How are your clinical skills??
Hello future veterinarians! When I was initially writing these blog articles, they were for me. Then, I started targeting future veterinarians - what would the next generation of veterinarians wish for? I had one colleague that was a veterinarian from South America and he wished to prepare for licensing in Canada, so I wrote a blog post on how to prepare for the PSA for the CPE. Since then, I have taken a break from blogging, but another veterinary student who wishes to become licensed in North America asked if I could write a blog on how to study for the BSCE. The Basic and Clinical Skills Examination is yet another part of the licensing process. Given that many veterinary colleges around the world will have different focuses, the BCSE ensures that foreign graduates have the equivalent knowledge of graduates from AVMA accredited veterinary colleges. After this comes the CPE (Clinical Proficiency Examination) - essentially a hands on examination that spans several hours and usually conducted over a few days. I have heard of the rare person actually passing all modules - so if you fail one module, do not feel defeated! If you are studying for the NAVLE, then you can equally be studying for the BCSE. Talk about acronyms galore!! I encourage you to first browse the information on the AVMA's website for the BCSE. This will have the information that is up-to-date (especially during COVID restrictions there were a lot of delays, postponements etc). Just as with the NAVLE - you can get a 'Question of the Day' emailed to you from ZukuReview. The BSCE has fewer questions than the NAVLE, and some folks figured that as long as you were studying for the NAVLE, then you would be fine for the BSCE. All folks who wish to be licensed in Canada or the U.S.A. must complete and pass the NAVLE. But only folks who graduated from non-accredited veterinary colleges have to take the BCSE. I would encourage you to plan ahead. If you are planning to write both, do not delay too long after writing and passing the BCSE and writing your NAVLE. I can be daunting to think about studying, but similar to the NAVLE - group things by major species: dog, cat, horse, cow, swine, small ruminant, poultry, etc Take a look at the primary groupings below: You must know the normal form and function - think about what are clinically relevant anatomical features for eat major group of species, are there any differences that stand out to you? Then think about clinically relevant physiological features. Typically, normal form and function is discussed in first year veterinary school. Then in second year you learn about the 'abnormal'. Once you know the 'normal' form and function, you can start delving into pathophysiology of disease. Can you tell me how secondary renal hyperparathyroidism is developed in a cat? What if you saw foci of abscessation in the lungs of a cow - how would that happen? What other findings would you see on the necropsy? A horse has a rotated P3 - what does that mean? How did it happen? If you're given a radiograph of a dog, and the stomach is gas distended - how do you know if this is bloat or GDV? Now that you know what is normal, and how to identify abnormal, you are on to how do you 'fix' it - in comes your medicine and surgery classes in third year of veterinary school. What is the treatment or management for the above diseases? What is the prognosis? These are just examples. A wise person once told me - study for the veterinarian that you want to be. My thoughts are, always study to be able to apply your anatomy and physiology. All of fourth year veterinary college is what will be jammed into the CPE. When studying for the surgical component of the BSCE, you may as well think about how you can overlap with what you would need to know for the CPE. For example, when you go to spay a female dog, what anatomical structures do you incise when opening the abdomen? How do you find the ovaries and uterus? Speaking of uterus - you may want to brush up on the signs of pregnancy in cattle. If you perform rectal palpation on a cow - when should you feel a membrane slip? Cotyledons? Regardless, I wouldn't worry tooooooo much about the BSCE, especially if you are already studying for the NAVLE. The CPE on the other hand... ;)
Ethical Dilemma: To Euth or Not to Euth
I have posted about Euthanasia in the past. It was the only part of becoming a veterinarian that made me not want to become a veterinarian. I was in grade 6 (so that age is what, 10 years old? I'm pretty sure), and a veterinarian came into our classroom to describe the work that they did. My take away from that visit - veterinarians kill animals. Being an animal lover, growing up on a farm, tending to lambs that were less than hours old, I couldn't think of having to do that. There was a story about how they had to inject animals with toxins, and then try to determine what the toxin was to safe this animal (maybe I was dreaming about this as a child, but having gone through Veterinary Toxicology I know what those old videos look like - horrid). So from that day forward, I didn't want to be a veterinarian anymore. Fast forward to 2005, I graduated with a BSc in Biology with a minor in Psychology. I had an interest in animals and social evolution, as well as reproduction. But when I graduated, all I knew was that I wanted to work with animals. I applied to a job ad as a Zookeeper. I didn't get that job, so I took a job as a laboratory technician. I actually took a HUGE pay cut to go to work as a laboratory technician in an environmental toxicology lab. But I loved it! I was previously working as a junior accounting. Punching numbers into a computer, balancing bank statements, balance sheets, running accounts receivable/payables, real boring stuff - which I now use for assisting with my hubby's company Green Ghost Media. Anyway, the contract work that I signed on for as a laboratory technician was a set 3 month contract, and since I needed to have something else, I saw yet another ad to the same zoological facility, and sent another updated resume. This time, I got hired! Becoming a Zookeeper can be difficult. In the U.S. it requires a BSc in an animal related field, as well as externships/internships as a junior zookeeper. I am not in the U.S. and while I didn't have an internship at a zoo, I worked on a hobby farm with sheep, swine, and cattle, which really are domesticated versions of Bighorn Sheep, Red River Hogs and Yak. I wasn't satisfied with *just* being a zookeeper. If you think about the pay structure for zookeepers, you are hardly going to make a living. So unless you have the ability to live with your parents forever, or have a spouse who makes a lot of money to support the both of you, it's not really sustainable, at least in the privately funded zoo that I started out in. Not that I want to discourage you from pursuing Zookeeping as a profession! Just make sure you know what you're getting into! A few months into becoming a Zookeeper, I revisited my childhood dream of becoming a veterinarian. At this time, I'm 25 years old, 15 years wiser than my 10-year-old self. I started volunteering at a local wildlife centre. Initially thinking that I wanted to be a zoo and wildlife veterinarian - who doesn't?? But it was at the wildlife centre working with a veterinary technician that I learnt the analysis of euthanizing an animal. It was a raccoon. A young male raccoon that had fractured canine teeth, and a broken bone. The technician discussed with me that she was going to euthanize this one. There was too much damage, and for him to be rehabilitated to go back into the wild, he would not be able to compete with other male raccoons for resources and mates, and may not survive. Going through this weighing of costs/benefits for the animal, including the time for rehabilitation, the resources needed from the centre, while it was sad, things started to make sense on why we couldn't save them all. Fast forward to today - 30 years after my divergence away from veterinary medicine. I am now a veterinarian that works in Urgent Care. I see a lot of death. I've posted about it recently on my TikTok if you have been following me over there. But contrary to popular belief, I will not euthanize every single pet that presents for euthanasia. I have a heart and a mind that has to live with the decisions that I make, and I do not take these decisions lightly. I weigh out all the options in my head. Who is benefiting from the death of this animal. Does it benefit the animal to have its life taken from them? We are allowed to say No. Does that mean that the pet parent goes elsewhere to get their pet euthanized? Yes. Does that also mean that my colleagues have to euthanize the ones that I will not? Yes. But I need to be able to sleep at night. So, I'm sorry I won't euthanize your otherwise healthy pet when you bring it in for me to "put to sleep". I have had pets present for euthanasia, having never met them or their pet ever, and I ask if the pet parent can try one more thing - I give them one easily attainable task that does not require spending endless amounts of money on diagnostics or treatment. I just ask that they try. If I ask them for one thing, and it doesn't work out, then I can at least feel better that we tried. I may not be able to save them all, but I have saved some from death by tasking one thing to the pet parent. So the ones that I have saved I will cling to. For all of the veterinarians or future veterinarians out there that think that death and euthanasia are the hardest parts of the job. It isn't. You just need to be able to stand up for what you believe in. It is not black and white. The reason I decided to blog today was due to an angry TikTokker. I shouldn't let them get to me. I have a right to decline euthanasia. So, to those of you sitting there thinking "Not another one of those vets" you can go ahead and wash the blood off of your hands, because I'm not doing it. For more topics on Veterinary Ethics, I highly recommend you pick up a copy of Bernard Rollin's book Rollin, B.E. (2006). An Introduction to Veterinary Medical Ethics: Theory and Cases.
Happy New Year! Or is it?? TikTok Cuterebra video.
The one thing that I always looked forward to over Christmas break was spending Christmas dinner with my family! Now that we are two years into our COVID-19 pandemic, and SARS-CoV2 and all it’s glory is here to stay, we need to adapt. It was fine when the government said, stay at home for two weeks and this will all blow over. The goal was to stop those cases from going up, up, up. We needed to flatten the curve. If we all worked together we’d beat this virus. Here we are early 2022, and the fear of COVID is our life. Or, for the anti-vaxxers, the fear of vaccine side effects is our life. For some people, they can thrive inside a bubble. If they have a family unit where all the good in the world is within their home. But there are people who live alone. I was just thinking about how many people I have been exposed to over the past two years. I wear my mask, wash my hands frequently, don’t go to huge social gatherings, but I’m feeling like I’m still missing out on life! My mother and step-father are currently in Mexico. As soon as their age group was able to get the vaccine, they did. I waited. Once the vaccine had been out for the length of the human gestational period, my husband and I got vaccinated. There was a fertility doctor that was interviewed on a livestream (Dr. Nayot), who mentioned that since pregnancy is a high risk condition that if you got COVID you would more likely end up intubated in the ICU, and therefore my husband and I agreed that it wasn’t a risk we were willing to take. Sure, I was scared of the myocarditis side effects of the vaccine. I have an arrhythmia, that is excerbated by sleep deprivation and alcohol, but I couldn’t be sure that I wouldn’t develop a severe side effect. Thankfully, all I had was some pain at the injection site. Hubby had some flu-like symptoms, but was good after a day. I went with the Moderna mRNA vaccine based on Dr. Nayot’s recommendations. I know I haven‘t posted much on here! I’ve been investing a LOT of time in my content on TikTok. This video has over 170k views on it. People like these weird and crazy things! This was my first Cuterebra rabbit patient. Of course I learnt about the parasite in vet school, but never thought I would see a case! The lifecycle of this parasite is interesting. The bot fly lays eggs around the rabbit burrow opening. When the eggs get warm from the body of the rabbit, they hatch and the L1 larvae attach themselves to the fur of the animal, and make their way into the mouth, nose or eyes of the rabbit. Already sounds gross! Once they are in the body, they migrate towards the skin’s surface and create a little capsule home for themselves. As they get older and larger they develop a little breathing hole in the skin which you can see with your naked eye! Ugh! The larval migration takes 3-4 weeks, so you would have to back track about a month to know when the rabbit was actually infected. Treatment is just as the video shows, removal of the larva. If not, the lifecycle continues with pupation. The pupae fall out of the breathing hole into the environment and an adult emerges to go on to lay eggs. Prevention and treatment will be dependent on the species you are treating. For rabbits, everything is extra-label. It’s not like we have a specific pharmaceutical for botfly larvae. But they tend to die off with macrocyclic lactones (avermectins). I typically use kitten labeled selamectin in rabbit patients. For more video content, please head over to my TikTok page!
Microdose Lupron Flare
For those of you who have been following along. My hubby and I started trying to conceive over 2 years ago now. We tried naturally for 6 months, and I had one chemical pregnancy/early miscarriage in October 2019. Then I was diagnosed with anxiety and depression late 2019. In the spring of 2020, I found out I had low AMH and low antral follicular count. Then we had our first stimulation cycle, which was converted from an IVF to an IUI, then converted to timed intercourse, which was a bust. We then did a mini-stim, which is supposed to be better for reduced ovarian reserve. I only grew one follicle, and they couldn’t find or retrieve the egg. We rolled this into a duostim, something that they do for women with ovarian cancer that wish to freeze eggs or embryos prior to cancer treatment. That duostim cycle was cancelled 1/2 way through. Now, this is the 4th stimulation cycle we are one. This one is the most aggressive as far as meds go. I’m on double the number of injections and a higher dose of FSH compared to all of the other protocols. From my reading, there are three groups of protocols: GnRH agonist (long), GnRH antagonist (short?) and Flare. So, perhaps I will go through those. But for now, I'll just talk about this protocol and cycle results. The Flare part of the protocol includes using Lupron to tell your pituitary to release its own FSH and LH pulses for growth of the follicles. The only thing I did for priming for this cycle was Androgel, because I had this thought that the Estrace was over-suppressing my ovaries. So, starting on Day 2, I did morning and evening injections of micro-dose Lupron, then started Rekovelle and Menopur on the 4th day (which they called day 1 of stimulation). I ended up doing five days of this prior to my first ultrasound. Here is where my first disappointment came. I only had 3 follicles. Sure, the doctor said "This is 3 times the number that you had for the previous cycle" but I have still been clinging to the AFC of 8 or 10. My original AFC was 8 when I did my baseline scan in spring 2020. I had a scan earlier this year and it was 10. So you can probably see why I was upset that I went from 8 to 2, or 10 to 3, whichever. There is a lot of attrition from the AFC to the number of healthy embryos produced during IVF. For example, the retrieval rate is around 60-75% depending on the practitioner, protocol and woman's anatomy. So, if you have 10 follicles (just making it a round number), then you can expect for them to collect 6-8 of those eggs. Of the eggs that they get, not all of them are mature and have the ability to fertilize. Then of those that fertilize, not all of them become blastocysts, and then of the blastocysts that you make, not all of them are genetical normal. So, overall, with an AFC of 10, you may be looking at 1 to 2 healthy embryos at the end. Then for a healthy full term pregnancy, you're probably looking at 2 to 3 genetically normal embryos per healthy pregnancy. This much I knew going in. Since we were unsuccessful with one follicle, I was just hoping that 3 follicles would at least get us somewhere. It's really difficult to keep going when you're not in contact with your REI. So I stuck myself with thousands of dollars of medications. Those three follicles grew to 16 mm, 16 mm and 20 mm prior to my trigger injection of hCG. We had this last minute run around to get to the city that our REI works in which is four hours away from home, during the wintertime. We drove through the mountains, because of course, COVID restrictions say you either need a PCR test 72 hours prior, or complete vaccination for COVID prior to flying, and we were only vaccinated 13 days prior to the flight out. Hubby arranged for a driver, and I just closed my eyes and hoped that we would make it to the other side! Once we arrived in the hotel, things were great. We relaxed for a bit and went to sleep. The next day, we picked up a rental vehicle, and Hubby had his appointment to make his 'deposit'. My check in time was noon, and the retrieval was supposed to go at 1 pm. The nurses were great with the pre-operative checks. Then, I met a new doctor. It wasn't my REI. I suddenly had my heart drop. I was suddenly nervous that it wasn't going as plan. The nurse noticed that my vitals, blood pressure and heartrate were suddenly up, and said, not to worry, she would give me something for this anxiety. This new doctor wasn't friendly, just very medical, not empathetic. Not heartless, but she didn't make any connection with me to put my mind at ease. The retrieval was quick, and I was in recovery with my husband and for the most part I have amnesia on how the rest of the day went. I think we found out that they only collected one egg out of the three follicles. The third disappointment in this cycle. Fortunately, the lab called the next morning to tell us that our one egg fertilized. I was elated! We had a baby growing in the lab! I could breathe a sigh of relief that maybe all of this was finally paying off! I'm not a person of faith. But I tried to maintain a positive outlook. We flew home, and it was back to work. Let's take a look at some stats. So, if you have an AFC that is greater than 5, and you are age 41-42, there is a success rate for on-going pregnancy of 23%. Of the women in that same age category, with an AFC of less than 5, the pregnancy rate is 0%. So when the lab called on the Day 6 update and told me that the embryo was still growing. She seemed positive, that I shouldn't worry. That the embryo was still growing, just slower, but that it had made progress, and the lab would call the next day. No one called the next morning. I went to work, and we had a meeting. I got busy, and then I had a euthanasia scheduled. Then I got a call. It turned out to be my REI. I knew just then that he wasn't calling with good news. I wanted to cry. But I had to go into a very sensitive appointment, so I had to swallow my own tears to be the support system that a pet family needed me to be. Do you know how hard that is?? Euthanasias are difficult. They aren't even the hardest part of my job, but they aren't easy. Now, try to do that when you have your own personal problems. You compartmentalize. You are not allowed to grieve while at work. So, instead of grieving then, it got pushed to the back of my mind. I called my husband during my break to let him know, but I didn't get a chance to grieve until weeks later while Hubby and I were trying to look for a sofa for the living room, I had a meltdown in the parking lot of the furniture store. At least fifteen thousand dollars spent on this cycle, with ultrasound and blood work, and tons of medications, then driving to another city, spending $10k for that one embryo, and flying back home, for nothing but another failure. So what do we do now?? My hubby and I had to sit down and have a heart-to-heart discussion. Because now, all the savings that I did have are dried up. Now we're looking at financing to build our family. What we agreed on was that we would try once more with my eggs, then we would have to look at alternatives to building our family. But, I'm again, still clinging to that 8-10 AFC. So when we meet with our REI in a few weeks, I'm going to ask him if we can be selective about which cycles we stimulate. Prior to injecting a bunch of expensive medications into my body, can we get an ultrasound to see what's going on first? That's the smart thing to do. As always, I will keep you posted! Until then, feel free to share your story if you need someone to talk to.
COVID-19 in Deer
You may not be the type to go hunting for deer, but if you are, you may have to rethink how you are handling the carcass afterwards. Approximately 40% of wild white-tailed deer in the US that have had serology testing for SARS-CoV-2 (COVID-19) have tested positive. In Quebec, Canada, the testing has been on-going and so far about 2% have tested positive. Deer do not get sick from the virus, but what becomes important to note is that deer can be a reservoir for the virus where is can then be passed on to people. It also can be a reservoir for new variants to occur. As Dr. Weese mentions, the disease will become difficult to control if there is an animal reservoir species. He also notes that if you’re hunting deer, you should use personal protective equipment when handling the carcass. Cooking the meat should make it safe to eat (that’s cooking to internal temperature around 70 C). Since we have no control systems in place to prevent the spread of COVID-19 in our wildlife populations, we can expect that the virus will continue to spread, and likely will become endemic in the wild white-tailed deer population. It's easy to see the disease moving through wildlife population like deer across the US-Canadian border. As always, every blog post only demonstrates my own personal thoughts, in the moment, and information can change over time. I'm sure that Dr. Weese will be keeping us up-to-date on his blog Worms and Germs, so I encourage you to keep checking in there.
TikTok for Vets?
Well, I finally and reluctantly created a TikTok account. I'm not hip nor do I keep up with the newest trends. However, I do see the value in the reach that TikTok can make when it comes to trying to educate folks. I kind of knew this going in, that the most popular posts would be similar to my Instagram account - the gross things. I posted this video two days ago and it has 64k views and close to a thousand likes. *shrug* If that's what people want to watch! I just wanted to come on here to mention it, just in case you are on that platform. A lot of the videos are shared from TikTok on to my instagram, so if you're not a TikTokker, then you'll still get similar content there! So far most of the posts are of YoYo. I haven't introduced YoYo on my blog yet, so I guess I should also get to her story! But other than YoYo, my plan is to share a few of the cases in quick video format to supplement what I am posting on here. Cheers and hope you're having a good week!
NAVLE Season: How to Study for the Biggest Exam of your Life
The North American Veterinary Licensing Examination is required to practice veterinary medicine in Canada and the U.S.A. Normally the NAVLE season is in November/December for final year students. If you are in the usual school year start of Aug/Sept, then you get a chance to write in the Fall, and if you happen to fail the exam, you get a second chance to write in the spring (April), prior to your graduation in May/June. Those that are writing in the Fall would have registered for the NAVLE in August. I don't mean to brag but... in my graduating class all of the students that wrote in Fall passed the NAVLE - yup, a 100% pass rate. ;) Now, not everyone in my class wrote in the Fall. I know of one that had to cancel due to illness. I'm not writing this to say that the NAVLE was a walk in the park. As this post says "it’s arguably the most important exam of your life up until this point." I have a colleague who failed twice, and now needs to re-write the exam, but with COVID-19 restrictions, she is having a tough time staying motivated to study. This is one of the reasons why I thought it would be nice to give some of these veterinary students a place to focus on because it's four years of curriculum jammed into one exam that changes the course of your life. The questions on the NAVLE get rotated, and no one is to speak of the questions from the NAVLE - not that you'll remember any from that grueling 6 hours you sat answering multiple guess questions. But the basic concepts are the same. Preparation for Licensing in Canada For those who are preparing for licensure having graduated from a veterinary college that is outside of an AVMA accredited facility, there are more steps to obtaining your veterinary license than writing the NAVLE. 1) Everyone, including veterinary students at accredited facilities, needs to register with the NEB. Click here for more information. All of the links below will pertain to licensing in Canada, so if you're writing in a different country you'll have to check in with your licensing body. 2) If you graduated from a non-AVMA accredited veterinary school, you will need to complete the BCSE, PSA, CPE and the NAVLE (not necessarily in that order). The Basic and Clinical Sciences Examinations (BCSE) The North American Veterinary Licensing Examination (NAVLE) The Preliminary Surgical Assessment for the CPE (PSA) The Clinical Proficiency Examination (CPE). I recently created a post for those preparing for the PSA, which you can read here. If you graduated from an AVMA accredited veterinary school, then your Objective Structured Clinical Examinations (OSCEs) are used in place of the BCSE/PSA/CPE, therefore, for licensure these students will need the NAVLE and the provincial examination. Studying for the NAVLE When you are studying for the NAVLE, I recommend that you spend the majority of your time on the Big Four species: Dogs, Cats, Horses, Cattle. Roughly 77% of the questions that you will get are about those species groups. So if the passing grade is 70%, and you study these four species groups really well, plus the really important select few diseases of the other species, then you will be just fine! Don't over think it! For more information on the break down of the NAVLE, you can find a nice chart here. Tips on Studying for the other species/topics For the other species groups (swine/porcine, small ruminants, exotic/pocket pets, poultry, pet birds like parrots, camelids, cervids, public health, other), you should probably know a few things about the Notifiable (Reportable) diseases in your country (or your neighbour's - for us it's the U.S.A.). In general, anything that can be transmitted to humans will fall under your responsibility to educate the general public, so regardless of whether you want to learn about chickens, communicable diseases and public health are part of your job. As an example, if poultry encompasses 2% of the NAVLE, that's roughly 7 questions. But you can expect that of those questions, those really important diseases are likely to come up, so focus there. Here's a quick list of Reportable diseases for Canada, and below will be some links mostly from the Merck Veterinary Manual for those diseases to help you study. The diseases are either highly infectious which could wipe out a population of that species, which would drastically affect the global food supply, or they are contagious with a high mortality rate for humans if they contract the disease. You may wish to note how the disease is transmitted, how would you make the diagnosis, and something about how you would treat it or control it. Diseases affecting Multiple Species: Anthrax (Bacillus anthracis) Bluetongue (virus spread by midges Culicoides that affects ruminants) Brucellosis (Brucella abortus, Brucella suis, Brucella melitensis) Cysticercosis (Taenia saginata, Taenia solium - tapeworms of cattle and swine) Foot-and-mouth (Aphthovirus, a member of the family Picornaviridae) Rabies Rift Valley Fever (mosquito borne virus affecting mostly ruminant species and humans) Rinderpest (declared eradicated by the OIE) Trichinellosis (zoonotic roundworm transmitted by raw or under-cooked meat, historically from consumption of pork, but also found in carnivores like bears) Vesicular Stomatitis (basically, any vesicular disease of ruminants and horses should be biopsied) Equine (Horse/Donkey/Zebra): African Horse Sickness (viral disease transmitted by midges Culicoides) Contagious Equine Metritis (venereal bacteria Taylorella equigenitalis) Equine Infectious Anemia (virus passed through blood feeding insects) Equine Piroplasmosis (tick-borne protozoal disease) Venezuelan Equine Encephalomyelitis Bovine (Cattle): Bovine Spongiform Encephalopathy (BSE, mad cow disease, a prion infectious disease) Bovine Tuberculosis (Mycobacterium bovis) Contagious Bovine Pleuropneumonia (a highly contagious Mycoplasma) Lumpy Skin Disease (pox virus) Of the other species, pigs (swine) encompass the next most abundant exam questions (approximately 6%, or 22 questions). Swine/Porcine: African Swine Fever Classical Swine Fever (Hog Cholera - enveloped RNA virus in the genus Pestivirus of the family Flaviviridae) Pseudorabies (Aujezky's Disease) Swine Vesicular Disease Small Ruminants (Sheep/Goats): Peste des petits ruminants (viral disease similar to Rinderpest) Scrapie (similar to BSE and CWD a prion infectious disease) Sheep and Goat Pox Poultry (Chickens/Turkeys): Avian Influenza Fowl Typhoid (Salmonella gallinarum) Newcastle's Disease (Avian Paramyxovirus) Pullorum (Salmonella pullorum) Cervids (Deer/Elk/Moose): Chronic Wasting Disease (prion disease like BSE) Other thoughts while I was writing this: Don't spend all your time learning about Sensitivity and Specificity. Sure, you'll get one or two questions on epidemiology and R0, but focus your time on the species that will count. On top of the above reportable diseases, think about creating a list of Top 5 or 10 diseases for the other species groups (similar to the VIN prep course). How do you identify or diagnose the disease? How do you treat or control that disease? If a disease or condition affects multiple species, it's probably something to study. Think about Vitamin deficiencies or toxicoses that can occur. To practice a NAVLE for timing of the exam, to ensure you can get through it all within the time allotted, you can head to the NBVME website to take a practice test or purchase a sample test. I did the VetPrep program for studying for the NAVLE and I took part in VIN's NAVLE prep course. VIN NAVLE prep course For the newest course catalog for VIN, head here. It essentially goes through the Top 20 diseases that you should know for each of the species groups. The next course offering will be for Spring 2022. If you are writing in the Fall and missed the registration for the current course, you can also go to the course archives and find a course. Don't forget that the VIN membership is free for veterinary students. A few of my classmates preferred to use the ZukuReview (which will email you a prep question every day if you sign up for their email list). I really hope that you find this information useful and Good Luck!
Case Study: Renomegaly in a Young Cat
This week’s blog post is another case study for those new and in-training DVMs. Case: 5-year-old male neutered DSH with history of lethargy and vomiting My patient is a young outdoor barn cat with a history of lethargy and vomiting and not able to keep food down. He was seen by his regular veterinarian for deworming and vaccines approximately two months prior to coming to our ER service. The owner has noticed a significant amount of weight loss since his previous vet visit. On physical examination he was normothermic, mildly depressed and mildly dehydrated. He had a bradycardia of 120 beats per minute and on palpation of his abdomen, he had larger than expected kidneys. Once you have your exam findings, you come up with a list of differential diagnoses of those problems. Vomiting: This clinical sign is non-specific for a cat, and could be anything from parasites (less serious) to cancer or severe kidney disease. A foreign object obstruction is also possible, or viral diseases like FeLV or FIP. More concerning findings are: bradycardia and renomegaly. The differential diagnoses for bradycardia in a cat would include electrolyte imbalances. This could include hyperkalemia - think about your blocked cats - but this cat did not have a distended, turgid bladder. Severe kidney disease, but not chronic kidney disease, because the kidneys were larger than normal on palpation. This could be heart related, heart disease or heart block. The enlarged kidneys could point to polycystic kidney disease, infiltrative disease, or renal pelvic distension from hydronephrosis. My first step for diagnostics in this indoor/outdoor cat was blood work. I offered a FeLV snap test as well, since that was on my list of causes of renomegaly, vomiting and lethargy. The chemistry panel came back with severe azotemia with a creatinine > 800 umol/L. While we were waiting for the snap test, I did a quick ultrasound of the kidneys. Reference values for kidneys on ultrasound for cats suggests that normal is between 4 - 4.5 cm in length. My suspicion for renal lymphoma was increasing. Looking at these kidneys we know we can rule out polycystic kidney disease and hydronephrosis. The complete blood count came back with a mild neutrophilia and mild lymphopenia. Nothing too interesting. Then this snap test was completed: Feline Leukemia Virus In March 2020, I wrote about a young cat with anemia, which I said, in this 3-year-old cat, feline leukemia was high on my list of differentials. A positive test is not necessarily a death sentence. Some cats can live with the virus, but these should be in single cat households and kept strictly indoors, as well as having routine veterinary care to ensure they do not get any secondary infections. Feline Leukemia Virus is called the friendly cat virus, because it is passed through social interactions, grooming, sharing of food and water bowls, sharing of litterboxes - essentially through saliva and feces. This is in contrast to the angry cat virus (Feline Immunodeficiency Virus) which is spread through bite wounds. Prognosis for long term several depends on which organ system is affected. If the bone marrow is affected (as in the cat from 2020), the prognosis is grave for any long term survival. On average, an FeLV positive cat can live 2.4 years after diagnosis. For our cat in this case, we could have started chemotherapy, and we may have gotten remission of the lymphoma, but the median survival time is about 200 days. Chemotherapy in pets is variable depending on the oncologist, but it could mean that the cat is on medication every 3 weeks, getting blood work done just as often to assess the response to medication and whether the bone marrow can handle addition immunosuppression medication. My personal take on it, I wouldn't put my own cat through rigorous medications and testing, but palliative medications would likely be my own response. Luckily, FeLV can be prevented. There is a vaccine to protect high risks cats. These would be indoor/outdoor cats, barn cats, or multi-cat households/catteries. There is no benefit to vaccination if the cat has already come in contact with the virus. For more information on the Feline Leukemia vaccination, discuss this with your veterinarian.
ABC’s of Vitamin Deficiencies: Vitamin D Deficiency
Some of the vitamin deficiencies are fairly straight-forward. Vitamin D is not the case. Most people in the northern hemisphere know that the further north you live, the less sunlight you get. Less sunlight is less UV light and UVB is responsible for converting inactive Vitamin D into a metabolite that can be used by the liver/kidney. We learn a lot about calcium homeostasis in vet school as calcium is extremely important in the normal function of the body. Vitamin D is required for this homeostasis as it increases calcium absorption from the gut. In short, a Vitamin D deficiency leads to a deficiency in calcium. When I think of Vitamin D deficiencies, I think of reptiles first. There is a condition called Metabolic Bone Disease, which is most commonly secondary nutritional hyperparathyroidism. Since Vitamin D is needed for calcium homeostasis, a deficiency in Vitamin D leads to a deficiency in calcium, because even if you are consuming calcium, you need the Vitamin D to absorb it from your diet. Reptiles that do not get Vitamin D3 in their food and/or do not have UV light exposure (that isn't blocked by glass), will be calcium deficient. Since calcium is required for bone structure, the deficiency in Vitamin D leads to osteoporosis, osteomalacia or fibrous osteodystrophy. Calcium is not just important in bone structure, it is important in the contraction of muscles as it regulates sodium channels in depolarization of the neurons and can cause paresis/paralysis of the limbs (something we see in sugar gliders - as an aside). For humans, a lot of dairy products are fortified with Vitamin D3 to prevent rickets (poor bone formation in children). Humans can get Vitamin D from conversion in the skin from direct exposure to UV light and from consumption in their diet. More on this later. If you're in second year veterinary school, you may be asked to write out the pathophysiology of this condition. If you're studying for board exams such as the NAVLE, if you get a case of a reptile with deformities, think of Vitamin D deficiency. In brief, when there is low Vitamin D, you get low calcium absorption from the gut, and this causes hypocalcemia. Hypocalcemia leads to an increase in parathyroid hormone release from the parathyroid glands. Parathyroid hormone signals to the bones to cause osteolysis by osteoclasts. Eventually there is not enough calcium in the bones to hold them together, causing deformities. Parathyroid hormone also signals to the kidneys to convert more Vitamin D into the active form (1,25-dihydroxycholecalciferol) signaling to absorb more calcium from the gut. Along with an effective hypocalcemia, a lot of the foods offered to reptiles are higher in phosphorus. Phosphorus binds with calcium, contributing to poor absorption of calcium from the gut. Another condition that is important in calcium and phosphorus regulation is chronic kidney disease, but I won't get into that here. You have to be careful with Vitamin D3 supplementation, as you can get the opposite, Vitamin D toxicity. Unlike Vitamin B's and C, Vitamin D is fat soluble and excreted from the liver into bile and out in the feces. If they patient is over-supplemented, the Vitamin D will contribute to mineralization of soft tissues. Have I confused you enough?? Ok, Vitamin D3 is the supplemental form of Vitamin D also called cholecalciferol. Cholecalciferol is not active in the body until it is converted by the liver to 25-hydroxycholecalciferol which is then converted to 1,25-dihydroxycholecalciferol by the kidneys - this is the active form of Vitamin D, in a nutshell. UV Light and Vitamin D So where does sunlight or UVB light come into play? There are species differences in the ability to convert pro-vitamin D into Vitamin D3 (cholecalciferol) in the epidermis (skin), which seems to be show that more carnivorous species get their Vitamin D3 through dietary intake, and the more herbivorous/omnivorous species getting it through UVB light conversion in the skin. In the skin of these herbivorous/omnivorous reptiles (adult bearded dragons and iguanas for example), the compound 7-dehydrocholesterol is converted to cholecalciferol (which is then converted as above). I told you it was complex. When the reptile hobbyist comes in and says, they have a UVB light therefore, they don't supplement Vitamin D3, check to see that the UVB lamp has been replaced often enough. The rule of thumb is to change the UVB bulb every 6 months. So if they say they change it when it burns out, that is not sufficient. Additionally, the mesh will block some of this UVB light, and glass/plastic/plexi blocks UV light. A few reptile breeders may have a UV light reader, while most reptile owners do not, so unless they are measuring the UV light at the spot where their reptile basks, it will be difficult to know how much UV exposure they are getting. Ideally, they are not using a material that blocks UVB between the lamp and the basking spot for their reptile, and that the reptile is both not too close and not too far from the UV light. A basking spot that is about 12 inches (1 foot) from the lamp is a good measurement. Greater than 18 inches is too far, and less than 6 inches can lead to UV burns (sunburn essentially). The bonus of using UVB light to convert Vitamin D is that excessive exposure will not lead to Vitamin D toxicity, so wherever possible, having a UV light for reptiles is ideal, even for the crepuscular/nocturnal species of reptiles. I have some folks say that the enclosure is close to a window, so they don't supplement UV light. However, windows are impermeable to UV light, and there is reduced metabolism of Vitamin D in the skin because of this. Air permeable mesh is probably the best option for containing your reptile, and allowing the UV light to access their basking spot in an amount that is ideal.
ABC’s of Vitamin Deficiencies: Vitamin C Deficiency
The poster child in the veterinary world for a Vitamin C deficiency is the guinea pig. The Caviidae family of rodents (also see the largest rodent a Capybara!) do not have the ability to synthesize Vitamin C in their bodies, like humans! This is because Vitamin C cannot be formulated in the body due to a lack of a specific enzyme (gulonolactone oxidase, if you're interested). Since I have been seeing a lot more exotic pets, I have seen a few clinical signs of Vitamin C deficiency in the guinea pig. You may see lameness and/or curly nails. Nasal discharge and dental issues, muscle wasting despite a chubby belly, poor digestion, necrotic penises. Just with every veterinary visit, a history of the animal's nutrition is important. I ensure that I check to see what the guinea pig is consuming. Not just what it is being offered! Inappetence, or a reduction in the amount of food that your guinea pig is eating, is a very non-specific clinical sign. It really could mean anything. The history you collect from your pet owner is going to be the ticket along with your physical exam. Guinea pig pellets are fortified with Vitamin C. But the Vitamin C degrades over time, so really, if your guinea pig doesn't consume that bag of pellets within 90 days, it's not good enough. The Oxbow Vitamin C chewable treat is 25 grams of Vitamin C. So if you have a 1 kg guinea pig, then one of these chews should suffice (if they are healthy and have no nutritional deficiency). For the ill guinea pig, or those that were deficient, they will need more vitamin C. As a rule of thumb, it is 10 mg/kg/day Vitamin C for a healthy adult guinea pig, and 30 mg/kg/day for a growing/young or pregnant/lactating guinea pig. Bump that up to 50 mg/kg/day for while they are ill. If your guinea pig does not enjoy the chewable treat, then ensuring there is enough vitamin C in their daily salad will be important. See this handout on the amount of Vitamin C in some food items that you can feed your guinea pig. BUT one thing to note is that you also do not want to feed a low of high oxalate vegetables to your guinea pig, as this can lead to calcium oxalate bladder stones. This is a good list of veggies and their oxalate content. Choose things that are lower on the list to feed your guinea pigs (cilantro, kale, pepper) and limit the amount of high oxalate foods (spinach, parsley, beet leaves). If you're not really interested in exotic species, then Vitamin C won't be that interesting for you, because dogs, cats, horses, cattle and pigs can all make Vitamin C. However, if you see a question on your board exam about guinea pigs, you may wish to remember this one.
Preliminary Surgical Assessment for the CPE
This post was inspired by a colleague of mine who graduated from an international veterinary school, who is preparing for licensure in Canada. The PSA (preliminary skills assessment) is the first practical exam (not like the sit-down exam of the NAVLE). In addition to this site, I’ve compiled some YouTube videos. If there are any skills in there that I do differently, I will let you know. 1) Prepare a cadaver (or simulation model) in a sterile manner for a laparotomy (essentially sterile prep for a spay procedure). In veterinary school, we don’t do the CPE as one big exam. We are evaluated over our four years on our clinical skills. Year 1, we had to learn how to suture, as well as the names of instruments and what they were used for. Year 2 we are scrubbing ourselves and our ’patients‘ aka cadavers. Year 3 we are doing actual surgery! For the PSA, you will need to demonstrate that you can prepare your patient to prevent infection. Just like washing your hands, scrubbing your patient is about contact time. If your patient comes in filthy, you will need to do an initial scrub, then a sterile scrub. The technician in the video below does a great job at demonstrating scrubbing the patient, first by starting at the midline where you will make your incision, and circling outwards. Since it is about contact time, you will want to keep doing this for a three minute scrub. Many technicians will do an initial scrub in their induction room, then move the patient into the OR for a final scrub. You should not be clipping the hair in the OR. Since I scrub myself differently than the doctor in this video, use this video as a guide for preparing your patient for its spay procedure, not for preparing yourself. 2) Prepare yourself for a sterile surgical procedure This will include a sterile scrub of your hands/arms and sterile ‘Gowning and Gloving’ When you are preparing for a spay, you need to have your scrubs or whatever else you wear, covered with a sterile gown. This is something that takes practice, especially with how to put on your gloves while maintaining sterility. In school, the first thing we would do is find our glove size, open the gown pack, open the gloves in a sterile fashion, drop the sterile gloves on the gown’s sterile field, then go scrub ourselves. One thing to note, there seems to be some variability in veterinary clinics, but the gowns should be double wrapped. Just don’t be surprised if they are not. If they are double wrapped, open each layer in a sterile fashion. The tab of the flap furthest away from you is opened first! Then the sides, then the tab closest to you, in order to not have your dirty arms hang over the sterile field. What I didn’t like about that first video above was that the doctor opened his gloves to the side (which would be ok for an open-gloved technique), and the scrub brush was on his sterile gown which he had to pick up with his dirty hands. The five-minute sterile scrub can be separated into one minute per hand, one minute per arm, then a final minute of contact time on your hands. Above are the scrub sponges we used. Prewash your hands. Open the package for the scrub sponge. Then clean your finger nails first (this is not included in the five minutes of contact time). Toss the pick. Pick up the sponge and wet it to get suds. Scrub all four sides of every finger and thumb, palm, back of the hand. You can watch the clock, or count the passes of the scrub brush on each side of your fingers to pass the time. Then switch hands. Then go from the wrist towards the elbow in a circumferential manner, and switch arms. Taking some of the chlorhexidine from the sponge, drop the sponge, then rub the suds on your hands for the final minute. Do this all while not touching the sink or faucet, and keeping your hands up so the suds go from hands to elbows. Here’s a great video that shows surgical scrubbing nicely. After you have scrubbed, it’s time to dry off. In the video below, the technician does a great job at drying so have a look and listen. This video shows how to don your gloves in the closed glove gowning technique, including some common mistakes people make. The only thing it does not include, is how to open the sterile pack that your gown is kept in. Practice, practice! Have a friend watch you and give you tips. They should point out where and when you broke sterility. 3) Perform a ventral midline celiotomy/laparotomy and close the ventral midline celiotomy, subcutaneous tissue and skin on cadaver. Now that you are sterile it’s time for surgery. Your pack will be partially opened by your technician, and you open the last wrap in the same fashion as above (the flap away from you first). If for some reason the pack is on the table or mayo stand in the opposite direction, you can ask for assistance to turn the table, but hopefully they do not try to trick you. You will drape your patient, either with a single slit drape, or using four separate drapes to cover the dirty part of the patient. Use the towel clamps to secure your drape(s). You may have the option for four drapes, and a slit drape. So drape the four sides first, clamp, then place the slit drape. When opening the slit drape, open away from you first, then towards you. Make sure to never reach your sterile gloved hands under the drape edges. To see one way to drape using four drapes and a large one (which you cut the slit on) here. Once your patient is draped, you’re ready to start surgery. The celiotomy is essentially opening up the body cavity of your patient in preparation for a spay (or any other abdominal procedure, like an exploratory laparotomy). Then closing the body cavity in three layers. In school, we were taught to incise the skin with a #10 scalpel blade, and switch the scalpel handle to a #15 to enter the peritoneal cavity. The reason for this is that the skin is clean, but not sterile. The peritoneum is sterile (in your healthy spay patient). Depending on who is evaluating you, you should be prepared to switch blades after the skin is incised. When entering the peritoneal cavity, don’t forget to tent the linea alba so that you don’t accidentally stab the organs underneath. Depending on your schooling, you may extend the linea using scissors, or how I learnt was to use thumb forceps as a guide to lift the linea away from structures and use my #15 scalpel blade to extend the incision. Here’s a video on opening the abdomen. Once you’re in, you’re going to close the body wall for this preliminary part of the exam. Closure is in three layers: 1) linea alba 2) subcutaneous layer 3) skin Closing the linea Again, depending on who taught your surgical skills training will depend on how you close. I close in a simple continuous and rarely close any other way. Some tips include: start closing at 3-5 mm caudal to the incision, and end 3-5 mm cranial to the incision. This helps prevent a space between the end of the incision and the knot. Clear the linea, especially the ends, of the subcutaneous tissue, or it may be difficult to see when you go to close. Take bites only through the rectus sheath, remember, muscle does not hold suture and will tear through. If using a continuous pattern, ensure you have the correct number of throws to provide a secure knot on both ends (6-8, depending on if you used a surgeons knot or not) Choose the right suture size for the amount of weight it needs to hold (3-0 Monocryl or PDS might be ok for a cat, but not a large dog) This is a lengthy video and she is using a laser, which you are unlikely to have for your exam. So maybe ignore that for the time being. If you scroll to minute 49 or so, you will see an example of a three layer closure, using a simple continuous pattern on the linea. I also like that she demonstrates checking the linea for any spaces that could lead to herniation of internal organs. If there is a space, just add a simple interrupted ligature in that spot. This video shows closure of the linea using a cruciate pattern. Closing the Subcutaneous Layer The purpose of closing the subcutaneous layer is to minimize the dead space. You can prevent seroma formation if you bring the tissues together. There are different ways to close the SQ just as there are for the linea, just stick with what you are comfortable with. Use this layer to help bring the two edges of the skin closer together for your skin closure. Closing the skin For the skin on a spay, I like to make things pretty. This is the part the pet owner sees. For a healthy spay I always close with an intradermal pattern. I’ll use a 3-0 reverse cutting needle, or sometimes in young cats a 4-0 as it is less bulky. Make sure you practice burying the knot! For one example of burying the knot for simple interrupted visit here. My final tip for preparing for the PSA is: If possible, job shadow a veterinarian to help with your clinical skills. Good luck on your examination!
Are Mental Health Diagnoses Still a Taboo Subject in Veterinary Medicine?
VETGirl just posted a podcast episode this week interviewing a clinical social worker, Jeannine Moga. It's definitely worth a listen as it will give a few tips on how to take care of yourself. Jeannine Moga mentioned that we need to tend to our Physical Health first. Hydration! Grab a fancy water bottle and fill it with ice first thing, then keep topping up with water as you go. I use the Klean Kanteen with the straw, just grab and sip. I think a lot of people know that they need to breathe through stressful situations. You can try Box Breathing (this is something that I also found on the AbilitiCBT app - which fortunately my workplace covered the cost of this) or breathing 4 seconds in, then 6 seconds out - a longer out breath than in breath. Don't forget to pause for a few seconds between. I'm also really grateful that several of our 'famous' veterinarians are speaking about their own mental health struggles. Once you are aware that you are suffering, it is easier to find help. In my first blog post, I mentioned that I got diagnosed with anxiety and depression and started on Zoloft. I had no idea that I had been suffering this way for years until I started the medication and realized that - this is what I should feel like. It gave me a whole new perspective of what life is like without feeling anxious and depressed all of the time. I just never thought I was depressed because I have never had thoughts of suicide. That was my naïve thinking, or perhaps because suicide is the worst symptom you can have with your mental health condition, that mine is not justified, as others have it worse than I do. I’ve been going through the Podcast episodes by Dr. Dave Nichol, ‘Blunt Dissection’ and there are a lot of episodes that include destigmatizing mental health illnesses in our profession. Most veterinarians get anxious over something, but it’s how we cope, or the lack of the ability to cope, that determines our ability to function. I was exhausted, irritable, and on my days off from work I spent a lot of time laying around. I started to feel indifferent to the things that used to give me pleasure. I started to not feel compassion or passion while at work, and the stress bled into my home life. My husband felt the brunt of my low energy and intolerance, because being empathetic and compassionate at work was exhausting, and I had no more compassion for him when I was at home. People call this compassion fatigue. Veterinarians feel compassion fatigue, but it’s taboo to have depression or an anxiety disorder. When do you know when you should be medicated? Most veterinarians have high-functioning anxiety. Anxiety that stems from wanting to be perfect, being a Type-A personality, and taking alllll those bad online reviews as personal attacks. But does that mean you should be medicated? Maybe you just need someone to talk to. There are a lot of options for telehealth appointments from social workers, counsellors, psychologists etc. I started medication on my family doctor’s advice. I thought it was normal to become fatigued and irritable - that was my normal. My husband admitted himself into a mental health institute when he was in his 20’s after he attempted suicide. He spent many years with therapy. Being prescribed the wrong medications and switching medications. Nowadays, there are more standardized testing for mental health disorders. So when my husband mentioned that I should maybe talk to someone because it wasn't normal for me to be laying around, or crying so much. I first took an online questionnaire, which was very similar to the one my family doctor had me take. There are several online tests. I can’t seem to find the one I did in 2019. But here is a link to one for the PHQ-9 questionnaire. I scored Moderate for depression and anxiety, and I got medicated. After I started my medication, I started understanding what real normal feels like! There is an increase in information on suicide in the veterinary profession. We are more likely to commit suicide than the general public - but also, we know how to kill things really well. So, a veterinarian who intends to put themselves out of misery, will more likely to be successful at it than someone in the general public. The general public may think that it’s euthanasia, or ‘putting animals to sleep’ that is the hardest part of our profession. Most veterinarians will say it can be a difficult part of our jobs. However, there are other more stressful parts of our careers that contribute to our on-going or chronic stress. 1) Dealing with difficult clients: This can be part of the development of compassion fatigue. Clients are more educated nowadays, through online sources, and therefore client expectations are much higher than they were in the past, and we have to learn to manage these high expectations. When you do not meet these high expectations, they will post an ugly review online about the interaction. 2) Financial pressures: There can be a huge student debt, more so in the U.S. than in Canada, and those trained overseas as ‘international students’. Veterinary students come out of school with $300k in debt and make $60k a year. If you decide to intern your first year out, you can look to making $35k that year. 3) Overworked and Understaffed: If you work in a busy practice, how often are you your own technician? Taking blood and urine samples, drawing up and administering your own patient’s medications, placing IV catheters? It means you are understaffed because veterinary technicians are also overworked. You have scheduled work hours for appointments, procedures or surgeries, but where is the time to call pet owners with results of diagnostics, to see how the treatment is working or to finish your medical records. Many take their medical records home with them, cutting into their time off when they should be relaxing to regenerate for the next work week. How to help with compassion fatigue? Start by talking about your feelings and experiences with your colleagues. Have a good vent. (As per Dr. Bree Montana) Develop a ‘wolf-pack’. I feel badly, when I start venting. My colleague who I vented with has just left the practice, so I need another person to vent to! Husbands are not good to vent to, because they don’t understand. Non-vets don’t get it. If you do not have a “wolf-pack” a group of colleagues to vent to, then you can go to Vets4Vets by VIN foundation for help. One thing that I need to pay attention to more is recognizing my own burnout or compassion fatigue before I become so agitated that I take it out on my team or my husband. It’s true, when I start snapping at my team, I know that I’m struggling with managing my stress. This year and a half of COVID restrictions has not helped. April was the hardest time for me in this new job. I worked 7 of 8 days, went immediately from curb-side only appointments to in-person appointments, and didn’t sleep well. “Not healing the little wounds that come up along the way“ leads to compassion fatigue. Veterinarians are good at medicine and surgery, but we have minimal training in dealing with the people who own the pets. You as the vet and the pet owner need to work as a team for the better health of the pet. You will gain more respect if you listen to your client and what their needs are. It will only make you more frustrated if you make all the recommendations and the client says no. Set Boundaries. What does that even mean? Ensure that you leave work at work. Yes, you have to do your medical records, but you do not need to do them at home. Ask for help or time to do your records during your work hours. If your manager is unable to accommodate, know that you are valuable, and you will be able to negotiate for your personal time, there or elsewhere. Do not give out your personal phone number or email address. People need to respect your time off. Learn how to say no. If you are not comfortable doing something, you can say no. If you need someone to talk to, there is no shame in reaching out to a therapist. There are people who can help, without having to pay an arm and a leg. Counsellors with a sliding-scale. Some employers will give you health benefits that cover therapy. Check Out DVM360 for some resources