Part one of this series covered whether you – as a mentee – are ready to carry out the work, as it is not easy-going; while part two discussed clarifying what you hope to achieve, as well as the type of mentor you are looking for.
Part three follows on with the critical stage of approaching your possible mentor the right way.
The approach
Before you ask
Like any relationship, don’t go in cold and ask someone to be your mentor – get to know him or her first. For example, ask him or her for an informal chat over coffee.
It is just not about getting to know the person; it is about assessing his or her ability to mentor and whether you connect with him or her.
You can also ask to meet him or her again before formally asking.
Mastering the ask
Let’s say you feel you have found the right person – how do you ask?
It starts with asking him or her to be your mentor in a specific area. Something similar to:
“I can see you’re a great team leader and I’m stepping into a management role for the first time. Are you open to working with me over the next year to become a great team leader; to act as my mentor?”
Then, if he or she is open to it, articulate what it looks like to you and ask for feedback.
It is best to be on the same page from the start – otherwise, confusion could arise about expectations and commitments later on.
Part four will cover what a mentoring relationship requires to be successful.
Anyone who’s ever worked a night shift, raised a baby or pulled some late night study sessions will be well aware of the effects severe sleep deprivation has on them. But those are the extremes. You do okay for the most part, don’t you?
All those years at university and being on-call have taught you how to cope just fine, despite a less than ideal amount of horizontal hours. Sure, you may feel a bit unfocused during consults after a Game of Thrones binge night, but it’s not like it’s really affecting you at work… right?
Well, you might be wrong.
It’s not you, it’s the job
Firstly, poor sleep affects judgement – including judgement when it comes to assessing what lack of sleep is doing to you. Sleep specialists say while you may think you are coping well on less sleep, you’re probably wrong.
Another factor is the type of work that we mostly do. Some research has shown, unlike many other measures of performance, the ability to do problem-solving tasks (things that require a bit more effort and reasoning; exactly the kind of thing most veterinary workers do most of the time) does not seem to be significantly impaired by a lack of downtime.
So, your ability to effectively get through a busy day of vetting, despite not having good sleeping habits, might have less to do with you and more to do with the kind of work you do.
Positive emotions
There is, however, a more insidious problem associated with insufficient sleep that we ignore at our own peril, especially in a profession plagued by burnout, compassion fatigue and career exodus: even low levels of sleep deprivation can start affecting emotional function.
One of the first impacts of sleep deprivation involves specifically positive emotions. Psychologists and sleep experts say our ability to express and recognise positive emotions in others suffers when we are not well rested, while resilience to negative emotions and coping strategies concurrently start to fail us.
Of course, there is much more to emotional well-being than sleep, but trying to build coping strategies when you are even moderately fatigued is a bit like trying to have a deep and meaningful conversation with your very drunk friend.
Just tired?
Who knows, maybe your job isn’t as hard as it feels?
Perhaps you are more than capable to cope with the challenges veterinary science will throw at you. You might just need a bit more sleep.
Next week, we’ll look at what good sleeping habits look like, and how to achieve them.
Part one of this series looked at making sure you are ready to do the work – in taking action, and implementing the decisions made and advice given – but also on building and maintaining the relationship.
Part two looks at getting clarity about exactly what it is you want to achieve from your relationship with the mentor, and what kind of mentor you are looking for.
Make the right choice
For example, you may be expecting a mentor to teach you veterinary business principles so that, one day, you can open your own hospital. But that person:
may not actually know how to do that, despite appearing on the outside that he or she does
may not be able to teach it to you, as it was set up before him or her by someone else and he or she bought the business with all the systems and processes in place
may not want to share that private knowledge until you have gained his or her trust and demonstrated loyalty
may appear successful on the outside, but, perhaps, are struggling, too
Knowing what you want and getting the right mentor is critical – otherwise, it could be a fast track to destruction, rather than success.
Be clear about what you want
What is it you want to achieve?
It is so important you determine this before searching for your mentor. Why? Because without clearly defining that for yourself, how do you know you have found the right person?
Each mentor will have different experiences and skills to bring to the relationship.
What kind of mentor do you want?
Now you have determined what you are wanting to achieve, what kind of mentor are you looking for?
When considering this, don’t just look for the most successful people – look for those who demonstrate qualities you want to demonstrate one day yourself.
It is best to steer away from potential mentor figures who are popular and do not demonstrate all you are looking for.
When looking for potential mentors, watch and follow them for a while then think whether he or she is the kind of person you would like to be.
What is it that you are expecting from him or her?
What does the standard mentee and mentoring relationship actually look like to you. Most relationships involve a formal or informal discussion for one to two hours once a month; some follow-up emails or texts may be exchanged to update progress.
Does this meet your expectation? If not, then what you are looking for may not be a traditional mentoring relationship. If you work with your mentor, informal interactions may occur at work, but a more formal meeting may also be scheduled once a month.
Part three will look at how to approach a potential mentor.
At this stage of the year, it’s hard for me to write about anything but revision. So, for those of you reading this as a means to escape, I can only apologise. At the same time, if your idea of time off from studying is reading my work-related articles, then I think we need to have a little sit down and a talk about healthy revision outlets…
With my last ever university exams (yeah, like, ever!) rearing their heads, I’m finding my own is a bit of a jumble.
The last several weeks before the big day can often feel, at least for me, like a bit of a roller coaster ride. There are ups and downs; terrifying “grip the handlebar” kind of moments; and occasional points where you reach the top, clear the clouds and see everything below you with level-headed clarity – and then the whole thing starts again from the beginning.
Happy birthday to me?
First of all there’s the build-up. Personally, I think the build-up to exams can be worse than actually taking the things.
As somebody with a birthday plonked squarely in early May, this has led to the anniversary of my birth becoming somewhat bittersweet over my past 20 (yes, 20) years of education. I’ve even had friends and classmates willing me not to age, just to fend off the dreaded exams.
If you’re lucky, it will have been a good year since your last exams, so it’s almost easy to tell yourself it can’t really be as bad as you remember it, and sure, you’re here to tell the tale!
So what’s all the fuss about? Besides, it’s months away, right… right?
Then the realisation hits you that those months have melted away into a measly finger-countable number of weeks. This is the feeling akin to the hard “thunk” of that metal seat belt bar strapping you in before the roller coaster ride. You’re locked in now, and the only way is onwards.
Like with any good roller coaster, the journey of revision is marked by a series of highs and lows. You can sometimes spend a day or two feeling really very good about yourself, quite smug actually, especially in the early swathes of revision while your brain juices are still flowing nicely.
“Wow”, you think to yourself. “I remember everything I read today. It may have taken 13 years of exam practice, but I think I’m getting the hang of this revision malarkey after all”.
Then a day comes when you wake up and it feels as though everything you once knew has fallen out of your ears overnight. Your brain feels like a clogged artery and the juices just can’t quite make their way round the bends. Paragraphs, facts and figures can start to swim together. Do horses lay eggs? Do chickens neigh?
It can feel like five years’ worth of content is trying to make it’s way to the forefront of your mind all at once, with no polite or mannerly order.
The important thing, I find, in order not to let the roller coaster get the better of you, is to make everything else in your life as smooth a ride as possible. Obviously, this is easier said than done, I’m no fool. Life will always throw things at you, especially when you feel like you already have enough on your plate, but start by controlling the things you can.
Remember the basics:
Sleep.
Eat.
Hydrate.
Practice self-care.
Treat yourself to that leftover easter chocolate, keep making plans with friends as something to look forward to, and let yourself clock off for a couple of hours before bed.
It all matters
It has been scientifically proven that increased levels of stress actually reduce our ability to take in new information – which is, ironically, something on this year’s syllabus – as do lack of sleep, under-eating, dehydration and depression.
Trying to revise under any of these conditions is like fighting with one arm behind your back, so never forget that what you do outside of your revision schedule is just as important as what’s in it.
When I graduated from university 10 years ago, I remember being told to find the right practice – one with the right boss; that is supportive, encouraging and shares knowledge; and helps you build your skills.
I don’t remember those people being called mentors, but that is essentially what we are calling them now.
Here is the tricky part – you can’t just start a new role and expect someone to be a good or right mentor, and for him or her to teach and train you in what you want and need. That type of expectation is wrong.
Why? I have three reasons:
It is an unrealistic expectation – you can’t expect just one mentor to be able to give you everything you need.
It is an uncommunicated expectation – given you have not told him or her your expectations of him or her. For a successful mentor relationship, you need to create a formal agreement; often it isn’t just “part of the role”.
It could be unachievable – your boss or chosen mentor may not be able to fulfil your needs.
So, what can you do? Well, the first thing you need to understand is that despite the fact, undoubtedly, you and your mentor will learn and benefit from the experience, it is you – as the mentee – who will be responsible for the majority of the work and keeping on track.
Are you really ready to be a mentee? Here is a summary of the steps you need to work through to make sure you are properly prepared.
Are you ready to do the work?
Are you prepared to put in the effort to maintain the relationship?
The mentor is guiding you and offering you advice – they are short-cutting your journey to success.
You are learning from their experience and hard-earned acknowledge, so it is only fair you are prepared to maintain the relationship.
Your mentor should not be chasing you – it is not their role to follow up on you and any homework set.
Are you prepared to take action and implement?
Don’t begin a mentoring relationship and taking up someone’s time, by asking his or her advice and guidance, if you are not going to be accountable and take the actions required to meet your goals.
Are you open for feedback and self-reflection?
A good mentor will be ready to listen, ask questions, then offer advice and guidance if needed.
Also, he or she is likely to challenge you and ask difficult questions – are you prepared for this?
You will need to be ready to explain what you are thinking, your thought processes and the decisions you made, then be ready to receive feedback.
Part two will look at getting clear in your head what it is you want from your mentor.
In the third and final part of this series, we look at managing seizures in pets, both in an emergency setting and in the longer term.
When presented with a patient in status epilepticus, appropriate emergency treatment begins with:
Providing oxygen therapy.
Placing an IV catheter, if possible.
Administering diazepam as an 0.5mg/kg to 1mg/kg IV bolus, rectally at 2mg/kg or intranasally at 0.5mg/kg.
Intubating, if required to maintain a patent airway.
Cooling, if hyperthermic.
Giving mannitol at 0.5mg/kg to 1mg/kg slowly IV if seizure activity lasts more than 15 minutes or there is any reason to suspect cerebral oedema.
Collecting full bloods – test glucose, electrolyte and calcium levels first.
If on phenobarbital, collecting a sample for baseline testing.
It is important to remember patients may continue to paddle slowly after seizure activity has finished, but if the eyelids are twitching, they are still seizing.
If the seizures are controlled by these first steps, give a 4mg/kg dose of phenobarbital and commence supportive therapy with IV fluids, including correction of any electrolyte and metabolic derangements.
If at first…
If these first emergency steps fail to get the seizures under control, the following steps can be attempted:
Diazepam 0.5mg/kg to 1mg/kg IV bolus – can be repeated every five minutes for up to three doses.
Propofol 2mg/kg to 4mg/kg IV titrated to effect to stop motor activity.
Phenobarbital slow IV 4mg/kg if already on maintenance therapy, mg/kg to 8mg/kg if not – can be repeated at 20 to 30 minute intervals.
+/- Diazepam (or midazolam) continuous rate infusion (CRI) at 0.5mg/kg/hr.
Propofol CRI following titrated dose, at 0.2mg/kg to 0.5mg/kg/min – continue for six hours then wean down slowly over next six hours.
Levetiracetam at 20mg/kg to 60mg/kg IV titrated can be used instead of propofol (this is safer if hepatic disease is present).
Ongoing treatment
The recommendations for when to start long-term treatment are summarised as follows:
Structural lesion present or prior history of brain disease or injury.
Acute repetitive seizures or status epilepticus (ictal event ≥5 minutes or ≥3 or more generalised seizures within a 24-hour period).
≥2 or more seizure events within a six-month period.
Prolonged severe, or unusual postictal periods.
Chronic therapy in patients with ongoing seizures aims to reduce the frequency to an acceptable and manageable level. The drug used to achieve this is often down to clinician preference; one or a combination of the following can be used:
Phenobarbital – solo and combination therapy, drug monitoring is required along with regular monitoring of liver enzymes and function is particularly important.
Potassium bromide (not cats) – combination therapy, drug monitoring is required and can cause pancreatitis.
Imepitoin – solo or combination therapy, does not require drug monitoring.
Levetiracetam – solo or combination therapy, does not require drug monitoring.
Regular testing of blood levels of anti-epileptics is important, although it does not indicate whether the drug should be working or not, it does help provide additional information when investigating when control is inadequate and to prevent toxic side effects.
In part one of this series we discussed the important questions to ask when taking a history from owners of dogs and cats that are having seizures. In this part, we look at the differential diagnoses for these cases.
There are many ways to classify the different causes of seizures, but the simplest is as follows:
Structural – where intracranial pathology is causing the seizures.
Reactive – where an extracranial issue is causing a seizure response in a normal brain.
Idiopathic – a diagnosis of exclusion where we are unable to identify a reason for the disturbances in brain activity.
Structural
Intracranial differential diagnoses include:
inflammatory processes (meningoencephalitis), such as steroid responsive meningitis-arteritis
viral diseases (for example, distemper)
metabolic storage diseases
neoplasia
vascular accidents involving clots or bleeds
hydrocephalus
trauma
Reactive
Extracranial differentials include:
hepatic encephalopathy due to hepatic failure or a portosystemic shunt
various toxicities, such as lead, chocolate, caffeine, ethylene glycol, parasiticides and slug/snail bait
metabolic issues, such as hypoglycaemia, hypocalcaemia and thiamine deficiency
Idiopathic
If diagnostic investigations (including advanced imagery, such as MRI) are unable to identify an underlying cause of recurrent seizures, this is referred to as idiopathic epilepsy.
To break down this list of differentials into a more relevant and concise list is to consider the most common differentials according to signalment.
Clients often panic when they think their pet is having a seizure and can skip over vital information.
Often, what an owner describes as a “fit” may actually be syncope, collapse from anaphylaxis or internal haemorrhage (for example, neoplasia), a vestibular event or a behavioural condition.
True seizures
True seizures can be divided into two groups:
Generalised (grand mal) seizures, which involve both cerebral hemispheres and result in loss of consciousness, incontinence and muscle activity.
Focal/partial (petit mal) seizures, which originate from a focal region in the brain. These can also result in alterations in consciousness, but more typically only manifest in the form of repetitive twitching or limb movement.
Once you have established the owner is likely describing a true seizure, there are many important questions to ask to narrow down your differential diagnoses and treatment options.
The important questions
So, as part of a thorough history, always ask:
Was the pet conscious during the episode?
This will help to determine whether the seizure was generalised or focal.
How long did the episode last?
Status epilepticus is when a continuous seizure lasts more than five minutes or when the patient has not recovered fully before another seizure occurs. This can result in severe secondary brain injury.
How many episodes has the pet had in the past?
Epilepsy is the condition of recurrent seizures. This can be further classified as primary and symptomatic epilepsy, with symptomatic being secondary to an underlying cause (such as head trauma or a brain tumour).
How close together were the episodes?
Cluster seizures are when an animal has more than two or three episodes within a 24-hour period.
If a patient presents first time with a cluster, this carries a poorer prognosis in dogs, but has no influence in cats.
Clusters are generally an indication for commencing long-term management.
How was the pet before and after the episode?
Seizures often come with predicting (pre-ictal) and recovery (post-ictal) events.
In the pre-ictal phase, the patient may act strangely (for example, agitated or clingy) and may vomit.
Alterations in consciousness prior to a seizure usually indicate an intracranial cause.
The post-ictal phase can last anywhere between minutes and days, and animals are usually disorientated and/or lethargic. They may also appear blind.
Has the pet demonstrated any other strange activity recently?
For example, if an animal has also been circling to one side, you can start to predict the location of the lesion.
Cats more commonly present with partial seizures compared to generalised – this is seen as stereotypic behaviours and bursts of activity.
Has the pet been exposed to any toxins or chemicals?
Seizures caused by toxins (such as snail bait) generally do not stop and start, but are continuous.
In the next part of this series, we will look at differential diagnoses for seizures and highlight the differences between dogs and cats.
This sodium deficit is then replaced over “x” hours, at an average rate of 0.5mEq/L/hr.
In hypovolaemic hyponatraemia patients – where the fluid deficits also need correcting – it is important to select a fluid where the sodium concentration is within 5mEq/L to 10mEq/L of the patient plasma sodium level.
Table 1 shows the sodium content of various fluids. If none of the fluids listed in Table 1 are suitable – for example, the patient’s sodium level is 110 – you can make your own fluid by mixing 5% dextrose in water using the formula below:
Volume of 5% dextrose in water to be added (ml) =
([current IV fluid Na+] – [desired IV fluid Na+]) × 1,000ml ÷ ([desired IV fluid Na+] – [supplemental IV fluid Na+])
Hartmann’s example
The most common cause of severe hyponatraemia is hypoadrenocorticism. Using an example of a severe hyponatraemia of 110mEq/L, I select Hartmann’s solution first, as it has the lowest sodium concentration. How low I dilute Hartmann’s depends on the patient’s volume status.
If the patient requires fluid resuscitation because it is showing signs of poor perfusion – such as elevated heart rate, poor pulse quality, pale gums, prolonged capillary refill time, dull mentation, low core body temperature and elevated lactate – I aim for a sodium concentration the same as the patient. For this example, I would dilute the Hartmann’s to 110mEq/L, as then I can bolus therapy this without elevating the patient’s sodium concentration.
So, aiming for 110mEq/L, the volume of 5% dextrose in water (D5W) required to dilute Hartmann’s is:
= ([130 – 110] × 1,000) ÷ (110 – 0)
= (20 × 1,000) ÷ 110
= 181ml of D5W.
This volume may not fit in the bag, so I remove 150ml from the Hartmann’s bag first and insert 850ml into the equation:
= ([130 – 110] × 850) ÷ (110 – 0)
= (20 × 850) ÷ 110
= 154ml of D5W to be added to the bag for a total volume of 1,054ml with a sodium concentration of 110mEq/L.
TIP:
Electrolytes can be used on custom solutions to check the final sodium concentration. It will be a couple of mEq/L above or below, due to variations in each Hartmann’s bag.
I bolus with this 110mEq/L of custom solution for correct perfusion, reassess the patient and sodium concentration – and make a solution between 5mEq/L and 10mEq/L higher – and administer at much slower rates with repeated monitoring.
The treatment of hypervolaemic hyponatraemic patients will not be discussed here, as it revolves around treating the underlying medical condition.
Conclusion
Hyponatraemia is a common and potentially life-threatening change in our critical patients.
It is crucial to establish whether this is an acute or chronic change, to avoid development of osmotic demyelination syndrome. If I have any doubt about the timeline, I treat as a chronic change and increase slowly.
The causes of hyponatraemia can be divided into three major categories, based on serum osmolality. This is further divided based on the patient’s volume status (Table 1).
Most patients we see in clinic fall into the hypovolaemic category, except patients with diabetes mellitus.
Table 1. Causes of hyponatraemia based on osmolality and volume status (from Guillaumin and DiBartola, 2017).
Hypo-osmolar
Hyperosmolar
Normo-osmolar
Hypovolaemic
Normovolaemic
Hypervolaemic
Gastrointestinal fluid loss
Third-space fluid losses
Shock
Hypoadrenocorticism (Addison’s disease)
Renal insufficiency
Excessive diuretic administration
Salt-losing nephropathy
Cerebral salt wasting syndrome
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Hypotonic fluid administration
Hypothyroidism
Glucocorticoid insufficiency
Psychogenic polydipsia
Reset osmostat (SIADH type B)
Congestive heart failure
Acute or chronic renal failure
Nephrotic syndrome
Hepatic cirrhosis
Accidental ingestion or injection of water (water intoxication)
Hyperglycaemia
Mannitol
Severe azotaemia
Hyperlipidaemia
Hyperproteinaemia
Common causes
In dogs, the three most common causes of hyponatraemia are:
gastrointestinal (GI) fluid loss
third-space fluid loss
fluid shift from intracellular fluid to extracellular fluid (ECF) as a result of hyperglycaemia
In cats, the three most common causes of hyponatraemia are:
urologic diseases
GI fluid loss
third-space fluid losses
In most patients, more than one pathophysiologic factor is likely to be contributing to the hyponatraemia.
Circulating volume
Hypovolaemic patients – those with, for example, GI losses, hypoadrenocorticism, renal losses and haemorrhagic shock – have a reduced effective circulating volume. ECF contraction triggers antidiuretic hormone (ADH) secretion, which leads to increases in free water absorption and thirst, and results in dilution of the serum sodium concentration. Aldosterone secretion is reduced in hypoadrenocorticism, so an overall reduction in sodium reabsorption compounds the problem.
Hypervolaemic patients are those with an increased fluid retention state, such as:
Congestive heart failure patients have a reduced cardiac output and, therefore, a decreased effective circulating volume, despite the presence of the extra fluid status. Renin-angiotensin activation leads to release of ADH and aldosterone, resulting in sodium and free water reabsorption, and increased thirst. Both lead to an excess of free water retention.
Advanced hepatic (cirrhosis) or renal failure (nephrotic syndrome) both result in hypoalbuminaemia, leading to fluid shifting into the interstitial space and third space, reducing effective circulating volumes. This leads to activation of ADH to increase free water reabsorption, to restore the circulating volume in the face of existing hypervolaemia and hyponatraemia.
Diabetic patients
Moderate to severe hyperglycaemic diabetic patients can be either hyperosmolar or normo-osmolar, depending on the serum blood glucose concentration. Hyponatraemia occurs when water shifts from the intracellular fluid to the ECF down the osmotic gradient, diluting the serum sodium content.
Despite this osmotic shift, not all diabetic patients develop hyponatraemia. Glucosuria also causes also causes a renal osmotic shift, sometimes resulting in urine water loss in excess to sodium. This offsets the hyponatraemia – in some cases, hypernatraemia results.
Treatment
Treatment of hyponatraemia hinges on how quickly it developed and the volume status of the patient. The rule of thumb is to correct hyponatraemia slowly – not exceeding 0.5meq/L/hr – especially in chronic cases, or cases where the duration of hyponatraemia is unknown. Keeping to this rate is paramount until serum sodium concentration reaches 130meq/L.
In acute patients with severe clinical signs, such as seizures, some clinicians may choose to use a higher rate of 1meq/L/hr to 2meq/L/hr until clinical signs resolved.
It should be emphasised, once again, this rate should never be used in chronic patients, patients with an unknown duration of hyponatraemia, or where frequent serum sodium concentration cannot be monitored. The rapid correction of hyponatraemia can lead to osmotic demyelination syndrome (myelinolysis).
Its effect will not be apparent until three or four days after therapy, and can result in neurological abnormalities such as:
weakness
ataxia
dysphagia
paresis
coma
For that reason, frequent electrolyte measurements are required, starting hourly then once a suitable rate of increase has been established and less frequently thereafter.
Part 3 will look at how to correct patients with hyponatraemia.
Reference
Guillaumin J and DiBartola SP (2017). A quick reference on hyponatremia, Veterinary Clinics of North America: Small Animal Practice47(2): 213-217.
