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Tag: exams

  • Triage, pt 2: secondary survey

    Triage, pt 2: secondary survey

    Secondary survey refers to the detailed physical examination performed after the primary survey, and should only be performed once the patient has been adequately stabilised.

    It is always important to perform physical examinations systematically to avoid overlooking organ systems. This could be difficult in a stressful emergency situation, so one way to remind yourself is with the following acronym:

    A CRASH PLAN

    A – Airway

    • respiratory pattern
    • airway patency

    C – Cardiovascular

    • circulation
    • heart sounds
    • pulses
    • capillary refill time

    R – Respiratory

    • respiratory sounds
    • bruising
    • external wounds to chest

    A – Abdomen

    • palpation
    • bruising
    • external wounds
    • fast ultrasound:
      • abdomen:
        • free fluid (diaphragmatic-hepatic site, splenorenal site, cysto-colic site, hepatorenal site)
        • bladder integrity
      • thorax (do this at the same time as assessing the abdominal cavity):
        • ensure you do both left and right sides
        • chest tube site
        • pericardial site
        • wet/dry/third space

    S – Spine and tail

    • gait and posture
    • pain sensation
    • crepitus

    H – Head

    • mentation
    • cognitive function
    • cranial nerves
    • external wounds/bruising
    • eyes – including symmetry, third eyelids, eye position, haemorrhage and detailed ophthalmological examination
    • ears
    • nose
    CPR
    The secondary survey will help identify any concurrent problems not seen on the primary survey.

    P – Pelvis

    • wounds
    • bruising
    • pain
    • cepitus
    • perineum
    • external genitalia

    L – Limbs

    • deformities
    • fractures
    • pain
    • bruising
    • wounds
    • weight bearing vs non-weight bearing

    A – Arteries

    • all accessible superficial arteries – pulses and pressure

    N – Nerves

    • mentation
    • cranial nerves
    • conscious proprioception
    • postural reflexes
    • peripheral spinal reflexes
    • withdrawal reflexes
    • deep pain
    • cutaneous trunci reflex
    • anal tone

    Stable patient

    By following the primary and secondary triage processes consistently, you should be able to quickly determine the order of criticalness of patients, institute appropriate resuscitative measures and manage life-threatening injuries. Then, with your thorough physical examination, identify any other concurrent problems not seen on the primary survey.

    Overall, you have a stable patient, and are able to formulate an appropriate diagnostic and treatment plan.

  • Urinalysis: the neglected test

    Urinalysis: the neglected test

    Urinalysis is an important diagnostic tool in veterinary practice. It is indicated for any patient that presents with polyuria or urinary tract signs, but also a necessary test to perform in conjunction with serum biochemistry.

    Urinalysis
    Urine sediment exams on Christmas day.

    Why do some clinicians fail to perform urinalyses even when they are indicated?

    Reasons include:

    • clinicians not seeing the importance of obtaining a urine sample
    • the difficulty of obtaining a sample in some situations (the patient may not want to void)
    • no access to an ultrasound for a guided cystocentesis
    • patients not urinating upon bladder expression

    Make it a priority

    However, it is important clinicians make obtaining a urine sample a priority. Where possible, a sterile sample of urine using ultrasound-guided cystocentesis is recommended, especially when there is a possibility the urine may be sent to an external lab for culture and sensitivity.

    For example, we’ve all been in situations were you start a patient on IV fluids only to find an azotemia on blood tests. Now you can’t determine whether it’s a pre-renal or renal cause, as you don’t have a pre-IV fluid urine sample.

    Also it would be best to avoid the situation where you have run all other tests available on an ill patient only to find the answer lay in that urinalysis you did not collect earlier.

  • 5 things I would tell my vet school self, part 1

    5 things I would tell my vet school self, part 1

    We all sometimes wish we could go back in time or redo some situations. Often, when looking back with hindsight and more life experience, we wish we could have done things a little differently, or focused our time and energy in a better way.

    I have been reflecting and, while I am incredibly proud of what I have achieved and where my journey has brought me, I have five things I would say to the young Gerardo Poli about to start university. Here is the first:

    Signalment

    When I was writing my study notes at university in preparation for my exams, I don’t recall writing down a lot about the typical signalment for different diseases. At the time I couldn’t see the relevance, nor importance, of it – especially when so many more pathophysiologies were waiting to be memorised.

    Fast forward a few years when I started working, and the first thing I want to know – even before I lay eyes on the patient – is its signalment. It is the one crucial clue that helps me narrow down a long list of differential diagnoses and, from there, help develop a diagnostic plan.

    Starter for 10

    Signalment can be so telling in some cases that my colleagues and I will often guess what the patient presented for.

    For example, a young Labrador retriever that presents with protracted vomiting is most likely going to be an intestinal foreign body, until proven otherwise, while a geriatric cavalier King Charles spaniel with dyspnoea is likely in congestive heart failure, secondary to its genetically predisposed mitral valve disease.

    Obviously, just knowing the signalment isn’t everything to reaching a diagnosis, but it gives you a place to start.

    With age comes wisdom

    The difference between an experienced and inexperienced vet is the former is a lot more familiar with the types of disease and illness a particular demographic of patients is predisposed to, whereas the latter is not.

    My advice is to read up on as many clinical cases as you can, and don’t forget to look at the patient’s signalment.

  • Tips for new graduates, part 2

    Tips for new graduates, part 2

    Following on from last week’s tips for new graduates, here are my final two tips that resonate the most with me in my practice and as a coach. I hope they help with transitioning into practice.

    Systematic approach

    In my role as a mentor and coach, one of the most important concepts I instil or emphasise is a systematic approach. Develop a step-by-step process that allows you to look at everything – it’s not only important for finding abnormalities, but it’s the only way you will get used to what looks and feels normal.

    This applies to physical examinations, ultrasound, radiograph and laboratory result interpretation, even when developing a diagnostic pathway.

    Some may think this is only for new graduates, but it is still crucial for experienced vets who rely on a pattern matching approach, as they can miss diseases by not considering other possibilities.

    Be coachable

    Some people, once they have graduated, want to prove themselves and demonstrate they know it all, they are not just another grad and have earned their place.

    In my experience as a coach and mentor, a humble graduate is more valuable and will learn faster than the ones trying to prove themselves and showing they don’t need support. It is actually concerning for me when new vets don’t ask for help or advice.

    Asking for help isn’t a sign of weakness or lack of knowledge; for me it’s a positive sign that someone is open, wants to be at their best and wants to be part of the team. It gives me real satisfaction to see graduates do things they never thought they could do. So, work together with your team of nurses and experienced vets, and never stop learning and asking for advice or guidance.

    The veterinary world is a profession I am proud of, and super passionate about – I cannot wait to see the future of this profession, and the impact every new graduate will make.

  • Crossing the finish line

    Crossing the finish line

    Finishing vet school feels like the end of a race I’ve been running for more than a decade. I don’t remember when exactly I started running it, or if there was ever even a conscious starting point, but it’s incredibly surreal to get to the end of such a long journey – and I’m still suffering with a heavy dose of denial.

    When will it feel real? When I don my cap and gown? When I first sign my name as “Dr”? Or when I walk in for my first day at work?

    The past few months have been both a whirlwind and an anticlimax all at once. There is nothing like stepping out of those final exams, feeling like the gazelles and giraffes blinking at the rising sun in the first scene in The Lion King – except far less magnificent and far more bedraggled because we truly had forgotten what sunlight was.

    Time to go

    Packing up my last ever student digs was also an emotional experience that felt more akin to dismantling an entire chapter of my life than simply packing boxes.

    Flatmates
    Eleanor Goad (centre) with her “comrades-in-arms”.

    I remembered standing in my bedroom two years earlier thinking how weird it would be to leave this house one day a real, qualified vet. I’d like to go back to past me and let her know she was wrong – it is so, SO much weirder!

    When one door closes…

    Image © elightshow / depositphotos.com

    It’s hard to be sad, however, when the end of university life opens far more doors than it closes.

    If I’m honest, I’ve always felt quietly smug for knowing what I wanted to do with my life since I could draw my first rudimentary cow. Up until this point I’ve been guided down a predetermined path of hurdles in order to achieve a particular goal. Now, rather abruptly, there’s nobody telling me where to go or what to do with my time.

    Where do I work? Where do I live? Do I specialise, or just get my feet on firm ground first? It seems very strange to me that a decision I made so early in life has since dictated every decision I have ever made up to this point, and I’m only now gaining true autonomy in my mid-20s.

    Brand new me

    Looking back, I’m a very different person to who I was six years ago (and yes, I did go out of my way to make the course unnecessarily long), but there are about as many things I’m grateful for in that time:

    My peers

    Not that I should really call them that because, after vet school, they’re more like my comrades-in-arms.

    There are a couple of friends in particular who got me through this intense roller coaster of a course, and from late night study sessions to a constant supply of baked goods, I will be eternally grateful to them for keeping me sane (as much as was possible).

    READ: You’ve got a friend in me

    Family

    I know how grateful I’ve been to have a place to go for home cooked Sunday dinners; comfort on the other end of the telephone at all hours of the day or night.

    • Mum: thank you for the monthly post cards.
    • Dad: thank you for the six-hour round trips to bring me home for those aforementioned Sunday dinners.

    READ: Thank you for everything so far

    Interns and residents

    Obviously, it goes without saying that I’m immensely grateful to all of the university staff for the work they do, but some amazing interns and residents at Langford got me through this last year of rotations. They represent a bridge between where you’ll soon be and the “god tier” level of an attending that seems completely unobtainable – which does wonders for the ol’ impostor syndrome.

    Quizlet

    Praise be. (Need I say more?)

    My poor cat

    For putting up with the constant, uninvited clinical exams.

    Me

    Or, at least, the younger version of myself who didn’t get too scared to put her running shoes on: we did it!

  • Tips for new graduates, part 1

    Tips for new graduates, part 1

    A date I will never forget is 6 June. Four years previously on that day I completed the final exam of my master’s degree, marking 11 long and tough years of study.

    I vowed at that point to never study again, although my love of learning didn’t allow that to last long.

    Then it was crunch and career decision time – which, for a new graduate, is exciting, but also causes anxiety.

    I have learned a great deal in my time since, so for all those students who recently completed their studies, firstly, congratulations and, secondly, over the next two weeks I have some tips that will help with the transition into being a new grad.

    Finding your first clinic

    Mentorpic
    Does the clinic you are considering working for offer an appropriate mentoring and structured learning?

    Don’t put too much pressure on yourself to find the best fit and perfect place, or overthink the process – you are just starting out and it’s likely your focus, passion and direction will change as your career progresses.

    Merits in waiting exist for a practice that fits with your wants and needs, but don’t wait forever as you need to start putting your theory into practice.

    I think the most important aspect to look at is the team. A practice with an amazing supportive team would be a wiser option compared to a practice with all the bells and whistles.

    The next thing would be do they offer an appropriate level of mentoring and structured learning?

    Ask if they have trained vets and new grads before, and do they have training and learning resources available to guide your learning?

    Perspective

    Days will occur where you make mistakes and feel as though you haven’t done a good job. It’s important to be able to put things into perspective – remember, everyone makes mistakes.

    I still have days where I feel like I’ve failed. It’s vital you can be clear that you may fail at a task or moment, but that doesn’t mean you’re a failure.

    If you have a bad morning, don’t generalise it into a bad day or bad week. It shows much more passion, talent and character to learn and grow from a mistake.

    Being a vet – especially in emergency – you have to learn to be able to stop, let go and reset a number of times each day so you are fully present for what comes next.

    Understanding perspective on bad days, and asking what can you learn from this, is a skill that takes time to master, but is one that will help you a great deal in your veterinary journey.

    Next week I will cover more tips when considering your first practice and starting your first role.

  • Life after vet school – graduation: where do I go from here?

    Life after vet school – graduation: where do I go from here?

    Nothing hits you quite as hard as reality, as you walk out of your final fifth year veterinary exam.

    Up until this very moment, your life has followed a structured timetable, carefully planned by the veterinary school. Now, with it all finished, who is there to lead you from here onwards? This is probably the most daunting question every final year vet student faces. University lecturers can only help you get so far, then you’re on your own.

    Forging your own path

    For those of us who are lucky enough to know exactly what they want in life, the path is quite clear. As the saying goes, “where there is a will, there is a way” – and it doesn’t get more true than that, for the rest the path is unclear, and there is uncertainty and doubt.

    In this post I share my thoughts about the three main options that for new graduates: general practice, rotation internships and emergency internships.

    General practice

    • Great at putting the last five or six years of learning into perspective, it will solidify what you have learned.
    • After one to two years you will have something to fall back on if you decide to try something else later.
    • You will have primary case control this will allow you to develop and fine tune your communication, medical and surgical skills.
    • The more remote the general practice, the likelihood you will be required to perform more advanced or complex diagnostic, medical and surgical procedures increases; therefore, the learning curve will be steeper.

    Generally, this is a good place to start, especially if you are uncertain as to what direction you want to head in. I started here. My only caveat is that you select a practice you feel best suits you and offers the best environment for learning.

    Rotating internships at specialist hospitals/referral centres

    Gerardo Poli during his graduation.
    Gerardo Poli during his graduation.

    Some new graduates go straight into rotating internships because of the opportunity to see a variety of cases and also because they wish to proceed down the pathway to specialisation.

    • Generally limited primary case responsibility as you will be following and assisting a specialist or registrar.
    • Offers the best exposure and foot in the door for a career as a specialist.
    • Exposure to a wide variety of complicated cases.
    • Opportunity to be involved in and possibly perform complex diagnostic, medical and surgical procedures.
    • Build connections and network within the specialist or referral community.
    • Most only last one year before a new pool of interns come through.

    If you have experienced general practice and you know it is not for you then a rotating internship at a specialist referral hospital will allow you to get a taste of what is available.

    Emergency internships

    I do not generally recommend emergency internships to new graduates, despite the fact I have developed training programs to assist in the transition into emergency and critical care. There are large emergency practices part of a specialist referral centres and small centres running within a general practice hospital, but not all emergency hospitals offer internships.

    Before deciding, here is what you need to know:

    • It has t best opportunity for a softer entry into an emergency career.
    • Generally prior experience is recommended as it can be a very steep learning curve.
    • The abnormal hours can be isolating socially and adjusting sleeping patterns can be difficult.
    • Most emergency internships are designed to retain interns not rotate them through, such as they “train to keep”.
    • You will get primary case control and exposure to more critically ill patients.
    • Depending on the type of practice and the arrangement you may get to perform more complex diagnostic, medical and surgical procedures as opposed to referring them to the associated specialist service.

    If you are looking at a career in emergency I would recommend a larger hospital where multiple vets are on at the same time and you have the support you need.

    Regardless of where you find yourself, the most important thing to realise is you have to start somewhere. Decide and take action. If you find yourself doing something you don’t like then you have learned what you don’t want to do. That is a valuable learning experience in itself. There are many ways to a destination, and no experience, whether it is good or bad, it is never wasted. Even in the darkest of days, remember, with every closed door, if you are looking another will open. Best of luck with all your future endeavours.

  • The revision roller coaster

    The revision roller coaster

    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.

    Image © Anna / Adobe Stock

    Highs and lows

    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.

    Image © Jacob Lund / Adobe Stock

    Stay in control

    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.

  • Are rabbits really ‘exotic’?

    Are rabbits really ‘exotic’?

    According to PDSA [PDSA Animal Wellbeing (PAW) Report 2022], rabbits are the third most popular pet in the UK behind dogs and cats. With an estimated 1.1 million pet rabbits in the country, that’s about about a tenth of the population of pet dogs and cats, which hover around the 9 to 10 million mark.

    So, if the pet ratio of dogs/cats:rabbits is 10:1, why isn’t this reflected in our teaching? Despite rabbit populations being endemic to the UK for more than a thousand years, they always seem to get lumped with guinea pigs and the cold-blooded pets like lizards and corn snakes when it comes to textbooks or university curriculums.

    I can confidently say my education on rabbit physiology and medicine has been dramatically less than 10% of what I’ve received for small animal medicine. Perhaps this is why many vets, especially new or recent graduates, feel more confident handing off any rabbit patients to the resident “expert” of the practice or even referring to an exotics specialist, rather than seeing it themselves.

    Accessibility

    It’s a sad truth that the less convenient education and health care are to access, the less people will reach for them. By extension, the less veterinary practices that advertise care for rabbits (and other exotics), the less rabbits are likely to be registered at a practice and receive regular preventive care.

    For example, as a native to the land of Kent, I only know of two or three practices that would call themselves “exotic specialists” and I know that, for a lot of rabbit owners, traveling half way across the county to visit one of these few practices would not be practical or plausible. Perhaps this is why, according to PDSA reports, at least 11% of pet rabbits receive no preventive health care, including vaccinations.

    rabbit
    Rabbits are a social species that has evolved to live in groups, not alone.

    Education

    The value of a veterinary consultation is not simply to talk through clinical signs or address a flea outbreak in the home, it’s a chance for owners to discuss management issues or to ask for general advice. When rabbits aren’t brought in for routine consultations, then discussions about their diet, husbandry and behavioural needs don’t get to be had.

    Some vets are already worried that the development of an annual rabbit haemorrhagic disease (RHD) booster rather than biannual is going to dramatically reduce rabbit welfare by halving the number of times these pets receive a clinical exam.

    Welfare

    Of course, like all “exotics”, there’s the argument to be made as to whether these animals are suitable pets in the first place. Personally, I feel that this is a moot point for the time being.

    The fact that more than 50% of pet rabbits are housed by themselves with no companionship speaks volumes about the lack of knowledge the general public possesses on how to care for these animals. However, with more than a million of them currently out there, they’re not going away anytime soon.

    The best we can do as professionals is educate our clients so welfare can be maximised as much as possible… and that starts with educating ourselves. I hope that in the near future the landscape of the veterinary degree can shift to better reflect the current demand for exotic vets – or at least rabbit vets.

  • Decision paralysis: how to choose

    Decision paralysis: how to choose

    From the moment you decide to become a vet, the road before you – from the start to the end of your course – is paved with decisions.

    From where to go, to what to look for in a job (although vet students do get to put off the dreaded entrance into the “real world” for a couple more years than the average student), the next choice to be made is always around the corner.

    Where to study

    When it comes to picking the right veterinary degree, my opinion (which is by no means gospel) is that it’s:

    • 10% course content
    • 90% location, location, location

    For students having a tough time choosing where to attend vet school (although, understandably, most are happy to go anywhere they receive an offer), it can be important to look above and beyond the curriculum. After all, the veterinary course in the UK is heavily standardised and, as much as every school wants you to believe that theirs has something special that nobody else’s does (and maybe they do), at the end of the day, you will leave each university with the same qualifications.

    I’m not studying where I am today because I fell in love with Bristol vet school, I fell in love with Bristol itself.

    Clockwise from top left: Bristol Cathedral © SakhanPhotography / Adobe Stock; Bristol’s colourful houses by shauking / Pixabay; sheep © Gill / Adobe Stock; promotional image for Hot Fuzz © Universal Studios / Focus Features.

    I still remember getting off the coach with my dad for an open day and having the biggest smile on my face from the moment I stepped on to the cobbled streets. To this day, I’ve no idea why – perhaps it’s the multi-coloured Balamory-esque buildings, or the accents and calls of “my lover” that made me feel like I’d stumbled into a remake of Hot Fuzz, or maybe it’s the fact there are sheep and cows roaming just a stone’s throw away from the clinical campus.

    Whatever it was, it wasn’t the labs, the course brochures or the lecture theatres…

    For some, staying closer to home is what’s important; maybe for childcare, financial or emotional support. For others, moving away from what is familiar and stepping out of your comfort zone can play a vital part in learning independence and gaining a wider perspective.

    What to study

    Selective/elective weeks, while only making up a small component of your final year, are a rare opportunity to tailor your education in what is otherwise a very nationally homogenised learning infrastructure.

    Work experience is another excellent outlet through which vet students can customise their teaching opportunities and prioritise what is most important to them. Practices where we feel most immediately at home are the ones that reflect our values around the profession, and the teams and individuals we bounce off easily are often indicative of the type of professional that you would/aspire to be.

    Where to work

    With the average retention of a veterinary professional standing depressingly at just seven short years, there’s been a massive drive from the ground up to improve the quality of the profession, and to make the career more mentally and emotionally sustainable.

    We’re taught about developing resilience and mindfulness from the first year of vet school, and in the past half-decade, four-day weeks have become the standard for a lot of vets up and down the country.

    With vets in such high demand, new graduates currently have a plethora of jobs to choose from. Considerations over commute times, staff retention, caseloads, OOH work, and weekend rotas (let alone salaries) are now luxuries that are becoming more and more affordable.

    I would personally love to see a day when vet students can take modules in their final year – and with mixed practices decreasing in number, there may eventually be separate institutions for small animal and large animal vets.

    As somebody soon to be entering the job market, I can tell you that decision paralysis is most certainly real, but I still believe that the more choices we are able to make, and the more control we have over our careers, will make us better and happier professionals.