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  • Raking it in?

    Raking it in?

    The assumption is often made that many people get into the veterinary industry for the money. In fact, it’s always been a widely held public view that vets are raking it in.

    This is, perhaps, due to a combination of the recognised difficulty of the job, seemingly extortionate vets’ bills and a propensity for Range Rovers.

    Whatever the cause, this view was made all the more apparent on the 18 May edition of Good Morning Britain.

    Concerns about cost

    The original topic of debate – “Should there be an NHS for pets?” – sparked a subsequent debate into the pricing of veterinary care, with strong implications being made that pricing in the veterinary industry is “unregulated” and, therefore, unnecessarily high and perhaps even greedy?

    As an outsider looking in, faced with an objectionably large bill for what you thought would only be a routine check-up, I can see how it’s easy to misunderstand where all that money can go, except into the pockets of the vets themselves – and yet this is a fallacy.

    Clients just don’t understand

    I feel an understandable nationwide misunderstanding exists of the true value of what we consider to be “routine” medical goods and services.

    According to an NHS calculator, without health care, the price of a hospital child delivery would range from £2,500 to £5,000, depending on any complications. In the US, a single doctor’s consultation can cost you upwards of $200 (£141), with the average American spending more than $10,000 (£7,000) in health care a year as of 2016.

    There’s no denying that we take human medical care for granted, so there’s little surprise when the cost of animal medical care puts our clients in need of a pacemaker (free of charge).

    In it for the money

    One of the very first things I learned about veterinary medicine – as I sat, rather excitedly, in a school-organised lecture given by the head vet of a local practice to a room of young, naive wannabe vets – was that if we were thinking of getting into the career for the money, we should change tack now, as we would be sorely disappointed.

    I know I am luckier, now than ever before, to have the luxury of both job and financial security when I leave university, but it needs to be said that neither myself, nor any vet student I have ever encountered, got into this business for the money.

    Even if we had, I think it would be fair to call us fools, as there must surely be an easier way to make money than five years of student housing, student loans, exams and poop scooping.

    Initial outgoings

    I think it also needs to be said that the phrase “it takes money to make money” could indeed be applied very aptly to the veterinary degree. A growing awareness exists of the potential accessibility imbalance when it comes to the vet course, depending on background, social class, funding and so on.

    It’s no secret to those on the inside that getting into, and through, vet school can insure some serious dents in your wallet, and those of your parents (sorry parents); between textbooks, steel toe-capped wellingtons, petrol miles, Airbnbs for long-distance placements and stethoscopes (the most expensive necklace you will ever own), you are looking at a sizeable sum before you even get to student loans.

    And that’s without considering being able to afford the time off work to travel to open days and interviews in the first place, with the assumption that you have a supportive network of family who have the money to fund your ambitions before you’ve even got your foot in the door…

    An NHS for pets?

    The topic of an NHS for pets aside, I think a great deal needs to be done to help us recognise the true privilege that is our human NHS, and the true value of the service given by all medical professionals.

  • Impostor syndrome: a pandemic among vet students

    Impostor syndrome: a pandemic among vet students

    The nature of the vet course is inherently competitive, with the odds stacked against you from the very beginning.

    During our A-levels we are told that only 1 out of every 5 to 10 applicants make it to vet school, and that you’re lucky to get a single interview or offer (any more than that is just greedy).

    In university, when students on other courses are totalling up their grades to calculate if they are getting 1sts or 2:1s, vets are given a pass mark of 50%, which has the paradoxical effect of making it seem like you should be sailing through the course when, in actual fact, the bar is set so low because – yes – it really is that hard.

    Negative feelings

    The majority of vets and vet students, I am sure, can report to experiencing some form of impostor syndrome at some point in their careers – if not throughout.

    Impostor syndrome is the feeling you are not as bright, or competent, or worthy of where you are in life as everyone around you thinks you are. It can be a toxic, self-deprecating and sometimes debilitating sensation, making you feel entirely alone when really everyone around you is most likely in exactly the same boat.

    No motivation

    From a little of my own experience, and through speaking to others in the field, I know this feeling has only grown stronger among my peers as a result of the coronavirus pandemic.

    After almost a year of online learning, open book exams and, in some cases, a complete lack of the hands-on practice and subsequent reassurance we should all be receiving right now, it’s only natural things don’t feel quite right.

    No motivation. Photo by Andrea Piacquadio from Pexels

    Being cooped up all day, and going long periods of time without seeing friends and loved ones, certainly doesn’t inspire productivity, and it can be hard to stay motivated with nothing to look forward to on the horizon – whether that’s a long holiday in the sun or just a nice catch-up with your mates down the pub at the end of the week.

    Under pressure

    After a year of lockdowns with nothing else to do, I think it’s all too easy to put too much pressure on yourself to accomplish everything because, look, you’ve never had this much free time before!

    I’ve heard from lots of students who think – especially due to last year’s open book exams – that they “don’t deserve to be here“; that they haven’t worked as hard as they could have, or should have; that they’ve dropped the standard, so to speak.

    But that’s the thing, even if it doesn’t feel like you’re working as hard as your old self used to in “the before world of February 2020 and earlier”, that’s because this is a completely different kind of work.

    Marathon effort

    It’s so much easier to sit down and do a day’s work with no distractions when the rest of your life is stable, but when it’s not, even the little things can become difficult – and that’s okay.

    Take marathon runners, for example: capable of running for miles and miles, so of course, that first mile, or even the first 10, probably feel like nothing (as a max 10km runner I wouldn’t know personally, but I can assume).

    That 25th mile, though – when they’ve already come so far, they’re worn out and their energy reserves are entirely depleted – is probably the hardest one of all. It’s likely a challenge to just put one foot in front of the other. It’s going to feel like they’re working 1,000 times harder than they had to for that first mile, even though the distance hasn’t changed – the conditions have.

    Photo by Tembela Bohle from Pexels

    Third and final (?) leg

    As the third lockdown trickled ever so slowly onwards, I think everyone felt like they were just trying to keep up on what they hope is going to be the last leg of this unprecedented journey.

    For marathon runners at least, they know how long that run is going to be, so they can go all out on that final sprint. In lockdown terms, though, we don’t really know when this race is going to be over (despite the Government’s road map out of lockdown) – and that makes it okay to not feel like you have to give it your all every single day, but leave some in the tank so you can keep going the next day and the next.

    No shame

    What I’m trying to say (through some very dodgy metaphors) is that we’ve all come so far, and there is no shame in taking extra days off, or extra rest breaks; that if you passed an exam or a year at vet school – open books or not – you deserved that pass.

    It was probably one of the hardest exams you ever had to take, at the dawn of a global pandemic when no one knew up from down or left from right.

    We all need to be proud of ourselves for whatever we’ve achieved over the past 12 months, even if that’s just making it through and being there for each other.

  • Linear foreign bodies, part 3: should YOU take it to surgery?

    Linear foreign bodies, part 3: should YOU take it to surgery?

    In the previous post we covered what to look out for on ultrasound when assessing for a linear foreign body. Now we discuss the things you should consider before deciding to take the patient to surgery.

    Read the following statements and answer the questions – either yes or no…

    • Linear foreign body surgeries can be technically difficult and can take a prolonged period of time to perform. The longer the surgery, the higher the rate of complications. Are you (or do you have access to) an experienced surgeon who has performed a linear foreign body surgery before, and do you have an additional pair of hands for surgery to help reduce surgery time?
    • Were bacteria visualised or is their presence likely based on the comparison of the abdominal fluid glucose and lactate to peripheral blood (see previous post)? If yes, then septic peritonitis is present. Approximately 40% of dogs with linear foreign bodies will have septic peritonitis. This means you need to be prepared to perform a resection and anastomosis; sometimes two. Have you performed a resection and anastomosis before?
    • Often a combination of gastrotomy, enterotomy, and resection and anastomosis are required. Are you prepared to perform a combination of these surgeries?
    • Linear foreign body surgeries can often require a significant number of surgical instruments and consumables. Do you have Balfour retractors, forceps, clamps, additional kit for closure, supply of lap sponges, as well as substantial amounts of lavage and access to suction?
    • Linear foreign body patients are often critically ill due to septic peritonitis. They can present in shock and have biochemical derangements such as hypoalbuminaemia, which indicates the need for perioperative critical care. Do you have experience stabilising, performing anaesthesia and postoperatively managing a critically ill patient?
    • Hypotension can be caused by hypovolaemia; however, if the hypotension has not responded to reasonable volumes of a balanced isotonic crystalloid fluid – for example, 30ml/kg to 40ml/kg – then the hypotension could be caused by vasodilation from septic shock. This means vasopressor agents will be required in addition to crystalloids. Do you have access and experience with vasopressor therapy?
    Image: Gerardo Poli.

    Conclusion

    This list of questions is not meant to be conclusive or definitive, but merely a list of considerations before taking a linear foreign body patient to surgery.

    If you answered no to many of these questions, then consider referral to a facility that is prepared and equipped for the challenges that often accompany linear foreign body patients. However, if referral is not an option, consider the list above as a way to be as prepared as possible for tackling those situations.

  • Linear foreign bodies, part 2: tips for diagnosing with ultrasound

    Linear foreign bodies, part 2: tips for diagnosing with ultrasound

    Following on from the previous post where we discussed tips on how to diagnose a linear foreign body on a radiograph, this post sees us cover how to diagnose it on ultrasound.

    If used by an experienced ultrasonographer who knows what to look for, ultrasound can be a highly sensitive and specific diagnostic test.

    What do we look for?

    1. Remember not all patients will have intestinal dilation as the linear foreign body may be only causing a partial obstruction. Alternatively, it could be occluding the gastric outflow completely.
    2. Intestinal plication, which looks like intestinal loops bunching up on each other around the tether.
    3. A central discrete hyperechoic line running along the middle of the bunching intestine. This bright line is the tether. Often when looking closely enough, the tether will have distal acoustic shadowing as the ultrasound pulses cannot pass through it.
    4. The leading aboral segment and the trailing adoral anchor will have acoustic shadowing.
    5. The adjacent mesentery is often hyperechoic compared to other areas in the abdomen, indicating inflammation.
    6. Gastric dilation with fluid is often seen if the anchor is in the pylorus, as it causes an outflow obstruction.
    7. Free abdominal fluid may be visible and a sample should be collected for assessment. If bacteria can be demonstrated in one of the following ways:
      1. By visualising free or intracellular bacteria under the microscope.
      2. By finding that the glucose is lower (lower than 20mg/dL) and the lactate is higher (2mmol/L) in the abdominal fluid sample compared to peripheral blood then this indicates perforation of the gastrointestinal tract has occurred and septic peritonitis is present.

    In the third and final post, we will cover things to consider when deciding whether to perform the exploratory laparotomy yourself, or if you should transfer the patient to a referral facility for surgery.

  • Linear foreign bodies, part 1: tips for diagnosing with radiography

    Linear foreign bodies, part 1: tips for diagnosing with radiography

    Linear foreign bodies can be tricky to diagnose, compared to normal foreign bodies, for many reasons. Mostly because you often don’t see the classic obstructive pattern appearance on radiographs or ultrasound.

    In this short blog series, we are going to cover some hints and tips that can make diagnosing a patient with a linear foreign body easier. Then, we’ll discuss things that should be considered when deciding whether you are the right person to take the patient to surgery…

    So, let’s start with radiography.

    1. Not all patients with a linear foreign body will be completely obstructed. This means you won’t always visualise classic intestinal dilation. In fact, it has been reported that up to 50% of patients with a linear foreign body will not have an obstructive pattern present on radiographs.
    2. Look for the characteristic small “comma shaped” gas pattern. This is caused by plication and bunching of the small intestine around the tether.
    3. The small intestine can appear to be bunched up in one area, rather than spaced out around the abdomen. However, obese animals – especially cats – can have “pseudo-bunching” due to large amounts of abdominal fat bunching the intestine together.
    4. Loss of serosal detail is often seen due to inflammation surrounding the affected intestine.
    5. Always include a left lateral radiograph in your series. Gastric contents will fall to the fundus on the left of the abdomen and gas will raise to the pylorus, which will highlight the foreign body anchor in the pylorus.
    6. Perform thoracic radiographs to assess for aspiration pneumonia and a potential oesophageal component of the linear foreign body. If aspiration is present then you know you will need to continue antibiotic therapy postoperatively.

    In the next post, we cover some key points for diagnosing linear foreign bodies on ultrasound…

  • The other side of the consult table, part 2

    The other side of the consult table, part 2

    Never have I seen my cat so happy as the days post-operation when she was flying high on pain relief (I personally remember being quite grumpy the days after I had a tooth removed, but Bluebell seemed entirely unphased), but that doesn’t mean bringing an animal home from an operation is plain sailing.

    The initial internal struggle of a vet student handing their beloved pet over to fellow vets is shortly followed by the hurdles of “medication dose mathematics” and valiant attempts to get said pet to ingest said medication.

    I once thought myself quite adept in the arts of pill-giving when Bluebell was on a course of steroids, up until the day when she’d had enough and spat it back out directly into my jacket pocket.

    However, once these hurdles have been mastered, teaching my parents to do the same can be a whole other ball game…

    A little knowledge goes a long way

    I think having even a little veterinary background can be a useful thing when you bring a pet back home from something big like this. You are reassured by the knowledge of what to expect and what can be counted as “normal”.

    Whether it’s coming downstairs to a very full litter tray in the morning – as was my poor mother’s experience – or dealing with some temporary behavioural changes, a reduced appetite, sleepiness or cleaning up after the occasional accident.

    Forbearance

    It’s all part of the process. No human wakes up right as rain the day after a big procedure, and when you’re only small, even a minor operation can be a huge ordeal. As with most things, patience is the key.

    I do feel quite sorry for the animals who undergo to the trauma of an operation and are then forced to return to the scene of the crime a week later in the guise of a “check-up”.

    But, thankfully, when we bundled Bluebell bottom-first into her carrier for the second time, all was well.

    Fang facts

    In fact, we learned she is managing to lose not only weight – which, since she’s always been a bit of a chonker, came as a nice surprise – but teeth!

    Only one in the actual teeth clean however – apparently another five have been lost at some point in her life, with all of us being entirely none the wiser!

    Luckily, I think the fact that she is still a chonker is evidence enough that losing those teeth didn’t phase her in the slightest.

  • The other side of the consult table, part 1

    The other side of the consult table, part 1

    There comes a time when even doctors and nurses have to make a visit to their local GP (perhaps somewhat begrudgingly), and I wonder if that evokes a similar feeling to when veterinary professionals take their own pets into an appointment?

    My own cat is going in to get her teeth cleaned in a matter of days, and although it is by no means her first trip to the vets, the act of taking her in feels slightly more surreal to me now than it did before I began my training and gained a more similar perspective to that of the vet or vet nurse behind the consult table.

    Familiar faces

    I’ve volunteered at my local practice for years and know the more senior members of staff rather well, but a newer face will obviously ask me the standard check-up questions and explain things the way they would with any other owner.

    To be honest, I never know whether to pretend it’s all new to me or admit I’m a third year vet student; I worry it sounds a bit off to just come out with it without being prompted – a bit like meeting Gordon Ramsay and blurting out that you, too, own several cook books and make a mean Shepherd’s pie.

    The hardest part

    The last time my cat, Bluebell had to undergo an operation I unfortunately had classes, and although the vet in question knew me well and offered to let me watch, I wasn’t able to – and with a small twist of irony, now that I am free as a bird, the logistics of COVID mean that I must once again sit this one out.

    Along with being the unfortunate messenger of the truly unknowable cost of a procedure to your parents (whose eyes widen at even your lowest estimates, though you try to explain it’s best to get it out of the way when she’s young and healthy), knowing the risks is probably one of the hard parts of being any medical professional – from hearing someone cough, and unconsciously jumping to the worst-case scenarios, to taking your pet in for routine surgery with the anaesthesia mortality statistics circa 2018 committed to memory.

    Not in control

    As ever, the advice you’d give to someone else never has quite the same effect when you try telling it to yourself, and when you’ve experienced the position of the person “in the driver’s seat”, so to speak, it can be hard to surrender control.

    COVID allowing, I would like to be in that operating room myself – and not just because it would be the first lot of EMS I’ve managed to wangle in the past nine months, but because, even if you are distanced from the world of veterinary medicine for any length of time, it never distances itself from you.

  • Could COVID-19 close the door to the veterinary course?

    Could COVID-19 close the door to the veterinary course?

    It has long been a fear – among those inside the profession and outside – that university places to study veterinary medicine are not as accessible as they should be.

    There is a perception the course, if not the vocation, is slightly elitist – not helped by the impression of most clients that the medical bills they are unaccustomed to paying for themselves mean vets must be absolutely rolling in it.

    I certainly think of myself as extraordinarily lucky to have snagged one of the over-subscribed university places four years ago. I had parents who could afford the time and who were willing to drive me to various EMS placements, and I lived in close proximity to friendly veterinary practices with the patience to have me shadowing them every week.

    Resources

    I also went to a school with the resources to support me through my studies and had a stable and happy home life, which gave me the secure space I needed to revise and prepare for interviews. I even had a grandmother willing and able to drop everything to fly to the other end of the UK for my Edinburgh interview at pretty much last minute’s notice.

    Veterinary medicine is an incredibly competitive, and sometimes arduous, application process, and even students with all the money, time, and educational and familial support in the world struggle to make it in.

    I can only imagine how the added pressure of COVID-19 could have made this process so much harder and reduced its accessibility even further.

    Striking a toll…

    When you combine the mental health pandemic secondary to the coronavirus pandemic with the mental health crisis affecting medical students at every stage of their training – even as early as pre-interview – it becomes apparent how striking a toll this year may have had on some would-be vets.

    Money can also, unfortunately, be a crucial factor when applying to any university position. With the financial burden impressed on countless families since the start of 2020 – and with national unemployment sky-rocketing – the door to further education may be closing to many more.

    Parents worrying about job losses and money problems may be less able to support a child through the application process, and those students coming from complicated or disruptive households have not had the option to take their studies elsewhere – namely a café or school library.

    Tears in tiers

    Those students who have remained in Tier 3 for the majority of the year will have been hit harder by these factors than those in lower tiers.

    Concerns have also risen for international students and maintaining diversity in the course. Overseas vets and vet students are invaluable in many facets of veterinary medicine – for example, they make up a large proportion of vets working in food safety and public health.

    I think it’s important that universities consider an application from every angle and consider the less obvious setbacks brought about by COVID-19 that are perhaps being over-looked. I want the veterinary community to be diverse and self-supporting, and this starts at the very beginning.

  • Mistake grieving

    Mistake grieving

    Everyone makes mistakes – we know that. But that still does not mean it is easy to let go of it, forgive yourself and move forward.

    A talented vet at work said something that has proven to be a golden nugget of advice – it’s okay to give yourself time to grieve; however, set a time limit.

    Essentially, you allocate and schedule time to grieve the mistake or negative event.

    Allowing time

    The powerful thing about this is that you are allowing yourself some time to think about it, which is better than trying to pretend all is okay. You get to dissect it and determine what went wrong, and have some time to deal with the emotions; however, you set a strict time limit.

    The time limit is important because rumination on mistakes can be very detrimental – you then start to add extra meaning to the mistake, then you create beliefs about yourself based on the story you created that are not real.

    By setting a time limit on your grieving process you still face what happened, but reduce the time you think about it. This is important, as the longer you think about something the more weight and importance you add to it, and the bigger and more significant it becomes.

    Shifting focus

    The longer you focus on disempowering thoughts, the more likely it will lead to disempowering beliefs. Your thoughts are not you; they just happen – so this means you don’t have to own them. Therefore, you can control how much weight to add to them and what beliefs you generate from them.

    Setting a time limit means you shift faster towards moving forward and focusing on what really matters, and what you must do next.

    Next time you are tackling something difficult and need to process it, set a time limit. Let yourself identify the lesson, learn from it and deal with the emotion – but when the time is up you let it go, and forgive and forget.

  • In the pink

    In the pink

    I can probably count the number of blood samples I’ve taken to date on a single hand.

    That does sound pitiful, I know, but please hold off on any judgement as I was unfortunate enough this year to have a total of 10 weeks’ work experience cancelled due to the recent pandemic.

    Like everyone else, I suppose, I saw 2020 panning out a lot differently as I began it… but from dark clouds come silver linings, and I am now proud to say that one of my startlingly few blood samples was drawn earlier this month from a flamingo.

    Going to the zoo, zoo, zoo

    My cohort is probably luckier than most, as the large majority of our learning is conducted online, with the exception of the occasional in-person presentation, practical or day’s work at Bristol Zoo Gardens.

    flamingo
    Eleanor takes bloods from a flamingo, under the close supervision of a zoo vet / Bristol lecturer.

    However, I’ll be candid and say the involvement of the local zoo in the running of my masters was the thing that really drew me in the most, the money and time being a small consequence if I had the chance to work alongside those who were living my dream – a dream I’d harboured for more than a decade and a half.

    And while I’m sure the thrill of my day’s work with those lucky individuals will fade (though it hasn’t yet), I think that short window spent working with the most amazing creatures and talented professionals almost makes up for all the time lost this summer.

    A very different experience

    It’s safe to say that working with wildlife versus small domestic animals is an entirely different ball game. For example, I have a friend who had a week’s EMS in a practice specialising in wildlife and spent most of the first day chasing a deer around a local park.

    Even if you are lucky enough to have the wild animal behind closed doors and easily accessible, or even if it’s already restrained or half-tranquilised, it’s astonishing how difficult a simple routine check-up and x-ray can become.

    It can take time to safely capture and restrain an animal, especially one as long and ungainly as a flamingo (don’t let the croquet scene in Alice in Wonderland fool you). Add this to the time taken to anaesthetise it, draw bloods, run checks, top up its fluids, take several x-rays from an array of angles – all while maintaining COVID-19 regulations on top of pre-existing health and safety considerations. It was no wonder my friend and I had about five minutes to wolf down our lunch before running off to the afternoon’s activities.

    Meal for none

    As a person who loves their food, it is with great surprise that I say I have never been so happy to skip a meal in all my life. I think I would have quite happily gone on working through until midnight, had government COVID-19 policy not mandated we leave the zoo by 5pm. I honestly didn’t want to leave, but I walked away with a strong respect for all of the staff working there on a daily basis.

    Working as a vet requires a sack full of patience at the best of times, but working with wild animals brings the job to another level. Not only do you strike the balance every day between interfering too much or too little, no other medical professional has to work with patients every day who are so unwanting of your help and will stop at nothing to get away.

    I do think that if doctors and nurses had to use bait to draw their patients in, bar the practice doors, and then try to grab them one by one with a very large net, medicine courses might not be quite so over-subscribed.