Have you ever had a puppy that just presents with lethargy, exercise intolerance and sleeps all the time?
This is normal for my teenage daughters, but not so for a young Lhasa apso that presented to my surgery. Physical exam was unremarkable, but the dog was so sleepy we administered IV fluids to perk it up.
Routine biochemistry revealed a low blood urea nitrogen (BUN), and a urine sample demonstrated the presence of urate crystals.
This triggered a request for a bile acid stimulation test, which showed markedly abnormal elevation postprandial levels.
Our diagnosis of hepatic portosystemic shunt was confirmed at Davies Veterinary Specialists and luckily this was shown to be extra hepatic. So, after some very smart surgery, the dog went on to live an energetic life.
Rupture of the cranial cruciate ligament in an English Bulldog by Uwe Gille, licensed under CC-BY-SA-3.0
For dogs weighing less than 15kg, cranial cruciate disease can be managed conservatively – weight loss until an appropriate Body Condition Score (BCS) is achieved, exercise restriction for 3 to 6 weeks, and possibly physical therapy and pain medication – allowing acceptable comfort and function.
In dogs weighing more than 15kg, cruciate disease will eventually cause significant arthritis, and dysfunction is inevitable without surgical treatment.
No single surgical technique is clearly superior, so the choice of surgical repair should be decided by the surgeon and the needs of the owner.
As a student on placement, I’m often in awe of the vets I’m working with. The ability to take a history, examine an animal, run through differentials and come up with a diagnosis or action plan within 10 minutes – all while listening to an owner commenting on the weather or traffic – seems superhuman.
This may seem an exaggeration (after all, vets aren’t superheroes), but when considered like that, it is pretty impressive.
While seemingly intangible at the moment, I know the ability to do this with such ease comes with practice – and clearly some presentations are far more complex than that.
However, while I find this impressive, others have a different opinion…
A family friend recently commented on their own vets, claiming they would avoid seeing the partners if possible because – in their opinion – they see an animal for five minutes and see it as a money making exercise, whereas the younger vets spend a bit more time with the clients.
Obviously I can’t comment on the vet/client rapport, which may have a huge influence on this opinion, but I can’t help but think that a younger, newly qualified vet would spend more time during consultations purely due to experience, or lack thereof.
It has become evident recently that the profession has an image problem and we must try to change that for the better. But what do the public consider as a “good vet”? Apparently the opinion differs depending which side of the table you’re on.
This is just one example, but in general, do clients want the vet to spend more time with their animal? They probably do – but, at the same time, they don’t want to be kept waiting and they want to be able to get an appointment. There has to be a balance between the three.
As for cost, I’ve seen some vets charge meticulously, whereas others would try and keep prices as low as possible to please customers. In the clients’ eyes, the cheaper the better. But a vet practice has to function. It’s no good offering neutering for £10 because the practice would be bankrupt within a week.
“The most highly qualified and experienced surgeon in the practice might not be the best at client communication,” claims Jordan.
Surgical skills and experience are perhaps something that the client will never fully appreciate. For a start, the vet seen in the consultation room may not be the same one who performed the operation, particularly if it’s something fairly routine. Also, the most highly qualified and experienced surgeon in the practice might not be the best at client communication.
A vet can have such a diverse set of skills and knowledge that it is difficult to pinpoint which of these defines a “good vet”. Many vets have certain areas of expertise and will be better than others in certain situations, but not all.
The key to time and money is striking the balance between what the client desires and what is realistic.
Communication, however, doesn’t need to be compromised and can be the difference that alters the client’s opinion. For example, the manner in which an examination is conducted and the attitude of the vet during a 10-minute consult could leave the client feeling rushed, whereas a different vet with a different approach could leave the client with a far more positive impression.
Client opinion is important, but at the end of the day, the welfare of the animal in front of you is your priority, whether or not the client values you highly.
While the profession as a whole should take heed of what clients want, the customer is not necessarily always right, and at the end of the day, it is the welfare of the animal in front of you that should be paramount.
Pyometra in a dog, seen during surgery. The uterus is distended with pus. Image by Joel Mills [GFDL, CC-BY-SA-3.0 or CC-BY-SA-2.5-2.0-1.0], via Wikimedia CommonsLast week I removed one of the largest, most pus-filled uteri from a large breed dog that I have ever seen.
I’m a bit long in the tooth now, but I still found the whole procedure a bit scary given the size and vascularity of the uterus – and this made me reflect on the benefits of early neutering.
We routinely spay bitches in our practice from five months of age with minimal long-term complications, and it’s so much easier.
I am aware that recent research indicates early neutering may have some long-term implications in certain breeds, but the procedure is so much safer in young dogs, and anything that prevents them developing pyometra in later life has got to be an advantage.
As I’ve done quite a few clinical tips now, I thought it would be interesting to ask our receptionists what their top tips from the front line would be.
Sara, one of our excellent branch manager team, says communication is essential. Passing on as much information as possible to the clinical team can sometimes be challenging if presented with a very worried or upset client on the phone.
Sara also says remaining calm is key, and she always does her best to reassure clients and ensure the patient turns up at the right surgery at right time.
Argentinian Tango dance duo German Cornejo and Gisela Galeassi. Image: Fuentes/Fernandez
Before the full force of third year hit, the first week back at vet school started with everyone catching up on tales from their summer holidays.
Before long, it was like we’d never left and the four months of freedom seemed to fade into a distant memory. However, one particular topic of holiday gossip that I have been dwelling on is extramural studies (EMS).
Everyone had undertaken some form of EMS over the summer, whether it was just a week or two, a solid two months, clinical, preclinical, large or small animal – there is a lot of room for variation in our placements, but I was still surprised to hear of how different some of my friends’ experiences had been, despite doing theoretically similar placements.
A number of us had embarked on our first clinical placements, and although we’re all at the same stage of our studies and therefore should be able to get involved during veterinary placements to a similar extent, the truth is somewhat different.
Just among my friends, there were experience levels at both ends of the scale, with some students having been simply told to observe consultations and others being allowed to scrub into surgical procedures.
This wide range of experiences can be attributed to many factors, including:
the veterinary practice
how well the vet knows the student (either from previous experience or length of placement)
how well the staff have judged the student’s knowledge and ability based on stage of the veterinary course
attitude and competency of the vet
the individual student’s skills, experience and attitude
I was advised by a final year student last year to undertake the majority of my clinical EMS at one single practice if possible, because by getting to know the vets well (and vice versa), they’ll be able to judge your level of competency better and encourage you to get more involved. I can now begin to appreciate this advice more, having listened to the anecdotes from my friends.
The practical teaching we receive at vet school is just not enough to be able to adequately develop and refine essential clinical skills that will be needed everyday in general veterinary practice. The solution to this is EMS, and we are constantly being told that we, as students, need to take responsibility for our own learning and ensure that we get the most out of EMS by getting involved. And I whole-heartedly agree – we can’t be spoon-fed forever and need to be proactive in gaining the right type of experience.
However, you could be the most enthusiast student in the world and read up on cases every night, and yet still be very limited in what you are allowed to do. While getting the most out of a placement is up to us, it takes two to tango, and we need the vets’ support too in order to enable us to do this.
I know taking on students and teaching or letting them practice techniques can be time-consuming and inconvenient, but we need to gain experience somehow. At some point during their training, all vets would have had to see practice and learn in the same way, so is it not just a way of giving back to the profession?
I can also appreciate that some people are just not natural teachers (after all we’re training to work in a vet clinic, not a school), but a little bit of patience and some advice can go a whole lot further than just ignoring a student.
It may sometimes be inappropriate for a student to be asking questions or trying things out – in the consultation room in front of the client, for example – but these situations can be fine when approached the right way. I was lucky enough to stand in with vets that would always try and get me to see/hear/feel things. If they found something interesting in the consultation room, they’d always explain to the client that I was a student and ask if they minded me having a look. This seems far more reasonable to me than telling a student they are to observe only.
Another approach I experienced myself was the vet taking the animal to the surgery room to take blood samples and allowing me to perform my own clinical examination (having not actually been in the original consultation).
As mentioned previously, there can be many factors involved in getting a “good” clinical placement. It also depends how busy the surgery is – if there are four clients waiting to see the same vet, it’s understandable for the vet to whizz through them without having much time for questions or explanations (whenever this happened to me, the vet apologised for not explaining, even though she really didn’t need to!).
I have to agree there are advantages to going back to a veterinary practice you know. I did work experience for three years before university at the practice I did my EMS at this summer, and definitely felt welcomed as part of the team, which can be difficult at an entirely new practice.
Yes, it is our responsibility to find the balance between getting involved to gain experience and not interfering with consults, but we also need vets to help us a bit too. Undertaking EMS is the only way we will prepare ourselves for the future, and we’re extremely grateful for the vets that encourage and help us every step of the way (partly why most vet students are pretty good at baking). I think it’s just a case of finding the right practice for both you and the vets you’ll be learning from.
Image by Nancy Wong (Own work) [CC-BY-SA-3.0], via Wikimedia Commons.I find retching cats usually present last thing in an evening surgery, leaving you with that tricky choice of whether to anaesthetise and investigate immediately, or delay until the next morning.
It also seems to be the ones you delay (because they’ve eaten, of course) that do have a grass blade while, more often than not, the ones you investigate there and then don’t.
Anything there?
A young colleague showed me a nifty way of elevating the soft palate with a spay hook, which neatly reveals the presence of grass (or not, as the case may be).
Some careful work with the crocodile forceps and you can usually whip out the offending blade of grass very easily.
A couple of articles have been brought to my attention this week regarding the public perception of vets versus the reality.
When somebody finds out that you want to be a vet or are studying veterinary medicine, there are a few arduous questions that usually follow:
“Is it seven years at university for that?”
“It’s hard to get into isn’t it?”
And, of course:
“Well, vets earn loads of money don’t they?”
Unfortunately, only one of those three assumptions is true. However, those detached from the veterinary world still uphold the perception that vets are rich and set high prices to rip off the unsuspecting public. What these people don’t understand is that a new veterinary graduate can expect to start on a salary of around £20k while working all living hours of the day, plus being on call.
While each individual job varies, the reality is that we can expect to earn very little considering the length of intense training required and the high levels of stress and responsibility that come with the job.
With experience and promotion to more superior roles – such as becoming a partner in a practice – the salary will increase, but often to less than half the average wage of a GP doctor. In general, vets accept this and are highly dedicated to the health of the animal they work with. If they were after a high salary, they’d be better off in a different career field entirely.
But the public can’t be entirely blamed for their own ignorance – I think a lot of the problem lies with the National Health Service…
“There is no NHS for pets, and I think many people would do well to remember this.”
We are blessed with a “free” health service in the UK, but this means those of us outwith the field of human medicine have very little understanding of how much treatments, operations or drugs cost.
Perhaps if people knew how much these things would cost if they had to fund them privately, they’d have a greater appreciation of both the NHS itself and the veterinary care they pay for for their animals. After all, there is no NHS for pets, and I think many people would do well to remember this.
My American friends tell me that clients in the US do seem to have a more grounded understanding of the cost of healthcare and are able to apply this to veterinary care without quite so much complaining.
It’s also worth noting that the money people spend on their animals’ treatments does not go directly into the pocket of the surgeon, but contributes to the cost of anything required for the procedure, including medication, electricity, needles and syringes, catheters, x-ray plates, bedding, food, anaesthetic, licensing… this list goes on – and somewhere at the bottom of that list sit the wages of the hardworking and dedicated vet, who often only receives a grumbling about the expense in “thanks”.
On a recent EMS placement at a small animal veterinary surgery, I witnessed a lot of this grumbling, and sometimes even full blown arguments about cost. Luckily it’s the few clients that are truly grateful and would do anything for their animals that make it all worth it.
I find it highly offensive and disrespectful when I hear remarks that vets are “only in it for the money” because, if that were true, then we are not as intelligent as our education might suggest.
Noel Fitzpatrick runs one of the most advanced veterinary practices in the UK.
In my interview for Glasgow vet school, I was asked the question “how far is too far?”, and recent episodes of The Supervet on TV had me musing on the topic again, particularly as I had used The Bionic Vet as an example in my answer.
At the time I discussed kidney transplants in cats in the US and, in the UK, the inspiring work and pioneering techniques being carried out at Fitzpatrick Referrals.
Arguably the most famous patient of Noel Fitzpatrick’s is Oscar the cat who, after having both back paws cut off by a combine harvester, had prosthetic legs specially engineered and fitted (see video below). Oscar’s surgery was the first of its kind, and a huge step for orthopaedic veterinary medicine worldwide.
While this type of surgery was a world first in cats, prosthetic limbs are not an alien concept in human medicine – and, at a time when the emphasis on “One Health” becomes stronger every day, why shouldn’t routine or even rare human procedures extend their applications to our domestic species too?
But at what point do we say that medical advances are not ethically suitable for animals? A person may have a reasonable quality of life in a wheelchair, but that doesn’t mean a dog with wheels for back legs would. Such a “cart” would dramatically effect the quality of life of cats like Oscar, but his new legs have given him the freedom to continue to “be a cat”.
Each individual case is different, and the benefits and risks of undertaking a new, advanced technique would have to be weighed up accordingly. I don’t believe the point at which we draw the line on “going too far” is set in stone – every case is unique.
Kidney transplants in humans are life saving, and yet not seen in the UK in cats. A cat with kidney failure would gain a lot from a transplant, providing the risk of rejection was reduced to minimal. The ethical issue here lies with the health and welfare of the donor cat and the fact the donor can’t consent to its healthy organ being taken.
Answering the question “how far is too far?”, Stephen King’s classic 1989 film Pet Sematary is available to buy from www.amazon.co.uk
In the US, donors are often cats from rescue shelters and the recipient cat not only gains a new organ, but also an adopted friend who will come to live with them after the surgery. I think this is an excellent compromise on the consent dilemma – both cats get a second chance at life.
But it is not just the ethical question of whether we should perform such surgeries on our pets, we also have to consider the practical aspects of these procedures (i.e whether we could carry them out if we decided it was ethically acceptable).
There will be a limited number of vets with sufficient surgical experience to attempt such innovations, especially if a certain type of procedure has never been attempted in a particular species yet (such as Oscar’s legs). Financial constraints are also extremely relevant – owners that would love to give their animals the chance to receive such surgery if needed may be limited by the cost that comes with them.
Personally, I think the work of the surgeons at Fitzpatrick Referrals is exceptional and a real inspiration to vets across the country. I would love to see the day that treatment options for our animals routinely match those available in human medicine, and really hope the work of Noel and his team encourages those interested in such developments to continue and further research in order to make it a possibility – within ethical limits, of course.
