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.

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.

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!

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!