Saturday, August 20, 2011

Things your vet student is good for

Recently, an owner refused to let me perform a physical examination on his dog. That was for the vet to do. I think he didn’t believe that I had any role in his dog’s care, and thought I was just along to watch and learn from the vets. Not so! (The examples below are all things that have happened to me and owners of my patients.)

  1. At a teaching facility, your vet student is your pet’s primary caretaker. She is the one who knows your pet the best. She has to present your pet’s clinical history to the residents and faculty every day, follow up on test results, and make sure nothing is overlooked or forgotten about. She is also the one who notices things like what kind of food your dog likes best, whether he likes to be taken a little farther from the hospital than usual so that he can pee on grass instead of stones, and takes time out of her day to cuddle with him if he looks sad. (To be fair, the techs also handle a lot of this sort of thing.)
  2. Your vet student is the one who lets you know how your dog is doing. She will call you at least once a day to tell you if your dog is stressed or not, and give you the updates that really matter, like “today he barked at me while I was writing up paperwork until I took him out of his cage to cuddle with him.” Sometimes hearing stories that remind you that your dog still has the same personality as he does at home is just as important emotionally as getting the complicated medical updates from the doctor.
  3. Your vet student is your liaison to the doctor. The doctor is a specialist who is very, very busy. He will give you lots of information, and you will try to digest it all, but you will have trouble really absorbing it. Your vet student is the one who will take the time to answer all your questions in terms you can understand. She will also be understanding if you are anxious about your pet and will tell you that you are going to do fine taking care of him once he comes home. Maybe she will even help you pad the blankets in your car just right before you settle him in to transport him.
  4. Your vet student is required to be a generalist. The faculty and residents on your pet’s case are all specialists. Sometimes having a generalist around is important. If your dog is in for orthopedic surgery, the specialists may be so focused on your dog’s joint problems that they may not think to perform a rectal exam on him, even though he is a ten year old intact male at risk for all sorts of cancer. But your vet student will remember. (The dog had a mass.)

Sunday, August 7, 2011

The curse of the missing uteruses, part three

The first dog I ever tried to spay had no uterus. (She had already been spayed.) And the first cow I ever did a reproductive exam on had no uterus. (She was a freemartin.) That should be enough missing uteruses for one lifetime. But no.

On a recent shelter medicine externship, I was spaying a kitten. On this externship, you get to spay several animals every day, and I had gotten comfortable enough at it that I was hoping to get through the entire surgery without ever asking for help. To understand what I was doing, you have to understand a little about cat uteruses. Human uteruses are one big sac, probably because we tend to have just one or two babies at a time. Cat uteruses are divided into two horns, each with an ovary at the top, and the horn and ovary are attached to the body wall to hold the whole contraption in place. The horns of pregnant cats fill up with kittens, all in a row.The two horns come together at their base, where there is a little uterine body, which connects to the cervix and from there to the vagina and the outside world. To spay a cat, you cut each ovary and horn away from the body wall. Then you have loose horns, and a base which still attaches to the cervix and vagina and outside world. You cut across the base, and then you have a free uterus and a spayed cat.

So I opened this kitten up, careful to make my incision very short. Longer incisions make visualizing your work easier, but obviously are more painful for the animal, and I had just been criticized on my previous spay for making too long an incision. I used my spay hook to fish around in the abdomen, found the first uterine horn and ovary, pulled them out, and cut them away from the body wall. I traced the now-free uterine horn back to the uterine body.

Finding the first horn is hard: you dip in with the spay hook and blindly bring stuff up, mostly intestines, which you have to repeatedly shove back in until you finally get the organ you’re looking for. Finding the second horn is easy: you follow the first one back to the uterine body, and then pull the second horn out where they both split off from the base. Except in this case, I couldn’t find it. I pulled on the uterine body, which should have made the horn pop out, but no go. I pulled harder. The uterine body started to fray. Oops! I didn’t want it to break before I could find the second horn. I had a moment of indecision: I really, really wanted to get through this whole operation without asking a vet for help.  And the problem was probably just that I had made the incision too small. But I had seen too many episodes of ER in which overconfident students got into trouble in exactly this way, and if the uterus split apart before I had a chance to put a suture around it to stop any bleeding, that could potentially be dangerous for the kitten. So I called over Dr. Vine.

Dr. Vine assured me that my incision was an excellent size, and pulled on the uterine body some more. It promptly broke off in her hand. (I congratulated myself on setting her up for dealing with that situation instead of getting myself into it.) It was not a big deal, in the end: she hunted down the stump and we put some suture around it. And she said: This cat only has one uterine horn. It only has half a uterus.

Freakish! And cool. And do you know what? Cats that only have one uterine horn always, 100% of the time, have two ovaries. So if you don’t go hunt down that second ovary, they will still have heat cycles. (They won’t get pregnant, of course, but cats in heat are no fun to have around.) Dr. Vine asked me where I thought the ovary might be. I suggested, in my usual precise fashion, “Somewhere sort of near the... kidney?”

It turns out that that was exactly the answer she was looking for, because, even weirder: about 50% of cats who have only one uterine horn also have only one kidney. And this cat was one of them.

In the end, we found the ovary, just sitting there not really near anything, and we removed it. One more missing uterus for my collection, or half of one. These things come in threes, right? Does this experience count as my third missing uterus, or just two and a half?

Friday, August 5, 2011

Land of eyeballs: ophthalmology rotation

I was really surprised at how interesting I found my ophthalmology rotation. Two weeks of eyeballs should have been mostly boring and creepy, right? But it turned out to be rife with my favorite kind of veterinary ethical issue: how we breed dogs.

Take the several bulldogs we saw who had so many facial wrinkles that their skin was folded over their eyes and rubbed against their eyeballs. (They also had yeast infections in the depths of their wrinkles, but that was a problem for a different department.) These dogs required surgical intervention to cut off the worst of the wrinkles. If they did not receive the surgery, they would be extremely uncomfortable (they all came in with red, squinty eyes), and would eventually get corneal ulcers which would proceed to infections and possible removal of the eye in question.

We also saw a raft of brachycephalic (flat-faced) dogs whose faces were so flattened that their eyes bulged out. Some of them could not completely close their eyelids. Their eyes were at risk for damage just due to being so out there in the world and unprotected. In the opinion of the ophthalmologists, pug owners all need to be given special eye care instructions when they acquire their new dog.

I asked the owner of one of the dogs that required surgery about where he had gotten the dog. He replied that the dog came from a breeder. I suggested that he get in touch with the breeder to let her know about the necessary surgery, so that she could use that information to help her choose wisely which dogs to breed in the future, and try to avoid producing more puppies with the problem. He replied in surprise, “I thought this was just a breed-related problem.”

Yes, these are breed-related problems. But breed-related isn’t synonymous with inevitable. It doesn’t mean we can’t try to avoid them as we create more dogs of that breed. Veterinarians can and should be more clear with their clients about this. They don’t have to be confrontational to do it! They don’t have to imply that the client made a mistake by purchasing the dog. They can instead look to the future: here’s what we can do to make the breed better.