Y4 Weeks 5 and 6: Small Animal Internal Medicine Rotation!

Just like that, the first rotation has come and gone! Since our fourth-year schedule is different than the prior didactic years, I will be doing a rotation debrief roughly every two weeks instead of a weekly blog.

My first two-week rotation was in Small Animal Internal Medicine, which is a specialty dedicated to treating complex, chronic, and rare diseases. Internists focus on the intricate interactions of internal organs and bodily systems and are experts in the fields of endocrinology, gastroenterology, nephrology/urology, immunology, hematology, and respiratory diseases. The specialists in this field are absolutely brilliant, and I am always in awe of the amount of information they are able to contain within their brains.

Having internal medicine as my first rotation was slightly nerve-wracking due to the notoriously demanding reputation of this rotation. This would also be our first time official time working in the Veterinary Medical Teaching Hospital (VMTH), so the novelty of it all added to the anxiety. Every hospital has their own rules and regulations, and the VMTH is no different. That being said, during the first week there was a steep learning curve. Luckily, we were not completely thrown to the wolves because the graduating fourth years overlap their final two weeks in the clinic with our first two weeks.

The outgoing fourth years on internal medicine were absolutely phenomenal. They helped us gain our footing and kindly explained things (multiple times). I am incredibly grateful for the overlapping period and the patience and guidance they provided. During that precious period of time I took advantage of our senior classmates and learned as much as I could about the hospital policies and also sought advice regarding their clinical year experience. I was also able to buddy up with Blythe, a graduating fourth year that I had met during my second year of vet school at a triathlon!

A typical day on internal medicine began between 7 and 7:30 with in-patient care and treatments. We were responsible for walking our patients, getting their vitals (temp, pulse, respiration, weight), cleaning their catheter, and administering their morning medications. We would then meet from 8:15-9 to discuss any cases that were transferred to our service overnight and come up with a treatment plan. We also used that time to discuss our in-patients and any pertinent changes in their wellbeing. I found these morning round sessions to be incredibly helpful and beneficial to my learning. There were times when we were put on the spot, which is something that many students do not enjoy, and a main reason internal medicine has a scary reputation, but in all honesty that is where the most learning occurred. Prior to entering the rotation, I was worried that I wasn’t ready and didn’t know enough which is completely natural and I know almost all of my classmates felt the same way. Even though I have only ever had positive interactions with faculty, my brain somehow convinced me that once we entered the clinic, we were supposed to be little experts and would be burned at the stake if we didn’t know the answer. I can assure you that this is absolutely false, and the whole reason we have a clinical year is to help form mental connections between the lecture material and clinical cases. The faculty on internal medicine were absolutely wonderful and extremely encouraging. We were not expected to know all the answers, but we were expected to try. They pushed us in a way that was challenging and made us think but also cultivated a safe place to be incorrect and learn. The residents also did an amazing job at facilitating a productive learning environment and were extremely supportive. After morning rounds were done, the day would usually consist of appointments and procedures.

Over the past two weeks I was able to observe some awesome procedures. I saw a cystoscopic laser lithotripsy, which involves passing a thin, flexible scope with a camera through the urethra into the bladder to find the stone(s). Once the stone is located, a laser is used to break the stone apart and then a little basket is used to collect the fragments and remove them from the bladder. This is a minimally invasive way to remove bladder stones, and it was exciting to watch. I also observed a foreign body removal with an endoscope which was impressive. I also observed feeding tube placements including nasogastric tubes and percutaneous endoscopic gastrotomy (PEG) tube placement. Since internal medicine encompasses multiple organ systems, I also had the opportunity to observe multiple echocardiograms with the cardiology service.

Lithotripsy PPE

After all the appointments and procedures have ended for the day, we would regroup and have another variation of “rounds”. On Monday, we would round on the cases from the day and our transfer patients. On Tuesday and Thursday, we would have topic rounds where we were able to request topics to dive into with our faculty mentors. On Wednesday and Friday, we did not have scheduled afternoon rounds. Once the rounds sessions were over, we would work as a team to complete the evening patient care tasks which included a walk, vital signs. The amazing ward technicians helped perform the evening medical treatments which was greatly appreciated!

On the internal medicine service, there are weekend responsibilities and between the two groups (side A and B) transfer responsibilities are split. Since rotations are typically 2 to 4 weeks, one side will take transfers for one weekend, and the other side will take them the following weekend. On my first weekend we did not have transfers, so we were just responsible for patient care in the morning and evening and then had some time in the middle of the day to get other things done. This past weekend we had transfer responsibility and received two transfers from the ER each day. These days were slightly longer since we were performing diagnostics for these new patients and formulating a treatment plan. Each week we get a 24-hour period off.

This past week I also had the opportunity to step outside my comfort zone and present a case at Grand Rounds which happens every other Wednesday morning. I vividly remember attending a Grand Rounds presentation while on a mini-shadow day during my first or second year of vet school and being nervous for the student presenting because the audience was full of students, residents, and faculty. Flash forward a few years and when there was a call for volunteers to present, I didn’t even hesitate. I have gotten to a point in my life where I do most things for one of three reasons, I genuinely enjoy it, I know it will be good for me in the long run, or it scares me. This opportunity combined all three of those reasons and my initial mental response of “heck no” confirmed that I needed to volunteer. I had the privilege of presenting a case for a sweet dog with a protein-losing enteropathy. This patient had been managed by the internal medicine and clinical nutrition service, both of which are up my alley and made the presentation a lot of fun. I have a passion for teaching, but I didn’t know if this was audience-dependent since I had only taught/lectured for undergraduates and not my peers and professionals. The hierarchy was flipped, and I didn’t know if this would impact my mentality and confidence around the presentation. Funny enough, as soon as Dr. Marsilio handed me the microphone, I was in my element and felt at home. I had a blast presenting my case and explaining the complexities of diet-responsive protein-losing enteropathies.

I am grateful I was given this opportunity and am also grateful for the support of the wonderful residents and faculty, especially Dr. Marks who still prioritized helping me with my presentation while lecturing in Australia, and Dr. Dear who also provided meaningful feedback while on vacation. This is just another example of the community that Davis cultivates and the desire for student success. 

Throughout the two-week rotation, I was able to work with many wonderful patients and dedicated owners. The complex cases were also extremely engaging, and I loved wracking my brain to try to make sense of my patient’s clinical signs. There seemed to be a running theme of immune-mediated thrombocytopenia (ITP) cases which is a condition where the immune system attacks and destroys its own platelets. This can be broken down into two main categories; primary and secondary. With primary ITP, the exact trigger is unknown whereas with secondary ITP the immune response is triggered by an underlying issue. This can be a tick-borne disease, cancer, inflammatory disease, or even a drug/vaccine. Regardless of the form of ITP, these patients typically need immunosuppressive therapy, supportive care, and long-term management in addition to treating (or eliminating) the underlying cause if known. I worked on two patients with this condition and although they received similar treatment and were both around the same age, they responded drastically differently, which highlights the complexity of medicine and immune-mediated conditions as a whole. My last case during this rotation was a little rock star with incredibly dedicated owners. Upon presentation to the ER, his platelets were estimated to be about 10,000. For reference, the normal range is 175,000 – 500,000; spontaneous bleeding can occur at around 50,000, and anything less than 10,000 is extremely worrisome. Over the course of three days, my little friend’s platelet count went from 10,000 to 59,000 and then on the third day he reached 146,000, and we decided that he was stable enough to continue to be medically managed at home! It was a fairytale ending to my time on internal medicine, and I am well aware that this is not how every story ends. Within those two weeks there were also many cases with extremely motivated owners and unfortunately their story did not end with a happy reunion.

Working within the walls of the VMTH provides a unique perspective within the realm of veterinary medicine. Owners don’t usually show up to a tertiary referral center and decline care; they show up and want to do everything under the sun for their beloved companion. Witnessing the extent that these owners were willing to go for their pets was a poignant reminder of the gift that it is to be in this field.

It has also been so much fun seeing all of my classmates running around the VMTH acting like little doctors. Time has flown and reflecting on where we all started makes me so proud of how much everyone has grown and accomplished. You all are rocking it!

IM Buddies

As I close out these past two weeks, I want to assure all of you who will be heading into your internal medicine rotation, or any rotation for that matter, it is not about how much you know, it truly comes down to how much effort you are willing to put in and your desire to learn. No one is going to intentionally bite your head off, and it is not as scary as people have made it seem in the past. The residents and faculty are pretty cool people and want to support you. They also want to help you grow, which may be uncomfortable at times, but it is out of a genuine desire to make you a better veterinarian! I know I am biased because I spent a majority of my undergraduate career under the guidance of a brilliant large-animal internist who constantly challenged me, but trust me, internal med truly is awesome!

Quote of the week: "This is the wrong entrance for me, I usually go with the colon" - Dr. Marsilio while discussing a renal case.

Babies at the Arboretum!