Intern for a week

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Thurs Jul 9, 2009

Dad and I woke up at 4:30 to get me to the airport on time. Even so, I nearly missed my flight. My pocket knife was still in my purse, unbeknownst to me, and so I set off the security. In the end, I had to pay some ungodly figure to mail the thing home and made it to the gate just as the attendant began paging me. However, I made it to Cincinnatti without further mishap and met up with my cousin, Jess Claudio. It was good to catch up with her: she had driven down to Cinci over the course of several days, staying with friends from school, and we were both excited to be heading off.
Rob Kaderly picked us up in Fort Myers, took us to his home to change into our scrubs, and rushed us off to his clinic. We got a quick tour. The clinic has two operating rooms off of the surgical prep room. The SP room is equipped with recovery cages, anesthesia, laundry facilities (for the reusable cloth) and autoclaves for the reusable metal and rubber bits. Also off of the prep room is the kitchen, Gayle’s office, an dthe employee bathroom. A hall connects this half with the other side, which includes the kennel, blood-lab station, three exam rooms, the supply rooms, and the front waiting area. Off of the hall previously mentioned is also the radiology room and developing machine. We met the two techs/cleaning crew/receptionists, Jen and Chrissy. Not long after our arrival, we watched our first surgery.
A little yorkie had medial patellar lexation (MPL), which meant that her kneecaps slid out of their tracks and no longer maintained its protective position over the joint. In addition, the sliding caps wore down the cartilage and could cause other issues. The surgery we watched Dr. Kaderly perform involved loosening a small piece of bone, to which the offending tendon was attached. The loosened bone would then be pivoted and pinned into place, taking the tendon and kneecap with it. Finally, the groove through which the patella is supposed to slide had to be deepened.
We watched little Daisy put under anesthesia with a breathing tube. It would become my job to monitor this, so I will explain now. The anesthesia is highly volatile isoflurane, which is picked up by oxygen that flows across it and down the breathing tube. The amount of anesthesia can be set to anywhere between 0 and 5%, and so the dial is accordingly numbered off-5. If the dogs heart rate (HR) and respiration rate (RR) begin to increase, it is an indication that it is coming out of anesthesia, and if these rates decrease too much, it is an indication that the dog is too deep. Additionally, and ECG (like an EKG) is set up within the operating room. While not particularly accurate (movement and cautery tools will through it off, as well as the placement of the skin clamps), I’m sure it can come in handy to an experienced doctor. Finally, the dissolved oxygen content of the dog’s breath was measured with a tongue clamp. I don’t know exactly what this does, but I have a feeling it is used to double check the anesthesia machine, if need be.
The surgery was fascinating. THe site was shaved, scrubbed twice in the prep room and once in the surgery with chlorohexane and 70% alcohol, and then the incisions were made. Blood vessels were cauterized, meaning that this surgery had little blood. First Dr. K cut out a kayak-shape section of cartilage, then a matching section of the bone underneath. Finally, he replaced the cartilage, which made the groove deeper while still allowing the patella to slide on the lubricated upper surface. Interestingly, he didn’t have to pin the cartilage into place, as the pressure of the knee locks it into place. Next, he pried the small piece of bone connected to the tendon and rotated it into place, finally drilling a small pin through the piece and down into the far outer cortex of the leg bone. He stitched the site up and did the same to the other leg. We then took final x-rays of the dog’s legs, took her out of anesthesia, removed the breathing tube, and put her in the kennel to recover. Griffin, the Kaderly’s sweet little pug, whined at our heels until Jen picked him up and allowed him to nudge and lick Daisy out of her sleep.
We then cleaned up and Jen showed us the proper way. Most of the metal instruments were first washed and scrubbed in soapy water, then dropped into “milk” and sterilized in X . Gowns were folded in a certain manner, and rubber tubes, bandages, swabs, some of the tools, and the k-pins were bagged. The drill set and the other tools were wrapped in two layers of surgical drape with accordion folds (to ensure that the surgeon’s hands are the only hands to touch the final wrap after it has been sterilized) and held tight with indicator tape. All of these were then put into the autoclave on the appropriate settings.
After surgery, Gayle made us a delicious spaghetti dinner with wonderful white wine ( ) and then Jess and I walked to Miromar Outlet mall. We talked most of the time, but we did stop at Godiva, flirted with the guy on staff, and bought the Kaderly’s a box of truffles. We came home rather late, and I hope we did not offend, but it was nice to have some girl time with Jess.
Fri July 10
Today we begin learning the day-to-day routine of the office. There are no surgeries scheduled, so we help clean and get both Daisy and Belle (a lab who had had hip replacement) ready to go home. Daisy’s mom, an RN, came in and told me their story. Evidently, she had had hard luck with her last boyfriend— she quit her job and moved for him, but he turned out to be a raging alcoholic, and so she suffered for a year with no friend but her little dog. I told her repeatedly that Daisy was a trooper and was doing well. I also learned a little about Chrissy, who has an 18 month old, Italian greyhounds, and a boyfriend. She used to work at a grocery store and somewhere else before this job, and she certainly is good with people. Gayle later told us that Chrissy had been a top tech, picking things up quickly and doing well in surgery, but after giving birth to her little boy, she and Rob have not been pleased with her performance.
Because the day was so slow, we left at lunch and the Kaderly’s dropped us off at Coconut Grove Mall. We ate Chinese and then we visited a store with fabulous clothes, Guess by Marciano. I found a dress that I loved, but it was much too expensive. We window-shopped our way to Dillards, where the MAC representative did our makeup. Jess got some eyeliner, and I have my eye on the “paint pots” a sort of eyecolor base that I would like when I have more to spend on beauty. We then made our way to Target and got disposable cameras— we had a plan for these. We went to Ross (Dress for Less) and grabbed an armload of dresses each. We did a fashion show/photo shoot back in the dressing rooms, and I ended up buying one, a classy green affair that was very simple yet very feminine. Rob picked us up with the news that we had a surprise surgery. A Chihuahua had broken all four toes of its front right paw and the vet had “dumped” her on the Kaderly’s an hour before closing.
We prepped the dog as before, going through the ritual of general tranquilizer and meds through IV, then anesthesia through the breathing tube. The paw was completely shaved (it was bruised and obviously caused her great pain, as her heart rate increased every time they touched it) and the three disinfection wipes were performed. The surgery was tedious and difficult (and my feet hurt like the Dickens). It was my job to monitor anesthesia, so I had a great view, but also an important task. Gizmo’s HR and RR were all over the place, and they would often jump twenty or thirty points, only to level out a moment later. I announced when major changes were taking place and Dr. K or Chrissy told me whether I should adjust anesthesia. The surgery itself involved putting pins through the broken bones to realign them while they healed— these pins would later be removed. While this sounds simple, in reality it was very complex, and a less able surgeon wouldn’t have been able to do it. The dog was 12 pounds with delicate finger bones— think the size of a coffee stirrer. The stiffer, larger K-pins were too big, and so Dr. K had to use the smallest pins, but these flexed a good deal and so were difficult to drill into place. Additionally, the space in the dogs bones that was meant to hold the pins was too small, so Dr. K had to hollow out a place before he could place the pins. In the end, he was only able to place pins in the two center fractures, as the other two bones were too small. This did, however, serve to align all four fractures more closely (as the post x-ray showed). Dr. K put on several layers of cotton gauze bandage and then soaked the cast material—fiberglass— in water and bandaged it. After the hard cast had set, he cut the fiber glass down its meridians, explaining that this would allow them to remove the pins and stitches and work with the dog’s leg without taking a noisy power tool to it while the dog was awake. He then taped the two halves together again and we brought the dog out of anesthesia. Another feature of the cast was that it did not have the bottom of the toes bound— evidently, dog’s have sweat glands on their paws and so the bottom is left upon so that moisture does not build up and cause irritation or infection.
Tonight we had hotdogs (veggie burger for Jess), a lovely blueberry salad, and sweet potatoe fries. These were great— Gayle simply wedged and chipped sweet potatoes, put them to bake in oil in a 400 degree oven, and sprinkled Vietnamese cinnamon on top. After this, we watched Rob’s favorite movie, Best of Show, which was a stitch. It essentially follows (and satirizes) the contestants of the West Minister Dog Show.
Sat July 11
We started at the office today, attending Gayle as she released Gizmo to her family. We watched her brief them on the medication schedule and care of the cast. Dr. K then came in and told them about the surgery itself and showed them the x-rays. Jess and I helped wipe things down and get the laundry going, but there was not much to do. The Kaderly’s then did some errands, dropping us successively at Walmart and the Miromar outlets. Jess got the work clothes that she needed and we both bought breakfast food and lunch items so the Kaderly’s wouldn’t have to feed us every meal. At Miromar, Jess and I haggled at Access, this fabulous jewelry store. I asked if the pearl necklace I wanted would be on sale before Friday, and the girl working said she could sell it to me half off right then. Jess got her sunglasses for three quarters their original price. We wandered around some, then went home, ate, swam and got ready for Gayle and Rob’s party.
They had invited their neighbors, Susan and Jerry, over to meet us. It started to rain, heavily, but they came as soon as it had abated, bring with them their margarita machine. THye have a wonderful recipe— a can (6 oz) of lime juice, a can of beer (normal), half a can of triple sec (3 oz), half a can of tequila, and, of course the ice and the salt. Rob grilled cheeseburgers, Gayle served up potato salad, deviled eggs, and baked beans, and desert was icecream sundaes and coffee. I can’t eat icecream, so I tried the coffee so that our hosts would not feel bad, but it was straight up decaf and I couldn’t do it. Later that night, Taylor called, and then Jess and I had a long talk about boys and life.
Sun July 12, 2009
We were lazy, bourgeois, sun-bathing ladies today. We spent most of our time by the pool reading and soaking in the sun. I am reading Wild Swans, a wonderful account of communist China. Before our relaxing afternoon, we drove out to Coconut Mall with Susan to see a craft show. It turned out that it was nothing but a pricey food event, so we hit TJ Max, where I got a second dress, and then returned home to veg. In the evening, we had California pizza and wine and watched Wild Hogs.
Mon July 13, 2009
Today began slowly, with Jess, Jen and I splitting the few chores we hadn’t accomplished last week. Dr. K made us a list of radiographs (the proper term for x-rays) and so we pulled those out to examine the various cases. We made our guesses and took notes about each one, also pulling up some of the computer files to examine the notes there. After this, Dr. K explained each one to us. We did lunch at Chic-fil-a with Jen and listened to Michael Jackson on the drive back.
We had thought that we would go home after this, as there were no patients, but upon arrival we learned that there might be a surgery for us to attend. A little doxin named Casper had a herniated disk between T13 and L1 (thoracic= abdomen, lumbar=tail end). We x-rayed and did blood work while the family digested the estimate. The first half of the procedure was called a myelogram, in which Dr. K had to slip a needle into the dura mater (outside cover of the spinal cord) and inject a dye. We then x-rayed the dog; the dye flowed through the spinal fluid and clearly outlined where the cord was pressed to one side by the disk. The family gave the go ahead and we prepped the dog for surgery, now armed with the knowledge of where the problem was.
Nearly all of the animal’s back was shaved. I helped prep it by holding it down to have blood drawn and the catheter placed, but I kept getting in the way of Dr. K. In surgery, they performed a left hemilaminectomy (removed the left half of the dorsal side of the two relevant vertebra) in order to get to the dog’s spinal cord. The cord itself was a small white line, no bigger than a thin yarn, that was tucked into the center of the vertebrae. Surrounding the cord, though, was white chunky matter that looked like toothpaste. This was the encroaching disk, and there was a lot of it. Dr. K removed the matter, showing Jess and I the relevant details. He later explained that the disks sat between each vertebra and acted as a shock absorber. These disks are rather like jelly donuts— there is a fibrous outer shell and a jelly-like interior. One end of these outer shells is always thinner and more prone to weakening and tearing— when a tear happens, the jelly oozes out and crowds the spinal column, leading to pain and paralysis. Poor little Casper had had his condition since March, and we were discouraged to note that his cord did not immediately resume its normal dimensions. Dr. K removed a strip of fat and placed it into the void left by the removed bone— it will never be replaced— and sewed him up. Upon bringing him out of surgery, Casper vomited and defecated, showing that his family had given him breakfast. The breathing tube was quickly removed and he was cleaned out so that he wouldn’t choke, set on some heated rice socks, and covered with a towel. He will stay with us for two days.
We went about our usual routine of cleaning the tools and the new routine of cleaning the floor. After tidying up, we headed home to some leftovers and clean laundry. We ran some errands, including checking my labtop for viruses, and then Jess and I took a walk. We talked late tonight.
Tues July 14, 2009
I woke early, as usual, to shower and to write. At the office we did a few housekeeping chores and packed instruments into the autoclaves. Gayle showed us how the computer system worked and printed out employee handbooks for us, so that we would have an idea of the business aspect of it. Her way with people continues to impress me; whether she is turning out a salesman, dealing with a client, or speaking to a friend, she is sincere and helpful. When Jen came in, she taught us how to dress “closed glove”, meaning that our hands, arms, gowns, and gloves remain sterile. Essentially, you cap and mask, and then wash your hands, starting from the fingers and moving towards your elbow. You should not finish before you end three rounds of “happy birthday”. After this, you dry your hands and arms thoroughly, carefully push your arms into your robe, but keep your fingertips inside the sleeves. Without freeing your fingers, you use your sleeved thumbs to pull on first one glove and then the other, taking care to keep your sleeves under your gloves. We had little to do but pet Casper, who will be here until tomorrow, and chat with Jen, who I like more and more. She told us today of the murder of one of her good friends, and how she believes that friend is her guardian angel, and that of her nephew in Iraq.
Later, Gayle made Jess and I triple cheese sandwiches and a delicious salad. She and Rob headed across the street to a dinner party, leaving us to entertain ourselves. I read, Jess napped, and then we did some weeding. We talked some more, and Jess remarked that Jen’s guardian angel statement really touched her. I am in a pensive, but relaxed mood tonight.
Weds July 15
It was another quiet day at the office today. We spent our time cleaning, purging old files from charts, and reading Rob’s medical books. Our surgery for today, a cat with a pelvic fracture, was cancelled because the animal had been euthanized. Despite this, Jess and I found some very interesting things in the books. For instance, I searched out pelvic problems and learned about the anatomy of and repairs to the pelvis. I also learned about the cranial crucial ligament (ACL in animals) and common problems with that. It struck me that Sandy’s lameness bears distinct similarities to each of the described symptoms, and I wonder whether it is just arthritis that keeps her down. I also read through an atlas of common medical injuries, which gave me a good appreciation of basic anatomy and a rundown of the most common problems. Jess spent her time researching what various drugs were used for, their MO, and potential side effects. Gayle came in and gave us a rundown of savings and retirement plans, and she had some good sound advice. As soon as I have a steady job, I mean to put away part of my monthly earnings into a designated retirement account.
Around lunch, Rob dropped us off at a local thrift store. Jess got two cute dresses, two pairs of pants (one of which is psychedelic) and a reversible hat. I bought a calphelon skillet, a hand mixer, and a hand painted bamboo plate for less than ten dollars. We called Rob to pick us up— Jess wore her crazy paisley hippie corduroys and got a surprised laugh out of Rob and Gayle— and we got ready for a second surgery that also didn’t happen. The man wanted to wait a week to repair his dog’s MPL so that he could stay home with it. Thus, we left without a surgery again today. Gayle made us chicken, sweet potato fries, and a salad with her fabulous muzerella balls and we had watermelon for dessert. Jess and I tried to work out, but the building was closed, so Gayle drove us to Miromar outlet. We stopped by at the Godiva store where the guy was working again. I flirted a bit with him, and he gave us a free piece of chocolate— really good dried apricot dipped in white chocolate. We wandered around until closing, then went across the street to check out the strip on the other side. Jess got hot fries and we passed the Godiva guy in his car. Finally, we returned home.
Thurs July 16
We began with some light cleaning. Jess curled up with a veterinary reference book of doctor Kaderly’s. I spent some time reading, especially looking at degenerative joint disorder (arthritis), sutures, blood components, and bandaging. I thought the bandaging was especially interesting; you usually use three layers— the first is usually a loose weave that allows the wound to seep. This can be either adhesive or non. The second provides pressure, support, and is absorbant and porous enough to get fluids away from the wound. The third also provides support and protection, but seepage should never reach it, because that provides access to bacteria. They talked about proper application of wet bandages, dry bandages, and pressure bandages.
We also had a number of patients. We put in a new nylon cranial cruciate ligament (ACL) into the knee of a westie, performed a bilateral MPL on a Chihuahua, and put a cast on a radial/ulnar fracture in a toy poodle. We had chicken nuggets, red cabbage/blue cheese coleslaw, and Rita’s ice. I had the mango, very good! Jess and I then cruised through Charlotte Russe and Rue 21, and I got a fun skirt and a flattering jacket thing. When we returned, I had the harrowing task of trying to fit everything into my suitcase.
Fri July 17
This morning, we finished packing all of our belongings and went to work. From the moment we arrived, it was just barely organized chaos. THe phones were ringing off the hook, there were numerous check ups that Jen (the only tech in today) had to deal with, and Jess and I did the best we could to stay out of the way. There was a cat that needed a bandage replaced and a three legged pit that needed radiographs interpreted. We fixed the mandible of a cat that had gotten into a fight with a pit bull (that cat was angry) and performed back surgery on a doxen that ended up having three slipped disks. All I can say of today is that it was intense. After taking pictures and changing out of our scrubs, we grabbed our stuff and headed off to the airport. Jess and I had the same flight back, but different seats. We chatted before and said goodbye after the flight, and then I began the second leg of my journey, from Cinci to Cleveland. It was a frustrating trip, but I am home now, with wonderful memories and a heart full of gratitude.

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