Alacrity:
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Showing posts with label imaging. Show all posts
Showing posts with label imaging. Show all posts
that estimate seems optimistic:
Oncology technician: "Okay, so the CT is down, but radiology says that the maintenance guy is here and it should be working again in an hour or so."
Alacrity:
Alacrity:
preferences:
Radiology technician: "Dr. Alacrity, do you want both pre- and post-contrast on this dog's thorax?"
Alacrity: "Yes, please."
Radiologist: "You don't need post-contrast on the thorax if it's a met check."
Alacrity: "Dr. [oncologist] prefers it - he thinks it improves sensitivity."
Radiologist: "Based on what publication?"
Alacrity: "None that I know of."
Radiologist: "I see."
Alacrity: "Yes, please."
Radiologist: "You don't need post-contrast on the thorax if it's a met check."
Alacrity: "Dr. [oncologist] prefers it - he thinks it improves sensitivity."
Radiologist: "Based on what publication?"
Alacrity: "None that I know of."
Radiologist: "I see."
orthopedic surgeon, reviewing some radiographs:
surgeon: "Ah, I see the problem. His penis is in his knee."
adventures in imaging:
Student: "What should I write in the box for 'history' on the radiology submission form?"
Technician: "Fucked."
Student: "...uhhhh."
Alacrity: "...or, you could write 'six week history of intermittent lethargy, collapsed this morning, suspect large splenic mass'."
Technician: "Fucked."
Student: "...uhhhh."
Alacrity: "...or, you could write 'six week history of intermittent lethargy, collapsed this morning, suspect large splenic mass'."
in the ICU:
Alacrity, to criticalist: "Okay, so what are your feelings about-"
Criticalist: "I'm a man. I don't have feelings."
Alacrity: "-so, what are your man-feelings about giving contrast if the patient is azotemic?"
Criticalist: "I'm a man. I don't have feelings."
Alacrity: "-so, what are your man-feelings about giving contrast if the patient is azotemic?"
ahhh, university life:
You guys, I'm currently working at a university, and that means:
1) About 85-90% of my work conversations include some permutation of the phrase: "But did you read the paper/study that showed (whatever)?"
Usually this is followed by, "No," which is then followed by "I'll send it to you/print it for you."
2) Everyone is very, very impressed if you can quote the authors when you're quoting a study to prove a point. At this point, I'm just excited if I can remember the study.
3) Stuuuuuuudents! Vet students are awesome. But seriously, you guys:
- Someone may care if you appear to be fire-stormingly fascinated with (whatever rotation you're on), but that person is not me. I know that those of you who are gonna be cow vets are probably about as interested in the intimate details of the canine cutaneous mast cell tumor prognostic panel as I am in the intimate details of synching herd ovulation: not much. You don't have to fake it.
- Don't let anyone make you feel small if you don't know the answer to a question. There is so much to know that you cannot possibly know it all. BUT it totally behooves you to look that shit up and recon with the person who was quizzing you when you DO know the answer.
- Sleep is really, really important. Take advantage of all opportunities to sleep. Sleeping is magical.
4) Ultrasounds take at least 45 minutes, sometimes over an hour. Also, everyone looks at you like it's your fault when the sedation wears off or the patient loses patience.
5) Appointments regularly take 6+ hours. I am not even kidding. If you're bringing your pet to a university for a consult, plan for it to be a day's event.
6) The anesthesia department is absolutely not fucking around. Neither is the ICU staff.
7) Some sort of conference, thesis defense, or guest lecture is always happening. I get e-mails about all of them. Sometimes there is food involved.
8) There are six or seven different on-call schedules for various situations that may happen in the night or over a weekend. They are all posted in different places and are varying degrees of accurate.
9) A parade of work-study students and residents wander by the oncology department at regular intervals. They ask for blood and/or urine samples from particular patients who have diseases that are relevant to their research.
10) There is so much hand sanitizer.
1) About 85-90% of my work conversations include some permutation of the phrase: "But did you read the paper/study that showed (whatever)?"
Usually this is followed by, "No," which is then followed by "I'll send it to you/print it for you."
2) Everyone is very, very impressed if you can quote the authors when you're quoting a study to prove a point. At this point, I'm just excited if I can remember the study.
3) Stuuuuuuudents! Vet students are awesome. But seriously, you guys:
- Someone may care if you appear to be fire-stormingly fascinated with (whatever rotation you're on), but that person is not me. I know that those of you who are gonna be cow vets are probably about as interested in the intimate details of the canine cutaneous mast cell tumor prognostic panel as I am in the intimate details of synching herd ovulation: not much. You don't have to fake it.
- Don't let anyone make you feel small if you don't know the answer to a question. There is so much to know that you cannot possibly know it all. BUT it totally behooves you to look that shit up and recon with the person who was quizzing you when you DO know the answer.
- Sleep is really, really important. Take advantage of all opportunities to sleep. Sleeping is magical.
4) Ultrasounds take at least 45 minutes, sometimes over an hour. Also, everyone looks at you like it's your fault when the sedation wears off or the patient loses patience.
5) Appointments regularly take 6+ hours. I am not even kidding. If you're bringing your pet to a university for a consult, plan for it to be a day's event.
6) The anesthesia department is absolutely not fucking around. Neither is the ICU staff.
7) Some sort of conference, thesis defense, or guest lecture is always happening. I get e-mails about all of them. Sometimes there is food involved.
8) There are six or seven different on-call schedules for various situations that may happen in the night or over a weekend. They are all posted in different places and are varying degrees of accurate.
9) A parade of work-study students and residents wander by the oncology department at regular intervals. They ask for blood and/or urine samples from particular patients who have diseases that are relevant to their research.
10) There is so much hand sanitizer.
weird emergency room skills:
1. Guessing weight.
Hey, that big dog is having a seizure! No time to get it on the scale. Instead, you guess, as in:
That looks like a 45 kilogram dog = 4.5 ml Valium (0.5 mg/kg, 5 mg/ml).
Also useful when you're tapping the sweet Golden's pericardial effusion and she goes into vtach:
That looks like a 30 kilogram Golden = 3 ml lidocaine slowly until she converts (2 mg/kg, 20 mg/ml).
You can also guess weight in multiples of cats. A medium-sized cat is 5 kilograms (12 pounds), so you go:
That dog looks like about the size of 7 cats = 35 kilograms.
2. The ghettecho.
Let's say it's the middle of the night, you have a patient with shitty cardiac output, and an ultrasound. With a little bit of knowledge, you can get yourself a lot of information:
- First, make sure your patient can breathe! Oxygen and sedation are your buddies.
- Once you've sort of stabilized and administered oxygen, Lasix, torb, or other drugs as needed, do a physical. Think about mucous membrane color, lung sounds (are there crackles? wheezes? are they...suspiciously dull or absent?), heart sounds (murmur? arrhythmia? can't hear the heart?), pulse quality (weak? thready? waterhammer? pulsus paradox?), etc.
- Chest x-rays would be pretty great, but your patient might not be stable enough for those yet. You can usually ghettecho while your patient sits or stands in a comfortable position, and you can totally do it through the oxygen cage porthole if needed.
- If your ultrasound has a cardiac preset or probe, use that.
- Figure out how to adjust your depth and gain settings.
- Find the heart with the ultrasound. Sometimes (especially if your patient is hypovolemic) this is harder than you think.
- Is the heart surrounded by a bag of fluid? Heeeey, pericardial effusion! Tap that! (caveat - sometimes you can be faked out by pleural effusion, which looks more like it has sharp corners on flash).
- Okay, next check out left atrial size. You don't need to actually measure it, but is it way bigger than the aorta? Lasix!
- Finally, find the short axis view, and look at ventricular function. The big muscular one is the left ventricle - does it look like it's adequately contracting to move the fluid inside it? If it looks like the walls move towards the center just a little bit, your patient's fractional shortening may be sub-optimal. If the right ventricle (the smaller, curved-around-the-big-muscular-ventricle one) looks really full, think about right heart failure.
- While you're there (if the patient is stable enough), check out the pleural space and the abdomen for free fluid.
The ghettecho is not as useful as a legitimate cardiologist or radiologist echo in any sense of the word, but it does have its place as a middle-of-the-night rough gander at heart function.
3. Euthanizing a wide variety of wildlife.
Ever done an intracardiac stick on a severely injured baby bunny or a tiny bird with a broken leg? It'll make you feel like a terrible person.
4. Standing high jump.
If your patient is larger than a medium-sized cat (see above) or if you are shorter than ~5'10'', you're gonna need to get on the table to do good chest compressions during CPR.
The fastest/least awkward way to do this (the CPR stool is never actually with the crash cart) is to put your hands on the table (while someone else is doing the compressions), vault onto the table in one jump, land (gently) on your knees, and take over.
5. Hitting a moving, challenging target.
You know what's fun? Intubating a healthy dog in sternal recumbency who has just gently drifted to sleep after receiving modest amounts of pre-meds and propofol.
You know what's less fun? Intubating a dog who has arrested in lateral recumbency while wedged between the crash cart and the technician placing the catheter whose head is moving because of the chest compressions while hemorrhagic fluid pours out of his mouth.
Hey, that big dog is having a seizure! No time to get it on the scale. Instead, you guess, as in:
That looks like a 45 kilogram dog = 4.5 ml Valium (0.5 mg/kg, 5 mg/ml).
Also useful when you're tapping the sweet Golden's pericardial effusion and she goes into vtach:
That looks like a 30 kilogram Golden = 3 ml lidocaine slowly until she converts (2 mg/kg, 20 mg/ml).
You can also guess weight in multiples of cats. A medium-sized cat is 5 kilograms (12 pounds), so you go:
That dog looks like about the size of 7 cats = 35 kilograms.
2. The ghettecho.
Let's say it's the middle of the night, you have a patient with shitty cardiac output, and an ultrasound. With a little bit of knowledge, you can get yourself a lot of information:
- First, make sure your patient can breathe! Oxygen and sedation are your buddies.
- Once you've sort of stabilized and administered oxygen, Lasix, torb, or other drugs as needed, do a physical. Think about mucous membrane color, lung sounds (are there crackles? wheezes? are they...suspiciously dull or absent?), heart sounds (murmur? arrhythmia? can't hear the heart?), pulse quality (weak? thready? waterhammer? pulsus paradox?), etc.
- Chest x-rays would be pretty great, but your patient might not be stable enough for those yet. You can usually ghettecho while your patient sits or stands in a comfortable position, and you can totally do it through the oxygen cage porthole if needed.
- If your ultrasound has a cardiac preset or probe, use that.
- Figure out how to adjust your depth and gain settings.
- Find the heart with the ultrasound. Sometimes (especially if your patient is hypovolemic) this is harder than you think.
- Is the heart surrounded by a bag of fluid? Heeeey, pericardial effusion! Tap that! (caveat - sometimes you can be faked out by pleural effusion, which looks more like it has sharp corners on flash).
- Okay, next check out left atrial size. You don't need to actually measure it, but is it way bigger than the aorta? Lasix!
- Finally, find the short axis view, and look at ventricular function. The big muscular one is the left ventricle - does it look like it's adequately contracting to move the fluid inside it? If it looks like the walls move towards the center just a little bit, your patient's fractional shortening may be sub-optimal. If the right ventricle (the smaller, curved-around-the-big-muscular-ventricle one) looks really full, think about right heart failure.
- While you're there (if the patient is stable enough), check out the pleural space and the abdomen for free fluid.
The ghettecho is not as useful as a legitimate cardiologist or radiologist echo in any sense of the word, but it does have its place as a middle-of-the-night rough gander at heart function.
3. Euthanizing a wide variety of wildlife.
Ever done an intracardiac stick on a severely injured baby bunny or a tiny bird with a broken leg? It'll make you feel like a terrible person.
4. Standing high jump.
If your patient is larger than a medium-sized cat (see above) or if you are shorter than ~5'10'', you're gonna need to get on the table to do good chest compressions during CPR.
The fastest/least awkward way to do this (the CPR stool is never actually with the crash cart) is to put your hands on the table (while someone else is doing the compressions), vault onto the table in one jump, land (gently) on your knees, and take over.
5. Hitting a moving, challenging target.
You know what's fun? Intubating a healthy dog in sternal recumbency who has just gently drifted to sleep after receiving modest amounts of pre-meds and propofol.
You know what's less fun? Intubating a dog who has arrested in lateral recumbency while wedged between the crash cart and the technician placing the catheter whose head is moving because of the chest compressions while hemorrhagic fluid pours out of his mouth.
i can't unthink that:
Radiologist: "Hey, you know what a quince is?"
Alacrity: "No."
Radiologist: "They're a fruit. They look like Big Bird's testicles. If birds had testicles. On the outside."
Alacrity: "No."
Radiologist: "They're a fruit. They look like Big Bird's testicles. If birds had testicles. On the outside."
mental blocks:
Okay, so you know how there are some things that you should be able to remember, but for whatever reason you always forget/are bad at them? Yup, you know. Here are (some of) mine:
1) Neurolocalization/most of neurology, actually.
Sometimes I try to chalk this up to never having a neuro rotation in vet school, but that's not it. I mean, I can generally sort out "brain problem" from "neck dog" from "back dog" from "lower lumbar dog", but most of the time the rounds-pimping by the neurologist goes like this:
Neurologist: "Okay, so what else could cause [these signs]?"
(silence)
(neurologist kicks me under the table)
Alacrity: "Neoplasia."
Neurologist: "Yes. What else?"
(silence)
Alacrity: "Inflammatory disease."
Neurologist: "EEEHHHH wrong. What else?"
Haaaa fun times! Also, if we're in vestibular-land, I have a bugger of a time sorting out central vestibular (unless the dog has other central signs) from peripheral vestibular (unless the dog has gross ears) +/- paradoxical vestibular (what even is this really).
2) Acid/base.
THIS SUCKS. You know, I've read my vet school acid-base notes an embarrassingly large number of times (and worked through this handy acid/base practice simulator developed by the University of Awesome's engineer-turned-criticalist) and I still internally panic every time I go to read a blood gas.
3) Reading thoracic x-rays.
I'm starting to get better at this one. Dr. Nell (radiologist) has taught the intern herd some quick tricks to help get through the overnights, and I'm hopeful that (with practice and epic mistakes along the way) I'm improving.
I secretly want to be better at this, not only because it's an important workplace skill but also because queers are supposed to be good pattern-recognizers. Think about it! If your dating life depends on good pattern-recognition skills (read: gaydar), you'll get good at it. And radiology is exactly that.
1) Neurolocalization/most of neurology, actually.
Sometimes I try to chalk this up to never having a neuro rotation in vet school, but that's not it. I mean, I can generally sort out "brain problem" from "neck dog" from "back dog" from "lower lumbar dog", but most of the time the rounds-pimping by the neurologist goes like this:
Neurologist: "Okay, so what else could cause [these signs]?"
(silence)
(neurologist kicks me under the table)
Alacrity: "Neoplasia."
Neurologist: "Yes. What else?"
(silence)
Alacrity: "Inflammatory disease."
Neurologist: "EEEHHHH wrong. What else?"
Haaaa fun times! Also, if we're in vestibular-land, I have a bugger of a time sorting out central vestibular (unless the dog has other central signs) from peripheral vestibular (unless the dog has gross ears) +/- paradoxical vestibular (what even is this really).
2) Acid/base.
THIS SUCKS. You know, I've read my vet school acid-base notes an embarrassingly large number of times (and worked through this handy acid/base practice simulator developed by the University of Awesome's engineer-turned-criticalist) and I still internally panic every time I go to read a blood gas.
3) Reading thoracic x-rays.
I'm starting to get better at this one. Dr. Nell (radiologist) has taught the intern herd some quick tricks to help get through the overnights, and I'm hopeful that (with practice and epic mistakes along the way) I'm improving.
I secretly want to be better at this, not only because it's an important workplace skill but also because queers are supposed to be good pattern-recognizers. Think about it! If your dating life depends on good pattern-recognition skills (read: gaydar), you'll get good at it. And radiology is exactly that.
taking my own radiographs, with peanut gallery:
I had this patient the other day who needed abdominal radiographs, and since the radiology technician was at lunch, I decided to take them myself.
That was silly. Here is how it went:
First I found a technician assistant (TA) and a visiting student to help me. I asked the TA if she knew how to set up the system (she did), so while that was happening the student and I got the dog on the table and on his back. He was a big fellow, and he wasn't very keen on being on his back.
I tape the dog's hind legs to the table, get dressed in lead, and hold his front end still.
The machine whirrs and makes a funny sound.
Okay, so I start setting up the system again while the student holds the dog. A passing technician sees how this is going (not well), and comes over to help. The dog escapes and starts vomiting. We clean up, regroup, and get the dog back on the table.
I re-tape his hind legs, get dressed in lead, and hold his front end still (again). The dog wriggles. The radiologist (Dr. Nell, who has apparently been watching this whole thing) snickers. This conversation happens:
Dr. Nell: "ALACRITY!"
Alacrity: "WHAT."
Dr. Nell: "USE BONDAGE!"
Alacrity: "I AM using bondage!"
Radiology technician returns from lunch at this point, assesses the situation, and joins in:
Radiology technician: "Did you have to hold the dog in the worst way possible?"
Alacrity: "Come on, man! I'm wearing lead and everything!"
RT: "Yes, but did you have to sprawl across the table so you're spraying your entire body with radiation?"
It was basically awesome. But I got diagnostic films!
That was silly. Here is how it went:
First I found a technician assistant (TA) and a visiting student to help me. I asked the TA if she knew how to set up the system (she did), so while that was happening the student and I got the dog on the table and on his back. He was a big fellow, and he wasn't very keen on being on his back.
I tape the dog's hind legs to the table, get dressed in lead, and hold his front end still.
The machine whirrs and makes a funny sound.
Okay, so I start setting up the system again while the student holds the dog. A passing technician sees how this is going (not well), and comes over to help. The dog escapes and starts vomiting. We clean up, regroup, and get the dog back on the table.
I re-tape his hind legs, get dressed in lead, and hold his front end still (again). The dog wriggles. The radiologist (Dr. Nell, who has apparently been watching this whole thing) snickers. This conversation happens:
Dr. Nell: "ALACRITY!"
Alacrity: "WHAT."
Dr. Nell: "USE BONDAGE!"
Alacrity: "I AM using bondage!"
Radiology technician returns from lunch at this point, assesses the situation, and joins in:
Radiology technician: "Did you have to hold the dog in the worst way possible?"
Alacrity: "Come on, man! I'm wearing lead and everything!"
RT: "Yes, but did you have to sprawl across the table so you're spraying your entire body with radiation?"
It was basically awesome. But I got diagnostic films!
that should obvs. go in the ultrasound report:
Radiologist, ultrasounding: "Holy shit."
Alacrity: "What?"
Radiologist: "This dog has raging, needs-more-cowbell pancreatitis."
Alacrity: "What?"
Radiologist: "This dog has raging, needs-more-cowbell pancreatitis."
gaydar fail, gaydar win:
so, these two conversations happened this week.
1) Alacrity and Dr. Treaphine (an ER doctor), discussing a case:
Dr. T: "Hey, is that puppy going home now?"
A: "Yes! He's doing really well. He's gonna wait with his owner while I finish his discharges."
Dr. T: "Awesome! I'm glad to hear it. (glances around, drops voice) Hey, you know...his owner is this really cute guy [wink] - I think he might be married, though."
2) Alacrity and Dr. Nell (radiologist), during an ultrasound:
Dr. N: "Alacrity, you went to vet school at the University of Awesome?"
A: "Yup! It was fantastic."
Dr. N (ultrasounding the dog's abdomen): "Oh, wow - check out this mass. You're gonna make these owners cry. (pause) Huh. (pause) Yeah, I think this is cancer. You'll need to get some aspirates of this, but we'll need to check her clotting times first."
A: "That sucks. I'll go talk to them."
Dr. N: "Sounds good - let me just see if there's anything else in here. (ultrasounding) So, did your partner move here with you, or does she live somewhere else?"
1) Alacrity and Dr. Treaphine (an ER doctor), discussing a case:
Dr. T: "Hey, is that puppy going home now?"
A: "Yes! He's doing really well. He's gonna wait with his owner while I finish his discharges."
Dr. T: "Awesome! I'm glad to hear it. (glances around, drops voice) Hey, you know...his owner is this really cute guy [wink] - I think he might be married, though."
2) Alacrity and Dr. Nell (radiologist), during an ultrasound:
Dr. N: "Alacrity, you went to vet school at the University of Awesome?"
A: "Yup! It was fantastic."
Dr. N (ultrasounding the dog's abdomen): "Oh, wow - check out this mass. You're gonna make these owners cry. (pause) Huh. (pause) Yeah, I think this is cancer. You'll need to get some aspirates of this, but we'll need to check her clotting times first."
A: "That sucks. I'll go talk to them."
Dr. N: "Sounds good - let me just see if there's anything else in here. (ultrasounding) So, did your partner move here with you, or does she live somewhere else?"
exotics resident to imaging resident:
"Hey, can you ultrasound the intumescence on this trouser snake?"
new perspectives are fun:
radiologist: "We're assuming that our bodies (and animal bodies) are sort of skin-confined water bags."
multidisciplinary knowledge at work:
surgeon: "Do you have a linear probe that has a sort of pseudo-curve-like aspect to it? Or whatever you call those things?
radiologist: "Uh...no."
radiologist: "Uh...no."
cardiologist, during an echocardiogram:
"Look, there's Fudgie the Whale! See, Fudgie is the left atrium, and the left auricle is his tail. Oh, this does not look good. Fudgie is a fat Fudgie."
with a condom!
The other day, we scoped a dog with:
1) a golf ball
2) a large piece of ruminant hoof
in his stomach. Let me tell you, a slippery golf ball is really hard to grab.
After we tried the little endoscopy net and grabbers, we then moved on to using a condom (Magnum, since apparently they're the largest. Who knew? Not me.), a plastic lunch baggie, and then...
(drumroll please)
...a sterile ultrasound probe cover (read: GIANT condom)! And it worked!
The medicine resident delicately scooped the golf ball into the giant condom and pulled it up the esophagus and out the dog's mouth. It was awesome.
1) a golf ball
2) a large piece of ruminant hoof
in his stomach. Let me tell you, a slippery golf ball is really hard to grab.
After we tried the little endoscopy net and grabbers, we then moved on to using a condom (Magnum, since apparently they're the largest. Who knew? Not me.), a plastic lunch baggie, and then...
(drumroll please)
...a sterile ultrasound probe cover (read: GIANT condom)! And it worked!
The medicine resident delicately scooped the golf ball into the giant condom and pulled it up the esophagus and out the dog's mouth. It was awesome.
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