What did I do? (Day -272)

Vet Student Operating

Last night I spent laid awake wondering about the kitten that I operated on. I read recently a quote I in relation to Dr Harvey Cushing that resonated here with me:

“no one has any right to undertake the care of any patient unless he is willing to give that patient all of the time and thought that is necessary, and of which he is capable.”

Did I give the kitten enough time?

Enough thought?

And was I really capable to do what I had done?

Did I know what was going happen once the skull had been covered. Was there going be pressure trapped inside? Was the skin going be enough to protect the brain? Should I have done anything else?

Were my sutures too tight? Is the blood supply to my flap enough? Will it heal?

If I could I would have spent the entire night watching the kitten. The kitten would have been hospitalised. Instead circumstances prevented this; however the kitten was watched carefully by the foster carer that had been caring all week.

I spent hours and hours during the week reading every surgical book I could find with a chapter covering the brain, head or skull. I spent hours looking for case studies and relevant articles in the literature. There was so little. Either it is so common that no one thinks it is worth writing about, or it is so uncommon that no one has had the chance to write about it.

I reached out to some of my contacts asking for advice and got some great support.

There were instructions that the minute anything happened I was to be called. Any time. So in this case no news is good news. However I still laid wondering.

Tomorrow I will see the kitten again to check the wound. And so far today no news really has been good news.

I realise that I love surgery – however it is the outcomes that give me the biggest satisfaction. Knowing that my impact has helped the life of another being is such a reward. However it comes with great responsibility that I must accept.  Every single time that I step up to an operating table I am responsible. That responsibility is why I am laid awake.

I do not yet know whether what I have done is good or bad.

Covering the brain (Day -273)

Rotation flap to close kitten skin

This afternoon I performed the most delicate operation that I have performed to date. I was allowed to perform a skin flap to close up the skin over the kitten with the hole in its head that I wrote about a week or two ago.

Since then the kitten has had two surgeries – the first to clean up the wound and soft tissue as it was very dirty. Then following this a second surgery was performed to remove the fragments of the skull bone that were unfortunately not viable. Since then the kitten has been on antibiotics – and we were waiting for a clean wound so that we could close the skin over the hole in the skull to cover the brain.

This was a relatively simple operation to move some skin from one place to another. However in doing so I was using a scalpel blade just millimetres away from the kittens brain tissue – a single slip wouldn’t really be a good thing.

Now there are many different techniques that could be used for creating and using the skin flap, however I believe that simple is best, and so I created what is called a rotation flap. This is where I take the skin next to the wound and rotate it over the defect.
Rotation flap to close kitten skin

Here you can see where the defect was originally, and then I made my incision along the dotted line on the middle image before then moving this piece of skin over to cover the hole. Different people suture wounds like this in different ways, however in this case I like the half theory. I started my first suture in the top left corner of the wound, then placed my next suture halfway between this and the end. And then placed my further sutures halfway between these spaces as well. For me doing it this way makes a lot of sense as I can see where things are going go bad without losing too much time, or having to change too many sutures to fix them.

So after this the hope is that the skin heals and as the kitten is still growing that the defect in the skull will close up with time.

A hole in the foot (Day -275)

Cow in crush after amputation

When you put your finger into a hole in the foot of a cow and can feel bone you know it is going be interesting for you and very painful for the cow.

Now to understand what happens here you need to understand that cows have two toes (or claws) that contact the floor on each foot. With such a severe problem involving the bones and tendons of a toe the normal treatment would be amputation of that toe. Cows can generally survive on a single toe pretty well just so long as regular foot trimming and management is carried out.

However in the case of this cow the second toe of the same foot was affected though it was only a mild case at this stage. So if we had done amputation here of the really bad toe, the second toe would deteriorate further to the point where it would not be able to support the cows weight, and so the amputation would be pointless.

Economics unfortunately come into play as each cow in the herd has a value, both as meat and as a milking cow. This can justify the cost of the amputation surgery or whether the cow goes to slaughter – however if she is a good milker it is often the farmers wish to avoid this. Now the economics of amputation followed by slaughter in a week or two do not balance and so a clinical gamble based on years of experience was taken by the doctor here.

Amputation is necessary however this amputation would only be done if the other toe recovered. However as with any infection the key is to remove the source and so it was decided that the necrotic bone, tissue and some of the toe would be removed from the toe that would potentially be later amputated.

This level of injury is painful, and so requires good anaesthesia. In cows anaesthesia is usually local – so it only affects the area of the body where the surgery takes place much like if you yourself go to the dentist.

For the legs we apply a tourniquet to separate the foot from the rest of the body, and then make an injection into the veins of a local anaesthetic drug. This time the anaesthetic drug we used was procain – it is another topic however just quickly when using drugs in cows we have to really careful to use drugs that will not get into meat or milk to protect humans.

I was offered the chance to try to make the anaesthesia, and after my dismal first attempt at blood collection on Monday made amends by putting the needle, and then the anaesthetic drug directly into the vein on my first attempt (yay!). Still really believe it was complete beginners luck as me and cows have not really ever got acquainted.

The doctor removed the sesamoid bone and the tendon around this before then debriding the open bone surfaces of the digit. In this process the bottom of the joint capsule was lost and so in an attempt to help preserve the toe for another two weeks for the second toe to heal we also placed antibiotic drugs into the joint space.

Just to show how well an amputation heals (and to avoid gross photos) I’ve chosen today’s photo to be a cow that had an amputation around 6 weeks before.

Tail blood (Day -276)

Cow reproductive management

Blood collection is one of the basic skills of medicine as blood can tell you so much about a patient. Something I’ve very little experience with however is cow medicine – and in cows you normally take blood from the tail. This is because the cow is massive, generally is a safe place from being kicked, and usually is quick when moving through a row of cows.

Theory going into practice though my first calf with this method I failed my first two attempts on the tail so decided to go for the jugular instead which was a lot easier for me to get. Getting a jugular vein in an adult cow however is a big effort as the cow needs to be properly restrained and often into a crush to do it safely.

So disaster for me – even though I had got the blood needed for testing from the jugular – it was still a really harsh personal insult that I had failed from the tail. The theory with collecting blood from the tail is that you insert the needle directly in the center of the underside of the tail until you hit bone. Pull back slightly and then the blood will flow. So simple yet I had failed.

There was still time though with maybe another 50 older calves to go. These were harder to restrain, a lot more work, and a lot bigger. Being bigger also meant that these calves had larger tail veins, and so every cow going forward I had no problem collecting my blood from the tail vein.

The second thing with cows that is important when it comes to cow medicine is managing the herd behaviour. For cows will run away from you, and look for a path to escape, and cows will fall especially if in a herd. And then the others in a panic will walk over the fallen ones to escape. So what was a herd of unvaccinated cows will become a herd of broken, beaten, unvaccinated cows.

We wrestled our way through these 50 calves using brute force and the fence of the pen to restrain them. With the last calf we were happy to be done, and the calves happy to see us go.

Outcome based veterinary medicine… (Day -278)

Outcome based veterinary medicine

In nature animal behaviour is driven by need. They balance their energy expenditure to the expected reward received. Yet it is proven psychologically that sometimes people do stuff just because the people before them did it. Check out the video here:

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So yeah, all those people started to do that just because someone else did. When asked why they did it they didn’t know. Unfortunately this also happens in veterinary medicine as well as human medicine as well as other professions.

A good example is the air port on an infusion giving set – many people just open it even with collapsible plastic bags/bottles because they always have. This is something that is used with fixed volume glass bottles to let air in to replace the liquid that is lost.

It is often easy to do what you always have as you feel safe, yet it does not always reflect what is correct or best. The worst case is when you have been shown to do something, yet do not understand why you are doing it. The best case is when you understand why you are doing what you are doing.

Now yesterday I spoke about evidence based medicine and the problem with statistics in research papers. Today I want to talk about another type of medicine that I have read about recently – it is called outcome based medicine.

So instead of doing stuff because that is the way it is always you decide what you want the outcome to be, and you take the steps to get to that outcome. The perfect example is that of fluid therapy. There are loads of guidelines and refinements to fluid therapy are happening all the time. However it is always about the amount, the speed, and type of fluid.

Traditionally though there was guidelines on the quantity, some on the speed of administration. However the thing that was undefined was that of when to stop even though the measurement of fluid deficit is subjective.

Now with outcome based medicine you are looking at what you want to achieve in a measurable way. With fluid therapy we have things such as the heart rate, blood pressure, capillary refill time that we can use with well-defined normal ranges. So if you want to get to these normal parameters you can give smaller boluses of fluids over a shorter time. Reassess these clinical parameters; if it is normal then you can stop, if not then you repeat the bolus until it is normal.

This way you know what your outcome is, why you are doing something, and you know how to measure it. For me when I think about surgery this is logical, I always try to have a plan of what I will do when I operate. I will know what my expected outcome will be.  I will then have backup plans with their expected outcomes. And then I will have plans on what needs to be done post operatively as well.

So taking this approach of outcome based medicine and applying it within internal medicine takes some of the guesswork away. And in combination with properly reviewed articles from evidence based medicine will I think this will form a lot of the future of veterinary medicine. In surgery especially we are already looking at computer models to predict the outcome of surgery on a patient by patient basis.

Statistics and medicine (Day – 279)

Statistics and medicine

So 75% of patients survived the surgery? Does this mean it is a good procedure? A great breakthrough in medicine? Something that every vet everywhere should be doing?

Well it depends…

The big craze that appeared recently is Evidence Based Medicine (EBM) where you use “evidence” from books and the latest literature to guide your treatment of a patient. Sounds great right as it means that everyone gets the same thing. However something that we are taught with research is that statistics are important.

So it turns out that if I have 4 patients and by pure dumb luck only one of them dies then statistically I have a 75% success rate. If I take a larger sample of 10 patients and I have a success rate of 75% then it means that 2 and a half patients died…

Yeah there is no such thing as a half patient unless we start talking about body and brain separately so maybe the third just suffered neurological damage.

However how accurate is it really saying 3 out of 4 survived? How much role did luck play? Or the environment? Or the skill of the doctor treating these patients? So does it really mean that if I attempt the same thing that 75% of my patients will survive?

However once you get out of the small sample sizes then you may get a better image… with 10 or so luck may have an influence… with 100 it may still be there however there will be smaller margin for luck to play a role… and when you start looking at studies with 1000 patients then you may definitely start to get reliable and repeatable results.

However studies with 1000 patients are difficult in clinical practice, and are also difficult when you are working with surgery techniques. Even for common things such as a spay, a vet may only do 1 or 2 a week so getting to the 1000 would take 10 years.

I always make the effort to read the full study to find out the sample sizes and the methods used. Statistical tests are notoriously difficult to understand and select the correct test to use, sometimes it appears that the test is chosen which shows a positive or statistically significant result even if it was inappropriate to use.

Reading studies in this way however takes a lot of time. And when there are a lot of studies then it becomes even harder. I’ve seen quite a few journal clubs pop up recently which are reviewing new studies in certain areas – however its almost like we need papers to review papers.

For now however I will try to focus on the papers that are directly relevant to what I am doing, and will take all my statistics with a grain of salt. Hopefully in the future there will be a public peer review system for vets where a journal article can be critiqued publically for all to then use.

The lessons of the past (Day -280)

The Knick Medical History

I’ve started to learn more about the history of surgery, and how the techniques used today developed. This is absolutely fascinating for me as I believe that we should avoid repeating mistakes that have already been made in the past. In fact I believe it is essential – and this will probably keep cropping up in my posts from here forth.

For me this started rather randomly with a TV show – The Knick which is based in the early 1900’s and is based on medical history which got me wondering what else used to be. This was just after the invention of anaesthesia and the main character is styled around the famous Dr Halsted. This show made me scared both at how patients died from common diseases which are now easily treated with antibiotics to how racism was so common even among such highly educated men.

Something that I found surprising was that in the 1800’s the official language of medicine was German. There are an original set of books from 1881 by Dr Billroth who is considered the father of abdominal surgery – and in fact some of the operations he developed are still commonly used today.

However what has also come up is how the techniques were developed often using animals in the past. For example at the start of the 1900’s Dr Harvey Cushing decided to teach a human surgery course on live dogs as the ability to learn on cadavers was not suitable. Actually a lot of the techniques for brain surgery were developed on dogs, not just by Dr Cushing but also by his colleagues. At one point Dr Cushing actually made a glass window in a dog’s skull so he could observe the blood vessels in the brain whilst he was observing the differences in intracranial pressure (the development of the Cushing reflex).

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Something really important though is that through this learning by human surgeons a vast amount of knowledge was collected about animals. This knowledge needs to be accessible and used. Still today many medicines and medical procedures are developed on animals. Yet there is still a divide between animals being used for development of these procedures and them being available after development for use in animals. This is why I believe One Medicine is so important and I do fully support The Humanimal Trust in making this happen.

I’ve still a few chapters left to read in Harvey Cushing: A life in surgery however already it has been an amazing story – and extremely inspiring.

Why do I need to cut? (Day –281)

Vet Student Operating

I enjoy surgery so much that it is almost a love, I find it so rewarding to be able to anesthetise an animal, and whilst it is sleeping fix it or stop the pain. For me it has been obvious for a while that my path will follow that of surgery, I’ve seen as much practice as I could with a focus on surgery. And I have spent every spare hour I have within the surgery department here.

Surgery is a massive thrill, the adrenaline rush of scrubbing in and picking up a scalpel is something that I am told will never vanish. And I love this. It makes me happy doing surgery, and it makes me feel fulfilled when the dog or cat or rabbit wakes up after surgery fixed. Well sometimes it is not so simple and there is a period of rehabilitation however every single day from the surgery the poor animal is getting better.

As I get better at surgery, my understanding and experience is deepening. Where before I looked for every opportunity to cut as a chance to do what I love and take the animal to surgery I am now not so fast to want this.

I was speaking about this with one of doctors the other day who told me that many years ago he was told that the art of surgery was not doing surgery, but knowing when to do surgery.

Something that has always bothered me is that sometimes surgery is simply to fix problems caused by humans. This came to a head for me on the Ophthalmology conference weekend when Professor Ron Ofri spoke about a surgeon walking out of surgery holding up a piece of skin he removed from a dogs forehead that stretched to the floor.

I asked the question – should we as vets be performing such surgery without requiring the castration or spaying of the animal at the same time? When a breeder has a litter of puppies that all require a visit to the ophthalmologist and surgery before they are a month old? Is this ok?

It’s not just the eyes though, another common surgery is for BOAS – Brachycephalic Obstructed Airway Syndrome – where part of the soft palate is cut away because it is too long and is stopping the dog from breathing properly. Often this is combined with plastic surgery to widen the nostrils which are too narrow.

Then there are dogs that have been bred so badly that they cannot give birth naturally. They can only be born by caesarean section.

Many years ago I read a book by a surgeon from America asked to present at a UK conference on castration implants in dogs – the press thought it was about plastic surgery and filled the entire room. And the surgeon lectured about the use of “implants” to replace the testicles removed during castration – he passed around some samples and one of the attendees mentioned how lifelike they felt to be told that the ones they had were the human version…

The outcry was because vets are not allowed to carry out cosmetic procedures on animals – this is why tail docking, ear clipping etc are all outlawed as cruel because they are cosmetic. Yet now the two cases above that I mentioned are commonly happening the press is silent.

Emma Milne recently did an amazing job of raising the issue of brachycephalic dogs such as pugs that cannot breathe properly as a welfare concern which got some media attention. Pedigree dogs exposed covered some of the crazy welfare issues. And yet at crufts a unhealthy German Shepherd was allowed to win.

I can cut, however the question will be whether ethically and morally I should cut. I believe if the deformity is so great as to require surgery than that animal should not be bred from. If by surgery I can relieve pain or suffering from the animal then it may be justified – however I believe that in this case the animal should be castrated or spayed before or at the same time.

Is it a brain, skull, or something else??? (Day -283)

Vet student in surgery

I remember many years ago watching ER with Carter dealing with a burn victim and on failing being told it doesn’t get any worse than this. No matter how much time you spend in clinic there are always going be surprises. Especially when you think it cannot get any worse, something will come in and take that place. I’ve seen some horrific things, sometimes enough that I wonder if I sleep if I will get nightmares.

The scary thing is however that a lot of horrific things are also extremely cool. Today was one of those horrific things that was also amazingly cool.

Cool because the kitten was alive. Cool because the kitten was ok neurologically. And cool because it was not something that you will see every day. Actually not sure when you would see it at all.

Now these are where the skills that cannot be taught in the classroom really are tested. I like a challenge, and this is definitely that. When the discussion you are having is whether what you are looking at is skull or dura (the covering of the brain).

Yes. There is a kitten running around. Playing. Drinking. With a great massive hole in its head.

So now to do something? I’ve spent hours and hours in textbooks and cannot find a single mention of what to do. We’ve not got CT or MRI. I so wish we did so that we knew what it was, and what was underneath.

Is there a brain abscess? Dunno… Maybe.

So kitten is scheduled in for cleaning of the wound. And then maybe we will know more.

A permanent solution to a temporary problem, suicide, perfectionists, and failure (Day -284)

Suicide. Death. The End. Is it an escape? Or being let down?

There was a meme that went round recently of a Dr leaving a consultation room after telling a family their son had died. It was captioned: only one of these people is going back to work today.

Now consider this:

Vets are 4x more likely than the general population, and 2x more likely than those in health care professions to die by suicide (UK study Bartram et al, 2010).

Nearly 1/10 US veterinarians suffer severe psychological distress, and 1/6 have had suicidal thoughts since graduation (CDC Notes, 2014).

Last week 2 vets committed suicide (that I know about).

We want the best vets possible so select the highest achieving perfectionist straight A students there are, push them through the toughest school there is, and put them into a profession where they will fail.

Why fail? Animals will die. No matter how good you are there will be animals you cannot save. Animals that owners decide are too much work or too big for their flat so have you euthanise. Animals that you do everything you know how to save that just die. Animals where owners cannot afford the treatment you want.

And then there are the questions you ask yourself. The questions that keep you from sleep at night. What else could I do better? What could I do different? Could I save that animal?

The next day it repeats. The next week it repeats. These people that have succeeded at everything they have ever done are failing. Nature is beating them in the battle of life.

Then there are owners. Who demand the world for nothing. And then blame the vet when they lose.

Could it actually get worse?

Now there is an even bigger potential problem with social media causing the suicide of vets through cyberbullying. Not by their patients, or owners that they have worked with. Complete strangers that have a single side of the story that judge them.

I saw it on Facebook  last night – a owner posting about making complaints to a vet after their pet died and getting cheered on by people that knew nothing about the backstory – a quick search of the group showed that the owner posted a few days earlier about their pet not eating for several days before they went to the vet…

Yet it is the vets fault the animal died. This perfectionist that tried to fix a problem compounded by the owners delay in seeking treatment who failed. Now judged publically as a failure by people they do not even know.

Is it a problem? Is the suicide rate going go up as cyberbullying increases?

There have been changes, there are people getting involved to reach out and help people who ask for their help. In the UK we have the excellent vetlife helpline which is there for vets in need.

Something that has always confused me is that we are really good at expecting people to come to us. We tend to be reactive rather than proactive. This is what I think the next step in reducing the number of suicides will be. Some kind of proactive system for monitoring the mental health of vets.

Actually around midnight last night I came up with an idea that I am going work on over the next month or so that I hope may be able to do this. I will keep you updated.