Week 1
I found that experience is really important, as I felt the round sessions at CSU and OSU set a good standard for me, and I felt very prepared for the round session at BVSC. I could also compare how academia and private clinics' round sessions can be different.
During the first week of my visit, I was able to watch a TPLO surgery and a severe hip displacement case. I was also able to conduct the drawer test, tibial compression test, and palpate the patella ligament effusion with a cranial cruciate ruptured patient. I have watched quite a lot of TPLO surgeries during my externship at Keunmaeum Hospital and Jangjaeyoung Veterinary Surgery Hospital, but I never really understood the details of the surgeries. Although I haven't learned orthopedics at school yet, it was possible to understand a little more than in my previous externship, thanks to extra reading and more surgical experience at CSU and OSU. At BVSC, I won't be able to take the case, so I thought it would be a good idea to make a brief surgery case report on TPLO to learn every detail of it.
A 5-month-old canine patient was presented for hind limb lameness, and it turned out that the patient had hip displacement and subluxation on each limb. I could join the consultation and further my knowledge on treatment options such as FHO and total hip replacement for this kind of case. It also sounded like the GP's role in noticing the disease at an early stage is very important to be able to conduct juvenile pubic symphysiodesis.
During the first week of my visit, I was able to watch a TPLO surgery and a severe hip displacement case. I was also able to conduct the drawer test, tibial compression test, and palpate the patella ligament effusion with a cranial cruciate ruptured patient. I have watched quite a lot of TPLO surgeries during my externship at Keunmaeum Hospital and Jangjaeyoung Veterinary Surgery Hospital, but I never really understood the details of the surgeries. Although I haven't learned orthopedics at school yet, it was possible to understand a little more than in my previous externship, thanks to extra reading and more surgical experience at CSU and OSU. At BVSC, I won't be able to take the case, so I thought it would be a good idea to make a brief surgery case report on TPLO to learn every detail of it.
A 5-month-old canine patient was presented for hind limb lameness, and it turned out that the patient had hip displacement and subluxation on each limb. I could join the consultation and further my knowledge on treatment options such as FHO and total hip replacement for this kind of case. It also sounded like the GP's role in noticing the disease at an early stage is very important to be able to conduct juvenile pubic symphysiodesis.
Week 2
During the second week, a bilateral TPLO was initially planned, but the plan was changed to a left TPLO. Studying the related anatomy gave me an even better understanding of the procedure compared to last week, and I will continue working on the surgery report. I will include pre-op and post-op measurements for TPLO to practice and improve my understanding of the procedure.
There was a minor complication with plate positioning, as fragments of the tibia surface were uneven. I learned that this can be addressed by bending the plate or repositioning the small cranial tibial fragment. I was also curious about why medial meniscus injuries are one of the most common injuries secondary to CCLD. It is because of the difference in the ligament's attachment between the medial and lateral meniscus, which affects their flexibility. The medial meniscus is attached only to the tibia, while the lateral meniscus is attached to both the femur and tibia, making it more flexible during cranial movement of the tibia on CCLD.
A Spey with gastropexy was also performed as routine. The Spey was done using the two-clamp method, and I realized that reviewing the differences in Spey surgery procedures with different numbers of clamps is necessary.
Placing a U catheter in a patient with urethral stricture was the most challenging case today. The patient was presented for bladder urolith, but it turned out that there were uroliths in the urethra as well. The initial plan was to perform a cystotomy after flushing the urolith into the bladder. However, during the procedure, a blockage of the U catheter in the proximal os penis was observed, and with the use of contrast, a urethral structure or potential urolith was diagnosed. Due to the patient being on chemo and experiencing severe diarrhea, the urethrostomy was postponed until the concurrent diarrhea is resolved. It was great chance to revise how to position the patient for radiograph and interpret radiograph.
There was a minor complication with plate positioning, as fragments of the tibia surface were uneven. I learned that this can be addressed by bending the plate or repositioning the small cranial tibial fragment. I was also curious about why medial meniscus injuries are one of the most common injuries secondary to CCLD. It is because of the difference in the ligament's attachment between the medial and lateral meniscus, which affects their flexibility. The medial meniscus is attached only to the tibia, while the lateral meniscus is attached to both the femur and tibia, making it more flexible during cranial movement of the tibia on CCLD.
A Spey with gastropexy was also performed as routine. The Spey was done using the two-clamp method, and I realized that reviewing the differences in Spey surgery procedures with different numbers of clamps is necessary.
Placing a U catheter in a patient with urethral stricture was the most challenging case today. The patient was presented for bladder urolith, but it turned out that there were uroliths in the urethra as well. The initial plan was to perform a cystotomy after flushing the urolith into the bladder. However, during the procedure, a blockage of the U catheter in the proximal os penis was observed, and with the use of contrast, a urethral structure or potential urolith was diagnosed. Due to the patient being on chemo and experiencing severe diarrhea, the urethrostomy was postponed until the concurrent diarrhea is resolved. It was great chance to revise how to position the patient for radiograph and interpret radiograph.
Week 4
It has already been a month since I started going to BVSC every week. It's been a fortunate coincidence that I've had the opportunity to observe numerous orthopedic procedures at BVSC while I'm studying orthopedics at school. Today, I successfully performed my first intubation on a live patient. The case was a bit tricky, as the patient's epiglottis wouldn't open simply by pulling their tongue. However, I managed to navigate this challenge using a laryngoscope to pull down the epiglottis, and the process was easier than I had initially imagined.
From a procedural perspective, I had the chance to observe three surgeries today. The first case involved a mass removal on the right thigh (mid femur level) which was closed with a flank fold flap. It was quite demanding to visualize each step of the flank fold flap from the textbook, but witnessing it in a real situation made understanding much easier. Creating a cotton model to practice different flap types would likely be beneficial. I've learned that thorough planning is crucial before initiating a flap, as once you make a cut, it cannot be undone. During the surgery, I was also curious about distinguishing the deep layer of the mass through palpation, as I observed muscle movement while palpating. However, the mass wasn't adhered to the muscle layer during the surgery. Following the mass removal, I observed the staining process and understood the importance of marking the lateral and dorsal sides of the mass, staining the deep margin, suturing the skin to the fascia, and differentiating between layers even after the fascia slides over the skin.
The second case involved a patient who required screw removal, a procedure that might seem relatively simple, but can be challenging depending on factors such as screw size and location.
Lastly, there was an urgent surgery on a kitten with a distal tibial physis fracture. A cross pin with a tension band was employed to stabilize the fracture line without impinging on the joint space. Personally, I found this surgery to be quite challenging, especially since the angle of pin penetration relied solely on the surgeon's experience without any predefined measurements like TPLO's D1 and D2 values. Watching the fracture fixation lecture prior to observing this surgery would have been beneficial, but ultimately, this surgery aided in enhancing my comprehension of the lecture.
I've also completed writing the TPLO case report and have developed a growing interest in orthopedics. While my initial interest stemmed from soft tissue surgeries, my experiences at BVSC are unquestionably providing me with a fantastic opportunity to explore various aspects of surgery.
From a procedural perspective, I had the chance to observe three surgeries today. The first case involved a mass removal on the right thigh (mid femur level) which was closed with a flank fold flap. It was quite demanding to visualize each step of the flank fold flap from the textbook, but witnessing it in a real situation made understanding much easier. Creating a cotton model to practice different flap types would likely be beneficial. I've learned that thorough planning is crucial before initiating a flap, as once you make a cut, it cannot be undone. During the surgery, I was also curious about distinguishing the deep layer of the mass through palpation, as I observed muscle movement while palpating. However, the mass wasn't adhered to the muscle layer during the surgery. Following the mass removal, I observed the staining process and understood the importance of marking the lateral and dorsal sides of the mass, staining the deep margin, suturing the skin to the fascia, and differentiating between layers even after the fascia slides over the skin.
The second case involved a patient who required screw removal, a procedure that might seem relatively simple, but can be challenging depending on factors such as screw size and location.
Lastly, there was an urgent surgery on a kitten with a distal tibial physis fracture. A cross pin with a tension band was employed to stabilize the fracture line without impinging on the joint space. Personally, I found this surgery to be quite challenging, especially since the angle of pin penetration relied solely on the surgeon's experience without any predefined measurements like TPLO's D1 and D2 values. Watching the fracture fixation lecture prior to observing this surgery would have been beneficial, but ultimately, this surgery aided in enhancing my comprehension of the lecture.
I've also completed writing the TPLO case report and have developed a growing interest in orthopedics. While my initial interest stemmed from soft tissue surgeries, my experiences at BVSC are unquestionably providing me with a fantastic opportunity to explore various aspects of surgery.
Week 6
It has been a week during which I gained valuable hands-on experience in various practical aspects of the clinic. Despite the constant busyness both within and outside of vet school, I am proud of my commitment to continue my learning throughout the second semester of my fourth year before entering the clinical year which includes documenting each week's experiences here to help me track my progress.
This week's schedule began with shadowing Dr. Marvin during consultations. One of the consultations involved a patient with multiple skin lumps, some of which had been diagnosed as mast cell tumors by the primary veterinarian. Mast cell tumors (MST) are the most common types of skin and subcutaneous tumors and are categorized as low-grade and high-grade. Low-grade MST has an 8-10% metastasis rate with a 5% recurrence rate after removal, while high-grade MST has a 70% metastasis rate with less than a 30% recurrence rate. The patient was a Staffordshire Terrier, a breed predisposed to this disease. Fortunately, the previous diagnosis indicated that all these multiple MSTs in the patient were of the low grade. However, body mapping was recommended to monitor the growth of these tumors and ensure there were no high-grade MSTs, as a single high-grade MST could significantly worsen the prognosis. The treatment of choice would be surgery with radiation, as no recent research suggests that chemotherapy may be effective in preventing recurrence of these multiple masses. Generally, MST metastasis occurs through the lymph nodes and eventually to the liver and spleen. Abdominal ultrasound was recommended for this patient to rule out metastasis before proceeding with surgery.
The first surgery of the day was alarplasty, sacculectomy and staphylectomy on a French Bulldog patient. While I had previously observed alarplasty at OSU, this was my first time witnessing a sacculectomy and staphylectomy. A staphylectomy is a surgical procedure that involves resecting the posterior soft palate tissue to open up the airway. Dr. Katherine explained that this procedure has become more aggressive with margin placement, making cuts more caudally along the natural fold of the epiglottis compared to earlier practices in staphylectomy. As for the margin of the laryngeal sacculectomy, it can extend as close as the tubercle lining. I also learned about the slow wake-up from anesthesia as part of the post-op management, providing the patient with more time with mannitol to mitigate the risk of post-op swelling. Dr. Katherine also taught me how to determine the relative width of the trachea on radiographs, which can be assessed by comparing the ratio of trachea width to thoracic width at the measured level. The normal range is approximately >0.18.
Another new surgery I observed was prescapular lymph node removal. Although relatively straightforward, the location of the incision seemed to be a critical factor in this surgery. Watching an enlarged lymph node helped me visualize how and where to palpate prescapular lymph nodes in patients. This week provided ample opportunities to practice lymph node palpation on various patients, which has undoubtedly boosted my confidence and skillset.
I also had the opportunity to perform fine needle aspiration (FNA) for the first time and prepare slides for in-house cytology. The results confirmed the presence of mostly small lymphocytes, with few large lymphocytes. I plan to delve deeper into this topic next week after discussing it further with Dr. Hannah.
In summary, this week was immensely beneficial for building my confidence in a wide range of essential skills I'll need as a future veterinarian. Unfortunately, I must conclude my writing here today as mid-semester exams are beginning tomorrow!
This week's schedule began with shadowing Dr. Marvin during consultations. One of the consultations involved a patient with multiple skin lumps, some of which had been diagnosed as mast cell tumors by the primary veterinarian. Mast cell tumors (MST) are the most common types of skin and subcutaneous tumors and are categorized as low-grade and high-grade. Low-grade MST has an 8-10% metastasis rate with a 5% recurrence rate after removal, while high-grade MST has a 70% metastasis rate with less than a 30% recurrence rate. The patient was a Staffordshire Terrier, a breed predisposed to this disease. Fortunately, the previous diagnosis indicated that all these multiple MSTs in the patient were of the low grade. However, body mapping was recommended to monitor the growth of these tumors and ensure there were no high-grade MSTs, as a single high-grade MST could significantly worsen the prognosis. The treatment of choice would be surgery with radiation, as no recent research suggests that chemotherapy may be effective in preventing recurrence of these multiple masses. Generally, MST metastasis occurs through the lymph nodes and eventually to the liver and spleen. Abdominal ultrasound was recommended for this patient to rule out metastasis before proceeding with surgery.
The first surgery of the day was alarplasty, sacculectomy and staphylectomy on a French Bulldog patient. While I had previously observed alarplasty at OSU, this was my first time witnessing a sacculectomy and staphylectomy. A staphylectomy is a surgical procedure that involves resecting the posterior soft palate tissue to open up the airway. Dr. Katherine explained that this procedure has become more aggressive with margin placement, making cuts more caudally along the natural fold of the epiglottis compared to earlier practices in staphylectomy. As for the margin of the laryngeal sacculectomy, it can extend as close as the tubercle lining. I also learned about the slow wake-up from anesthesia as part of the post-op management, providing the patient with more time with mannitol to mitigate the risk of post-op swelling. Dr. Katherine also taught me how to determine the relative width of the trachea on radiographs, which can be assessed by comparing the ratio of trachea width to thoracic width at the measured level. The normal range is approximately >0.18.
Another new surgery I observed was prescapular lymph node removal. Although relatively straightforward, the location of the incision seemed to be a critical factor in this surgery. Watching an enlarged lymph node helped me visualize how and where to palpate prescapular lymph nodes in patients. This week provided ample opportunities to practice lymph node palpation on various patients, which has undoubtedly boosted my confidence and skillset.
I also had the opportunity to perform fine needle aspiration (FNA) for the first time and prepare slides for in-house cytology. The results confirmed the presence of mostly small lymphocytes, with few large lymphocytes. I plan to delve deeper into this topic next week after discussing it further with Dr. Hannah.
In summary, this week was immensely beneficial for building my confidence in a wide range of essential skills I'll need as a future veterinarian. Unfortunately, I must conclude my writing here today as mid-semester exams are beginning tomorrow!
Week 7
For the first time ever, I returned straight to the university library after a 4-hour drive and 10 hours of shadowing at BVSC. Today, I had the opportunity to observe one of the coolest surgeries I have ever watched – a ureteral stent procedure. I am planning to write my surgical case report for September on this fascinating surgery. In addition to this surgery, I shadowed Dr. Marvin during consultations and observed some cases in the internal medicine department since it was relatively quiet in the surgery department.
Starting with the internal medicine cases, there was a pug patient who had been hospitalized due to a seizure cluster. She had a cardiac arrest, which the veterinarians and nurses were able to resuscitate with CPR. However, the owner ultimately decided to euthanize the dog. While I didn't gain academic knowledge from this case, it did prompt me to contemplate the challenges posed by financial constraints and the difficult decisions that owners sometimes have to make. It left me with the task of reflecting on what qualities make a good veterinarian when it comes to managing these complex and emotional situations.
One of the consultations I observed today also left me with a similar assignment. The owner was financially constrained and unable to pursue all the different diagnostic imaging options to arrive at a definitive diagnosis. The patient, a terrier with a history of mammary gland adenocarcinoma that was removed during her spay, presented with right forelimb lameness. The lameness was severe, classified as grade 4 due to its non-ambulatory nature with no voluntary motor function. While reviewing radiographs from the primary vet, we discovered lysis in the mid-diaphysis area, an uncommon location for osteosarcoma. Consequently, the leading differential diagnosis was metastasis of adenocarcinoma, which we couldn't confirm definitively with an abdominal ultrasound. Due to financial constraints, the owner couldn't proceed with a bone biopsy, and the possibility of euthanizing the dog without a definitive diagnosis was deeply frustrating for me. I understand that veterinarians cannot save every single animal, but this experience has solidified my determination to pursue a career as a surgical oncologist and engage in more research to discover more effective treatments and diagnostics to save more lives.
Lastly, a 4-month-old greyhound patient was presented with abdominal pain two days after spaying. Ureteral damage was highly suspected, and a radiograph with contrast confirmed a rupture of the ureter. Initially, a subcutaneous ureteral bypass was considered, but during the surgery, a ureteral stent was successfully inserted. Handling the fragile stent proved challenging, given its delicate ending, but Dr. Harvey skillfully managed to insert the stent into the kidney and bladder before suturing the ruptured ureter back together. Dr. Joy emphasized the fragility of the ureteral tissue, which can easily develop strictures, underscoring the need for gentle handling to prevent potential complications.
As this month's focus is on soft tissue surgery, I believe this case would make an excellent topic for a case report.
Starting with the internal medicine cases, there was a pug patient who had been hospitalized due to a seizure cluster. She had a cardiac arrest, which the veterinarians and nurses were able to resuscitate with CPR. However, the owner ultimately decided to euthanize the dog. While I didn't gain academic knowledge from this case, it did prompt me to contemplate the challenges posed by financial constraints and the difficult decisions that owners sometimes have to make. It left me with the task of reflecting on what qualities make a good veterinarian when it comes to managing these complex and emotional situations.
One of the consultations I observed today also left me with a similar assignment. The owner was financially constrained and unable to pursue all the different diagnostic imaging options to arrive at a definitive diagnosis. The patient, a terrier with a history of mammary gland adenocarcinoma that was removed during her spay, presented with right forelimb lameness. The lameness was severe, classified as grade 4 due to its non-ambulatory nature with no voluntary motor function. While reviewing radiographs from the primary vet, we discovered lysis in the mid-diaphysis area, an uncommon location for osteosarcoma. Consequently, the leading differential diagnosis was metastasis of adenocarcinoma, which we couldn't confirm definitively with an abdominal ultrasound. Due to financial constraints, the owner couldn't proceed with a bone biopsy, and the possibility of euthanizing the dog without a definitive diagnosis was deeply frustrating for me. I understand that veterinarians cannot save every single animal, but this experience has solidified my determination to pursue a career as a surgical oncologist and engage in more research to discover more effective treatments and diagnostics to save more lives.
Lastly, a 4-month-old greyhound patient was presented with abdominal pain two days after spaying. Ureteral damage was highly suspected, and a radiograph with contrast confirmed a rupture of the ureter. Initially, a subcutaneous ureteral bypass was considered, but during the surgery, a ureteral stent was successfully inserted. Handling the fragile stent proved challenging, given its delicate ending, but Dr. Harvey skillfully managed to insert the stent into the kidney and bladder before suturing the ruptured ureter back together. Dr. Joy emphasized the fragility of the ureteral tissue, which can easily develop strictures, underscoring the need for gentle handling to prevent potential complications.
As this month's focus is on soft tissue surgery, I believe this case would make an excellent topic for a case report.
Week 9
It was a relatively calm day at BVSC. I observed several medical procedures, including a liver biopsy on a small poodle, euthanasia for two wildlife cases with limb fractures, and a cat undergoing a CT scan to investigate a potential meningioma.
To begin with, a small poodle required a surgical liver biopsy referred by the internal medicine team due to its petite liver size. Dr. Joy and Dr. Harvey used a ligasure device for the biopsy and explained the importance of taking a substantial tissue sample to ensure undamaged liver tissue for analysis. I asked whether using sutures for the biopsy might be better for such a small patient, but they clarified that sutures could also damage the tissue and wouldn't significantly differ from a ligasure-based biopsy. This prompted me to realize the need to revisit various liver biopsy methods for a better understanding.
The remaining cases were rather unfortunate. Two wildlife animals were brought in with limb fractures, and euthanasia was the only option. A 15-year-old cat exhibited head pressing behavior, and suspicion of a meningioma arose due to clinical signs such as the absence of menace response (CN2,7) in both eyes, no pupillary light response (CN2,3) in the right eye, and no proprioception in both forelimbs. A CT scan was recommended since surgery is curative for meningiomas. Regrettably, it was discovered that the brain tumor was located at the center of the mid-brain. In this case, palliative treatment options like radiation therapy or ventriculoperitoneal shunts could be considered.
I also had the opportunity to observe corneal burring in a canine patient while shadowing the ophthalmology team. As the upcoming mid-semester exam would cover ophthalmology, I decided to spend a day with the ophthalmology team for valuable insights.
Although witnessing the euthanasia of two animals and observing a cat with a poor prognosis left me feeling somewhat empty, I understand that we cannot save every animal. The essential mindset of a veterinarian is to give their best effort to save lives, and this always motivates me to continue learning and deepen my knowledge. I have about one to one and a half months left for my externship at BVSC, and I'm determined to put in even more effort to expand my knowledge further.
To begin with, a small poodle required a surgical liver biopsy referred by the internal medicine team due to its petite liver size. Dr. Joy and Dr. Harvey used a ligasure device for the biopsy and explained the importance of taking a substantial tissue sample to ensure undamaged liver tissue for analysis. I asked whether using sutures for the biopsy might be better for such a small patient, but they clarified that sutures could also damage the tissue and wouldn't significantly differ from a ligasure-based biopsy. This prompted me to realize the need to revisit various liver biopsy methods for a better understanding.
The remaining cases were rather unfortunate. Two wildlife animals were brought in with limb fractures, and euthanasia was the only option. A 15-year-old cat exhibited head pressing behavior, and suspicion of a meningioma arose due to clinical signs such as the absence of menace response (CN2,7) in both eyes, no pupillary light response (CN2,3) in the right eye, and no proprioception in both forelimbs. A CT scan was recommended since surgery is curative for meningiomas. Regrettably, it was discovered that the brain tumor was located at the center of the mid-brain. In this case, palliative treatment options like radiation therapy or ventriculoperitoneal shunts could be considered.
I also had the opportunity to observe corneal burring in a canine patient while shadowing the ophthalmology team. As the upcoming mid-semester exam would cover ophthalmology, I decided to spend a day with the ophthalmology team for valuable insights.
Although witnessing the euthanasia of two animals and observing a cat with a poor prognosis left me feeling somewhat empty, I understand that we cannot save every animal. The essential mindset of a veterinarian is to give their best effort to save lives, and this always motivates me to continue learning and deepen my knowledge. I have about one to one and a half months left for my externship at BVSC, and I'm determined to put in even more effort to expand my knowledge further.
Week 11
Today, I had the opportunity to shadow the ophthalmology team, led by Dr. Anna and Dr. Laura. It was a pleasant surprise to reconnect with Dr. Becky and Dr. Laura, whom I had met back in vet school during my first and second years. It always amazes me how time flies when I see them now in the midst of their residencies. But let's get back to the main topic; I observed four different surgical procedures today, including one orthopedic surgery and numerous ophthalmology consultations.
I'd like to briefly share my observations of the surgeries I witnessed. The first patient was a pug requiring cataract surgery and a permanent medial tarsorrhaphy procedure. Frankly, studying ophthalmology in school was somewhat dull, but witnessing this delicate surgery was an entirely different experience. Unfortunately, I'm short on time to provide a detailed account, so I'll summarize the cataract procedure briefly. A small incision is made on the dorsal or ventral cornea to allow access to the ultrasound machine, which is used to break down the cloudy lens material and remove debris. Once all the lens material is cleared, an artificial dog lens is placed, which comes with a frame that fits and secures the lens in the original position. Finally, everything is sutured back together. Regrettably, this patient experienced a suture break from the medial tarsorrhaphy later in the afternoon, requiring another surgery that I couldn't witness due to another ongoing orthopedic surgery.
The second patient presented with a descemetocele, and a corneal conjunctival transposition procedure was performed. The cornea was mainly used for the flap, with the very thin epithelial layer removed, and half of the stroma layer was also excised, while the remaining half was used as a flap. Watching these intricate layers being manipulated and removed in real-time was truly awe-inspiring compared to studying them on histological slides.
Lastly, the last patient came in with neck pain, and a suspected meningioma mass was detected on a CT scan. The mass was located beneath the C2 vertebra, intradural and extramedullary. Dr. Katherine successfully removed it using a dorsal laminectomy approach, but there were challenges in controlling bleeding from delicate blood vessels around the lateral C1 area. Additionally, defining the dura layer for surgical access was tricky. Dr. Katherine initially used a needle for cutting but later switched to a probe-like instrument, the name of which I'm not familiar with. To be honest, I couldn't fully follow or comprehend the entire procedure, but it was still a valuable experience. It showed me how surgeons handle complex surgeries and adapt when unexpected complications arise.
I have one or two more days scheduled at BVSC in the upcoming weeks as the second semester is drawing to a close. Balancing the demands of vet school with spending an entire day at BVSC has been challenging, but it has undoubtedly been a meaningful and enriching experience.
I'd like to briefly share my observations of the surgeries I witnessed. The first patient was a pug requiring cataract surgery and a permanent medial tarsorrhaphy procedure. Frankly, studying ophthalmology in school was somewhat dull, but witnessing this delicate surgery was an entirely different experience. Unfortunately, I'm short on time to provide a detailed account, so I'll summarize the cataract procedure briefly. A small incision is made on the dorsal or ventral cornea to allow access to the ultrasound machine, which is used to break down the cloudy lens material and remove debris. Once all the lens material is cleared, an artificial dog lens is placed, which comes with a frame that fits and secures the lens in the original position. Finally, everything is sutured back together. Regrettably, this patient experienced a suture break from the medial tarsorrhaphy later in the afternoon, requiring another surgery that I couldn't witness due to another ongoing orthopedic surgery.
The second patient presented with a descemetocele, and a corneal conjunctival transposition procedure was performed. The cornea was mainly used for the flap, with the very thin epithelial layer removed, and half of the stroma layer was also excised, while the remaining half was used as a flap. Watching these intricate layers being manipulated and removed in real-time was truly awe-inspiring compared to studying them on histological slides.
Lastly, the last patient came in with neck pain, and a suspected meningioma mass was detected on a CT scan. The mass was located beneath the C2 vertebra, intradural and extramedullary. Dr. Katherine successfully removed it using a dorsal laminectomy approach, but there were challenges in controlling bleeding from delicate blood vessels around the lateral C1 area. Additionally, defining the dura layer for surgical access was tricky. Dr. Katherine initially used a needle for cutting but later switched to a probe-like instrument, the name of which I'm not familiar with. To be honest, I couldn't fully follow or comprehend the entire procedure, but it was still a valuable experience. It showed me how surgeons handle complex surgeries and adapt when unexpected complications arise.
I have one or two more days scheduled at BVSC in the upcoming weeks as the second semester is drawing to a close. Balancing the demands of vet school with spending an entire day at BVSC has been challenging, but it has undoubtedly been a meaningful and enriching experience.
Externship Review
Week 3
During week 3, a patient underwent a splenectomy due to a splenic mass. I observed the splenectomy procedure at JanJaeyoung Veterinary Surgery Hospital and Ohio State University previously. The procedure itself was quite similar, but this patient had the largest mass I had ever seen. It wasn't just the size of the mass that differed, but I also noticed a significant improvement in my knowledge and the questions I could formulate over time.
Initially, I was curious about whether such a large mass might increase the likelihood of gastric dilatation and volvulus (GDV) compared to a normal splenectomy, considering the increased space in the abdominal cavity. However, Dr. Marvin explained that this was unlikely to cause GDV in this patient, as the patient wasn't deep-chested, and he mentioned that he would definitely perform gastropexy for a German Shepherd. Another concern I had was the potential for infection and metastasis from the hemabdomen. Dr. Marvin clarified that blood is sterile, and regardless of the type of spleen cancer, the prognosis remains similar. Hemangiosarcoma is the most common type of spleen cancer, by the way.
I had the opportunity to observe and practice musculoskeletal and neurologic examinations with different patients, which coincided perfectly with the MSK/Neuro exam tutorial I had earlier in the week at school. It was enlightening to witness various clinicians performing these examinations with different priorities and techniques.
Revisiting a patient who underwent arthrodesis provided an ideal case to reinforce the orthopedic lecture from earlier in the week. I learned that arthrodesis patients tend to experience swelling at the surgical site due to the aggressive nature of clearing joint cartilage, and proper bandaging is crucial. Although these patients may exhibit an unusual gait during the healing process, their quality of life appears to remain satisfactory (The patient was observed engaging in running and jumping activities on the seventh day post-op, which unfortunately led to an instance of dehiscence.). Once again, I observed that the choice of bandage type and degree of tightness varied based on the surgeon's preference.
The removal of a chest tube was a relatively straightforward procedure, yet observing the change in the patient's comfort level before and after the removal was enlightening. It was evident how uncomfortable the tube could be for the patient, and I gained insights into the decision-making process for tube removal based on the type of fluid or air extracted, including cytology.
Lastly, I encountered the kitten again from the first week, which had initially presented with a pathological fracture due to an imbalanced diet from the breeder. The kitten returned for a recheck before scheduling surgery. I inquired about the necessity of plate removal for the growing kitten, given that the fracture was not on the physis. Dr. Marvin reassured me that plate removal would not be required, as the fracture did not affect the physis and the kitten's bone growth would proceed normally.
Initially, I was curious about whether such a large mass might increase the likelihood of gastric dilatation and volvulus (GDV) compared to a normal splenectomy, considering the increased space in the abdominal cavity. However, Dr. Marvin explained that this was unlikely to cause GDV in this patient, as the patient wasn't deep-chested, and he mentioned that he would definitely perform gastropexy for a German Shepherd. Another concern I had was the potential for infection and metastasis from the hemabdomen. Dr. Marvin clarified that blood is sterile, and regardless of the type of spleen cancer, the prognosis remains similar. Hemangiosarcoma is the most common type of spleen cancer, by the way.
I had the opportunity to observe and practice musculoskeletal and neurologic examinations with different patients, which coincided perfectly with the MSK/Neuro exam tutorial I had earlier in the week at school. It was enlightening to witness various clinicians performing these examinations with different priorities and techniques.
Revisiting a patient who underwent arthrodesis provided an ideal case to reinforce the orthopedic lecture from earlier in the week. I learned that arthrodesis patients tend to experience swelling at the surgical site due to the aggressive nature of clearing joint cartilage, and proper bandaging is crucial. Although these patients may exhibit an unusual gait during the healing process, their quality of life appears to remain satisfactory (The patient was observed engaging in running and jumping activities on the seventh day post-op, which unfortunately led to an instance of dehiscence.). Once again, I observed that the choice of bandage type and degree of tightness varied based on the surgeon's preference.
The removal of a chest tube was a relatively straightforward procedure, yet observing the change in the patient's comfort level before and after the removal was enlightening. It was evident how uncomfortable the tube could be for the patient, and I gained insights into the decision-making process for tube removal based on the type of fluid or air extracted, including cytology.
Lastly, I encountered the kitten again from the first week, which had initially presented with a pathological fracture due to an imbalanced diet from the breeder. The kitten returned for a recheck before scheduling surgery. I inquired about the necessity of plate removal for the growing kitten, given that the fracture was not on the physis. Dr. Marvin reassured me that plate removal would not be required, as the fracture did not affect the physis and the kitten's bone growth would proceed normally.
Week 5
This week has certainly been one of the most challenging for me. Balancing a demanding schedule, including a 4-hour commute for my clinical externship, starting my own research proposal, reading through 12 books and preparing for 3 book club meetings in August, along with managing 2 mid-semester exams and 1 assignment while attending vet school, has been no easy feat. However, there's a sense of fulfillment in every moment spent tackling these tasks.
Speaking of my experiences at BVSC this week, I had the opportunity to witness one of the longest surgeries I've participated in so far. The patient presented with a cystolith and, interestingly, we discovered both an adrenal mass and an anal mass incidentally. It was a fascinating experience to address all three issues in a single surgery.
Starting with the clean procedure, the adrenalectomy, I was able to differentiate the prenicoabdominal vein and renal artery. The prenicoabdominal vein runs close to the adrenal, while the renal artery is situated dorsally to the kidney and adrenal gland. This anatomical arrangement adds complexity to the surgery. Due to the relatively small size of the vein, Dr. Marvin opted to hemoclip it before ligating it with the Ligasure device, which can securely ligate vessels down to a minimum size of 7mm. The challenge was compounded by the fact that the right-side adrenalectomy is more intricate due to the dorsal-caudal location of the kidney and adrenal gland. The procedure demanded delicate precision to avoid any rupture of adrenal gland or its artery.
Following the adrenalectomy, we performed a cystotomy, a procedure I've had the opportunity to engage at OSU. Lastly, I observed an anal sacculectomy, a procedure I've missed out on during my time at CSU. This particular surgery is typically performed in a closed manner to prevent contamination complications. In this case, it was done as part of mass removal and so was done in closed manner as well. The mass showed poorly demarcated margins from the anal gland, making it challenging to achieve a clear margin. Dr. Marvin emphasized the importance of thoroughly checking the glandular part of the anal gland after the mass was dissected to ensure no residual tissue remained.
Today, I observed two thyroidectomy surgeries, though I could only watch the entirety of one due to timing constraints. Thyroidectomy turned out to be relatively simpler and quicker than I had imagined. The procedure involved a continuation of blunt dissection, with the main anatomical concerns being the jugular vein and carotid artery and addressing any of these potential complications with clamping and ligation will ensure a successful procedure. Interestingly, my readings from Withrow's textbook and Dr. Julius Liptak's website indicated that 30-50% of thyroid cancer cases are likely benign tumors. Metastasis rates vary: if the mass is under 5cm, the rate is 20%, while 40% of patients are diagnosed with metastasis, and 80% develop metastasis over the long term.
Lymph node palpation has been an area I've been focusing on improving since my externships at OSU and CSU. This week, I had the opportunity to practice palpating various lymph nodes and received invaluable guidance from both nurses and clinicians regarding their precise anatomical locations. This practice has been beneficial, and I aim to continue refining my lymph node palpation skills during my time at BVSC. I also performed my first anal palpation, marking a milestone in my learning journey.
Furthermore, I engaged in a lot of bandaging work today. The practical bandaging session I had at school last week provided a solid foundation, and now everything is making more sense as I encounter different scenarios and styles under the guidance of various clinicians. This has served as a valuable revision and an opportunity to learn diverse bandaging techniques.
In conclusion, despite the demanding nature of this week, every experience I've had at BVSC has been incredibly enriching, allowing me to learn and grow in various aspects of veterinary medicine.
Speaking of my experiences at BVSC this week, I had the opportunity to witness one of the longest surgeries I've participated in so far. The patient presented with a cystolith and, interestingly, we discovered both an adrenal mass and an anal mass incidentally. It was a fascinating experience to address all three issues in a single surgery.
Starting with the clean procedure, the adrenalectomy, I was able to differentiate the prenicoabdominal vein and renal artery. The prenicoabdominal vein runs close to the adrenal, while the renal artery is situated dorsally to the kidney and adrenal gland. This anatomical arrangement adds complexity to the surgery. Due to the relatively small size of the vein, Dr. Marvin opted to hemoclip it before ligating it with the Ligasure device, which can securely ligate vessels down to a minimum size of 7mm. The challenge was compounded by the fact that the right-side adrenalectomy is more intricate due to the dorsal-caudal location of the kidney and adrenal gland. The procedure demanded delicate precision to avoid any rupture of adrenal gland or its artery.
Following the adrenalectomy, we performed a cystotomy, a procedure I've had the opportunity to engage at OSU. Lastly, I observed an anal sacculectomy, a procedure I've missed out on during my time at CSU. This particular surgery is typically performed in a closed manner to prevent contamination complications. In this case, it was done as part of mass removal and so was done in closed manner as well. The mass showed poorly demarcated margins from the anal gland, making it challenging to achieve a clear margin. Dr. Marvin emphasized the importance of thoroughly checking the glandular part of the anal gland after the mass was dissected to ensure no residual tissue remained.
Today, I observed two thyroidectomy surgeries, though I could only watch the entirety of one due to timing constraints. Thyroidectomy turned out to be relatively simpler and quicker than I had imagined. The procedure involved a continuation of blunt dissection, with the main anatomical concerns being the jugular vein and carotid artery and addressing any of these potential complications with clamping and ligation will ensure a successful procedure. Interestingly, my readings from Withrow's textbook and Dr. Julius Liptak's website indicated that 30-50% of thyroid cancer cases are likely benign tumors. Metastasis rates vary: if the mass is under 5cm, the rate is 20%, while 40% of patients are diagnosed with metastasis, and 80% develop metastasis over the long term.
Lymph node palpation has been an area I've been focusing on improving since my externships at OSU and CSU. This week, I had the opportunity to practice palpating various lymph nodes and received invaluable guidance from both nurses and clinicians regarding their precise anatomical locations. This practice has been beneficial, and I aim to continue refining my lymph node palpation skills during my time at BVSC. I also performed my first anal palpation, marking a milestone in my learning journey.
Furthermore, I engaged in a lot of bandaging work today. The practical bandaging session I had at school last week provided a solid foundation, and now everything is making more sense as I encounter different scenarios and styles under the guidance of various clinicians. This has served as a valuable revision and an opportunity to learn diverse bandaging techniques.
In conclusion, despite the demanding nature of this week, every experience I've had at BVSC has been incredibly enriching, allowing me to learn and grow in various aspects of veterinary medicine.
Week 8
Finally, I went down to BVSC without worrying about exams coming up next week but instead just worrying about how I'm going to finish my assignment next week! Today, I was able to watch three surgeries in total!! Isn't that amazing? I was getting physically and mentally tired as the semester was becoming very busy and stressful, but I really found that every moment I spent at BVSC was relaxing and rewarding. Being able to watch and do what I truly enjoy and pursue has been a great experience.
Before diving into the details of the surgeries or discussing what I did today, I'd like to share my thoughts on why I think I love surgery specifically. Firstly, how do I know I like surgery more than other things? I've noticed that I don't get mentally fatigued with all these surgeries or after working overtime during my externships, and I've found that I truly love this job. It was only during BVSC externships that I started to discover specific reasons why I love surgery. One of the reasons is the fact that I used to be a perfectionist and have been working hard not to be one for a long time to avoid stressing myself. However, being a surgeon is one of the few professions that require a perfectionist mindset. I also love the moment when I naturally become immersed in the surgical procedure during surgery. Maybe I'll create another whole post about this topic, but this is what I recently discovered during my externship at BVSC, spending time with surgeons who truly love their jobs.
The first surgery of the day was the removal of retropharyngeal lymph nodes and prescapular lymph nodes. The patient was only two years old and suspected to have lymphoma. To proceed with proper treatment, an excisional biopsy was required. Sometimes, surgical excision of a mass can be curative in Hodgkin lymphoma, but with multiple lymph node enlargements on physical exam, it seemed more likely to be a non-Hodgkin lymphoma. During my last externship at CSU, Dr. Aki explained to me why she prefers to approach the easier side of the mass for excision. During the surgery today, I could think of why the medial side of the mass was approached first, even with two close complicated structures: the carotid artery and vagus nerve, while the lateral side had only a single complication, the jugular vein. I concluded that the medial side might offer more room for incision, being closer to the incision site. This may not be the only or correct reason, but I could see that my thinking process has been expanding.
The second surgery was relatively short and involved the removal of a soft tissue sarcoma on the plantar surface. The mass was relatively large compared to the size of the dog, a Maltese patient. Dr. Marvin mentioned that leaving as much skin as possible is key for this surgery to facilitate the healing process, especially if radiotherapy may be planned after obtaining the biopsy result. I also thought that minimizing dead space with a walking suture might be crucial since the surgical site had limited soft tissue structures compared to the relatively large mass.
The last surgery of the day was the highlight! It was a TPLO surgery, my first since I completed my TPLO surgery report. It was so rewarding to understand every step of the surgery and the reasoning behind the surgeon's moves throughout the procedure. It was also the second laparoscopic surgery I watched since the laparoscopic spay at OSU. Dr. Craig mentioned that he personally prefers not to use the zigzag pattern, and I could tell that he prioritizes minimizing surgery time in general. He even let me cut out the cranial cruciate ligament, which was so cool! I also assisted Dr. Joy in her first TPLO surgery by preparing the screw and changing the driver head for the next procedure. I found that it's not as easy as it looks. Even picking up the screw with the small forceps didn't go as smoothly as I imagined. I truly realized that surgery requires a lot of practice and is not as easy as it appears. It served as a reminder that these residents and specialists have gone through countless cases to make these procedures look easy, which was a great motivator for me to work as hard as these amazing people.
Week 10
Today, I had the opportunity to spend a significant amount of time with Dr. Craig, and I thoroughly enjoyed his thought-provoking questions. His inquiries often shed light on what I don't know and what areas I should focus on for further study. For instance, despite recently completing my orthopedics paper exams at school, I found myself struggling to provide satisfactory answers to his questions about the primary elbow injuries in dogs. Although Dr. Craig's challenging questions can be nerve-wracking as he always ask questions during consultations, they undeniably help me retain knowledge for a longer period. I genuinely appreciate these stimulating inquiries.
The only surgical procedure I was involved in today was the removal of a lag screw from a patient who had presented with a short oblique fracture on the distal tibia. This procedure appeared relatively straightforward, and it seemed that a more aggressive approach with the tissues was necessary to locate the screw head, as it could be challenging to locate otherwise.
I really wish I had more time to thoroughly study and cover all the topics that Dr. Craig has discussed with me. However, this week has been quite challenging in terms of time management, as I've been busy catching up on lectures, completing assignments, preparing surgery reports, and getting ready for the upcoming mid-semester exam. Therefore, I will briefly summarize three key areas of study at the same level of depth as I have done in the photo below.
The only surgical procedure I was involved in today was the removal of a lag screw from a patient who had presented with a short oblique fracture on the distal tibia. This procedure appeared relatively straightforward, and it seemed that a more aggressive approach with the tissues was necessary to locate the screw head, as it could be challenging to locate otherwise.
I really wish I had more time to thoroughly study and cover all the topics that Dr. Craig has discussed with me. However, this week has been quite challenging in terms of time management, as I've been busy catching up on lectures, completing assignments, preparing surgery reports, and getting ready for the upcoming mid-semester exam. Therefore, I will briefly summarize three key areas of study at the same level of depth as I have done in the photo below.
