Nose To Tail

Patient cooperation? That’d be the bloody day.

Rewind to the 1st of February, and you’ll find me hanging off the head of a cow, trying to pry her eyelids apart as she throws herself back and forth.

“Will you stand still!? I’m not going to hurt you!” Okay, this probably will hurt a bit, but it’s going to hurt more if you fight with me.

There was a brief respite from the thrashing as she stopped to catch her breath. I took my opportunity to separate the eyelids and push her eyeball backwards a fraction into the socket, so that the nictitating membrane jumped out across the surface. I had less than a second to make my assessment of her eye before she began throwing her head again. I let go and stepped away, “This girl needs a break.”

I made my way over to another set of stocks with a different cow in it. This lovely lady was always selected for my practicals. She was extremely tall, and mostly white with blue patches. The repeated prodding, pulling and squeezing that vet students do while they learn never seemed to fluster her, and I was able to practice the eye exam a few times, which is a tricky manoeuvre.

This class was one in a series of practicals in the Professional & Clinical Skills course. This course runs through the whole degree and teaches skills such as physical exams of different species, methods of collecting information about a patient, use of instruments like stethoscopes and thermometers, and professional skills such as client communication, managing mental health, and ethics.

Today was clinical exam of the head and neck of the ox*. We made our subjective assessments from a distance, taking into account demeanour, body condition, posture, coat, noises, and respiratory rate. You take respiratory rate before you approach an animal, because it shoots up once you start touching them and stressing them out.

The physical exam then generally proceeds from nose to tail so that you don’t miss anything. But today was just the head and neck. There’s a lot to examine at this end, which includes eyes, ears, nose, mouth, mucous membranes, symmetry, sinuses, horns, lymph nodes, arteries, larynx, trachea, and jugular. The result was that each student wanted to try examining each structure at least once. It’s important, so that you know how to do it and what a normal animal should look, sound, smell, and feel like. But the cows soon got pretty fed up of multiple people pulling and squeezing parts of their faces.

I tend to feel quite guilty towards the end of a session. I need to have a go to learn how to do things, but I can’t explain to the animal why it has to be done yet again or ask her to cooperate with me. She didn’t volunteer for this or give consent. She just sees another pair of hands coming towards her face and can’t do anything to stop them. So I try to be gentle and brief, but I’m still new to this and I still fumble.

*Note about ox: in vet school we refer to bovines as “ox”. This is because the word “cow” specifically refers to a female ox which has had at least one calf. Ox is a general term which includes bulls, steers, cows, heifers, calves, and freemartins. All of these terms specifically refer to ox of a particular gender, age, or state of reproduction. “Ox” therefore covers them all! I refer to cows in this practical because they really were cows in the technical sense.

On Thursday, I found myself at the head of a horse instead. But this practical was part of the LASTA (large animal surface and topographical anatomy) course – confusing, I know, I barely keep up with it myself.

This course reviews and builds upon our anatomical knowledge of large animals to help us identify the location and extent of internal organs from the outside of a live animal and use that knowledge to perform physical exams and understand locations and methods of diagnostic and surgical procedures.

But the equine head I was standing next to was definitely not alive. I could tell the minute I walked into the room, and the sour smell of decomposition washed over us all. We were in the school’s dissection room, and stood to one side of it was an entire black and white horse, suspended in a metal frame so that it stood upright. He was missing parts of his face, where the lecturer has dissected out the superficial and deep structures of his head and neck for our class.

The lecturer took us in small groups to give a demonstration with the dissected horse. She talked us through the locations and courses of all the structures of the head, both just under the skin and deep inside the skull. It was incredible to see all the separate structures I’d learnt about finally shown together in a single animal, just as it will be every time I see a patient. Things made so much more sense!

Halfway through the 3 hour session, we all left the dissection room and hiked across campus to the equine hospital, where the teaching horses were waiting for us. After we’d changed into overalls and boots, we divided ourselves up between the horses. These are healthy animals which belong to the vet school, by the way! And for the next hour and a half, we mapped out on the surface where the internal structures were, and why we might need to find them in the future. It’s fabulous stuff, this – it’s why I came to vet school!

The following Thursday I was back with the Professional & Clinical Skills course to examine the thorax and abdomen of the horse with a stethoscope. The vet teaching us  was giving a briefing on how to use our “stethies” to identify heart sounds and overt murmurs.

“Okay, you’re going to be familiar with your basic ‘lub-dup’. In horses, sometimes you can hear the third and fourth heart sounds but today we’re going to focus on the first two. You’ve done your cardiovascular module, right?”

As a matter of fact we had, before Christmas, but the nodding was tentative. If you claim to know something at vet school, expect to be questioned on it. At the time we were blasting through enormous numbers of neurology and reproductive lectures, and cardiovascular felt like a lifetime ago. Even this most basic of concepts, the heart sounds, made us doubt our knowledge recall.

He took the mumbling as a yes and asked, “So what is it that generates a heart sound?”

Immediately, twenty brains launched into search mode, rifling through hundreds of pages of lecture notes. We were silent for too long, and he said, “Turbulence! Turbulence generates sound. What’s our lub then, what’s generating the first sound?”

Everybody looked at each other. You know what? Screw it, you know this Elise, just say it for God’s sake.

“Atrioventricular valve closure?” Not sure why I said it like a question, but there you go.

“Yes!” he practically exploded with excitement, “AV valve closure! When?”

“Um, systole?”

“Yes, systole! What about dup, what about our second sound?”

The group were a bit more confident now that the ball was rolling, and somebody said, “Aortic valve closure in diastole.”

“Yes! Aortic valve closure! Okay, but what if there was an abnormality, say we’ve got mitral valve incompetence or aortic stenosis – where are we going to hear that?”

I stood silent like the rest of the group, whilst the answer jumped around on the tip of my tongue. Finally, like Hermione Granger, I kind of spluttered, “In systole, between S1 and S2.” And then, for some reason, instantly regretted what I thought must have been the wrong answer.

The vet go so excited about this I thought we were going to get a live demonstration of cardiac arrest, “Absolutely, these are systolic murmurs. And so what about aortic valve incompetence or mitral stenosis?”

“In diastole, between S2 and S1.” somebody said.

Delighted with our progress, the vet shouted, “Alright then! Let’s hear a heartbeat. Lub-dup… lub-dup… lub-dup, come on everyone! Lub-dup… lub-dup… lub-dup”

It took a while, but soon the whole group was standing in the middle of the stableyard chanting the heart sounds like some sort of nerdy cult. Suddenly, the vet shouted, “Let’s hear a systolic murmur!”

There was panic and wild arrhythmia as we all tried to process the timing of the murmur and vocalise it. Eventually we came back into synchrony, “Lub-shh-dup… lub-shh-dup… lub-shh-dup… lub-shh-dup…”

The vet was like a passionate conductor at the front of his cardiovascular orchestra, “Alright, diastolic murmur!”

Panic. Arrhythmia. Confusion. Then, “Lub-dup-shh… lub-dup-shh… lub-dup-shh… lub-dup-shh…”

Buddy you’re a boy, make a big noise, playing in the streets, gonna be a big man some day, you got mud on your face, you big disgrace, kicking your can all over the place, singing:

“Lub-dup-shh… lub-dup-shh… lub-dup-shh…lub-dup-shh…”

Okay, so Queen didn’t actually have a reunion at Easter Bush, but we were soon transitioning perfectly between systolic and diastolic murmurs, before we disbanded to go and auscultate the horses. Hearing the heart sounds of a horse is quite a difficult task to learn, partly because the heart sits behind a large slab of shoulder muscle, and because the chest is so deep that the sounds get muffled. Not only that, but the patient often spontaneously feels the need to walk off just as you think you’re hearing a rhythm.

The gut sounds we slightly easier, however. I’d been told that the sound of gut contents rushing through the caecal valve was like hearing a toilet flush from the bottom of the garden. I had identified the location of the caecal valve and placed my stethoscope on the side of the horse, just in front of the hip. For what felt like an eternity I had stood and listened for this sound, and heard just nonspecific rumblings and the creaking of my own bloody fingers. I was seconds away from stepping aside to let a colleague try, when there it was… a perfect toilet flush, as if from afar. Well, I’ll be damned!

At the end of a very long week of neurology, large animal anatomy, epidemiology, reproduction, and an endocrine exam, the weekend was a prime bucket-list opportunity. And so on that freezing Sunday halfway through February we took a wander down to the Palace of Holyroodhouse and, in fantastically tourist-y fashion, took an audio tour:

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Holyroodhouse is definitely worth a visit – I’m not a history buff but Mary Queen of Scots had a crap time of it!

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After our chilly tour, we stopped to have a hot chocolate and a sausage bap on the Royal Mile. In over a year and a half of living with Rowena, it was the first time we had been out and had lunch together in a cafe. Our flatmates, on the other hand, seemed to be meeting people for lunch every other day. We sat, relaxed for the first time in a very long time, sipping hot chocolate and just enjoying being out for lunch. Is this what it feels like to be a student?

But it wasn’t long before my eyes were drawn to a clock on the wall, and we agreed it was time to get back and get some studying done. It’s because of this relentless and inescapable onslaught of information that I haven’t written in so long. As I write this, we enter the final week before a set of big exams, and even the most even-keeled students in my cohort are cracking under the pressure. In two weeks’ time, I will write about the rest of February and March. Until then, my head will be down to join my peers for this final stretch. I’ll see you on the other side, and I look forward to sharing with you all the brilliant things that have happened in the meantime!

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