Submitted by dasko2 on Fri, 02/19/2021 - 13:09

The Veterinary Detective:
The Case of the Hippo Who Wasn't Hungry


released December 29, 2020

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Dr. Ashley Mitek: Hi, I'm Dr. Ashley Mitek, a member of the faculty at the University of Illinois, College of Veterinary Medicine.  Over the next several weeks, we're presenting a mini-series called "The Veterinary Detective". In each episode we discuss a case with a veterinary clinician who walks us through the diagnostic process to help us understand how they apply clinical reasoning in their practice.

Sometimes, even when clinicians are confident of a diagnosis, treatment for the malady can be risky for the patient.  How does the patient’s welfare inform a clinician’s decisions? We’ll examine that question in this episode we call “The Case of the Hippo Who Wasn't Hungry".

Joining me is Dr. Jennifer Langan. Dr. Langan is a board certified specialist in zoological medicine at the University of Illinois College of Veterinary Medicine and a senior staff veterinarian at Brookfield Zoo in Chicago.

Let’s hear about the case.

Dr. Jennifer Langan: So, I was called to take a look at our 28-year-old pygmy hippo. Her name is Obesa. And she presented for not wanting to eat and not moving around normally, did not want to go for her morning swim. So, the animal care staff immediately had concerns about her wellbeing and asked for the veterinarians to come take a look at her. So, that's where we started.

Dr. Mitek: How often do you get a call from the caretaking staff of, the presenting complaint is really nonspecific, of, "She doesn't want to swim"? Is that a big red flag for a hippo?

Dr. Langan: That's a great question. The animal care staff are almost like a pet owner, where they know their animals really, really well. They know their personality, their activity level, their brightness. And as soon as they sort of see something change, they'll usually alert the veterinary staff, depending on how dire the change is, as far as whether it's an initial emergency, or if it's sort of a slow change that might have started. So, in this case, it was really unusual. This pygmy hippo really liked her breakfast, and for her not to want to eat her breakfast, that was a pretty big red flag. So, they wanted us to come take a look at her pretty quickly.

Dr. Mitek: So, you get this phone call-I'm assuming it's a phone call. And then, you walk out to her enclosure? Or, you ride out there? And then, what are you thinking in your head as soon as you get this information?

Dr. Langan: That's a great question. So, being able to practice veterinary medicine in a zoo and conservation park, we have that option. There's some animals that are close and we can go see on foot. It's kind of nice variety if we're actually going to prepare for procedure, where oftentimes, we'll pack up our veterinary truck, much like a food animal veterinarian would to go do things in the enclosure. In this case, it was initial visual exam. So, we piled the veterinary students and our resident into a golf cart and headed across the park.

The very first thing we usually start with is close observation skills. I think one of the things that the students always would like to know is, we want to rush to some diagnostics, but actually, the power of observation and monitoring an animal's behavior, or response to a veterinarian potentially being present, is one of the things that is really telling about the animals. Some of the animals really enjoy our company. We might be able to have the opportunity to feed them on a regular basis so that we're associated with positive things. And in some cases, some of our patients we see for shots, for example, and they don't have such a good opinion of us, and they respond in a way that they certainly let us know that they're not real happy if we have to come give them an injection. In this case, this animal was not one that we would look at regularly. So, I was just one of the public, for example. So, she didn't respond to me individually in a positive or negative way. But she definitely appeared lethargic. Did not want to rise. The thing that's most telling is that when her animal care staff sort of called her over, and she knows them the best, she really didn't even want to lift her head.

And, she had not passed stool for 24 hours, which is also really unusual. That would be similar to like a cow or a horse if they didn't pass stool. Maybe not quite so as dire as in a carnivore, like a dog. But if an animal ingests a lot of herbivorous material, they should be passing stool on a pretty regular basis. So, the fact that she wasn't passing stool, and that she sort of was off feed that morning, was a concern.

Dr. Mitek: And so, when you go out there and you first observe her, I think in my comfort world of dog and cat, when I have a presenting complaint like that, the next thing I would want to do after I take a look, just hands-off exam, is I want to put my hands on them! Can you go into her enclosure and do a physical exam with where she's at at that point?

Dr. Langan: That's a good point. So, some of the enclosures even with animals that we would consider dangerous-which, a pygmy hippo, she's about 600 pounds, they have very long, four or five-inch long sharp canines. We definitely wouldn't work in or go into the same space with the animal for safety reasons. Pygmy hippos are generally known to be solitary and a little bit more aggressive, as is the Nile hippo, though they're a herd animal. But, this is an isolated, or, this is an animal that usually spends a lot of time by themselves in the forest. They're nocturnal, and they usually only come together for mating. But they are really aggressive when threatened. So, we don't necessarily work in the same space. We work in a way called protected contact. So, there's some sort of barrier between us and the animal. It's almost like a stanchion for a stallion exam or something like that.

And in this case, potentially, the animal might come over to where we could potentially get a closer look or use a thermography camera on her to see if she had a lameness. In this case, she was just generally dull and really didn't even want to come to the front of the enclosure. So, we did have to sort of put things into gear and change our schedule that day, and start with anesthetizing her. Since she'd already been fasted, that was not a concern. And we did have to anesthetize her to be able to do a full physical exam on this animal.

Dr. Mitek: You mentioned a thermography camera, and how that could be used in your zoo med world. Can you explain what that is and how you use it?

Dr. Langan: Sure. A thermography camera is really similar to sort of an old point-and-shoot kind of Nikon-type camera, but it shows temperature images of whatever it might be pointed at. And we use that pretty frequently on animals that present with a lameness or toothache, even in a bird that's not bearing weight on a single leg. It might show up at a much different color, usually a red, and it can show inflammation. Usually, it's associated with pain that we can see in the patient. But sometimes, where they hide their symptoms really well, it can help differentiate, maybe the animal broke a toe, or it has some sort of foot infection, or hoof inflammation, that we can't necessarily pick the foot up and look at it readily under sort of restraints. But, for example, we could shine the camera and see whether or not there's any visual inflammation associated with some sort of pain response, which we did not notice in this animal.

Dr. Mitek: So, you would point it at a localized area, not necessarily just at her forehead or something like that.

Dr. Langan: You could even do the whole body. You could put the whole hippo on the camera potentially, and you might see a subcutaneous abscess from a previous injection or vaccine. In this case -- hippos, they can get abscesses from even antibiotic injections or vaccines -- she didn't have any external changes. They have a really thick dermis that insulates their sort of underside really well. So, it can be pretty difficult if there's anything deeper than immediately underneath the skin, or potentially a limb, for that to really help us out in this case.

Dr. Mitek: And you talked about how you decided pretty quickly based upon how she looked that you wanted to go ahead and anesthetize her to do more diagnostics. And it seems as though you realize there's an urgency to this situation. Can you talk about how you take that leap? I imagine that was a risk for her, to anesthetize a hippo. And you seemed very confident that you wanted to take on that risk. Can you talk about how you made that decision?

Dr. Langan: As a 28-year-old animal, general life expectancy can be between 30 and 50 years, depending on the individual. That's like telling us a person can live to 60 or 100. So, that geriatric age span can be pretty large. But she was definitely considered geriatric at this point in time. Post-reproductive. One of the things that I haven't mentioned yet is that she had about an eight-year history of having an asymptomatic abdominal umbilical hernia, which had changed size along with her going off of food and not producing any stool, and just seeming acutely lethargic

We do routinely anesthetize pygmy hippos for examinations. It's certainly something that we plan for, generally, or are well prepared for, should there be an emergency situation. This was a pretty easy decision for the animal care staff, the curators, the veterinarians, where we have an animal where we might have a very narrow window to have an impact with veterinary care. Potentially, for an animal that's gone off food, if she had some sort of intestinal obstruction, we have a window of what we would think of as 12 to at most maybe 48 hours to potentially consider any intensive veterinary care. So, we wanted to make sure that we didn't go past that window and not have the ability to have veterinary care make a difference in a colic case.

Dr. Mitek: So, you've made the decision, you want to go ahead and anesthetize her and do more diagnostics. At this point in your head working up a case, are you starting to come up with your list of differential diagnoses, of what you think could be happening in this patient? Do you already have a list of, "These are the five things that make a hippo not want to swim and not want to eat"? I'm curious what was on that list, and what you thought was going on at the time.

Dr. Langan: That's a great thought. For pygmy hippos, they're generally easy keepers. They generally do not fracture things or hurt themselves. They have a low center of gravity. They're generally pretty tolerant of a wide diet and don't colic nearly as easily as a horse. They don't have routine volvulus or abomasum that can flip like a cow. But we did have gastrointestinal upset or potential obstruction that can potentially develop a volvulus with their voluminous intestinal tract or in an intussusception or obstruction trichobezoars or plant material that can accumulate to a hard rock, can either be a partial obstruction in the stomach type setting or an obstruction in the intestine. There's a rare case of a rectal stricture that had been reported. So, there's a few things.

And, as an aging animal, we also think potentially as a female animal, maybe she had some acute reproductive disease that may have made the animal go off. And then, of course, she still had the hernia. About 10% of horses maybe develop some sort of strangulation with a hernia. So, that previously had been something we had talked to other equine specialist about, because it's not something that we see very frequently in our zoo species. And up until this point, we had really not pursued that. So, that was on the list, but we previously had had pretty low risk concern associated with this chronic hernia. But it was something that she still had and maybe got bigger-it was rather subjective.

Dr. Mitek: And what type of diagnostics were on your list to complete when you were thinking you wanted to anesthetize her?

Dr. Langan: No, that's a big thing to weigh, because in animal that 600 pounds, palpation is not very fruitful; auscultation is very limited. They're just large, liquid, GI-filled sort of intestines, which oftentimes don't percuss well. In addition, the skin is so tight and taut, it doesn't really move even with both hands blotting things. So, that was very challenging to consider, as far as what we were going to do to get the exam.

I think the first thing that we submitted was stat bloodwork on this animal to kind of rule out whether or not there was an inflammatory or an infectious component, versus maybe potentially, in an older animal, neoplasia of some kind, or GI distress that maybe hadn't had time to respond. So, we did get some acute bloodwork started. And there was some inflammatory changes. They were still within reference ranges, so it didn't look like she had a perforation of any kind yet, or had a really severe inflammatory response with a bacterial infection like a left shift, where she had a lot of bands, but she definitely had more white blood cells at this time than she'd had in previous exams.

The other thing we think about potentially in an older animal that's acutely food would be a pretty significant dental disease issue, either an abscessed tooth or a fractured tooth, potentially even a fractured jaw that wasn't visible on the outside. So, I would say everything from cranial to caudal on the GI tract was definitely on the list.

Dr. Mitek: I want to go back just a couple steps. You talked about doing bloodwork. Can you explain how you get blood on a hippo? Where do you take that sample?

Dr. Langan: It's a little bit like bleeding an orange, quite honestly. They are one of the most challenging species to catheterize, which requires ultrasound-guided catheter placement, usually in a distal limb. But they have such a short, stubby neck, and their jugular is very deep, almost pig like, but it's probably four or five inches between the rolls, and the skin doesn't lend itself well for a typical pig positioning for a stick. But we were able to get blood from her medial saphenous vein. So, if you can imagine another sort of medium-sized animal, they would have some sort of vasculature that we could get blood from. But it seemed like there were a lot of valves present, and we had great difficulty getting catheters into this animal. For maintenance, for having some sort of IV access, we ended up using lingual vessels, so tongue vessels underneath their tongue, to have some sort of reliable IV access for safety purposes under her immobilization period.

Dr. Mitek: And you mentioned that, with the bloodwork, it could help guide you during the process of trying to figure out what was wrong with her, and that you could look at changes on the bloodwork that might indicate inflammation or infection. And you mentioned a left shift. Could you explain to the listeners what it means when we say a left shift on bloodwork?

Dr. Langan: Sure. So, what we were really wanting to rule out, were looking for, was whether or not she had an overwhelming inflammatory response, to usually a bacterial infection, where the body is putting out more brand-new neutrophils from the bone marrow that are fighting off infection to show a very new response to a really severe infection, that the body's not quite able to mature those neutrophils, and the neutrophils that are being released from the bone marrow into the circulating bloodstream have a different nucleus that is shaped like U, and we call those bands.

Dr. Mitek: And so, you get your bloodwork from her back. I'm trying to think through the logistics of, you go to anesthetize her. She had to be anesthetized to get the blood sample, correct?

Dr. Langan: For this patient, and under these circumstances, yes. We have been able to get injections into animals voluntarily, particularly hippos. But in this particular animal, because she wasn't motivated by treats or attention, she did have to have the blood sample taken under anesthesia.

Dr. Mitek: You take the blood sample, and then, do hand it off to somebody and say, “Go run this really fast so I can decide whether to wake her up or keep her asleep"? I imagine there's a limbo period where you're not sure if you should keep her anesthetized a little bit longer or let her wake up.

Dr. Langan: Correct. So, the initial process on that particular day was really to get baseline diagnostics. And we are fortunate enough to have a tremendous hospital team that, particularly when something this big, or that needs this many hands on, that you can even just move the patient from one side of the stall to the other. We also have extra veterinary technicians that are able to run the sample back to the hospital and an in-house lab where we can get acute results for our CVC chemistry in-house, which is a huge benefit, of course, in an emergency situation with critically ill animals. So, that was helpful.

And while that was taking place, we were able to do some other diagnostics on the animal. So, for example, we have a portable ultrasound machine. And just like in the equine colic case, we did a fast ultrasound on its very specific locations to kind of rule out some really major things. And one of the easiest things to focus on is whether or not there's any fluid accumulation or effusion around the intestines in the abdominal cavity. And sure enough, she did have that. In addition, she had a very firm structure which was very different in her umbilical area than ever before. So, where previously she had a rent in her abdominal wall and the content of her hernia were very soft, almost like fat or omentum-like, during the physical exam, while the blood was running, we were able to get our hands on and determine that in the hernia area of her umbilical hernia was a very firm structure. And with ultrasound, we had a strong suspicion that it appeared to be entrapped bowel.

Dr. Mitek: Just to back up for a moment, abdominal effusion is an abnormal finding where free fluid can be identified in a patient's abdomen. It's normal to have fluid IN your stomachyou’re your intestines, but it is NOT normal for there to be large amounts of fluid AROUND those structures.

Dr. Mitek: And you felt comfortable at that point saying that that was what was causing her illness? Could you explain how that could cause the effusion, the abdominal effusion? You mentioned you saw a fair amount of fluid in her belly when you were ultrasounding.

Dr. Langan: So, we were able to find the fluid and also collect a sample, which we submitted for cytology, which showed an inflammatory component. So, there were neutrophils within the fluid that was free in her abdomen. No free bacteria, but there was a neutrophilic inflammation within the effusion, which suggested there was some sort of acute GI concern, potentially developing towards perforation or some sort of entrapment or volvulus, something causing leakage, or maybe even a gastric ulcer would have been on the list. At that point, we weren't really sure. Maybe the ultrasound of the umbilicus was still a red herring. We really didn't know.

Dr. Mitek: And you mentioned that you didn't see any free bacteria in the sample. Could you talk about why that's something that's important to look for on those types of samples?

Dr. Langan: So, one of the things that we were really focused on was whether or not there were any infectious organisms that could be identified in that fluid. And the way we do that is simply preparing the skin sterilely like we would for surgery, inserting a needle sterilely in the area where we can see the fluid via ultrasound, and taking a small sample, and then we Gram stain those or Diff-Quik those stains or slides, and either have our vets team -- or, we actually are very spoiled, we have pathologists on-site. Oftentimes, they're helping us read the cytology while we're still patient-side. They can help us with that, because it can be a little bit difficult to for sure say there aren't any organisms in a pretty active inflammatory effusion. But the reason that we were so concerned about trying to rule out whether or not there was bacteria in the sample, oftentimes that suggests or might confirm some sort of intestinal integrity loss or some sort of perforation, alteration, or infection that's actually free within the abdominal cavity, potentially even a pancreatitis, I guess.

Dr. Mitek: So let’s pause and regroup.  We have Obesa, a 28-year-old, 600 pound pygmy hippo with a history of having an asymptomatic abdominal umbilical hernia, who won’t eat. After examination and tests, all signs point to an intestinal obstruction.  But can you even perform a laparotomy on a hippo?

Dr. Langan: So, that was probably the more difficult question, since she'd had an intermittent hernia for years, and there really had only been one or two previous abdominal surgeries reported in an animal of this size and this species. The risks of potentially doing a laparotomy were much greater than any of our domestic species and many of our non-domestic species. And the biggest concern is that their skin doesn't seal closed again. And this animal generally depends on going into the water every day for activity, for defecation, urination. But mostly, the skin, like in elephants and hippos and rhinos, is not very elastic, so it just doesn't seal or close very well. And there's been numerous attempts with dehiscence, and particularly in an aging animal with sort of a rotund midsection. Actually, with their anatomy, there's some 500 pounds that will need to be held back together again, should there be a laparotomy decision. So, there was great concern in a geriatric animal, to potentially consider putting her through an exploratory to address what we thought might have been an entrapped hernia at that point in time.

And certainly, we do surgery on a large variety of species. But if it's that large of an intestine, we don't routinely stock every staple or large animal surgical supply. And we don't do colic surgeries day in and day out. So, for specialized veterinary cases where we know one of our colleagues does them more frequently or faster or better, what we're really good at is teaming up with the best specialists to put a team together to prepare ourselves, to make sure that we have anesthesia taken care of for an extended period where an animal is going to be on its back that's this large, and potentially help with analgesia for such a large and long procedure, as well as an equine surgeon to help with the colic component.

So, we recovered the animal from its initial exam, and waited another 24 to 48 hours until we had all the supplies we needed, all the people we needed, and waited out to see if the animal would show any improvement. She got started on pain medication and on antibiotics. And she really still did not want to eat or move around very much.

So, at that point, it was either really a quality of life discussion where we needed to be headed based on the welfare of that animal, or we would give it a shot and try something nobody else has done before. And it's always a really important discussion. It's not a lot different than talking through a really difficult case with owners, where you don't know what the outcome is going to be, potentially in a hemangioma case or a hemangiosarcoma case, where the outcome is likely not to be very good, or you could have significant difficulties during surgery. We all had very frank discussions with the animal care staff.

Dr. Mitek: Since pain medication and antibiotics weren’t improving Obesa’s condition, surgery was the only option for treatment. Anesthesia and surgery are always risky, and as Dr. Langan mentioned, this surgery had never been performed before. So the options were to either euthanize the animal, or take the risk and perform surgery.

Dr. Langan: One of the things that I value most about the team at the zoo where I get to work in the University is that everyone really comes together to support the effort at hand, and is willing to do what's best for the animal. So, everybody bent over backward. We were able to move the animal to the hospital. We were doing surgery into the wee hours of the evening, I think, to make this happen. And in this case, we knew there was a really significant risk at hand, but then, sort of weighing those risks and having an open and honest conversation, everybody was still trusting enough to let us try, which I think says a lot of trust between the animal care staffer, in this case, the sort of owner staff and the veterinary staff, despite the really significant challenges that were anticipated in the days and hours and weeks ahead.

Dr. Mitek: So, you wake her up from the initial diagnostic anesthetic episode and plan to do a more invasive procedure to her in the coming days. Can you talk a little bit about how you guys accomplished this great feat of anesthetizing her, and doing the surgery?

Dr. Langan: So, we move large animals fairly frequently. That goes with the territory. But the unique thing about pygmy hippos is that they have glands all over their body that secrete a reddish oily substance. So, on top of being 600 pounds and not really having any handles or horns, they're really slippery. And their whole body is covered in what I would say is like Vaseline. Once they're in a stretcher, it's okay, but before you can get them into a stretcher of some kind, it's really difficult to hold on to them or move them. And then you really need almost 15 or 20 people to move the 600 pounds out of an enclosure onto a flatbed to the hospital, those sorts of things. So, it takes a small army to sort of get the animal from one location to another.

Once we've got her at the hospital, we really have a really sufficient large animal setup to be able to move animals around on sufficient stretchers. To be on the super safe side, we actually repeated the ultrasound with our then-radiologist and a CT. We were really fortunate, we had a radiologist literally standing side by side with us through this procedure at the hospital. So, we had instant feedback on both the CT and recheck ultrasound results, which confirmed that there was still involved some sort of loop of bowel entrapped in the hernia, and that there was increased effusion from the few days prior. So, that really suggested that we really needed to move forward with some sort of therapy. The other thing was that the bowel was slightly dilated cranial to where this area was now, which had not been the case previously. So, it did seem like there was some sort of obstruction associated with the entrapped bowel at this point in time.

Dr. Mitek: I just have this image in my head of the hippo getting stuck in the CT hole. Did that happen? Or, if she had enough Vaseline around her, you could slide her through?

Dr. Langan: It might have happened with a regular CT scanner, but we are lucky enough to have a human large bore CT, which was specifically donated to the zoo, but it was originally in a human hospital, and it was specifically designed size-wise for very large people, upwards of 500 pounds. So, we were lucky in that the hippo actually fit through the opening, or the bore, in the CT machine. So, that was a big advantage.

CT was really helpful, actually, looking back at it, to look at her skeleton or arthritis at that age of animal. It does lose some functionality with that thick of a patient. So, even though she fit through the bore, the waves of radiation that pass through the animal to make the CT are diminished, or not all of them can pass through, so the image quality on such a large, wide animal with soft tissues is not as good as we get off of something smaller like a tiger, for example.

Dr. Mitek: And once you have her in the operating room, and you decide to go to surgery, can you tell us what you guys ended up doing to treat her surgically? And then, I'm assuming she needed some care post-operatively, too.

Dr. Langan: That was probably the most difficult part. The surgery seemed relatively straightforward for the equine surgeon, Dr. Chris Downes, who helped us out that day. It was an extended procedure, but something that he seemed very... like, with the animal covered up, it could have been a horse underneath. And he was very comfortable both with the anatomy-we ended up finding a piece of intussuscepted bowel, which is intestine pushed inside of itself. And if it stays long enough like that, it can cut off the blood supply. Being stuck in the hole of the herniated area, it actually had lost some blood supply long enough to where the entrapped bowel became necrotic, or that tissue died. So, aside from removing the loop of bowel and repairing the hernia, Dr. Downes actually helped us do an intestinal anastomosis. So, he removed the disease component or damaged part of the small intestine. In this case, it was the ileum, sort of just before the colon. And then, he had to so those two ends together, or anastomose them, so that she had continuous bowel.

Right away, she had good intestinal motility, which was really encouraging to see. But the real challenge came thereafter. It took about nine weeks of recovery. So I think while we were sprinting at the beginning of the race, what ended up really being a marathon over a period of multiple weeks and nine or 10 anesthesias to follow, I think that was really the touch-and-go part of not knowing whether or not she would recover or not. But, she was very strong through it all, and tolerated a multitude of recheck exams. I think part of what we struggled with most, as was anticipated from our very first hesitation, was getting the abdominal incision to heal. And that took the full eight weeks post-surgery, and required quite a lot of ingenuity. It eventually needed reinforcement by using industrial-sized zip ties to close her body wall incision, which is probably not part of everybody's normal surgical pack. But between debridement of the incisions and some post-operative incisional infection control, we did end up coming to a positive outcome and were able to send her back to her pool, which she gladly jumped into, about nine weeks after that date of surgery.

Dr. Mitek: And you mentioned she had nine or 10 additional anesthetic episodes. What were those for?

Dr. Langan: We put a post-op belly bandage, much like you would do in a horse for a colic surgery, not knowing how that might fare. While she's under anesthesia, those secretory glands actually stop producing mucus, and we were able to put an elastic yarn or very sticky bandage around her belly to help support the weight of the incision and keep it clean. But when she woke up, she started secreting her natural oily skin substance. And then, by the next morning, that bandage was nowhere near the incision. And it slid back or forward several different times, and several different attempts. So, we tried that.

That was some of the initial anesthetics or sedation. Because we couldn't go in or put her in a stanchion or stocks to work with her without having her sedated or anesthetized for every time that we really wanted to either see her incision or really do any treatment, she had to be sedated for us to work with her safely. I did duct tape my iPhone to multiple different golf clubs to try and film underneath her belly to get a good view of the incision over, and to try and do flushes with Betadine and such wound care options. But really, to do a thorough exam, and kind of make sure things were healing or debrided appropriately, we really had to sedate her.

The zoo has an entire team of craftsmen that, for her recovery, built her a temporary stanchion that allowed us to film from underneath and occasionally try to get a view while she was getting fed. When she recovered a couple days after surgery, she started eating voraciously again, and actually would eat at the front of the stanchion, and we could kind of lay on the ground and take a look at her incision. But she was very leery of letting us touch any of it, of course. So, if we wanted to do any debridement, check the sutures, or replace any sutures from time to time, for that she had to be under general anesthesia.

Dr. Mitek: I’m glad to hear that Obesa’s surgery was successful.  I am always inspired when I get to work with you, Dr. Langan, of the creativity of you and the team up at Brookfield when you guys are challenged with new situations. I love the golf clubs. Were those your personal clubs that had to be sacrificed?

Dr. Langan: No. They were probably already being used for some variety of veterinary use already. So, we have all different kinds of adaptive tools that fit into zoo medicine, whether it's recycled sporting equipment or otherwise.

Dr. Mitek: I'm going to ask you a final question that we ask all of the veterinarians that come on the show, which is, as a new veterinarian having just graduated from school, what did you tend to do wrong?

Dr. Langan: I think I was expecting to work more quickly and didn't give myself really realistic expectation of how long doing things for myself might take. When you work alongside with experienced mentors who can do a surgery or an exam or know right off the bat what they're palpating... I think, just giving yourself time and using those resources, and not expecting to be them from the day you graduate-it's almost like watching mom bake. How come she can get the cake to turn out and mind doesn't? But in this case, not holding yourself up to those same skill set as mentors right out of the starting gate, but appreciate that there is a lifelong opportunity of learning, and it just continues. And if you take that attitude, I think you will continue to enjoy even the frustrating components of what it takes to become a good doctor.

Dr. Mitek: I think that's great advice. Lifelong learning is an important part of our profession.

And that’s the case. Our thanks to Dr. Jennifer Langan for sharing this case with us. 

And thanks to all of you for joining us.  Please subscribe and tell your friends about the show.  It's available on iTunes or the podcatcher of your choice.

One last thing. In addition to this podcast we offer a wide range of learning opportunities for veterinary students and veterinarians. You can learn more about those by visiting

I’m Dr. Ashley Mitek, your veterinary detective.

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