Addison’s disease (hypoadrenocorticism) is one of those annoying diseases that does not always play by the rules.
One of the main reasons is the clinical signs of Addison’s disease can be frustratingly non-specific and we don’t often see the classic “low sodium, high potassium” electrolyte changes we are attuned to noticing. Therefore, it is important to recognise the early signs, or have a set of clinical signs, history and biochemistry changes that trigger the Addison’s disease alarm bells.
Once diagnosed, we can look at the approach to stabilising a patient in an Addisonian crisis.
Clinical signs
The clinical signs of Addison’s disease can be vague and non-specific, these include:
anorexia
lethargy
weakness
gastrointestinal signs
polyuria and polydipsia
A history of chronic intermittent vomiting and/or diarrhoea that resolves with symptomatic management would be one of the triggers.
Another trigger is the subtle changes in blood tests. These include:
the absence of a stress hyperglycaemia in a sick patient (normal glucose or even a low blood glucose, for example)
hypercalaemia (ionised) of any degree
absence of stress leukogram
These changes are often seen in isolation, so don’t expect them to all be there at the same time. We see patients all the time with inappropriately normal or low blood glucoses with gastrointestinal signs that we later diagnose with Addison’s.
Hypercalcaemia – what’s the big deal?
Why hype up and down about normal or low blood glucoses? Because low blood glucoses are rarely caused by inappetence or gastroenteritis alone, and the body is pretty good at maintaining glucose within normal levels (except, maybe, for very young patients and some toy breeds). Any low glucose Addison’s should be considered, and a stress hyperglycaemia is so common in ill patients that its absence makes me concerned.
What is the big deal about hypercalcaemia? It is so tightly regulated that any elevation Addison’s is on the differential list. How does Addision’s cause these changes? Corticosteroids are released during stress or ill states, which result in a stress hyperglycaemia. They also play a role in the excretion of calcium in the urine, so preventing a hypercalcaemia.
What about the electrolyte changes, the hyponatraemia and hyperkalaemia? When these changes are present they make diagnosis much easier, but they are not always present, such as with “atypical hypoadrenocorticism”, so the absence of that classic change does not rule out Addison’s.
One of the most exciting and yet terrifying things about being a veterinary student is the fact there is always more to know. You can be the best student and even the best vet in the world, but you can never know everything – it’s simply impossible.
I’m in the second year of my course and I’m still getting to grips with this fact; and I know it’s something a lot of other vet students struggle with too.
I think it’s completely understandable; every step towards getting into vet school is incredibly competitive: from day one we’re taught to push ourselves, branch out from our A-levels and be as knowledgeable as possible to stand out from the crowd. It’s only natural we follow this desire to learn and keep learning as we enter the course.
Know-it-all
But it’s important to realise you don’t need to know everything, while also acknowledging learning all the anatomy, physiology and biochemistry available won’t make you the best vet – or even a good one.
Of course, it’s vital you know your stuff (your clients put their trust in both you and your medical knowledge), but when people are trusting you with their animals – whether they are their best friends or livelihoods – they’re not expecting you to be a human encyclopedia.
No, they’re expecting another human being across that examination table; they’re expecting communication, a calm, professional confidence and a reassuring, friendly face in those moments that matter most.
Not by rote
GCSEs and A-levels train us to memorise textbooks like our lives depend on it, but that’s just not feasible when you get to university. In secondary school you’re lucky enough to have a set curriculum and a finite number of facts to learn. We no longer have that luxury, but it doesn’t have to be a bad thing.
The fact there’s always more to discover, that I can never stop growing and improving – I find it amazingly exciting. Daunting, yes, but exciting nonetheless.
I’ve been volunteering at my local veterinary surgery for more than five years and I’ve seen all the staff, including the head vet, refer back to their textbooks on a regular basis – textbooks they bought and studied with all the way back in their first years of university.
Collective intelligence
At the end of the day, medical practitioners are only human; they have strengths and weaknesses. However, one of the key attributes of a good vet isn’t knowing it all, but applying existing knowledge to any situation that might present itself.
Our lecturers are constantly encouraging us to help each other through this course and to share our strengths with others. Working as an intellectual collective is a talent that carries through to general practice.
When I see my local vets duck out of the consult room to confer with their colleagues I don’t lose confidence in them; in fact, quite the opposite. Having the confidence to admit when you’re out of your depth is an invaluable skill and the sign of a true professional.
In the 1990s, this disease resulted in the mass culling of hundreds of thousands of livestock, devastating the farming community and causing ripples throughout the British economy.
Soaring meat prices, a ban on UK beef exports and sizeable public concern arising from the last outbreak led to extensive media coverage on a topic many people not involved in the medical field rarely entertain.
Not all puppies and kittens
Although you might not think it, food safety and public health are two of the most vital roles vets perform for society.
I feel there’s a common misconception all vets are bound to the same path; when speaking to my uni friends about future careers, they never seem to assume I’ll end up anywhere other than small animal practice – and this may be true for the majority or veterinary graduates, at least those from the UK. Mixed practices are dwindling and veterinary food safety workers are predominantly sourced from overseas.
That aside, veterinary involvement in the food industry is vital in keeping the public safe. Meat having the stamp of approval by professionals trained in parasites and pathology gives the British public – as well as importing countries – confidence in our farmers and serves to strengthen our economy, and build up domestic farmers and their businesses.
Only the beginning
Within the meat industry, the job of a vet is not over once the animal is slaughtered – they are just as involved in death as in life. Zoonotic diseases and parasites can be spread between people and animals, and vets ensure these never reach your supermarket shelves.
At food crisis moments – such as the events that occurred over two decades ago – vets have two main responsibilities:
A duty of care to those animals who must be put down with a delicate combination of haste and humanity.
To work with farmers during the financial struggle they will most likely suffer following the loss of a large proportion of their livelihood.
For the many, not the few
Medical bills make up a substantial amount of costs when running a farm, and any vet going into the industry will quickly realise treating a herd animal is a far cry from treating a pet. They need to master the art of putting the needs of the herd over any individual.
Of course, what might be the greatest responsibility of any farm vet is to aid farmers in preventing further outbreaks. To pool the resources of all field areas – researchers, clinicians, food technicians and farm workers – to improve productivity and ensure the continued safety of the public.
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“If you don’t know where you’re going, any road will get you there,” said the Cheshire Cat to Alice when she tumbled into Wonderland in Lewis Carroll’s timeless tome.
Sometimes, it can feel like we’ve fallen down the rabbit hole completely, with no sense of direction or idea of where we should go or what we should do next.
Challenge accepted
Yet, it appears RVNs can do plenty if contemplating a new challenge, as you will hopefully see in the October edition of VN Times – from volunteering with rhinos to topping up your skill set or retraining completely, all while still putting your knowledge to good use by caring for animals in need.
Research has revealed confusion still reigns around the exact nature of the role of the RVN, which suggests more needs to be done to raise its profile in the eyes of colleagues and clients.
Yet, take heart. As we speak (or indeed, as I write), steps are being taken across the profession to tackle this issue – from career advisory days to research projects on how to effect change.
What’s more, moves are also being made to boost diversity in all forms, as you will see in the pages of October’s VN Times. So, instead of existing in a career cul-de-sac, it would appear a plethora of new paths exist for RVNs to take.
Make your choice
The only real problem is choosing which exciting route to traverse first.
When Alice asked the Cheshire Cat which way she ought to go, he said: “That depends a good deal on where you want to get to.”
The question is, rather excitingly, where do you want to go? Look to the horizon; the possibilities are endless.
The relationship between vets and animals is an odd one.
When I tell people the course I study, 90% of them ask me if I’m vegetarian; when I say no, all of them ask me why not – and, to be perfectly candid, I never really know what to tell them.
As a professional in practice, my relationship with animals will be as doctor to patient. This affiliation is simple enough. But when I go home, crack open the freezer and fry up a steak with a nice Sauvignon blanc, the line begins to get a little fuzzy.
Keeping a distance
Although the path my career is destined to take is still very much in the works, if I do decide to go into farm work then a certain emotional distance will have to be observed when treating patients. You have to find the perfect balance of respect for the animal and a desire to preserve life, but also the acknowledgement of that fact your patients are, and always intended to be, food.
One of the big things they taught us in the first week of vet school wasn’t scientific or mathematic. They told us, through the course, our attitude towards animals – what it meant to be a vet – was going to change.
I’d be lying if I said my own philosophy surrounding what I want to do with my life, as well as what I put on my plate, hasn’t evolved. It has, it definitely has – In fact, it still is.
Is meat murder?
“My course has forced me to confront the fact I see a beef cow and a golden retriever in very different ways.”
I know everybody has their own opinion on the subject. People tend to get very passionate about their own food choices and go to great lengths to defend them and convert other people to their way of seeing things, especially as the vegan lifestyle grows more popular.
As vets and as medical practitioners we are, of course, entitled to our opinions like everyone else, but when we step behind the examination table or don the metaphorical white coat, the way we conduct ourselves cannot always be driven by our own personal beliefs, but a combination of the welfare of the animal and concerns of the client.
The cute factor
We like things that are cute. Although some people go through life ignoring this fact, my course has forced me to confront the fact I see a beef cow and a golden retriever in very different ways. No matter how hungry I may be, I have never considered eating a dog – and yet I will one day be required to treat both.
I do not believe either is entitled to a higher standard of care and yet, quite obviously, I hold their lives in opposing regards.
Perhaps it’s purely cultural or the way my parents raised me (they’re both big meat eaters), perhaps it’s an intelligence thing – the fact I assume dogs have more cognitive awareness than the average cow – but this line of thinking does threaten to drag you down an ethical rabbit hole of sentience and animal rights.
Valuable lesson
So, perhaps it’s not that complicated, perhaps humans, on an unconscious level, simply love fluffy things.
As a veterinary student you are taught, from the off, to analyse your way of reasoning and question it. I think this might be one of the most valuable things they can ever teach us.
My classmates and I recently reunited at our beloved university to celebrate joining the profession as qualified vets around a year ago. While there we attended a CPD event based around managing difficult situations as a new grad, be that with clients, colleagues or bosses.
While the scenarios were entertaining, they also highlighted aspects of working life as vets that were very relatable, sparking a number of interesting discussions. Many issues were covered, but the most significant points were certain legal or business aspects of veterinary work rather than clinical ones.
For many of us, our first job as a vet will also be our first full-time, salaried job. As such, many new grads may be unsure of their basic minimum legal entitlements, such as holidays, sick leave and contracts, and, therefore, will not necessarily realise if they are receiving these.
Almost one-third of attendees, despite having been graduated for well over a year, still had not received a contract – much to the shock of the representatives from the various veterinary organisations running the session. I, too, find it incredulous some practices deem themselves impervious to certain legal requirements.
This is perhaps one of the ways in which corporate practices actually have the upper hand on independents – they tend to be better at the paperwork side of things and, even though the contracts can often be vague, they are present. This does not, however, make them any less likely to take advantage of the absolute minimum benefits that can be offered.
More for less
For example, the legal minimum holiday allowance is calculated in weeks. For some of my colleagues who work a four-day week, this means their holiday entitlement seems outrageously small, even if it is, in fact, correct when counting the weeks.
What is not taken into account is many of those who work a four-day week will work longer hours on each of those days, which means they’re still working a 40-hour week. Because of this, and despite working the same amount of hours, some vets are finding themselves drawing the short straw when it comes to holiday entitlement.
The veterinary profession is unique in many ways, but that does not make veterinary employers exempt from their legal responsibilities or from trying to allow employees to have a good work-life balance.
Second time around
There is so much variation within the profession, with some practices hitting the nail on the head when it comes to looking after their vets, while others work them into the ground and wonder why they have an issue with staff retention.
It is issues like these that contribute to the loss of young vets from the profession so quickly after graduating.
While many of my university friends are happy in their current roles, a lot (myself included) are already in their second roles, due to problems or changes in circumstances with their first jobs – and, while some of us feel confident about a long-term veterinary career, some are already considering the options for diversification after getting a bit of experience in clinical practice.
Many of us have partners, friends or family in other professions who seem much better off financially, socially and physically that it becomes impossible not to wonder whether the grass is greener elsewhere. While we do have an extraordinarily variable and interesting day job, the stress and poor remuneration compared to other roles makes you wonder whether it’s really worth it.
I look at my friends who work flexible hours and can accrue almost double the amount of holiday time I get by working only a couple of hours extra a week (which vets inevitably do anyway without time in lieu or overtime pay). They can book last minute holidays and take sick days with no questions asked – all without feeling they are putting everyone else under pressure when they do. They are often less qualified (sometimes with no qualifications at all), yet earn more, have far better pension packages, guaranteed pay rises and bonuses.
Yet, some veterinary employers can’t even hoof a contract together within an acceptable time frame.
The good, the bad and the understaffed
Some veterinary employers are on the button; they have realised the way to keep staff is to give them comparable benefits and treat them like humans, not just robots with no life outside work, but unfortunately a lot aren’t.
I appreciate the nature of our work makes it unpredictable, that we do have to work late sometimes, that we can’t all be allowed time off at the same time, and, in some respects, it simply isn’t comparable to some other jobs. But when talking to some of my veterinary friends this weekend, I was genuinely angered at the raw deals some of them seem to be getting, and infuriated some practices still get away with treating professionals this way.
It does seem to be getting better, though – slowly, but surely, the profession is being dragged into the modern way of working, and practices that continue to dig their heels in will soon find themselves without any staff.
As me and my (non-vet) partner sat down for a rare mid-week breakfast together, I made an offhand comment about “having” to vaccinate 15 puppies that day.
“What do you mean ‘have to’?” was his response. “Most people would love that, and you get paid for it.”
I considered this – and, while I’m more of a kitten person than a puppy person, who doesn’t love puppies? It‘s the little things like this we, perhaps, take for granted.
Sharing the joy
All too often, as vets, we focus on the negatives: the long hours, on call, the stress of trying to keep to time when everything goes belly up, the emotional strain, the difficult clients, surgical complications, mystery cases with unanswered questions… the list goes on.
In the midst of it all, while we‘re able to show enthusiasm during the puppy or kitten vaccine consult, sharing the owners’ joy is soon forgotten when it is swiftly followed by a few challenging consults or clients.
At the end of a couple of stressful working weeks (for a number of reasons), I found some peace having formulated a plan for a couple of complicated medical cases and finally convincing a difficult client to get on board with a particular treatment.
It’s easy to get wrapped up in the vet lifestyle – researching cases when you get home at night (and even when you don’t), not being able to sleep because, subconsciously, you’re trying to work out the best course of action for one of your patients.
Rattling off the list of procedures or appointments for the day will just seem the norm to other vets, but take a step back and remove the “vet blinkers” and actually think for moment about what we do.
If you talk to any non-vet friend or family member about your working day, they often show seemingly exaggerated enthusiasm or squeamishness. It’s tempting to brush this off, but it’s usually genuine. From their perspective, our “normal” work can be fascinating.
Everyday heroes
We may not be saving lives in a dramatic fashion every day (or maybe you do), but, as vets, we get to help a number of animals on a daily basis and, as a result, their owners.
This can be done in what feels like the smallest of gestures sometimes; as much as we may resent the notorious anal gland appointment, what that actually involves is giving a poor dog (or cat) almost instantaneous pain relief.
While I don’t think any vet will particularly enjoy an anal gland appointment, my point is to look at the bigger picture: what may be mundane to us does actually make a difference to the individual – our day-to-day routine work is far more interesting than a lot of other jobs.
Let it go
Being a vet is mentally and physically draining at times, but no day is the same and we will always have stories to tell.
So, if you’ve had a bit of a crap week (or haven’t), take a moment to think about what you’ve actually done in the past few days and enjoy the good moments – whether that’s the puppy vaccination or draining the really satisfying cat (or, in my case, cow) abscess. Then think of the clients who have been thankful for your help (even those who don’t show it) and let go of the bad moments in between.
What a month is has been. Surely, August 2018 will go down in the annals of history as one the most prolific in the fight for animal welfare in England.
From the banning of puppy and kitten sales in pet shops to outlawing electric shock collars, campaigners have had a spate of notable victories to celebrate in a matter of weeks which, it is hoped, will enhance animal welfare and shape a better future for pets and owners alike.
Indeed, such has been the influx of news, we were still filing articles on the day of going to print, to ensure the latest news – the electric collar ban – reached you hot of the press.
But new causes and campaigns are never far away, as evidenced by the fact that, according to some organisations, cats are the latest victims of the public’s “thirst for endless novelty” with RVNs again “ideally placed” to help tackle the issue.
Every little helps
Yet it doesn’t matter if you are fighting on the front line of a campaign trail or caring for a forlorn feline in a small animal practice; every act, every consult and every action is an amazing feat and should be applauded.
You transform the lives of animals and their owners daily, and make their futures a little brighter in the process.
With so much demanded of RVNs, I imagine it could be easy to get a little overwhelmed. In the face of conflict, Second World War politicians sought to raise the British public’s morale with the ”Keep Calm and Carry On” posters. They seemed to work. Sound, and still relevant, advice methinks.
If animals could speak – from kittens in clinic to rescued horses – I am think they would say “thank you” for all your hard work. Which is what I want to say too, as it happens.
Whoever you are and whatever you do, keep up the amazing work and (to coin the phrase) keep calm and carry on. When future generations are reflecting on this pivotal time in animal care, you can say with pride “I was there”.
The veterinary community is changing. We are gradually moving towards a world of better work-life balance. Rotas vary massively from practice to practice, and even within practices, depending on particular species bias. One way some practices are adapting rotas is using a seven-day working week.
The knee-jerk reaction is often negative – especially when we consider the seven-day week in relation to the NHS. We’ve witnessed the junior doctor strikes to negotiate better contracts. No doubt, some of us have experienced the NHS staff squeeze first-hand, having been presented with long waiting lists for diagnostics or procedures.
With this in mind, the suggestion of a seven-day week for our human medical counterparts seemed ludicrous in the beginning – if staffing was an issue before, surely aiming to provide more services, such as routine procedures at the weekend, would only worsen the problem?
Be that as it may, the veterinary profession is not the NHS. We are more attributable to private medical services, where work-ups can be done immediately, results reviewed and treatments provided much faster. While we, too, are in the midst of an employment crisis, each practice varies wildly and some remain fully staffed.
Advantage
For adequately staffed practices, the seven-day week can, indeed, be implemented to everyone’s advantage. This doesn’t mean everyone works more, it just means the rota has to be managed differently.
An equine practice I’m aware of runs this rota. To my knowledge, the way it is implemented is some vets work alternate weeks – that is, seven days “on” and seven days “off” – while others work four days “on” and four days “off” in turn. Weekends are treated as a normal working day, so there are no more “weekends on call”, and the nights on duty are simply distributed within each vet’s working days. As you can appreciate, this means, for some staff, the days off are constantly shifting.
This is just one example of how the seven-day working week can be implemented, and, ultimately, results in more availability for clients and more time off for the vets. However, this sort of rota would not necessarily work in all practices or fit in with all lifestyles. The workload would have to be sufficient to make it economically viable to treat weekends as normal days and the staff would have to assess whether this sort of rota would work for them.
Many people value the traditional weekend, because it fits with non-vet partners’ working weeks, family or other weekend commitments, which is the main barrier to the introduction of this sort of service on a nationwide scale.
The seven-day week doesn’t mean working seven days a week, every week. It simply means providing normal daytime services to the client seven days a week, with vets slotted into working hours accordingly.
In a stressful professional work environment – taking into consideration on-call work and the 5:30pm pyometra surgery that keeps you working well beyond your alleged finish time – forward-thinking practices should be allowing their “full-time” vets adequate downtime: be that time off in lieu, a four-day working week as standard, and flexible working patterns or shifts, opposed to the traditional 11-hour days. Numerous ways exist to implement a better work-life balance, with the seven-day week being one of them.
Retention solution?
With the staff retention problem in the profession, it is imperative those practices still dragging their heels and working their vets into the ground take on board these ideas, and change their rotas for the better.
Likewise, vets are struggling with their mind-bogglingly old-fashioned rotas should not stand for them – there are better options. If vets start voting with their feet, eventually, those workplaces stuck in the past, will have to adapt, otherwise they will find themselves even shorter of staff.
