Blog

News / Blog

Life after graduation - Jordan Smith

  • PDP
  • 14/02/2019 12:09:00
  • View Count 3835
  • Return
Life after graduation - Jordan Smith

August 2019 – Three Scary Letters: G D V

When I first qualified there were three letters that terrified me the most – GDV. I recall how my lecturers casually described stabilisation, manual detorsion of the stomach and the differing pexy options as though they were a walk in the park. However, on EMS I listened to clinicians describe experiences which differed greatly from this relaxed approach and thereafter the fear was certainly instilled in me!

Working in a supportive hospital environment has allowed me to quickly learn and improve a number of skills, including my surgical skills, however it seemed like nothing could prepare me for my first ever GDV.

In the back of my mind I had images of a bloated Great Dane at 2AM and nothing seemed more terrifying. My first week of solo night shifts were due in the summer of 2018 and time was beginning to quickly slip away. I was desperate to have some exposure to a GDV; I needed to see at least one before being left alone. I began bugging the rest of the team to call me out of hours and quizzing the surgeons at the hospital for any tips they might have developed over the years. I left my number plastered across the prep room and badgered the night team to call me in.

Approximately 6 months after qualifying the moment arose. The phone rang at 4AM and I heard my clinical mentor utter those three letters – “GDV”. It was time to finally do this. I threw on my scrubs and drove to work. I was greeted by a very bloated Dogue de Bordeaux and I was guided through the stabilisation process and scrubbed in on my first ever GDV. I felt reassured the whole time by my mentor and was able to perform the gastropexy.

 I was surprised. It wasn’t as bad as I’d built it up to be. Of course, I still had someone holding my hand and answering questions, but at least some of the irrational fear was gone and those three letters that terrified me more than anything were now just a little less frightening.

When the time came to tackle my first solo GDV I was ready, albeit I was alone and nervous, but ready. I was able to stabilise and competently perform the surgical procedure without any major complications. It was done and I’d managed it on my own. What a feeling of accomplishment! However, I couldn’t help but feel a little anti-climatic. I’d been building up the fear for so long and it was over. I work in a supportive hospital and if I need help, it can be found – what was I worrying for?

I realised from that moment on that anything new is inherently scary and it is human nature to fear the unknown. I was fearful because I was inexperienced, didn’t know what to expect and the GDV was the unknown. After I’d worked hard to learn the theory and been exposed to the surgery, it was no longer the unknown – just another skill to practice.

Nevertheless, I don’t think the surgery should be underestimated at all. There are many potential complications and emergency surgery is always unpredictable. It is not meant to be easy, but I now know it is not something to become obsessively terrified over.

From then on I became cursed. I went on to have the first ever triple GDV in 24 hours at the hospital and now I seem to be collecting the cases.blogpic1

Most recently I was able to pass on some skills to one of our new graduates. It was 2pm and we were enjoying our weekly vets meeting when the nurses called up to the office. Who knew GDV’s didn’t just happen in the small hours of the morning? I was able to guide the new graduate through the stabilisation and surgical correction including an incisional gastropexy.

I had now made something a little less scary for someone else. I was able to make the unknown the known for somebody and it felt great!

So what have I learnt from all of this? Firstly, it is okay to be nervous about the unknown but don’t let it rule your life or impact your confidence. Secondly, it is impossible not to be nervous or apprehensive about the first ever GDV you take to theatre, BUT at the end of the day it is like learning any other new skill. Learn the theory and jump on any opportunity possible to gain some exposure and you’ll be grand.

Good luck and try not to crumble when you see that reverse C, after all it is just another skill to learn and they’re only three little letters – don’t fear them!

---------------------------------------------------------------------------------------------------------------------------------------------------------

July 2019 - back to Basics

Another July has come and another set of fresh faced new graduates have donned their mortar boards and thrown them high (despite university health and safety rules). The butterflies are building for their first day at work and suddenly feelings of anxiety begin to build. But these brilliant new graduates need to remember that there isn’t a single person in this career who hasn’t had ‘a first day at work’ and experienced these feelings! We all have to start somewhere and it is not abnormal to feel like you’re not doing a good job – remember as long you leave each day knowing you’ve done your best then you’re winning!

Something that was drummed into my veterinary education as an undergraduate was “always conduct a FULL clinical examination” and it is a rule I’ve tried to stick to during the last 2 years at a busy hospital.

Consulting is a real art; balancing the many techniques of taking a history, performing a full and thorough clinical exam and also chatting to the owner to build a good professional relationship. It is not easy, do not be ashamed if you find this a challenge on your first week of work.

I understand what it is like to have a waiting room full of clients and missing your breaks, but nevertheless I still try to fully examine every patient!

Conducting a full clinical examination particularly when the patient has presented for a ripped dew claw may seem like overkill, however there have been many cases when I have found something significant. I recently saw a patient for ocular discharge and found a large abdominal mass which had not been palpated before. This mass turned out to be an enlarged iliac lymph node and subsequently went on to be diagnosed with metastatic spread from a small MCT in the inguinal region which I also noted on the examination.

Working at a hospital with an ‘Out of Hours’ service has been pivotal for the development of clinical, professional and personal skills. Learning to balance the numerous inpatients with appointments and being able to utilise the art of effective triage can be enough to make your brain hurt. Additionally, I found decision making particularly difficult and learning not to doubt my decisions has been hard. However, I would (and still do) reassure myself by knowing I have conducted a full and thorough clinical examination. It may seem like a basic skill, but it is possibly the most important one to perfect.

When a client calls at 11pm describing certain clinical signs, it is difficult to not fall into a trap and assume what your diagnosis will be or which treatment plan you will probably embark upon. I’ve been caught out before by the middle aged GSD presenting with tachycardia, poor pulse quality and abdominal distension. I was narrow minded and assumed I’d be finding a hemoabdomen and subsequent splenic mass (and even asked the nurses to prep theatre). It was to my surprise that I aspirated clear fluid from this dogs abdomen and then immediately thought “Oh Jordan, you numpty”. I went onto diagnose congestive heart failure in this patient due to dilated cardiomyopathy. From that moment on I have tried to prevent my brain from jumping to conclusions and look closely at all the clinical signs, create a problem list and consider all possible differential diagnoses.

Good luck to all of the new graduates starting their first jobs! It is going to be a rollercoaster of a year with lots of learning, frustrations and probably some tears, but as long as you’re going home each day knowing you’ve worked as hard as you possibly can then that is all that matters!

And remember, always do a full clinical exam – even if its on an owl!

JordanPDPblogJuly201...

 

---------------------------------------------------------------------------------------------------------------------------------------------------------

June 2019 - A relationship that should be built on trust

Before starting Veterinary School back in 2011 I had seen practice with vets and nurses whom I aspired to be like. I watched admirably as they moulded professional and trustworthy relationships with their clients., clients that listened tentatively and followed their advice.

I went to vet school under the impression that I too would be able to form such professional relationships with clients throughout my career.

Don’t get me wrong – I’ve definitely built lots of brilliant professional relationships with many absolutely lovely clients, some of whom have shown huge amounts of appreciation. However, I have been surprised by the increasing amount of mistrust, suspicion and scepticism of veterinary advice that I’ve been encountering.

I am not asking clients to take my advice as gospel or worship the recommendations I make for their pet’s health, however adjusting to the challenges of client communication has been a big eye opener since qualifying as a vet.

I want my clients to know that I have their pet’s best interest in mind and that there are no catches or tricks. I have no influence on the prices and do not get any returns for the amount they spend. The diagnostics I recommend are the ones that are relevant to the case and the treatment options that are available are always explained in full, including complications, costs and prognosis.

But there are two phrases I dread - “I’ve read on Facebook” and “I’ve googled this already”.

Using the most recent evidence-based medicine and up to date knowledge doesn’t seem to be able to rival ‘Facebook’ and the many opinions that can be found there. It can be a real challenge when discussing certain areas of veterinary medicine, including vaccinations, preventative health and medications. Social media is an important tool for so many things, but giving veterinary advice doesn’t seem like a useful application. I always remind owners that these are mostly opinions and the advice given cannot be generalised to all patients. In particular, an online claim that a certain drug is evil and will kill their pet is just plain ignorant.

The amount of times I have had to reassure owners that the veterinary products we use have been rigorously investigated and evaluated in terms of efficacy and safety. Although I do, however, highlight that safety doesn't indicate that the product is risk free. I am also very upfront with owners if they have any queries and will not just dismiss their concerns, particularly to potential adverse events.

A recent case has been the inspiration for writing this blog entry. A 4 week old DSH kitten presented out of hours with a history of collapse and lethargy. Clinical examination revealed white mucous membranes, a significant skin tent, hypothermia (35.9C) and a severe flea infestation. A very small jugular sample was obtained and revealed a PCV of 5%.

The clients stated they had 3 other kittens in the litter which seemed to be okay. On further questioning, the queen and kittens had not been treated with any flea products. I discussed with the clients the importance of applying a suitable product, however they were adamant that their pets did not have fleas and they did not like to use chemicals unnecessarily. After a long discussion the clients decided to listen to the advice and treat the remaining pets at home and the environment in order to prevent the other kittens from deteriorating or becoming clinically unwell.

After we had stabilised the kitten with fluid therapy and active warming, we applied an appropriate flea product and continued with supportive care. Unfortunately, his prognosis was guarded to poor.

So, what has changed since I was a blue eyed work experience student? Why is it that now I am finding more clients mistrust the advice I give? Has the demographic changed? Has technology and social media created this relationship breakdown? I am not sure I can answer any of these questions. Perhaps I was naive back then and there was always a level of mistrust by some clients. Or, perhaps social media has allowed for the opinions of some to be forged into fact. All I know is that I am working extra hard to ensure my client communication is as good as it possibly can be and to not judge or criticise a client for not taking my recommendations.

pdpblogJordan-July

---------------------------------------------------------------------------------------------------------------------------------------------------------

May 2019 - Those pesky tendons!

It was one of those busy Mondays and I felt like I was rushing around the hospital having no control over the cases. Emergency appointments are coming out of my ears. A client is adamant her dog needs to be seen because she has found a couple of new lumps on his abdomen. After triaging the dog and correctly identifying these lumps as nipples, I attempt to have a 5 minute sit down with a cup of tea – of course after all the patients were stabilised, had undergone diagnostics and had treatment plans written up.

The next emergency appointment arrives and the hospital nurse triages the patient to ensure it is stable. I am asked to assess the patient urgently as there is a wound which is soaking through a firmly applied pressure bandage. A very bouncy and happy 9 month old Labrador named Archer greets me on the consult room floor, which has subsequently become a sea of red - his tail acting as a blood soaked whip.

His owners informed us that he had slipped off a groin at the local beach and they had rushed him straight to us because of the excessive bleeding. Clinical examination revealed a large ‘U’ shaped laceration to the plantar aspect of his right metatarsal region however a full examination was obscured by the large amounts of haemorrhage present.

With blood pumping out of his leg it was time to work fairly quickly. I applied a loose tourniquet and reapplied a pressure bandage whilst discussing the next steps with the owner and gaining consent for a general anaesthetic. An intravenous catheter was placed in his right cephalic vein and a premedication of methadone given slow IV. The patient was induced with propofol and a cuffed ET tube placed allowing for anaesthetic maintenance on isoflurane and oxygen. Cefuroxime (Zinacef) was given slow IV at the start of the procedure and repeated once after 90 minutes of surgery.
 
Once an adequate plane of anaesthesia was achieved, I assessed the wound more closely. I identified 2 arterial bleeds which were responsible for the degree of haemorrhage. The tourniquet was tightened and a timer of 20 minutes started by an assisting nurse to ensure that the tourniquet was not left in place too long. I could now see what I was really dealing with. It was worse than I had expected. Archer had severed is SDFT and partially severed his DDFT on his right hind when he had slipped off the groin.

Sterile lube was applied to the wound and the limb was clipped in preparation for flushing. Sterile saline and dilute povidone-iodine was used to reduce the contamination of the wound. Although not ideal, I ligated the peripheral arteries which were responsible for the haemorrhage with 3/0 Monocryl and asked the nurse to release the tourniquet. Hurrah! The bleeding had stopped!

Now I was left to deal with the tendons. I drafted in the advice and skills of a soft tissue surgeon and together we pieced the DDFT and SDFT with a monofilament suture (PDS) via the Pennington locking-loop suture pattern. I then proceeded to close the wound with tension relieving sutures and achieved fairly good skin apposition with minimal tension.

A flexion bandage was applied to immobilise the limb in attempt to reduce failure of the tendon sutures. Archer recovered well from the general anaesthetic and was soon back to his happy self in the kennels.
 
I discussed with Archer’s owners that I did have some concerns regarding the degree of damage that the groin had caused and that it was more severe than previously anticipated. I outlined the possible complications including wound breakdown, inadequate blood supply, suture failure, bandage sores and infection. I also discussed the long road Archer had to recovery.

The plan was to continue Archer on IV antibiotics and analgesia for 24 hours with the hope to transitioning to oral medications and changing the flexion bandage every 48 hours.

After 48 hours with us, Archer was discharged on strict cage rest with instructions that his buster collar must remain on at all times unsupervised. He was dispensed oral Cephalexin  (Rilexine) to be given twice daily and Carprofen (Rimadyl) to be given once daily. Archer’s owners were completely on board with his care and were very thankful for the teams hard work.

Archer is progressing very well. The wound healed without complication and the tendons are continuing to do well. Archer’s owners are beginning to increase exercise slowly and are looking forward to getting him back to fighting fit.

This was a challenging case to be presented with on the emergency shift and it highlights the need to ask for help when you are out of your depth or you feel uncomfortable!

 

 

---------------------------------------------------------------------------------------------------------------------------------------------------------


April 2019 - BSAVA Congress 2019 – the fun, the facts and the friendly

It is that time again - April. This can only mean one thing and small animal vets across the UK start packing their bags in preparation for a long weekend of learning and laughing. Having attended congress as both a student and a new graduate, I was certain that I would be using some of my CPD budget to attend once again. Not only does congress offer a wide variety of lectures, discussions and practical sessions, but it also offers the opportunity for reunions and networking.

When I first graduated from vet school I was overcome and completely drowned by the level of knowledge and skill that I just didn’t have. It is a cliché, but everyday was a school day and it was really hard learning curve. Attending BSAVA congress during this year was a mind blowing experience. I sat in lectures feeling completely disconnected because there were still days that I couldn’t successfully take blood from a cat without letting it ruin my day.

The new graduate stream is one I highly recommend if you’re at this phase of your career and want lectures which are relevant and beneficial.

However, I was ready for BSAVA Congress this year. My mentality has changed. Transitioning my mind set to accepting that it is perfectly fine to not have all the clinical skills or knowledge that others may have.

Settling into clinical practice has enabled me to focus my attention on what I enjoyed most and the areas which stimulated my interests. For BSAVA Congress 2019 I had my goals set on attending as much internal medicine as I could fit in.

Highlights include an entire day in haematological medicine and the oncology stream.

Congress doesn’t just offer a variety of CPD, it offers the opportunity to see those special people you spent 5 or 6 years with and enjoy the many social events on offer. Catching up with old friends and making new ones and potentially finding your next career change.  The evening of the penultimate day shows one of the lecture theatres being transformed into an exotic paradise. A beach themed evening of fun including the classic silent disco which is always a hit.

Congress 2020 looks to be an absolute banger – see you there!

----------------------------------------------------------------------------------------------------------------------------------------------------------

March 2019 - The Rat Race? A Competition? The Olympics?

 

Whether you are working within a small animal practice with one other veterinary surgeon or you are driving the breadth of the county rasping teeth, your progress is YOUR progress. It doesn’t matter how many ovaries you’ve removed or whether you diagnosed the first case of chicken-pox in a bearded dragon (disclaimer: my bearded dragon knowledge is not great), it is a personal, unique journey which you and only YOU have to take – and your first year is just the start!

It is probably fair to say that we all have a competitive nature to our personalities given that we’ve worked hard to gain a place at University. However, comparing your skill set and your personal progress to one of your peers or a colleague is an impossible feat. We are all presented with different opportunities, differing teaching methods and different cases. Some of your friends may work as an intern or in a small mixed species practice or at a busy veterinary hospital, but their experiences are theirs and not yours. We should be utilising their knowledge and discussing cases openly with each other without judging or criticising.

We need to remove this internal feeling of guilt and pressure that a new or recent graduate should be perfect and be able to recognise and diagnose every condition. Have confidence in the knowledge you have got because it is likely more relevant and fresh compared to others. Do not feel insecure or self-critical for not being able to perform a TPLO three months post graduation (even if your friend tells you they’ve done 10 – probably not the truth too!). There is no gold, silver or bronze medal for how fast you can spay a cat or place an IV catheter.

Having recently returned from a trip with some university friends,  I can clearly see the desire to rapidly complete PDP is prominent.

It is no lie that learning to become reflective is difficult, tiresome and a challenge. We probably found these sort of activities pointless during our undergraduate degrees.

After graduating from the University of Nottingham I was all too familiar with reflection. One word (well it might actually be two): ‘PebblePad’. A form of online assessment and a learning tool to encourage reflection on cases, skills, hobbies, events – well anything really. If someone had asked me 3 years ago whether I thought PebblePad was useful or integral to my development I would have probably laughed.

However, in all seriousness, reflection is the key to self-improvement and pivotal for focusing your precious time on something you’d like to improve. Devoting just 5 minutes a week to PDP can allow you to track your progress and also highlight areas to focus on. It is irrelevant if it takes you 12 or 36 months, as long as you are able to show yourself that you are progressing.

19 long months since graduation and I was signed off from my PDP. Each day a steep learning curve and large amounts of self-doubt and criticism, but don’t rush to finish this race. PDP is only one lap of what is hopefully a very long marathon of a career.

Your development doesn’t stop when the certificate is in your hand and remember your progress is YOUR progress.

On a lighter note, treasure and enjoy the moments when you are reunited with your vet school friends. Your friendships are individual and they know all too well what the trials and tribulations are for a new or recent graduate.

 

----------------------------------------------------------------------------------------------------------------------------------------------------------

February 2019

Hello!

My name is Jordan and I am a University of Nottingham veterinary graduate!

I am delighted to be asked to become a PDP blogger for the BSAVA and I look forward to writing about my adventures in a busy small animal, primary care hospital.

I am based in the, supposedly, ‘sunny’ county of Norfolk and work close to the city of Norwich in a large veterinary team consisting of approximately 15 veterinary surgeons.

I’ve found their knowledge and expertise a useful tool for being a recent graduate. The team has a range of qualifications including post-graduate certificates in cardiology, dermatology, diagnostic imaging, endoscopy, internal medicine, orthopaedics and soft tissue surgery.

The rota at work has three main roles; consulting, surgery and hospital. The first two are self explanatory, but the hospital vet’s role is to triage and admit emergency appointments and manage the care of the numerous inpatients in the hospital. This specific role at work has been fundamental in my development as a veterinary surgeon.

It has provided clinical freedom to fully work up cases from admit and diagnostics to instigating treatment protocols. Exposure to more complicated clinical cases and to be given the opportunity to perform minor and major surgical procedures at such an early stage in my veterinary career has been paramount to advance my skills further.

So time for one of my interesting cases…

I’ll set the scene. It was one of those sunny Friday’s where you’ve been ridiculously busy all week, but for some reason the day is pretty steady. I was the hospital vet for the day and I had seen 1 emergency appointment and I had no inpatients!

It was 4:30pm and I was looking forward to the 6pm finish and actually being able to leave on time. However, I was informed there was an eight week old puppy that had eaten a bone en route.

Upon arrival I was greeted by two worried owners and one very bouncy female, entire, black Labrador retriever. The owners were adamant that their beautiful pup had managed to access a rib bone in the bin and swallow it whole.

I was stood contemplating how a hard and inflexible structure would orientate its way through the pharynx and into the oesophagus and I couldn’t see that this was physically possible for such a small puppy to swallow such a large bone.
Upon clinical examination, her vitals were normal and the only abnormality detected was the occasional contraction of her diaphragm.

We opted to take a conscious radiograph first to avoid sedation however this wriggly, little puppy was not keen to lay still. We did manage to get one radiograph which showed a large, long and thin radiopaque structure in the caudal thorax/ cranial abdomen – even with all the movement blur.

I had a discussion with the owner outlining the need for some form chemical restraint. With the likelihood of surgical intervention I advised a full general anaesthetic to repeat the radiograph and take appropriate action.

My anaesthetic plan involved placing an IV catheter, starting the puppy on IVFT and obtaining a blood glucose reading. A premedication of low-dose methadone was given IV and then propofol IV was given for induction. After intubation we opted to take a second radiograph. A peri-operative dose of cefuroxime (Zinacef) IV was also given before surgery.

That is when I really discovered I was wrong – it is physically possible for a puppy to swallow a large bone whole.

I had a discussion with the owner outlining our options were quite minimal and that a surgical procedure was essential. I was slightly worried about the stomach wall if prompt surgical action was not undertaken so the owners consented to the procedure and we jumped into action.

So, there I was winding down on a Friday afternoon and then BOOM I was scrubbed and about to operate on an 8 week old puppy.

I performed an exploratory laparotomy and subsequent gastrotomy to remove the foreign body and closed the stomach wall in two layers before closing the exploratory laparotomy incision in a standard fashion. The rest of the stomach wall was examined thoroughly along with the rest of the abdomen.

Throughout the general anaesthetic, the nurse monitored the patient closely ensuring temperature and blood glucose were stable, amongst other parameters. A post operative radiograph was taken to examine the stomach after removal of the bone. Some radiopaque material remained present in the stomach on the post operative radiograph, however I was confident this would pass through the gastrointestinal tract and I was more concerned about ensuring the anaesthetic duration remained as short as possible.

Recovery was smooth and I opted to keep the puppy in overnight for further monitoring and
analgesia. The puppy was discharged the next morning to two very relieved owners and re-seen 5 days later for a post operative check.

Success and definitely worth staying past 6pm!
 

Share

Post a Comment

Registered Company No. 02837793. A Company Limited by Guarantee in England. Registered as a Charity in England and Wales No. 1024811.