:X Now I'm having imposter syndrome. I've never worked telemetry data and I only have one rotation left. Should I have?
For real though, I have massive imposter syndrome that comes and goes, if that makes you feel better! I haven't seen a case of CHF from intake to diagnosis in vet school, I haven't seen a pyometra in school, I've only placed one drain, only unblocked one cat... All small, kind of random things, but I worry about seeing them for the first time post-graduation and maybe not recognizing what's going on, especially now that I matched to an internship with so much primary case responsibility on ER. A clinician pointed out what she said was pulmonary edema on a ferret rad a couple days ago and I just didn't see it at all.
Dude(tte).
Vet school isn't about seeing everything from intake to diagnosis in vet school. It's about learning how to make medical decisions. Pure 'n simple. It isn't some kind of pictorial atlas of all medical conditions that you're supposed to pattern match on. Pattern matching is what experience is for, and you don't have that.
If you're going off to do an internship with ER-heavy responsibilities, it likely means you will be surrounded by techs who are experienced. Trust your techs. They know ****. If you ask right, they'll tell you the diagnosis before the animal arrives and they'll be right 90% of the time - you just have to suss out the other 10%.
And when in doubt, always always always remember your basic role on ER isn't to fix ****: it's to stabilize the patient and get them in the right hands. Keep them breathing, beating, and not bleeding, and you've basically done your job. Maybe you goofed up a little and forgot to save urine for IntMed to culture the next morning, or you gave an nsaid when you shouldn't, or ... you know, whatever. All the little crap. Who cares - that might be frustrating to the next doctor, but ultimately you didn't let the wheels come off the cart and that's all that matters. Stabilization is your job on ER. Fixing is not your primary responsibility (obvious exceptions being obvious, like suturing up some laceration repair).
But even then you're going to find yourself in ambiguous situations where the right step is unclear: do you vomit this dog or not? do you suture this back together or say "not a chance" and open-wound it? The answer is always: Tell the owner all the pros and cons, make sure THEY understand that there's uncertainty, and give them options. I have given the "vomit yes/no, scope yes/no, surgery yes/no" speech so many times in the last 2 years......
So you haven't seen a pyometra. Big deal. You know what it is. You know to consider it on any intact middle-aged female (esp with that classic history of ADR who was in heat a few months ago). And you know how to diagnose it (rads! ultrasound!). And you know how to fix it (stabilize and spay!). Right? Boom, done. Who cares that you haven't seen it. (As an aside, one of my first pyometras was a reportedly spayed female that I ultrasounded; I kept staring at the caudal abdomen saying "why is there a big bifurcating tube back there......"? Not as spayed as she was reported to be.)
Question for both of you: I've never aFASTed/tFASTed anything in my life and I've probably done full abdominal ultrasounds three times so far? Do you have any recommendations for resources on knowing what you're seeing? I know you're looking for fluid lines, obviously, but I had a resident one time talk to me about comet tails and other things I've never heard of and don't remember now. Just worried I'll flash something and completely miss what's wrong. Is it bad that I haven't had that experience yet?
If you've done full abdominal ultrasounds you can aFAST - it's just a four-quadrant search for fluid, right? A *true* FAST-scan can be done in 15 seconds. In reality, most of us do something between a FAST scan and a diagnostic ultrasound; especially the more comfortable with ultrasound you get. And if you're in a situation where a dyspneic patient is too unstable to radiograph and you don't yet have the chops to dx it with ultrasound but you suspect fluid or air because you put your stethoscope on them - ok, fine, that's life. Tap the chest. Never be afraid to stick a needle in a chest.
Comet tails are a resident showing off their ultrasound chops and trying to impress you. (It's an artifact, don't be impressed.) You don't need to know what comet tails are to do a FAST scan.
For someone just graduating I would focus on aFAST (know your four quadrants, know how to find fluid, be comfortable aspirating it). For the chest, I would focus on recognizing pericardial effusion. Those are the biggies. Pleural effusion and a pneumo are things you'll more easily pick up on radiographs until you're more comfortable with ultrasound.
I don't have a reference for you - maybe Orca's book is great, dunno. But I do know the ultimate reference is experience. When I went into ER practice, I FASTed like every other patient through the door if I had time (I only charged them when it was well and truly indicated.). I mean, it vomited once? Hey, let's FAST scan it as long as there aren't other patients waiting! My techs used to roll their eyes, but after a few weeks they got used to Dr. LIS just being weird and liking to scan everything. There just isn't any substitute for doing it over and over. Fast forward almost two years and I use it for diagnosing a much wider variety of things (it's a great tool for those "should I cut or should I not cut" suspected foreign body patients), and I'm debating doing some more advanced training and starting to offer diagnostic ultrasounds instead of 'just' FAST scans. But I started with just "Ummmm.... nope.... there's no fluid there."
Bottom line: Keep it simple, focus on stabilization when you're on ER, use the tool to the level you're competent and trust experience to grow the competency, and trust your techs as long as they are experienced old hands.
🙂
