Tricks of the Trade– Chris Dominic
Participating in the Chinook Project was a unique experience, to say the very least. The Project requires, sometimes forces, a student to improvise, to adapt, and to develop a level of independence. And all of this occurs very early in a student’s clinical year when they first begin working like true veterinarians. It can be an overwhelming experience, but for me, it has also been invaluable.
A basic physical exam is part of the bread and butter of veterinary medicine. You cannot hope to be a good clinician if you can’t perform a standard physical. However, learning to perform a good physical exam requires practise. You cannot expect to perform 1-2 physicals, and all of a sudden become an expert. It can be very frustrating as a student to perform a physical exam, thinking you’ve done a good job, only to have your supervising clinician point out something you’ve missed. This is the reality student veterinarians all face when they first start seeing patients.
In order to increase your competency, you need a routine. While working on the Chinook Project, Dr. Heather Gunn-McQuillan gave the students some advice: “Establish a routine when performing your physicals. Find out what works best for you and stick with it. If you perform your physical exam the same way every time, you are less likely to overlook or forget to check something.”
For me this took a tip-tail-tip approach. I start at the head of the animal and begin with checking the eyes and cranial nerves. From here I move to the ears, followed by the mouth. Next I feel for all peripheral lymph nodes and any external masses I may palpate over the patient’s body — also feeling for any asymmetry of the muscles or swellings/crepitus within joints. Once I get to the back of the animal, I start moving forward again, palpating the abdomen for any abnormalities. Lastly, I listen to the heart and lungs. An important thing to keep in mind as a young, still-student veterinarian is that even though I may not know the significance of everything I find on a physical exam, I can recognize it is an abnormality and know that it requires further investigation.
As I have become comfortable with my routine, my exams take less time, and I am more confident about my findings. This is largely due to the number of patients I saw during the Chinook project, where I saw such a large volume of patients in such a short period of time.
The first surgeries you perform on your own as a student veterinarian could almost serve as a comedy show for onlookers. The frustration experienced by students as we struggle to find instruments on our trays, attempt to untangle suture material or try to make a square knot but instead end up with a Granny, is indeed maddening. This is often the scenario at the AVC, where we have all the bells and whistles, like proper surgical lighting and surgery tables that can be raised to accommodate the height of the surgeon. Since the Chinook Project makes its own surgeries wherever it can – often in schools or fire-halls, its equipment is rather different: surgical lighting provided by lamps duck taped to the closest wall and surgical tables sometimes a mere 3ft in height. As a 6ft student, you can imagine how the “comedy” of first surgeries was magnified for me – and for the other students on the trip – by the surgical conditions. Perhaps you can even imagine how my back felt at the end of every day.
My guiding clinicians, although unable to help with the lighting or table height, did have a few tricks of the trade they were more than happy to pass along. Dr. Rebecca Inkpen taught us a “third-hand technique.” When castrating a male dog, you want to place sutures fairly proximal along the spermatocord. Doing this can be easier said than done when the cord keeps sliding back inside the vaginal tunic. It can be difficult to visualize exactly where you are placing your sutures. Dr. Inkpen taught us to flip over our hemostat after we have closed it around the cord. This holds the spermatocord outside the tunic, allowing better visualization for suture placement. Dr. Marti Hopson taught us a similar trick: turning over the hemostat and weighing it down by placing a second instrument through the handles, helping to allow better visualization for suture placement. I found this particularly useful during ovariohysterectomies, in order to help me visualize the ovarian pedicle, which is naturally found deep within the abdomen. Dr. Hopson further passed on a helpful hint for placing strong knots around thicker tissues such as a fatty ovarian pedicle or the uterine body. She taught us to cinch down our knots pulling them a little tighter each time to firmly place them. This is in contrast to simply pulling very tight initially which can often lead to breaking your suture material and having to restart your ligation.
Typically when veterinary patients are anesthetised for a surgical procedure, we maintain a surgical plane of anesthesia using inhalant anesthetic agents. Unfortunately, since the Chinook project operates in fly-in locations, we are limited with the amount of equipment we can bring. Due to these constraints, we can only travel with one anesthetic machine and vaporiser. This means that for some of our patients, we have to perform surgery using a different technique in order to reach a surgical plane of anesthesia. We accomplish this by maintaining anesthesia using injectable anesthetic agents. This is something that is no longer commonly performed in veterinary medicine and as such is taught very minimally in veterinary schools.
It is a little unnerving when you first begin using injectable agents for maintenance anesthesia. My adrenal glands were definitely in overdrive. I was watching my patient constantly, afraid that the moment I looked away, the dog was going to get up and walk away from the surgery table. I was watching the dog the entire procedure, looking for the slightest movement, eye roll, increase in jaw tone — anything that would indicate the dog was becoming too light under anesthetic and required more injectable anesthetic agent. Eventually, after using the injectable agents for several procedures, I was feeling more confident. I began to realize the effects certain drugs had on the body and how long they would typically last before I would need to give more to a patient. The injectable drugs worked well, and the patients seemed to recover well from being under the anesthetic. Although I emerged from my experience with the injectable agents unscathed, I am grateful for the inhalant anesthetic agents and I hope I do not have to perform injectable anesthesia in the future.
The Chinook project took me outside my comfort zone. It provided me with experiences that few other students in my class will get to experience. Working with this amazing team of fellow students and seasoned veterinarians I learned a great deal, from the basics to tasks I will rarely, if ever perform again. The Chinook Project provided me with a certain level of confidence and a foundation to build on during the remainder of my clinical year.
Chris Dominic, AVC 2017, traveled to Nain & Sheshatshiu in 2016 as one of the student participants on the Chinook Project. As part of the experience, the students craft various pieces of reflective writing. This is one of Chris’s pieces.