Saturday, November 4, 2017

Burnout

I don't want to have one foot out the door, but I do.

I like the practice I work for.  The people are great, they strive for a good culture and to practice medicine with a high standard of care, so they attract some of the best clients around.  But, I am still having days where I'm just ready to quit and find a new career.  Why?  Let's see...

Low pay.  The most I've been paid is $25/hr and that's an anomaly.  Mind you I got no benefits at that rate, so I was paying around $280/month for health insurance.  With 5 years' experience and some heavy negotiation I'm now at $21/hr with benefits.  That might be a dream come true for techs in other areas, but I'm in the California Bay Area -one of the most expensive places to live.  My half of rent is $1100 a month.  After 11 years my car finally died last year, so now I have a $140 car payment each month too.  I don't have cable, I have a bargain-basement 500MB cell phone plan, and yet I have to watch every penny in order to have at least $100 in my account when my next paycheck is due.  The thought of saving for retirement is laughable and yet we all know this is a physical job that we won't be able to handle forever.  Most of us already have back problems just a couple years in.

High expectations.  We are trained and expected to provide customer service, draw blood, place both IV and urinary catheters, take diagnostic x-rays, do ultrasound scans, calculate medication doses, understand how those medications work and be able to compound them as well, advise clients on blood and other testing, have knowledge about nutrition and the wide variety of prescription diets out there, take dental x-rays, scale and polish teeth, do dental exams, monitor anesthesia, scrub into surgery when necessary, suture skin and gingiva, do simple dental extractions and more.

Long hours.  With an endless stream of appointments throughout the day as well as emergencies, surgical patients, and lots and lots of cleaning that needs to be done there's often no time for breaks.  We're usually doing at least 2 things at once, more often 3 to 5 things.  In an industry that requires high accuracy we often fail due to an unrealistic workload.  This leads to us feeling like we're failing much of the time.  And then, to top it off, we're routinely asked to skip lunches or stay late to get everything done. 

Employers are sympathetic, but say they cannot afford to pay more and say the workload is necessary to keep the clinic afloat.  The catch phrase is that everyone knows there's no money to be made in Vet Med yet clients are always complaining about cost.

I don't know the answer.  I do know that if employers can't pay more and the workload stays at level "insane" we have no choice but to leave the industry due to burnout.  I graduated 5 years ago and over half my class no longer works in the industry.  All the experienced people leave and the clinic spends more time and money training new graduates driving costs up and service down. 

Maybe once all the new hires at my hospital (including me) are trained our workload will be easier to handle, but there's really no room for growth and that's something I need to decide if I can live with.  I'm currently planning on working to get by VTS in Clinical Practice in 2018 and that may open up new doors within my current practice or in education or something else.  We'll see.  I'm passionate about Vet Med, but I want to do adult things like own a house, save for retirement, and have things like vacation days and more than 3 sick days a year (especially since this industry is #1 in suicide).  I also really, really, want to stop crying at work.


Wednesday, October 18, 2017

Setting the oxygen flow rate on your anesthesia machine

There is a lot of disagreement out there on how to set the oxygen flow rate when running anesthesia.  Individual clinics and techs seem to have their own rule of thumb, but here's a review of how the anesthesia machine works, how to monitor ETCO2 and how to determine if you're wasting oxygen and your anesthetic gas.

Assuming a rebreathing system, no ventilator, and just an oxygen tank (no nitrogen, etc):

When your patient is hooked up the only gas available to him.her is oxygen.  That oxygen has 2 functions, for profusion of tissues (to keep the pet alive) and to carry your anesthetic gas.

How do you know if your O2 flow rate is too low?

There is no other gas in the system other than oxygen and the exhaled CO2 of your patient.  So, with O2 flow rates that are too low you'd see:
  • difficulty stabilizing anesthesia level because below 0.5L/min most vaporizors cannot reliably deliver anesthetic gas at the set percentage
  • the reservoir bag would not be inflated
  • the inhaled or IN CO2 would be above 0
  • ETCO2 would steadily increase as CO2 builds up in the circle faster than the O2 can replace it
  • SpO2 would begin to decrease
  • mucous membrane color would turn cyanotic
  • patient death

How do you know if your O2 flow rate is too high?

  • you're going through oxygen tanks too quickly
  • your reservoir bag is fully inflated
  • you're going through your anesthetic gas too quickly
  • your patient gets cold despite your warming efforts
Clearly a balance is needed, and you want to error on the side of too high of a flow rate.  Most clinics use a default O2 flow rate of 1L/min for anything under 100lbs and that works well.  Others calculate the rate based on 30ml/kg with a minimum of 500ml/min based on their vaporizor's limit for minimum O2 flow.

Common myths:

  • Increasing O2 flow rate will decrease ETCO2.
    • If the patient is not inhaling any CO2 than the cause of a high ETCO2 is inadequate ventilation.  This means the rate or quality of breaths is the issue.  Increasing the amount of oxygen available won't change ETCO2 in this case.  Manual ventilation should be used to decrease the ETCO2 and anesthesia depth should be evaluated to see if the cause of inadequate ventilation is excessive anesthesia depth.
  • Increasing the O2 flow rate (alone) will change anesthesia depth.
    • While it is true that turning the oxygen flow rate up or down will also effect the amount of anesthetic gas in the system, the amount of anesthetic gas breathed in by the patient will remain the same unless you also change your vaporizer setting.  This is because the amount of gas present is a percentage of the oxygen being delivered so it is flowing out of the system faster or slower too.  It's like turning a hose on in a box with a hole in it designed to keep the box 2% full at all times, then turning the hose up and having the hole get bigger at the same time -you're just using more water, but the box stays 2% full.
    • NOTE:  It is true that increasing the oxygen flow rate for a short period of time while making changes in the anesthetic gas percentage will help the change take place faster since it will push the gas out of the system faster.

Cautions:

  • If your patient is not adequately ventilating and you start giving him manual breaths, along with an increase of oxygen he/she will also be getting more anesthetic gas (because your oxygen is carrying a certain percentage of anesthetic gas, so more O2 means more gas).  If the reason for inadequate ventilation was excessive depth, manually breathing for the patient could make the problem worse, so be sure to turn the vaporizer down and flush the system prior to PPV.

Sunday, September 24, 2017

How to brush your pets' teeth.

Brushing a dog or cat's teeth sounds ridiculous to some, but getting into the habit can both allow you to find issues in your pet's mouth earlier and will save you money on dentals in the long run.

Before we begin, a little blurb on why veterinary professionals are against anesthesia free dentals.  Most people are afraid of anesthesia, so these dentals done on awake pets sound way safer.  The problem is that there is no way to clean or examine the teeth below the gumline.  The part of dental disease that is most harmful to pets is below the gumline.  That's where blood vessels mix with bacteria and carry that bacteria from the teeth/mouth to sensitive organs like the heart and kidneys.  Clean looking teeth just hide the real problem.  It makes the owner feel better, but what the pet really needs is a full cleaning and x-rays to fully assess his/her oral health and fix problems before they become bad enough that the pet can no longer hide or compensate for the problem teeth and/or pain.

Okay, sorry, rant over.  Here's how to brush your pet's teeth:

1.)  Get an enzymatic toothpaste, preferably CET or one with the VOHC seal -these have scientific studies to back them up.  Toothpaste comes in many flavors, my dog loves poultry flavor.  They make mint, but most pets don't like it.  The toothpaste has no odor, so don't worry about the smell.

2.)  Get a toothbrush designed for pets (there are many, from finger brushes to double-ended brushes, choose whatever works best for you) or any soft brush designed for adults or children.

3.)  Find a good time when your pet is relaxed or looking for attention/treats and put some toothpaste on your finger.  Allow the pet to lick it off.  Do this once or twice a day for at least a couple days.  The goal here is for the pet to think the toothpaste is just a tasty treat.

4.)  Once your pet is happy to see that toothpaste tube, start putting the toothpaste on the toothbrush and allowing him/her to lick it off.  This will get them used to the way the bristles feel.  If your pet thinks it's weird do this until they no longer make a big deal about the brush.

5.)  As soon as your pet is comfortable with the brush, use it to apply the toothpaste to one canine tooth.  Just transfer the paste to the tooth and let the pet lick it off the tooth.  When that's no big deal you can move on.

6.)  Start brushing just the one canine tooth. Progress to include more teeth as the pet allows.  There is no need to spend 2 minutes brushing as we do, just some simple stimulation at the gumline is good enough.  If you see blood, redness at the gumline, broken teeth, discolored teeth, overgrown gum tissue or anything else that worries you, it's likely worth having a vet take a look.  A full dental will likely be needed at some point whether you brush your pet's teeth regularly or not.  Just like us, regular professional cleanings and exams are still needed, but you may be able to put them off or at least save money by needing fewer (or no) extractions.

NOTE:  It is important to know that the insides of the teeth (all the sides that face the tongue) rarely have tartar or issues, so there is no real need to brush the insides.  Also the top teeth, canines, and front teeth are usually where the most tartar and problems occur, the back teeth on the bottom can be difficult to brush, if you can't do these it isn't a big deal.

There.  Most pets will regard tooth brushing as a somewhat weird treat.  They may not love it, but if you stick with it most will tolerate it.  Let me know how it goes in the comments!

Saturday, May 6, 2017

Understanding an EKG or ECG

You have access to ECG's if you have a surgical monitor with 3 clips that are put on as shown here:

These clips are pretty cool.  They pick up the electrical impulses generated by the heart as it beats and conducts them through wires to the monitor which displays them as a wavy line that should look something like this:


So, what do those waves mean?  Well, let's label them so we can discuss each part of the wave individually:
Okay, now we can start finally start talking about the heart!



The heart beats like this:
1.  the atria contract (these are the small chambers on the "top" of the heart)
2.  the ventricles contract (these are the larger chambers on the "bottom" of the heart)

The blood flows like this:
1. de-oxygenated blood enters the right atrium
2. when the atrium contracts the blood is pumped into the right ventricle
3. when the right ventricle contracts the blood is pumped into the lungs and oxygenated there
4. the blood comes back from the lungs and enters the left atrium
5. when the left atrium contracts the blood is pumped into the left ventricle
6. when the left ventricle contracts, the oxygenated blood is pumped out to the whole body

The electrical activity of the heart flows like this:
1. the SA node is the "pacemaker of the heart" and is located in the right atrium, it fires and the atria both contract, this is the "P" wave as shown above.
2. the electrical impulse then travels through the center of the heart and down to the ventricles, when they contract you see the "Q","R", and "S" waves shown above.
3. the electrical impulse then re-polarizes or "resets" which creates the "T" wave shown above.

Interpreting abnormal ECG's:


Above we see a normal beat (a P, Q, R, S, and T), another normal wave, and then a long pause followed by a Q, R, S, T and then another normal beat.  So, that 3rd set is preceded by a long pause and is also missing it's "P" wave.  What does this mean?

The "P" is where the electrical activity starts.  The SA node fires and the atria attract.  There is an issue here.  This didn't happen during this beat.  When the ventricles don't get a signal to contract they wait for a little bit and then, rather than not beating at all, they'll fire on their own.  So, the impulse to beat didn't happen so the ventricles fired on their own.  This is called an "escape beat".



Above we see a T wave (the end of the previous beat), then a normal P, Q, R, S, T followed by a P-wave without a Q, R, S, and T.  Then another P-wave all alone, then the next complex is normal (P, Q, R, S, and T).  After that is another P-wave without a Q, R, S, and T, then 2 more normal complexes.  What is happening here?

Well, when there is a P-wave that is not followed by a Q, R, and S you have an electrical signal that is firing the atria, but then not getting passed along to the ventricles to cause them to contract.  This is called "heart block" -an appropriate name since the signal is getting blocked between the atria and ventricles somewhere in the middle of the heart!

The above is a very brief although only slightly simplified introduction to ECG's.  For more information I highly recommend checking out: http://ekg.academy/ where they have lessons and lots of practice leads to nerd out on!

Tuesday, September 17, 2013

Compounding Math

Pharmacy math is often intimidating, but it is really important that we get it right, so here's a little post aimed at making you more comfortable doing compounding math.



1.  Make 10ml of Methimazole with 5mg tablets at 5mg/ml.

We need 10ml at 5mg/ml.  That's 5mg for every ml. 
So, if we want 10ml, we multiply top and bottom by 10. 
That's 5mg X 10 = 50mg in 1ml X 10 =10ml.

We need 50mg of Methimazole and our Methimazole is in 5mg tablets.
So we divide 50mg by 5mg to get the number of tablets we need:
50 / 5 = 10.  We need 10 tablets.

And our total volume is 10ml, so we need 10 tablets in 10ml of solution.


2.  Make 30ml of Doxy from 50mg capsules at 25mg/ml.

We need 30ml at 25mg/ml.  So, multiply the top and bottom by 30:
25mg X 30 = 750mg.  1ml X 30 =30ml 
So we need750mg of Doxy in 30ml of solution.

Since our Doxy is 50mg we need to know how many capsules to use to gt 750mg:
750mg/50mg capsules = 15 capsules
So, we need to use 15 capsules and 30ml of solution.


3.  Make 20ml of 15mg/ml Meloxicam from 7.5mg tablets.

We need 20ml at 15mg/ml.  So, multiply the top and bottom by 20:
15mg X 20 = 300mg.  1ml X 20 = 20ml
We need 300mg and we have 7.5mg tablets, so:
300mg/7.5mg tablets = 40 tablets in 20ml of solution.


4.  Make 12ml of 25mg/ml Baytril from 100mg/ml (injectable) Baytril.

This is a little different since our medication is liquid.  In the above problems our total volume and amount of solution needed were always the same, but for liquid medications the medication's volume has to be taken into account as part of the final solution, so we need to use the formula: 
(C1) X (V1) = (C2) X (V2)

Original concentration (C1) = 100mg/ml Baytril
Original volume (V1) = unknown amount of Baytril
Final concentration (C2) = 25mg/ml Baytril
Final volume (V2) = 12ml of solution

So:  100 X (x) = 25 X 12
Multiply each side to get:  100x = 300
Solve for x:  300/100 = x, so x = 3

So, we need 3ml of Baytril.
And we need 12ml total.
So, 3ml Baytril and the rest of the volume will be solution.
Find the amount of solution by subtracting the amount of Baytril from the total volume:
12ml total - 3m Baytril = 9ml of solution


5.  Make 4ml of 10mg/ml Baytril from 100mg/ml (injectable) Baytril.

4 X 10mg = 40mg
4 X 1ml = 4ml

C1 = 100mg/ml Baytril
V2 = unknown amount of Baytril
C2 = 10mg/ml Baytril
V2 = 4ml

100 X ? = 10 X 4
100X = 40
X = 40/100
X = 0.4

0.4ml Baytril

Total solution = 4ml
4ml total = 0.4ml Baytril means 3.6ml of solution will be used.

Thursday, August 8, 2013

Evaluating a blood smear

1.  Make a blood smear and stain it.  For a refresher on how to do this, check out this video:
http://www.youtube.com/watch?v=R1DU_N6eazg
2.  Put the slide on the microscope and focus using low power magnification, then move up to high dry.
3.  On high dry magnification, briefly scan the slide to find where your monolayer is.  The monolayer is where you'd do your cell counts -the area where the cells do not overlap, but cover the whole viewing area without many gaps.  Then find the feathered edge where the cells are more spread out at the end of your smear.  Evaluate whether there are more white blood cells at the edge than the monolayer or not.  If there are, this may erroneously decrease your white blood cell count and another smear should be made.
4.  Move up to oil power and then scan the feathered edge for platelets.  Again, if there seem to be a lot of platelets or clumped platelets at the feathered edge this will erroneously decrease your platelet count and another smear should be made.
5.  If everything looks okay, move to your monolayer and begin your evaluation.

Things to look for by type:
  • White blood cells (in order of prevalence in dogs and cats):
    • Neutrophils:  
      • Segments:  Neutrophils should have 4-5 segments on average.  They may appear to have fewer due to their being viewed in 2D.  When a good percentage of neutrophils have more than 5 segments indicates hypersegmentation or older neutrophils that may be kept around longer due to decreased production as happens with steroid use.  Consistantly seeing hyposegmented neutrophils (or neutrophils with fewer than 4 segments) may indicate younger than average neutrophils as happens at the beginning or end of a left shift.  A neutrophil with a nucleus that has parallel sides for its entire length (no segments) is called a "band" and seeing many bands in a smear indicates a "left shift".  If under 50% of neutrophils are bands the left shift is regenerative.  If over 50% of the neutrophils are bands the left shift is degenerative.
      • Signs of toxicity:  Dohle bodies appear as dark spots in the cytoplasm.  Vacuoles look like "bubbles" or white spots in the cytoplasm.  Blue or "basophilic" cytoplasm, or more noticeable granules in the cytoplasm (toxic granulation).
    • Lymphocytes:
      • Abnormal findings:  Red granules in the cytoplasm of more than a few cells can indicate Ehrlichia canis infection or cancer..  Lymphs with deeper blue cytoplasm are reactive lymphocytes and can be normal in young animals.
    • Monocytes:
      • Distinct from lymphocytes due to their large size and vacuoles as well as their less dense nucleus and larger amount of cytoplasm surrounding the nucleus.
    • Eosinophils:
      • Segments:  Should be evaluated the same as neutrophils although they may be difficult to see due to the visible granules.
    • Basophils:
      • Very rare to see.
      • Segments:  Should be evaluated the same as neutrophils although they may be difficult to see due to the visible granules.  No link provided because Cornell's basophil photo is very poor. 
  • Red Blood Cells:
    • Cell size:  If the cells differ in size, this is called anisocytosis.
    • Cell color:  Large cells that are more blue are called "polychromatophils" and are not quite mature.  Pale cells are called "hypochromic".  Clear cells are called "ghost cells" and indicate that the cell membrane had a leak.
    • Shape:  If an RBC has a knob or an "ear" or "nose" growing out of it, this is likely a Heinz body.  RBC's that look like splats may be acanthocytes or echinocytes.  Acanthocytes have irregular protrusions that may be round on the ends while echinocytes have a pointier protrusions all over the cell.  Target cells look like targets in that they have an area of central pallor with a circle of red inside of it.  If it looks like a red blood cell was ripped and you are just seeing a piece of it the piece is called a schistocyte.  Teardrop shaped RBC's are dacryocytes and are usually an artifact from making the smear.  Spherocytes are smaller RBC's with no area of central pallor.  A general term for differently shaped red blood cells is poikilocytosis.
    • Inclusions:  Large dark circles that make the RBC look like a googly eye or a fried egg are early stage cells that still have their nucleus, these are called metarubricytes.  Smaller dots in the red blood cell are Howell Jolly bodies if they are not refractile (shiny when the focus is moved up and down).  If they are refractile they are likely granules from the stain.  Real Howell Jolly bodies often occur between the center of the cell and the membrane rather than right in the center or touching the membrane.  Basophilic stippling appears as lots of granular looking dots and can mean resolving anemia or lead poisoning.  RBC parasites may also be seen.  Check the menu on the left of this page for more about these: https://ahdc.vet.cornell.edu/clinpath/modules/rbcmorph/para-f.htm
  • Platelets:
    • Platelets appear as irregularly shaped basophilic cells that are usually smaller than a red blood cell.  If you are in the monolayer and you are seeing 10-15 platelets per oil field you can assume the platelet count is average.  If you are unsure or are asked to do a platelet count than count the number of platelets per oil power field across 10 fields and then average them.  Multiply the average by 15,000 and you'll get an estimated platelet count per microliter.  Normal platelet counts should close to or above 200,000 per microliter.
Relevant information based on the patient:
  • For basic manual differentials:  Evaluate as many fields in the monolayer as necessary to count 100 white blood cells by type.  At the end the number of each cell type gives you the percentage of that cell in the smear.  For example, 64 neutrophils, 26 lymphs, 7 monocytes, and 3 eosinophils means there are 64% neutrophils, 26% lymphs, 7% monocytes, and 3% eos.  But, you should also be taking note of any irregularities in the WBC's or the RBC's and should take a mental note of the platelet numbers you are seeing by field as well.  If nothing seems out of the ordinary just give the cell percentages, but if anything abnormal was found it should be reported.
  • For patients who are anemic:  A platelet count is usually what is asked for.  In addition to the platelet count the RBC's should be evaluated fully.  This can give the doctor a hint as to what the problem might be or an idea of whether or not the anemia is regenerative or not (whether the animal is creating new RBC's and then losing them or if the issue might be that they have stopped producing them).
  • Heartworm microfilaria:  Examine the smear on low or medium power.  The microfilaria are longer than 50 RBC's strung together, so they should be pretty obvious if present.


Sunday, June 23, 2013

Work Journal -June 23, 2013 Euthanasia

When asked the "what do you do for a living?" question my reply is usually met with the response that "euthanasias must be so hard".  In reality, most pets are euthanized for good cause and it is much harder emotionally when an owner can't make the decision to end their pet's suffering.

Today a stability check was called for a dog that "wasn't doing well in the lobby" and when I ran to go get it I was met with a receptionist running towards treatment with the dog.  I helped open the door for her and grabbed the oxygen as she laid it on the table.  As I placed the mask over the dog's mouth the receptionist began to tell me the patient's history.  He had a history of CHF (Congestive Heart Failure) for the last 3 years, well managed with medication, then acutely had trouble breathing and wet sounding respirations this morning.

The dog was given a dose of furosamide and then the doctor left to talk to the owner.  Upon her return I reported that the dogs color was getting worse and his RR had nearly doubled.  But, I was told the owner wasn't prepared to euthanize and had to think it over.  The doctor attempted to suck out some of the pinkish foam that was gathering in the dog's pharynx to allow him to breathe better and when it was clear that it wasn't really helping she left again to tell the owner that the dog was going downhill pretty fast.

And, as the owner weighed the decision, I was left standing there with this bug-eyed dog who was fighting for air.  At first he was making up for his fluid filled lungs by simply breathing faster.  This allowed the tiny portion of his lungs that weren't drowning in fluid to exchange enough oxygen to keep him alive and pink at first.  But by the time the doctor came back from talking to the owner the dog's color was muddy and he was trying to sit up in an effort to allow his lungs to expand just a little further.  After the doctor left the second time the dog started to fight the oxygen mask.  He was panicking as he was drowning due to the fluid in his chest.  He tried standing several times, but the increased effort caused him to breathe even harder and faster with each attempt.  I tried to calm him, tried to hold him up so he could expand his chest without using extra energy to stand.  I tried to deliver the oxygen in any way I could think of to reduce his stress, and tried to talk to him, pet him, keep him warm.  But the whole time I kept staring at the real solution -the euthanasia solution in the syringe one foot away.  Because I knew there was no winning this fight.  All that could be hoped for was a peaceful end -soon.

And it eventually happened.  He just went limp in my arms and seized as his heart gave up.  In the end the owner didn't have to make the decision that she dreaded so much.  I cleaned him up and carried him in for her to say goodbye and she got to skip seeing him panicked and fighting for air for who knows how long.  I don't blame her for her hesitation, though.  I know firsthand that giving the okay to euthanize feels like you, yourself, are killing your friend, your family member.  But as one who spends those last precious moments with many terminal patients I can say that euthanasia is not something I fear.  In fact it is sometimes something that I sometimes wish for desperately.