Be honest - how much fun have you had this year? (Adult life - it’s tough.) Maybe you should come and have some (tax free!) fun with us in New Zealand in August, while still ticking the ’serious adult life’ CPD box with our world class speakers. (And at Vets On Tour - even lectures are fun!) Last 10 tickets are still up for grabs here.
If you’re in need of high volume, high quality vet learning on Aussie soil, then I’m speaking and podcasting at a few of my favourite local conferences over the next months. Come to give your CPD a serious bump, and argue with me about AI:
Science Week - Gold Coast - 24 - 26 July
ASAV - Sunshine Coast - 12 - 20 August
Green Cross - Sydney - 7 and 8 Nov. (Vet Vault nerds can get a 20% discount by using code VETVAULT20 at checkout.)
(For non-Australian readers - these are all spectacular locations and excellent excuses to have a holiday down under - feel free to message me for travel advice.)
From Episode 223 Surgery Feed With Dr Paul Aldridge
You’re in theatre wrestling with an intestinal tract that has seen better days: maybe it’s a bad linear FB, or a volvulus. Whatever the cause - a scarily large section of that gut is purple, and it all needs to come out. You know you can safely remove about 70% of the small intestinal tract without any major long-term issues, but figuring out what 70% looks like in the patient in front of you is a challenge. Emergency surgeon Dr Paul has a pro tip that will save you unpacking the entire GI tract and pulling out your measuring tape:
The small intestine is on average 3.5 times the length of the dog’s body
If the length of gut you want to resect approaches two body lengths of your patient, start getting cautious - you’re up around 60% plus of the GI tract
This is much easier than trying to measure the whole thing and working out ratios
From A Cut Above Advanced Surgery Podcasts, with Dr Mark Newman and Dr Chris Tan
First you check proprioception, then you check withdrawal reflexes - light toe pinch, then you check for pain - really crush that toe so it hurts! That’s how you do a full neurological exam, right? Until you’ve done all of those, you’ve not done a proper job.
At least, that’s how I was taught. But here’s a 🤯 moment from our detailed neurological exam episode that will save a lot of dogs a lot of unnecessary pain:
Fact: If your patient walked into the consult room, even if it’s not walking well, you do not need to check for pain, which means you don’t need to go crushing its toes.
Here’s why: remember that with compressive spinal cord disease (eg disc problems, trauma etc) neurological function is lost in a very predictable order:
Light compression will take out your proprioception
Next to go is motor function
And only then - with significant compression - will we lose pain sensation
That’s because the fibres that carry pain sensation sit very centrally in the spinal cord. So you have to squish everything else before you start squishing those central pain fibres.
That means that, by definition, if your patient still has voluntary limb movement, then they will definitely also still have intact pain perception.
One of the first things that struck me when I started delving into this deeper is that if that animal’s walking on those legs, you don’t need to go crushing its digit. That’s really quite cruel. If they’ve got movement, they’ve got pain sensation.
From Episode 229 Medicine Feed With Prof Jill Maddison
It’s a great feeling: you’ve run some tests, and there, printed in black and white, is an abnormality. You have an answer! Job done, moving on.
What’s a not-so-great feeling is when it turns out that you are wrong. Somehow, that test result deceived you, and you missed the diagnosis. Sometimes it’s an easy course correction, but we all know that a wrong answer can be catastrophic.
We’ve just released a two-part conversation with diagnostic reasoning guru Professor Jill Maddison, talking about all the reasons why we might miss the mark with our thinking. There’s a lot in that conversation you need to hear, but to start you off, here are a few pearls that I’ll be keeping in mind as I work through my tricky cases:
It’s been shown in human medicine that the most common causes of medical misdiagnosis are:
A misleading/incomplete/incorrect history - 60% of the time
Incorrect physical exam findings - about 20-30% of stuff-ups
Diagnostic testing errors or misinterpretations - about 20-30%
So takeaway nr 1: The reason you are not getting the right diagnosis is probably not because you didn’t run the right test or the test gave the wrong information. It’s because you rushed the history.
There seems to be this tendency to think that the diagnostic tests are what you absolutely need. And I’m not saying that you don’t need the diagnostic tests, but without using diagnostic tests in the context of your clinical reasoning decisions that you have reached through your thorough history and physical exam, they become just thrashing in the wind.
Don’t be fooled by the positive result - part 1
Remember - a test with good sensitivity still doesn’t mean 100% sensitivity.
Example: a SNAP pancreatic lipase has very high sensitivity at 93%. That means that in 7% of cases with pancreatitis it will tell you that the patient does NOT have pancreatitis - that’s almost one in 10 cases.
Don’t be fooled by the positive result - part 2
Prevalence matters. If you’re testing for something that is fairly common in the population of animals that you’re testing, your test results become more believable. Now - run that same test in a population of animals where the disease is not very common, and you start running into problems.
Example: A lymphoma screening test is 79.3% sensitive and 98.9% specific. Amazing - that means only around 1 in 100 dogs without lymphoma should test positive. But thanks to a little mathematical gymnastics called Bayes’ theorem, if you run that test in a population of dogs where lymphoma is very rare, that number becomes a lot less reliable:
Test 100 young, non-Golden Retrievers, where lymphoma prevalence might be around 0.1%, and you’d expect about 1 false positive, but only 0.08 true positives. In other words, almost every positive result is likely to be a false alarm.
Now run the same test in 100 middle-aged Goldies, where prevalence might be closer to 5%, and you’d still get about 1 false positive, but now you’d also expect about 4 true positives. Suddenly, a positive result is much more believable. Same test. Same specificity. Completely different meaning.
Don’t be fooled by the positive result - part 3
Your positive test result might be accurate, but it doesn’t mean that that is your patient’s problem.
Example: Pancreatic lipase is positive and the dog does have pancreatitis, but the underlying problem is actually an intestinal obstruction, or some other significant abdominal pathology that’s upsetting the pancreas.
This trap of ‘I have a diagnosis - I can move on! has a name: it’s called ‘satisfaction of the search’ - or ‘premature closure.’ Watch out for it.
2 Other Things
“That’s one of the things with parenting that people don’t talk about enough: it’s massively inconvenient.”
-Dr Becky Kennedy on the Tim Ferris Show (I had to share this sentence because it’s such a massive understatement, and also so very true. If you have kids or think you ever will - this episode is well worth your time.)
“Tell me, what is it you plan to do with your one wild and precious life?”
-From Mary Oliver’s poem The Summer Day - which you should definitely read right now.
I saw this thread in an online community: a woman asking for opinions on what constitutes a reasonable amount of sex in a marriage + kids. Apparently her husband - bless him - felt that 2 or 3 times a week is a reasonable expectation. The questioner suggested that - what with the time and energy constraints imposed on her by that bottomless time-and-energy pit called children, plus full time work, she wasn’t feeling the romance quite as often as her husband, and wanted to know if she was being unreasonable. I ran to the kitchen to get some popcorn before opening the comments. They were exactly as entertaining as you’d expect - a veritable deluge of comments from flabbergasted women all basically saying - WT absolute F?!
I mean - you have to admire the fool for aiming high.
But as I kept scrolling the comments became less and less entertaining and more and more depressing: “Maybe once a month…. every few months… it’s been 7 years… we’d both be keen for more but there’s never time.”
This is not a post about sex, relationships, equal distribution of household chores, or about how silly men can be. All important and valid conversations, which I will now attempt to deftly sidestep…
This is about why the hell we’re all so busy, so tired, so disconnected, that the idea of having time for intimacy (physical or otherwise) with somebody we love has become preposterous. Another tick box on the to-do list - right at the bottom. Why are we so overwhelmed?
“Because, Hubert, the kids have to do music and soccer and camp and and…, and we work this hard because school fees and new shoes and the car repayments, the internet bill, and have you seen the price of petrol and cappuccinos? We need the money. It’s just normal adult life.”
Do they? Do we? And who decided that this is ‘normal?’
These are societal agreements, not facts. A mutually agreed upon cultural ‘bar’, that - for the majority of us - again…
Think about the money - like - really think. If you’re reading this you’ve likely got enough to meet your physical needs. What you (I) ‘need’ it for are emotional reasons: status, relevance, and not feeling like a loser.
The busy-ness can be the same, but also - I like my work - to some extent we do it to fill some other emotional needs, like purpose, impact, and recognition. It feels nice to be useful. But if you do a bit less, does that make you useless.
Maybe we can consider walking around that cultural bar, instead of trying to jump over it. (Again - I urge you to go read that poem by Mary Oliver from our 2 things. ) Create a bit of breathing room - some space for human connection.
Who knows - you might even get laid.
I had this post mostly written yesterday. Then, in the afternoon, I interviewed someone for the podcast. He had done well in business - retired a few years ago just shy of 60, spends about a third of his time at home, a third at their beach house, and the remaining months travelling abroad.
Sounds nice - I could go for that. I asked - what do you need to be able to retire like that? ‘5 Mil in super.’ (Retirement fund - for our non-Aus readers)
I spent the next 24 hours in a horrible mood, feeling like a total loser and wracking my brain as to how I could possibly accumulate 4.5 million dollars in the next decade. This morning I very nearly decided to ditch this post, because I’m clearly a complete hypocrite. But maybe this is exactly what this post is about: cultural norms and expectations run deep. Comparison is deeply baked into our psyche. It helps to be aware of it.
So maybe I’m not quite ready to side-step the cultural bar. But I’m thinking about it.
Much love,
Hugh
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