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Why is my vet writing me about a girl and a rock band?
If you have a few minutes, read this and find out.....
I have a senior veterinary student working with me right now. Her name is Nicole and she is a senior in veterinary school at University of Florida. Her presence has made me think a lot about how the world looked to me in that time frame. I recognize a couple things immediately...sleep deprived, carb loaded, eager to dive in. After 4 years of veterinary school, there is so much information in your head it could crack, but no way to find out what is clinically important except experience, or someone telling you. Her specific area of interest is acupuncture, and she is originally from Old Town...so what a match.!
I'm reminded this week that the teacher/student relationship works both ways. The student can see how pieces of information are put together to form a clinical course of action. The teacher gets to see old problems through new eyes. Win-Win.
Nicole's presence this week made me remember a very formative experience when I was a senior veterinary student.
We started our clinical rotations in the summer following our Junior year. The first 3 years were strictly coursework. Although we had the opportunity to learn surgical techniques and palpate cows and actually touch animals before senior year, it was only then that we could exercise skills with actual patients.
My second rotation was Small Animal Medicine. My first patient ever was a cat named Jeremy Eagle. He was referred to our Small Animal Medical Clinic in Virginia from a doctor in West Virginia who had found a lump in Jeremy's jaw. Xrays and records were sent with the patient, and as I walked into the room I met a very nice middle aged couple. Its funny that I should say that because I'm going to guess they were a little younger then than I am now, and I would never consider myself middle aged.
They had thick southern accents, and a warmness that I found very common in Virginia. They were clearly worried about their Jeremy. I would like to think I was confident and reassuring, but I probably looked like a deer in the headlights. I did my exam, felt the lump, reviewed the notes and came up with a rule out list to present to my attending veterinarian.
Dr. Deb was a specialist in internal medicine with a subspecialty in oncology. As you can imagine, there were very intimidating professors, but she wasn't one of them. She had a reputation of being very supportive and patient, and almost always had a smile on her face. It was my first presentation though, and I was nervous as hell. She asked me my list of rule outs for Jeremy's lump. I gave her a long list, with endless pauses and very unlikely (in retrospect) possibilities. She let me present my proposed moving forward plan...bloodwork, chest Xrays, biopsy. She agreed and went into the room to introduce herself to the Eagles (and you thought it was going to be the band). As she spoke, I stroked Jeremy. He liked me, or at least he liked being stroked by a nervous student.
Since the Eagles lived so far away, we hospitalized Jeremy and started the workup. I set him up a cage, got him some water, and made my notes outside of the ward where he stayed. I put in a catheter, got some blood, brought him to radiology for the chest Xrays. I say that like it was a piece of cake, but the first catheter didn't go in right, he hated being restrained for his bloodtest and the student holding him for his Xrays came back and handed me Jeremy, saying..."Good luck with this one" .
I noticed that she wasn't bleeding, but that Jeremy looked pissed.
We were able to get a scheduled biopsy the next day with a surgeon, who besides being on another service, was one of those VERY intimidating professors. There were students that were assigned the surgery rotation, so I had to coordinate with another student while he got his biopsy. I was relieved that night when the surgery went well, the bloodwork came back normal and the chest Xrays showed no signs of cancer in his lungs.
It took two days to get the biopsy report and during that time, I took care of Jeremy and talked to the Eagles at least once a day. Jeremy set up some rules for interaction right from the start. I could fiddle with whatever I had to fiddle with as long as I spent a few minutes petting him first. If I violated his terms I got a bite or scratch, usually more of a warning than attempted homicide.
When I got the report back it was given to me by the surgical student. The diagnosis was Squamous Cell Carcinoma..a particularly common cancer in the mouth of cats. I had the information before the attending vet did, so I took the opportunity to read over everything I could find on Squamous Cell.
The basic facts (as we knew them then)
--#1 oral tumor in cats
--Treatment choices are surgery (hemimandibulectomy-removal of ½ of the jaw) - mean survival 5-7 months
Surgery and radiation-14 month mean survival
Radiation and chemo-5-7 month survival
Later that afternoon, Dr. Deb met with me to digest the information and give me the real choices. Virginia Tech did not have the capability then to do radiation, but it could be done in Ohio or Maryland. Surgery could be done there, chemo could be done there. Options were euthanasia, surgery +/- chemo, or referral for radiation. In addition, Dr. Deb told me something that the book hadn't. Cats with the surgery don't eat well, and not eating in fat cats (OK, Jeremy was fat) for as little as 5-7 days can result in liver failure.
This wasn't class anymore. I had to call the Eagles and tell them this?! I pictured Jeremy having ½ a jaw and even then having a pretty bad prognosis. I told Dr. Deb that maybe the best thing to do was to put Jeremy to sleep.
"Its not your choice Mark, its Jeremy's owner's choice. Your job is to tell them their choices and what we know scientifically. Together you make a plan based on what the Eagles want for Jeremy. Each person's situation and each patient's situation is different, and you should not go into the relationship telling them what to do."
She told me she would make the call, and that she would briefly tell them the information and then request that they drive back so that we can talk about it face to face.
The Eagles got in the car that night and drove the 4 hours to the vet school. They arrived with red eyes. Dr. Deb had told me to call her when they got there and she would come in to have the discussion. She lived 5 minutes away.
When I walked into the room I had nervous energy, no idea what to say, and Jeremy was comfortable in his cage back in the ward area. As soon as I walked in, they hugged me. I didn't see that one coming, and immediately found it even harder to talk.
"How is he?"
"He's doing fine, we stopped the pain medication after the biopsy, he's eating pretty well"
They thanked me for my care and immediately asked me what I thought was the best course of action.
"Damn" I thought (ok, that's not exactly what I thought).
What followed, by my memory was a long monologue covering all of the information. Way way too many words. I had definitely decided at that point after Dr. Deb's wise words that I wouldn't share my first reaction of euthanasia.
Finally Dr. Deb came in. She had a white smock over shorts and tennis shoes. By that time, I had gotten Jeremy in the room and the Eagles were holding him.
She went over the options again fairly neutrally. She considered the specifics though. The approximate expense of each choice, the not eating thing, how long he would be recovering from the surgery, his specific personality (feisty) as was related to hospitalization and post surgical recovery.
The Eagles chose surgery, no chemo, no radiation. They had discussed it on the way and although the mean survival was 5-7months, we might have gotten it earlier...and even if it was less time, they wanted to feel like they did everything they could within reason to give him more time.
The next day the same surgeon who did the biopsy did a hemimandibulectomy on Jeremy. They let me watch the surgery and help in the recovery with the surgery student. I was unofficially on the case, and frankly, by that point they would have had to beat me away with a stick anyway.
Predictably, Jeremy did not eat after the surgery. On the 4th day the surgeon recommended a feeding tube. We had learned in pharmacology that several drugs had the side effect of increasing appetite in cats. Mrs Eagle called me to check in and tell me that they were very apprehensive about putting a feeding tube in Jeremy. They asked if there were any other options. I told them about the medications, and I told them that I would talk to the surgeon about it.
So, did you ever say anything in a moment of emotion that didn't seem like such a good idea when the emotion passed? I had a white hat and Jeremy's best interest in mind when I was talking to Mrs Eagle. Remember this surgeon was one of the scary ones? Suddenly I felt like maybe a feeding tube wasn't such a bad idea. As I thought about it more, I realized that was the fear talking.
I went to the surgeon's office. His resident told me he was in the library. It was a long walk to the library. Actually, it was less than ¼ mile...but that seemed really long that day.
I found him in front of a stack of books. He did remember me and that I was the medicine student that was on Jeremy's case. He looked hugely annoyed though as I asked him about trying the valium. He told me that in his experience (vast, between the lines) those drugs didn't help at all and this patient needed a feeding tube. He looked back down at his books. I had been dismissed. I spoke with Dr. Deb. She agreed with the surgeon.
I had to call Mrs Eagle back. I told her that the attendings were in agreement that the tube was the best way to go. She told me to have them put it in then.
For the next few weeks, Jeremy hated the tube. He did poorly with it in and took it out at least every other day. A pharyngostomy tube in a cat goes in through a hole in the side of the neck and is kept in place by a bandage. Each morning I would check on him, I would peek around the corner to see if the tube and bandage material were shredded in a heap or not. After two weeks he had lost 3 pounds. By this point I was talking to the Jeremy's owners daily, taking care of him, having other patients to present and hospitalize. Every day though I started with the Jeremy love fest and after a few minutes he would grant me fiddling time.
The Eagle's came to visit. They were very concerned that he looked so badly. We talked on the floor of the ward, with Jeremy between us. They brought me a card with lottery tickets. They told me that they had been thinking that maybe putting Jeremy to sleep was the best way to end his doing poorly. I grasped in my mind for options. We could try the appetite stimulants now and try to get him off the tube. Dr. Deb granted my request. It didn't work.
The Eagles had Jeremy euthanized.
What came next for me was the largest of many times in my life when I thought I might just not be cut out for being a vet. Now 22 years later, I think that it actually is why I am supposed to do what I do.
But I gotta tell you, that time was almost a deal breaker. Dr Deb gave Jeremy the injection, Mr and Mrs Eagle and myself were present. I was embarrassed that I couldn't stop my sobbing. I left totally dejected and pretty sure I could never ever ever do this in real life.
I apologized to Dr. Deb afterwards for my display of emotion and told her I just got too close to Jeremy and his owners and that I was questioning my suitability to be a veterinarian.
She put her hand on my shoulder, looked me in the eye and told me that I should never lose that capacity and that People don't care what you know until they know that you care.
That advice has done me well because it is very true.
So tomorrow, I'm back to working with Nicole. She doesn't know this story, but I think I'll send it to her. I couldn't have told it anyway, its too long and even typing it brings back the tears.
She is going to be a fantastic veterinarian. She cares, she has great surgical hands, she is smart as a whip.
I think I'm going to send this to her.
If you guys have any words of advice for a young veterinarian, now is your chance.....
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