Caring For Lindy: Feeling Guilty

I've been caring for a cat with chronic kidney disease (which I learned was the proper term today) for a long time. Years.

Normally, I don't feel too guilty about things with Lindy. However, I can still remember a few occasions of intense emotion and regret.

One was when she was first diagnosed. She was two years old and I was in veterinary technology school. I'd learned in school that polyuria (increased urination) and polydipsia (increased drinking, which is most often a result of the polyuria) were not normal. I'd also noticed that Lindy was significantly PU/PD (shorthand for polyuric/polydipsic) compared to Simon. I brought her into her veterinarian's office and requested blood work. The vet said I was nuts but if I wanted to waste my money running blood work on a healthy two year old cat then she'd do it.

She called the next morning to say that Lindy was azotemic and her urine was isosthenuric. In short, she had chronic kidney disease. I felt like someone had just punched me in the stomach, wishing I had caught it earlier. I put Lindy on a kidney diet and she did well for awhile...

(Note for all my veterinarian readers-- looking back at her paperwork from the rescue group, Lindy had a high creatinine when she was spayed at six months. I'll never know if her problems stemmed from congenitally deformed kidneys or from one or a number of UTIs either when she was a feral kitten or possibly silent/not clinically symptomatic UTIs while she was in my care-- ultrasound at age 2 didn't show any cysts, which was my fear then, just gross structural changes)

She continued to do fine for several years.. until I left her with my then girlfriend in the Santa Cruz mountains for a weekend, where she had her first acute on chronic episode-- I suspect because my girlfriend deprived her of water for a long time (since cats with chronic kidney disease cannot concentrate their urine they dehydrate easily which leads to the kidneys getting less blood flow which causes further damage in a vicious cycle) but I'll never be able to prove the neglect. I still feel guilty for leaving her there that weekend. She's been on fluids ever since, 175 ml LRS every night (she's a big cat).

She's also on aluminum hydroxide and pepcid. Why? Up until this week all I knew was that the aluminum hydroxide was to bind phosphate, which was high. And that pepcid was for the uremia resulting from high levels of toxins in her blood (BUN, creatinine).

Well, I learned a whole heck of a lot more this week.

Gastrin is a peptide that is normally filtered at the glomerulus, but due to the decreased glomerular filtration rate in chronic kidney disease, gastrin is filtered less and so builds up in the blood. Gastrin stimulates hydrochloric acid release by increasing histamine release from enterochromaffin-like cells and hence the drug used to block its action is a histamine receptor antagonist, pepcid.

Phosphorous is also filtered at the glomerulus, and like gastrin its levels in the blood become increased as a result of the decreased glomerular filtration rate seen with chronic kidney disease. In fact, renal failure is the most common cause of hyperphosphatemia according to my notes.
And here is the part I was totally clueless about up until Friday-- consequences of hyperphosphatemia. My notes list two:
1. Metabolic acidosis. Inorganic phosphorous is present in many acidic forms so with hyperphosphatemia there is a buildup of acids.
2. TISSUE MINERALIZATION !!! Hyperphosphatemia also promotes increased calcium complexing with phosphorous. If excessive, it can lead to precipitation of the calcium-phosphorous complexes, allowing mineralization and damage within the soft tissues.

I didn't realize that when I frequently skipped giving Lindy a phosphate binder for weeks at a stretch around the time of my neuroanatomy final that she was probably beginning to mineralize her stomach, kidney and lungs. It's so incredibly awful that it makes me feel sick just thinking about it.

It's not all my fault though. Client education, folks. You can bet that I will explain to my clients exactly WHY they are giving the phosphate binder to their pet with chronic kidney disease and what the results will be if phosphorous levels are not kept from becoming high.

I wanted to cry all Friday afternoon after my chronic kidney disease function/dysfunction rounds. Instead I studied with a bunch of classmates. But I still feel terrible about it.

Feeling Lucky To Be In Vet School: Fish Lecture

I got to go to a really neat lecture last night that made me feel lucky to be in vet school. The lecture was titled "Aquatic Pet Cases Important For All Vets To Know" and was given by a local veterinarian from Buffalo, Dr. Helen Roberts. She owns an exotic practice and sees many clients with pet fish. She also writes extensively on the subject and is involved in all aspects of pet fish medicine.

I feel lucky to be part of a profession that is so diverse. I don't know if I will ever treat pet fish, but this lecture definitely piqued my interest and made me want to learn more about fish anatomy and medicine (both of which are covered in separate distribution courses offered during the winter that I may elect to take).

It's just neat to know that I could treat anything from a pet fish to an Amazon parrot as a veterinarian (if I chose to develop expertise in those areas).

Here are a few interesting points that I gleaned from her lecture:

• Water quality evaluation is part of the minimum database for fish.

• Poor water quality is the most common stressor of fish and kills more fish than infectious diseases

• How long has the pond been around is an important question to ask when treating fish who live in ponds.

• Signs of parasites include weight loss, abdominal distension and buoyancy disorders.

• Fluorescin dye can be used to show superficial ulcers on the skin of fish.

• You can do a neurological exam on a fish.
  

Guide Dog Puppy Love

Check out this adorable, squishably lovable German shepherd puppy dog that is in training to be a guide dog for the blind. See how attentive she is to her trainer in the top photo, see the intelligent, inquisitive look on her face? (I know she isn't wearing a jacket, but she's just a baby). Her current trainer will have her for 16-18 months. It's the kind of thing I hope to be able to do someday...

A Different Kind Of Spooning

The top photos is with my new camera (thanks again!). The bottom photos are from my old camera. Note how neatly I always make my bed.

Back To The Law School To Hear Shannon Minter Speak

Above: The law school on a typical rainy spring day. It reminds me a lot of the style of buildings at Duke, where my father teaches.

It's the unusual veterinary student who makes the long trek down to the law school on two separate occasions within one week. But it was well worth the effort. Hearing Shannon Minter speak was way more of a treat than the same-sex marriage debate with Maggie Gallagher last week.

Once again, I feel woefully inadequate trying to summarize what I heard. I'm just not that conversant in legal matters. But it was the first time I had heard anything substantial about Perry v. Schwarzenegger so that was super interesting. The one name that stuck in my mind was Ilan Meyer, who gave expert testimony on the effects of stress on minorities. Minter said that Meyer stated that a situation that is not inherently very stressful becomes stressful for a minority because it invokes the reminder that the whole social and legal system opposes them. I would be more eloquent writing about this if I had taken any notes and if it weren't fairly late on a school night when I have a lot else to do.

One interesting legal tidbit that I picked up is that it matters how California's Supreme court interpreted the victory of proposition 8 and their interpretation of it being a denial of rights to a minority, or something like that, might matter immensely in how the courts handle the current appeal. This was something I hadn't understood before-- apparently no higher court can redefine the meaning once constructed by the California Supreme court. Again, sorry if this makes no sense as this is not my area of expertise by any means.

While certain areas of law are incredibly fascinating, I am still responsible for learning the entire physiology of the kidney this week and so must get back to work.

I definitely felt Minter's excitement and anticipation when he talked about current legal cases. Suffice to say that while a substantial portion of my class has spent the last few days taking breaks to watch vampire flicks, I'd much rather be at the law school when I'm not studying. It's not even that it's a more meaningful diversion, it actually is more thrilling to me, there is more plot tension in the same-sex marriage legal saga for me than in any movie.

Remind Me Why I'm Going To School Again: Problem Lists

As the year has gone on, I've become progressively more disillusioned with school. It seems like a lot of what we do is memorize and regurgitate copious volumes of information. And the worst part is, I don't even remember a good portion of it past the exam.

I'm tired of memorizing. Besides, you can look just about anything up on the internet these days, or if you are more old-fashioned, in a book.

I've had two brilliant professors remind me this past week of why I'm here and what I'm ultimately supposed to be learning.

The first introduced my class to POMS, the Problem-Oriented Medical Scheme. As part of this, we learned a mnemonic for coming up with differential diagnoses, DAMNIT-V. It stands for:
Degenerative (chronic, progressive)
Anomalous (i.e. congenital abnormality)
Metabolic (systemic metabolic derangement)
Neoplasia
Infectious, Inflammation
Trauma, Toxin
Vascular (compromise blood flow to an organ)

I'm thrilled to have been given a more systematic way to approach cases and have started trying to come up with differential diagnoses using this scheme every time I hear/see/read about a case.

He also introduced us to the concept of a problem list, which comes before the differential diagnosis. A problem list is made from the initial abnormality list and has to account for every single abnormality in the smallest number of possible listed problems. It is also critically important that the problems do not include any assumptions and are only "defined to the highest level of understanding," not beyond.

Then on Friday, in our Function/Dysfunction Rounds, the professor (a different one) started by emphasizing the importance of a problem list to us again. He said that one of the most important skills we can develop as students is the ability to generate a good (i.e. concise yet complete) problem list, because from that one can then quickly come up with a list of differential diagnoses that does not miss anything.

And as it turns out, not missing anything is the name of the game. And my Achilles heel. I want to jump straight to the most likely scenario/differential diagnosis based on my clinical experience. And that is the biggest pitfall I have to learn to avoid. Tunnel vision is not just my problem, it plagues all veterinarians at various times and judging from my professors' stories, can lead to some truly horrific mistakes.

The professor lecturing on Friday said that something like 80% of cases could be diagnosed by someone who compiled a list of signs and used the internet. It's the other 20% that are tricky. But if you always go straight to the most likely diagnosis without making a list of differential diagnoses and ruling in/out/down each one then you will miss that 20%.

I guess it's a good enough reason to keep memorizing in the meantime.

But what I'm really interested in is the analytical thinking. One year and at the very end I finally get to the problem list. The tantalizing part. Now the question is how to get good at generating one. Of course, part of that is oodles more memorization so that I can actually come up with differentials that I don't even know now (yay for my bacteriology, virology, parasitology class next year).

At least I know that some analytical, critical thinking lies ahead, thank goodness.

Beautiful, Lazy Saturday: Pileateds And Lucifer Falls

Today was one of the most beautiful days we have had all spring in Ithaca.

I had a nice breakfast of French toast and spicy buffalo sausage patties with my roommate and then headed out to the Farmer's Market to pick up my usual weekly staples, bread, salad and apples. The guy that I usually buy my free range eggs from had duck eggs, which is something I've wanted to try for awhile so I picked up a few of those. I really like trying out new things at the farmer's markets. In California, I got into cooking fish that way-- there was a guy I'd buy fresh fish from every week and it was how I got my first taste of sand dabs, sablefish and squid. Here in Ithaca, I've been experimenting with different varieties of buffalo (from steak to heart to sausage though I have not yet been brave enough to try tongue) as there is a nearby buffalo farm that sells meat at the farmer's market.

On the way home from the farmer's market, driving up Stone Quarry road, a crow-sized bird with flashes of black and white on its wings flew across the road in front of me. I slowed down, turned my head and saw the unmistakable shock of red feathers on the bird as it landed on a tree trunk-- a pileated woodpecker! That makes the third time I have seen a pileated woodpecker in my life, the other two were in Maryland two summers ago.

In the afternoon, I went on a four plus mile hike in Robert H. Treman state park. I stupidly decided not to take my camera because I didn't want to slow down my roommate by taking a ton of pictures. We hiked up to Lucifer falls, which is quite an uphill at the end, and then back down. Although I didn't take photos, you can find plenty of photos of the falls on the internet if you're curious about what it looked like.