could have been done differently for a possibly better outcome. What a way to turn a negative into a positive and help others learn!) The article describes how a cat who presented for a wellness visit developed severe dyspnea, became cyanotic, and was euthanized due to a rapidly deteriorating condition. It was truly frightening to read and, like most veterinarians, I found myself wondering, “What would I have done in that situation?”

And with that, I announced to the staff that we would take advantage of this particularly slow morning we were having by running through an emergency scenario.

A short time later, one of the receptionists charged into treatment carrying a cardboard box with a lifeless toy dog inside.

“He’s not breathing!” she said.

“Here,” I said, taking the box from her and setting it on a treatment table. From there, three technicians swooped in and began assisting–one held the lifeless patient in her hands, another wheeled the anesthesia cart over and began administering pure oxygen via face mask, and another started retrieving and recording the items I was requesting. I told the receptionist to escort the imaginary distraught client to our comfort room so we could get to work.

It was hard not to feel at least a little silly “intubating” a stuffed animal, but everyone agreed that going through the motions and thinking through the different possibilities was very valuable. I loved seeing the great team work of our staff in action.

We know that emergencies come in all kinds of varieties, and they never show up at a convenient time, but I am truly grateful that this “Lessons Learned” article spurred us into action on an otherwise sleepy Tuesday morning. The cat featured in the article I read may not have survived, but thanks to the impromptu emergency response training it inspired today, perhaps we will be more ready to save a life tomorrow.

Coming Full Circle

Almost one year since my last post on this blog, I am returning to writing here. I have thoroughly enjoyed writing blogs for Clinician’s Brief (under the heading The Learning Vet), and will continue to do so, but on more of a quarterly basis. So I thought I would reflect on where this experiment started, where it has taken me, and where I hope to go.

When I started this blog, I wanted to focus my posts on experiences or observations that I felt were educational, either to myself or others. I figured my audience would primarily be veterinarians and students of veterinary medicine. Fearing criticism, or perhaps just disdain from those more knowledgeable and experienced than myself, I chose to write anonymously.

But afterall, this blog is about experiences, new and revisited. Not all of the experiences in my career are clinical in nature. In fact, only a relatively small percentage of them are directly related to the medicine I practice on a daily basis. An overwhelming, and exceedingly important, amount of what I do is all the “in between” stuff–communication, social media, finding life balance, etc. As I return to writing my own blog on my own site, I want to use a broader definition of learning–not just what I learned in veterinary medicine, like how to catheterize a female rabbit or how to spay a bearded dragon, but what I’ve learned about transitioning into a corporate setting at work, why I love AAHA, and even what I’ve learned about just writing itself.

Writing for the Clinician’s Brief blog did two things (at least): 1) I realized I could actually get paid money (not a ton of course, but still!) for writing, a previously foreign concept for me; and 2) putting my experiences and thoughts into writing taught me that I highly value the perspective one can gain by reflection–something I hadn’t really appreciated before. And a third thing: it exposed my identity, thus I open myself to adoration and admonishment alike! An uncomfortable feeling, but I’m along for the ride to see where it takes me!