Well, hello everybody. This is Dr. Steve McLaughlin. It's a great pleasure to see you tonight. Welcome to session three of the Zuku's NAVLE® prep Accelerator Hoot Camp. Tonight we'll be talking about a classic small animal case from cats. We have with us the one and only Dr. Catherine Reiss there. And as we always do at Zuku Review Hootcamp, we'll be starting with a warmup. We're gonna do a little warmup on some stuff we covered the last session a week ago. Then we'll cover our feline classic case with live Q&A. You've got the one and only Dr. Reiss here so you can ask her anything you want. I'll be covering study strategies tonight on the value of mistakes and what a powerful engine for learning that is. For reinforcement, at the end, we always do a low stakes quiz, no stress. We're just gonna redo a little revisit to some of the topics we covered today, and then i'll give you a very short 15-minute assignment to try to do before our next session on Sunday. 

What we try to do at HootCamp is we try to model what you should do in your study. So if we study a thing, we're going to try to quiz ourselves on it. We're gonna try to warm ourselves up and pull stuff out of our brains because it turns out that retrieving stuff out of own minds is one of the most powerful engines of getting information, not just to stick in your head, but to be available to you. Okay? We're reinforcing your knowledge and putting what's in your brain at your fingertips. 

So here we go, here's our warm-up for the week, session three, question one. A six-year-old pregnant ewe in late gestation carrying triplets is presented with mild depression, anorexia, and you suspect, pregnancy toxemia. What is the most practical next step for confirming your clinical suspicion in a field setting. So you suspect pregnancy toxemia, what's the most practical next step? Is it to check the urine for ketones with a dipstick? Is it submit a liver biopsy for histopath? Is it perform cerebrospinal fluid CSF analysis? Is it send the serum to a ref lab to measure BHBA? Is it to evaluate the hepatic enzymes on serum chemistry? So just let us know in chat what you all think. You suspect pregnancy toxemia. What they used to say at Cornell is this is not uncommon. You will certainly see it. I did. You'll see this usually in adult ewes or adult female goats and they're often carrying twins or triplets or something like that. So a big metabolic load. Let's just check our chat room, see how we're doing. Very good. 100%. Good job, everybody. Yeah, so if you're in the field, you're on the farm, you're not submitting liver biopsies, you're doing a CSF tap, and you're submitting things to a reference lab, what you really are gonna do is check the urine ketones with a dipstick. Basically, if you confirm ketosis in a late gestation animal carrying twins or triplets, you're worried about pregnancy toxemia. Well done, everybody! 

Question two. You're treating a moderately affected goat for pregnancy toxemia with oral propylene glycol. Which choice is the most appropriate caution regarding this treatment? So what's your most appropriate concern or caution about treating with oral propylene glycol in a late pregnant goat or sheep? Is it you want to avoid the use of this treatment in animals with hepatic lipidosis? Is it don't use this treatment concurrently with calcium supplementation? Is it administer only via IV for maximum effect? Do you want to limit your duration of treatment because it can suppress the rumen microflora? Or is it inappropriate to use that treatment in goats with twins? So just take a stab. Remember, we've talked about this a little, and we're going to talk about it more as we go forward. If you're not sure, it's always OK, in fact, it is a good habit to simply cross out the choices that look wrong to you, narrow it down to two, and then take a guess out of two. So if you're not sure... Eliminate as best you can, narrow it down to two, take a guess. But when I look in chat room, I can tell you guys have been paying attention. Good job, everybody. Excellent job. All right, so here's our answer. And what I like about this is we have some different answers tonight and that really fits well with what we're talking about on tonight's strategy topic. So the correct answer is actually, you want to limit the duration of your treatment with an oral propylene glycol, because that can suppress the rumen microflora and then you have problems with metabolic issues in the first place and we're dealing with a metabolic problem where the mom has too many mouths to feed, even if they're still inside of her. And if the rumen stops working, it's gonna be that much harder to keep her alive and keep the babies alive. Good job. 

Oh, goodness gracious. We're going all the way back to session one with a cow question. Should you panic? Nah, this is normal. You're gonna see all kinds of things on the NAVLE® and you want to build your comfort level with kind of rolling with it, okay? So, which management practice is most effective in reducing the incidence of displaced abomasum in a dairy herd? So this is dairy cows. If you want to minimize the incidence of DAs in a dairy herd, are you gonna increase the calcium content of the lactating cow ration? Are you going to feed high energy rations immediately after they calve? Are you going to restrict access to forage pre-partum? Are you going to emphasize a balanced pre-partum nutrition to minimize negative energy balance? Or are you going to administer oral electrolytes during the dry period to increase the dietary cation-anion difference? You know, anybody that looks at farm animal medicine and says it's not complicated, go work with dairy cows for a while. It can get complicated. But the answer to this one in this case is pretty common sense. So let's see how chat looks. Oh, excellent. We've got some people. Got a couple of guesses now across the board. I'm glad to see that. No matter what the true answer is, if you miss a question, don't feel too bad. The ones we miss, we remember better because it stings a little bit, nobody likes that. And the next time you get that question, you're probably gonna remember it. And the beauty and the value of practice testing yourself is the more you miss, as long as you keep moving, as long you have that habit of continuing to practice test, you'll see those questions again. And the more miss, the more get right next time. Okay? So we're going to talk about more about this tonight, but here's your answer. There we go. So the correct answer is D. You wanna do a balanced pre-partum, so before they calve, you have a balanced nutrition to minimize the negative energy balance that happens when they calve. And suddenly you got this dairy cow that's literally milking 100 pounds of milk a day. Which is a lot like, remember the problems you saw with pregnancy toxemia, where you get a little old sheep, she's carrying triplets and she just doesn't have the bodily metabolic reserves to keep those fetuses healthy or the babies healthy after they're born. 

All right, we're back to pregnancy toxemia. Which choice is the most effective herd level prevention strategy for pregnancy toxinia in small ruminants? So this is a lot like what we just talked about with the cows. Is the most effected herd level prevention strategy to prevent pregnancy toxemia, is it prophylactic administration of calcium to all pregnant animals in the last trimester? Is it routinely deworming in late gestation? We know that parasites are a big issue in small ruminants. Is it to feed grain formulated for pregnancy to all dams? Is it, to administer NSAIDs prophylactically in late-gestation? Or is it to group animals by fetal number and body condition for tailored feeding? Remember, you know more than you think you do. And sometimes, even if you know nothing about sheep and goats, your common sense will tell you, hmm, one of the answers or two of the answer look more common sense than others. In this case, the correct answer, you wanna group your animals by fetal number and body condition for tailored feeding. So if you've got ewes or female goats with twins or triplets and they're not in great body condition, they need the most nutritional support. And if they've got those things but in their good body condition maybe a different nutritional support and in the singletons, probably gonna be okay regardless. 

Okay, last question for the warmup. A client presents a valuable ewe that's heavily pregnant, due to lamb in about a week. She's not eaten well in the last few days. She's now recumbent. She seems unaware of her surroundings. This is bad. Temperature pulse and respiration are normal. A urine dipstick is positive for ketones, so she's ketotic. Ultrasound shows two dead twin lambs. What's the best option to save this ewe? Antibiotics and anti-inflammatory therapy? Induce labor with dexamethasone? Supportive care until the you goes into labor on her own? Thiamine supplementation? Tube feeding with IV, tube feeding and IV calcium? So what's the best option to save this valuable ewe? All right, lots and lots of answers here. Excellent choices, guys. Good job. All right. So the correct choice here is to induce labor with dexamethasone and try to get her to abort those dead baby twins. As low intervention as possible. Okay? Good job.

So hey, guys, we're going to talk about a classic feline case today. That is my boy, Thomas, right there. So we will jump in, and we're actually going to talk about a different kitty here. This is Felix. This is actually a very real case I had about a week and a half ago now. I thought he'd be great for this presentation. So Felix is a three-year-old male neutered domestic shorthair. He is an indoor-only kitty and up-to-date on his vaccines. His owners have a fairly young baby and they did just move to the area. And he presented to the emergency clinic for straining to urinate. The owners also noted that he hadn't been eating or drinking for about 24 hours and that he was hiding and not acting like himself. So we go to do our physical exam. Felix is bright alert responsive. He's a very nervous kitty. He is tachycardic, but his heart sounds normal. His abdomen is very tense and painful. He's pretty guarded with that. And he's about 6% dehydrated. With our urogenital exam, we do note that he has a moderately-sized, very firm, very painful bladder. We can see some white debris there around the prepuce you can see in the picture. And the ultrasound does confirm a very large circular bladder. And we see no free fluid in his abdomen. So again, very classic feline case. Hopefully you guys can all take a good guess at this. So what is our top differential diagnosis for poor Felix? We'll give everybody a second. All right, let's jump in. 

So tonight we're going to be talking about urethral obstruction, so feline uretheral obstruction. Alright. Really, really common to see. I honestly saw over the past week and a half, I think five cats, just me and managed some others for some other people. So very common presentation. And that's anything that obstructs them from urinating, anything that prevents urine from moving from the bladder out the urethra. The by far most common cause that we see in these kitties is feline idiopathic cystitis. You'll hear that called fluted, feline lower urinary tract disease. And you'll sometimes hear it called FUS or feline urologic syndrome. It's all the same thing. It's a disease where they have an imbalance that creates extra stress and anxiety. And that's actually an imbalance between the sympathetic nervous system and the hypothalamic pituitary access, these cats essentially misinterpret stress. And what that leads to is decreased blood flow and increased inflammatory mediators in that lower urinary tract. So we get lower urinal tract edema. We get muscle spasms. We get pain. We get from that are essentially these plugs, these debris from that diseased bladder wall, sometimes including crystals, sometimes not, we'll get into that. But these little plugs will get into the urethra and cause an obstruction. We can get a functional obstruction from any of the causes we're going to talk about, and that's when they're having so much spasm in that urethra that while there's not a physical blockage, they're still too spasmodic to urinate, and we have the same issue. About 15% of felines presenting for urethral obstruction will have actual urolithiasis, so bladder stones. Most of those are going to be struvite. Of those, most are still going to be sterile struvite, so not caused by bacteria. We can see some calcium oxalate as well. Much less common causes is the urinary tract infection. We all love to look for it, but it is truly uncommon when we look at the studies. And then very, very rare would be neoplasia or stricture. So we always want to keep those in mind. But again, feline idiopathic cystitis is absolutely number one with this disease. 

And then what happens when the urethra is obstructed is we get increased pressure in that bladder. We get wall necrosis, bladder wall necrosis and mucosal damage. We can risk bladder rupture if that is ongoing and that pressure that's building up is transmitted from the bladder through the ureters to the kidneys and that gets us to an acute kidney injury or acute kidney failure stage. If these guys are obstructed for about 24 plus hours, it does depend on underlying diseases, how long they've truly been obstructed. We will start to see azotemia, hyperphosphatemia, and most importantly we'll start to hyperkalemia. So that potassium will begin to rise because the body is not able to excrete it and that rapidly becomes the most life-threatening aspect of the situation. We'll also see metabolic acidosis and dehydration. And you can see this urinary bag here with this very bloody urine. That represents the bladder damage from the stretching to that long. 

All right. So our male cats are vastly over-represented versus our female cats. And it's not that females don't get FIC or feline idiopathic cystitis or bladder stones. They do. But they don't get as obstructed the way males do. And that's because males have this kind of curvy and very, very narrow urethra that we can see in this picture. So these plugs go down in that urether and actually get lodged and create a true obstruction. They tend to be younger cats. You can see it in older cats, but usually they've also had a history. So we tend to see the first offense in their younger years. And then research shows us that they're more likely to have this if they're indoors, overweight, on a dry food diet, and or have recent stressors in their lives. That's really important information to go through with your owners. And we could have acute or chronic signs. They may have a history of some plaqueuria, stranguria, hematuria. They may do an inappropriate urination, so periuria, or they might present, and this is the first time they've ever had issues or the first time the owners noticed they had an issues. 

And then in addition to those urinary signs at presentation, we might also have a history of vomiting. They might be dehydrated, lethargic, and quite painful. And we do get a range of these cats, from our very stable cats who are not experiencing some of those blood work changes, all the way up to really critical even moribund cats who've been obstructed longer, where this is becoming a really rapidly and immediately life threatening situation. That bladder is going to be distended on palpation. Don't be fooled, though. I will say every cat has a slightly different bladder size. Sometimes it feels smaller to me than I would expect. But if it's firm, round, and very painful, you still absolutely want to be thinking obstruction. They tend to be normothermic. And most of the times, we'll have a regular heart rhythm. But we can see both hypothermia and brady arrhythmia. There was a study that looked at hypothermic and bradyarrhythmic cats and found a 98 specificity, 98% specificity for being or having an elevated potassium over eight. But don't be fooled. They can have a normal rate if that sympathetic nervous system has been activated. They will not have a normal rhythm though. So we can see on this EKG that we still have rapid heart rate here with this cat, but we've lost our P waves. We have those very tented T waves. This cat has a very high potassium with a normal rate but a very abnormal rhythm. 

All right, so let's talk about Felix. Felix was actually a financially restricted case, which means we really have to pick and choose what we're gonna do for him. So diagnostically, the most important thing that we wanna know about Felix is what is his potassium and what are her kidney values? So luckily for him, his potassium was in this well-normal range for this iStat, and his BUN and creatinine are also nicely normal. And that was really important before we started treating him. Because the owners were sharing with us that we just can't do absolutely everything. And so knowing that he was on the stable end of the spectrum gave us the ability to kind of move forward with a little bit of a truncated plan than we might, feeling like we had a good chance with him. If these numbers had been really high, we might have had to have a different conversation about how much care he really would need. 

So diagnostically with these guys, everybody would ideally get an EKG. So we are looking for some of those rhythm problems. Blood work again, the most important is your electrolytes and your chemistry values to look at those renal, BUN, creatinine, phosphorus. But ideally we'd also get a little bit more in the form of a PCV or a CBC. If you have a critical kitty, it's really nice to check for some metabolic acidosis. Let's get some blood pressures. I really like to put an ultrasound probe on all of these guys. It does help confirm what your hands are feeling. I also don't like to squeeze their belly too hard when I'm suspecting this. It's not super nice for them and we risk bladder rupture with these guys. So I like to look at my ultrasound. We also want to check for free fluid. If there's a large amount of free fluid, we need to consider that uroabdomen. A little bit just around the bladder is normal because again, we have that edema in the bladder. I've heard people call it bladder sweat. We're okay with a little but we're not okay with a lot. The other thing I do is I kind of look and see does that bladder look really rounded. Cat bladders non obstructed on an ultrasound will look more oblique or more like an oval. And those really turgid, obstructed bladders look like circles. 

And then we do want to get x-rays, we want to assess for those urolithiasis and we want to check the urine. We're usually doing that after we get these guys unobstructed. We're going to use that same x-ray to check our catheter placement. And we're going to look for crystals. Again, they're not uncommon, but the most important thing to remember about this is they're not the sole cause of that urinary obstruction. We get crystals secondary to pH changes that are caused by all that bladder wall edema and the urinary stasis, but they're not our only problem here. All right, so then that's a big bladder stone in a cat. Usually they're smaller when they slip in the urethra, so you really have to look them. 

All right, and back to our little Felix here. We give him methadone right away at presentation. We want to be aggressive with our pain control. We get that blood work done, and because we're happy with our blood work, he gets a little dexmedetomidine because he's a nervous boy. We help get that catheter in place. We're getting him started on fluids right away at two times maintenance. We know he's dehydrated and we want to support his kidneys. And then we're gonna move to anesthesia to get ready to unblock him. So we give a little propofol IV. He's on some good monitoring. And then, we're going to do a coccygeal block and that is a caudal epidural. It helps relax that area, really helps with their pain levels, lower anesthesia rates, and relaxes that urethral sphincter. So it helps us get those urinary catheters in. So this is Felix getting his little epidural there. And cystocentesis. Do not be afraid to do that. We don't do it when they are like before they're sedated. We do want to make sure we have a non wiggly patient. So Felix has already had the beginning of his anesthesia here, notice we're doing sterile technique. But doing a cystocentesis can relieve some of that really turgid bladder pressure. We're immediately helping those kidneys out, but we're also helping to pass our urinary catheter. If we're not working against the pressure from the bladder, still forcing that plug in urethra, we can get that catheter through a little bit easier sometimes. So it seems scary, it seems like you might rupture these bladders, but there's definitely great techniques to do those cystocenteses, like we're doing with this little butterfly catheter here. It's a 23. Um and relieving some of that pressure ahead of time so that helps Felix out. 

We get now ready to unblock him all right we're going to get our three and a half french slippery slam slippery slippery Sam which is my current favorite catheter. There's a lot out there. So we extrude his penis if you can't see well from this picture but his feet are now pointing to his head my technicians holding that up that helps extrude the penis a little bit and pass our slippery sam with a lot of lube. We're very gentle, okay, and we work our way in there. And then once we're in there, we drain the rest of the urine out before we start flushing that bladder with sterile saline. We wanna flush out that debris as much as we can. And we're gonna attach a closed collection system. He does get his x-ray at that point to make sure our catheter is at a good spot and we don't have any bladder stones in there which we're really happy about for him. And then there's our closed collection system. I let my techs decide how they're going to attach that to them. They all have their own ways. And since they have to manage it, they get to decide. And then this is him actually just like an hour after waking up from anesthesia. He is purring and headbutting. He feels so much better. He's gonna continue with pretty aggressive pain management, but with Gabapentin and sublingual buprenex for most of my kitties, we want them really comfortable and as least stressed in the hospital as they can be. For Felix, again, we had to truncate his time in the hospitals a little bit. He was doing well. We pulled his catheter at 28 hours. He urinated two hours later and got to go home. We talked to his owners. He did have crystals in his urine. We did an oopsie. We looked under the microscope because we didn't have enough money for a full urinalysis,  but he did have some crystals. So we talked about a prescription diet and in particular with him, what we could do to reduce his environmental stress. 

All right. So let's talk about treatment of these guys in general. Again, you've heard me say it a couple times now, but analgesia, these guys are so incredibly painful. This is a high pain score disease. We want opioids, okay? Ideally, pure mu opioids. I really like methadone in these kitties, or hydromorphone if you have it. Buprenex is a great option in cats. Please don't use torbogeasic. It is not a good pain control, okay, that is not mu opioid. And also, please avoid NSAIDs. These guys have already taken a hit to their kidneys, even if they're not azotemic yet, this is not the time to hand an anti-inflammatory. We get those catheters in, we start the IV fluids. And if they are hyperkalemic, we want to manage that to cardio protect them until we can unblock them safely and get the potassium moving out of their body. The first option for that, that we're using to cardio protect is to give some IV calcium gluconate. So if you remember all those fun action potential curves, basically elevated potassium raises the resting membrane potential of those myocardiocytes. So that resting membrane potential is approaching our threshold membrane potential and that makes the myocardiocytes have more difficulty firing. So what calcium does is it takes that threshold potential and raises that. So essentially, we're taking it and we're shifting it up temporarily, but we're re-establishing that gradient that lets those myocardiocytes fire. It's temporary, okay? We have to give it slowly IV, we have to monitor them with EKGs, then we wanna move to getting the potassium out of their system. With the severely affected cats, we can also work to transport the potassium temporarily into the cells to reduce the overall load on the periphery, the load on the myocardiocytes. We use a combination of insulin injection followed by a dextrose CRI, so we don't risk the hypoglycemia. And using bicarbonate or injectal terbutaline are also options for that. 

All right, so now we move on to using our urinary catheter again, we do deep sedation to anesthesia for these guys. Thinking about using a benzodiazepine to relax that urethra is really, really helpful. Ideally, we'd do it in all of them. Remember, Felix didn't have a lot of money, so we did skip it at him. If they're hyperkalemic, we want to avoid some of those more aggressive sedatives, dexmedetomidine, ketamine. Those are okay in your stable cats. Try to avoid them in everybody else, but we can still use propofol, alfax. We might intubate them if we're expecting this to be a more difficult deobstruction process. Lots of monitoring. Again, use your coccygeal blocks to help you and use that decompressive cystocentesis, especially if you're having trouble getting that urinary catheter through. Go and relieve that pressure from the bladder before you start flushing through that urinary catheter. So sometimes you're using a sterile saline syringe, kind of flushing this can break apart that plug. But if some of that saline is getting into the bladder before your catheter does, that increases the risk of bladder rupture. So don't be afraid to do those cystosensitis appropriately, sedation, carefully, but they are safe. And there's a ton of great videos out there, tons of different catheter options. It all comes down to what works best in your hands. The only thing I'll say is those open-ended Tomcat catheters, those propylene catheters. They're great for getting through like really hard obstructions sometimes. Please don't suture them in place. They are too rough on that urethra, that bladder that's already damaged. Not meant to be indwelling catheters. I do see that sometimes. 

All right, and then we get them set up. We're gonna really monitor their urine output, especially with our azotemic kitty. We can see some pretty aggressive post obstructive diuresis, meaning their body is just making tons of urine and we need to keep up with them. They're usually already dehydrated and if we're not increasing our IV fluid rate to keep with their losses, we'll get a more dehydrated kitty. You can get to pretty high IV fluid rates with these guys, which gets a little scary, but that's why we have to really be watching those ins and outs. Again, aggressive analgesia. We don't use Prozacin anymore. We don't use those urethral relaxation. Recent studies have actually shown increased risk of re-obstruction with those guys. If those electrolytes and renal values are abnormal, we're monitoring them. The more abnormal, the more aggressively we're monitoring them, the more frequently. We want to make sure those numbers are getting better quickly. And then as Knox, this is a kitty from this weekend, is showing you his really opinion about his e-collar, they do need to wear e-colors. They will rapidly take out your beautiful urinary catheter if they don't have e-collers. But obviously, Knox was not really thrilled about his. 

And then outcome. When do we know when to pull that urinary catheter? So I tell my owners, OK, we have a couple boxes to check before we get to take that out. One, we have to have normal kidney values. We have to not have those high urine output rates so we know that they can keep themselves hydrated. They're no longer needing those IV fluids. If we have gone to high rates, we are weaning them down appropriately. And that urine is ideally completely clear. We'll see debris still coming through those lines. A lot of times they're bloody. We really want to get to clear urine. And then we pull that urinary catheter. I really like to see them urinate on their own without straining. I usually tell the owners just once, if they do it once. Get to go home because they're going to be less stressed at home. Cats are very particular to their own litter box. So let's get right home. But we really want to see that they can do it once because they are still at risk of obstruction even after we do all that. 

And then just a couple pearls of wisdom with these guys. We're almost done. They have a great survival rate if we can treat them appropriately. Even those really critical moribund kitties where the creatinine like talking to number 20. You can get them all the way back most of the time, not 100% of the times, but most. So 90 plus percent survival is great, but they do have a 50% lifetime risk of re-obstruction. So that's something to really talk to the owners about. If you have a cat who's doing an obstruction multiple times, they need a perineal urethrostomy, which is a surgery to change that anatomical problem. That is not a surgery that's undertaken lightly. I refer to it as a salvage procedure for the owners, and that is a difficult surgery that is not for everybody to do. But the way to help reduce this is the home care and management, really taking the time to talk to these owners, giving them the resources. The biggest thing you can do is increase that water consumption, whether that is wet food, which is number one, water in the sink, Thomas loves to drink out of the sink so we always have a bowl in there for him. Anything we can do to reduce stress with this new baby in the house who was maybe starting to crawl. Maybe Felix needed a cat tree so he'd feel safe. There's lots of ways if you sit and talk to your owner to help reduce that kitty stress. I do often do the prescription diets if we've had crystals in there. I usually tell the owners the only downside to these diets is to your wallet. They are complete healthy diets. They can live their whole life on it, but it's less expensive to buy a prescription diet than to come back and see me on emergency. So I do use them, but just remember that the driver of this disease is stress, not those crystals. All right, and we get back to Thomas and see if we have any questions. We can take it in. If you have questions, we go in the Q&A too. Thank you so much, Dr. Reiss, that was fantastic. 

So mistakes can be extremely valuable. And I always like to say, well, if mistakes are the best teachers, how come I'm not a genius by now? But the truth is, there are plenty of objective studies peer-reviewed which show that one of the most effective ways to firm up your foundation of learning is to quiz yourself and get better at retrieving information out of your head. It sounds backwards. I'm pulling information out of my head. Why would that make me learn better? All I can tell you is it works. And when you make mistakes, we tend to remember them. They sting a little bit. Nobody likes that. And that is valuable. In Zuku, your missed questions recycle until you get them right. So if you miss a question, you're going to see it again. And the next time you see it, you're more likely to get it right. You can use that. 

We call what we do, whether it's clinical practice or preparing for a test like the NAVLE® or the BCSE, we call that practice for a reason. We are practicing to get better. The whole point of life and of NAVLE® is not to avoid mistakes. The way to success is to learn from our mistakes and improve. You don't need 100 on this test to pass, okay? We just have to improve. So tonight we're gonna talk about that. Because this is what we do. We're gonna start with a pop quiz. Yay. All right, so here we go. 

Which animal has the slowest resting heart rate? Dog, pig, cat, ferret, or horse. Now you may know this, or maybe you don't. If you don t know it, just eliminate the choices that you think might be wrong, narrow it down to two, and take a guess. All right, chat room says somebody said iguana. That's not a choice. All right. I see a lot of people know this one. Good job. And if you don't know it, it's okay. So the correct answer is the horse. Horses are athletes. That is what they are basically bred to do. So horse heart rates tend to be very low, 28 to 44 beats per minute. Bonus because I got a really great picture here. You can palpate the facial artery and get a pulse. If you just put your fingers here under the masseter muscle where the facial artery passes, you can feel it. 

So question number two, we're just playing around here with getting things right, getting them wrong and remembering them later. What do you do when you see this pattern on the ECG of a racehorse? Do you run around waving your arms? Do you weep? Do you check your electrode placement? Do you administer oxygen? Do you set up to place an IV stat? Or do you yawn? What do you guys like? I see some yawning. I see some A, I see some C, I a little bit. Let's see, what do we see? We see some check your electrodes. I see run around waving your arms. That's what I would do. Great job, guys. So here's your answer. What are we looking at? We're looking at here where you've got, here's P, here's QRS's, here is P, QRS, P, QRS. We're missing a QRS, aren't we? Yeah, we got a little issue here. What you do is you yawn. An occasional dropped beat, that's the dropped QRS in an athletic horse, is basically no big deal. Horses are prone to a normal arrhythmia called second degree heart block. So what that means is you get that little P beat and it doesn't initiate an actual heartbeat. In a healthy athletic horse that's normal. Now if you miss that, maybe right now you're feeling a little bad. You're feeling like, oh, I must be stupid. No need to feel stupid. Everybody is stupid about something. And most of us are stupid about a lot of things if we haven't studied it yet. It's very normal. I am Dr. Zuku. I miss questions all the time. The name of the game is not to avoid the pain of missing a question. What we're here to do is to learn from the ones we miss, okay, because they stick and you'll get them right next time. So you see a question about a dropped beat in a horse. I hope you remember this and say, oh, I remember that. This is normal, okay? 

So what's going on? The bigger the animal, the slower the heart rate, typically, and on top of that horses are basically giant athletes. These animals are prone to that normal arrhythmia we just talked about. You can see it there with the blue lines right here. From a respiratory point of view, horses cannot breathe through their mouths. They breathe through up here in their nose and they have enormous lungs. They are built to run. 

So this is just a setup to help inoculate you to the idea that there are two big wrong ideas about learning and most of us have these ideas in our heads. I certainly did. So number one, a lot of us had this wrong idea that cramming facts into my head, that's learning. It's not, okay? It's not about stuffing stuff in your head. It's about learning to pull out what you can find in your head. It's about access, it's about retrieval, it's opening the doors in your mind to where the information lives. And the other bad idea that most of us have about learning is that mistakes are bad. Mistakes are your best friend, okay? If you guess on a question and you get it right by accident, you will probably not remember that. But if you miss it, we are hardwired to flinch when we miss one, and that is your best friends. You can learn from it. You don't need 100 on this test. So let's learn while it's practice time so on the big day of the test in October or November, you get more right. 

So I wanna encourage you to learn better by testing yourself. That can be whether you're doing practice tests or whether you are doing independent study with notes. You want to have a habit of quizzing yourself, okay? You wanna make your study active. Even when you're reviewing notes, make it active and we'll practice that in a few minutes. What we're trying to do here is to pull information out of our head, retrieving it. Because studies show very clearly retrieval practice is the most effective way to get information well stuck in your head. So the way you do it, low stakes practice testing. Low stakes just means there's not a lot riding on this. I'm just doing my daily habit of doing practice tests so that the more I do, the better I feel about it, the lower my anxiety. I'm used to this. This is boring. I do this every day so that by the time you hit your big test in October, it's routine. You're increasing your comfort with risking making a mistake. You're increase in your comfort with learning as you go. And learning is something we do. It's not something we glue into our heads. It's like going jogging to train for a race, okay? And as the missed questions randomly recycle back at you, the more you do day in, day out, the better you're going to do on your test. That's how you learn. 

So tell us about retrieval practice. It's a learning strategy. It's not a way to assess yourself. It's way to learn. What we're shooting for here is what they call in the research papers, desirable difficulty. The mental struggle that you and I go through when we try to remember what the best answer is or we admit we don't know it, and we narrow down the choices and we take a guess. That mental struggle is what strengthens your learning. It's a thing we do, okay? It's not a thing that we stare at on a page, it's an activity. A little desirable difficulty, that's better than when you're learning without a struggle. So when you just staring at a page or looking at your phone and you're not really paying attention, that's too passive, it's too easy. You need to challenge, okay? How do you challenge yourself? How about read your notes and then hand them to a friend and say, quiz me on that. What's a classic case look like? How do I treat it? What test would I do? Okay. Or make a flash card. It's, I compare this to practicing a musical instrument like the saxophone or learning a new language. When we practice our knowledge, we get better at it, okay? So here we see the very famous jazz man, that's Miles Davis, this is John Coltrane. They didn't become virtuosos of jazz by reading about music. They became virtuosos of jazz by doing it. So when we practice our knowledge, we get better. So this is a habit anybody can do every day, just like going to the gym. 

So how do we do it? So when is best? The best time to quiz yourself is just after you had a lesson. So we just had a listen about what? Blocked cats. So we're gonna quiz you about that right after, okay? That is a way for the most robust learning. If you're doing independent study with notes or video, best time to do a little retrieval practice is right after. Um, it's also very good to challenge yourself a day later or a week later. Okay. Space it out. So you do a little bit at the same moment or the same day. And then another one where you review and quiz yourself a little bit a day after another review. And then a week later. You're never really done. It's something we do. Should I expect some feedback? Yeah, absolutely. If you miss it, you want to know right away. If a friend is quizzing you, you want them to tell you. If you're doing practice questions in Zuku, you wanna find out right away, okay? That helps you correct mistakes in the moment, which is vital. And also, if you read the correct explanation, it helps you, fine tune, okay. You don't have to remember it all. You don't need every detail in your head. But you do wanna walk away with a take home message about what's the correct answer. Well, should I use multiple choice? Should I use short answer? Should I use essays? Should I do column response or square dancing? I don't know. All of the above, folks. Anything that requires you to try to access and pull and retrieve that information out of your head is a good thing to include in your study. Okay now the NAVLE® is a multiple choice test so I would say two-thirds of your prep should be doing practice questions or timed test questions and then about one-third is some sort of independent study with notes and books and things like that, okay? But the ways you retrieve the information, you can play with that a little bit, especially on that one third of independent study. 

Quick pop quiz, horses usually cannot do which one of these things. Breathe through their nostrils, vomit, digest grain, sleep standing up, or I can't really read it, something about passing gas, pass gas. Everybody knows horses can pass gas, okay? One of the guys who went to vet school, an old dairy farmer used to say a farting horse never tires. I don't know, he would just walk around saying stuff like that. What can horses usually not do, like a physiological problem? Check in the chat room. All right, good job, everybody. Good job, yeah. Yeah, generally horses should not be vomiting, okay? It has a little bit to do with the anatomy, the position of the stomach when it's full, plus a tight sphincter there between the esophagus and the stomach, make vomiting for horses nearly impossible. So if you see a horse that's vomiting or see food coming out of the nose, that's bad. This is Director of Content and Senior Editor, Dr. Norah Grenager, with a nasopharyngeal tube in a horse. So it's an emergency. If you see a horse with food coming out of their nostrils, you've either got an esophageal obstruction or you've got a stomach that's about to rupture. Either way, that's an emergency. And this is why we pass nasogastric tubes on any horse with a colic, okay? So they don't vomit. 

So we're going to do one last question on how to, and then we're actually going to practice retrieval practice. Should I do it for grades? Nope, that's not the point. This is like going jogging, we're just in training, and we're training for a big race called the NAVLE®, okay? So this is low stakes. I'm practice testing, I'm trying to get comfortable and inoculated to the whole concept of doing practice testing. If you put less pressure on yourself, it gives you more comfort, more permission to make some mistakes. If you learn from those ones you missed. You're doing it right. Do I need to change my whole life? Do I to rearrange the entire way that I study and think about veterinary medicine? No, you don't. But you do wanna try to add quick retrieval opportunities to that routine you're doing. You wanna make this a habit you do every day, okay? You're really just practicing pulling the information out because that's what you're gonna do in November. Are frequent quizzes gonna increase my test anxiety? I mean, for 99.99% of the people, they generally don't, okay? The idea here is you're trying to habituate yourself to that feeling, okay. If you find even when you're all by yourself and you just got plenty of time in the world and you're doing a practice quiz and it's freaking you out, then maybe it's time to talk to somebody like a psychologist who can give you a little help with some anxiety, okay? There is normal anxiety, that's absolutely true, but I'm talking about like incapacitating anxiety from a little low-state quiz. If you're feeling that, like a panic attack, you know, get somebody to help you out with that. You don't have to be alone with it. 

All right, so let's try some pulling information out. And these are not things we've studied yet. And this is gonna be another theme of the study strategies part of Hoot Camp, which is helping you gain your own confidence in what you already know, helping you access your prior knowledge. You know more than you think you do. And even if you don't know the answer, you do have the tools to guess strategically, okay? And we'll be doing lots of things like that. A goat farmer calls you because one of her prized goats is recumbent after a period of staggering around and bumping into things as if she's blind. On physical exam, the animal displays opisthotnos and dorsomedial strabismus. So here we see the recumbant animal. She's in opisthotnos. She's got her head back like that. And then here we an absolutely classic dorsomedial strabismus okay? So the nose is here, medial is here, up is up here, here's the ear, so this is dorsomedial okay? This is an absolutely classic presentation pathognomonic for one disease you might know what the disease is but remember in real life and on the NAVLE®, the question may not necessarily be... What's your diagnosis? The question may very likely be, what tests you do? What treatment do you wanna do? What do you tell the owner? Okay, that's real life and that's real NAVLE®. So in this case, the question is, what's your treatment of choice? Okay, I'll show you options in one second here. But just thinking out loud, tell me in chat guys, what disease are we thinking about here? What are you worried about? Okay, some people are already on it. There it is, yeah. Polioencephalomyelitis, I see tetanus, that's a great option. I see scrapie, definitely think about those neurodiseases. Good job, guys. Those are three things I would definitely have on my differential. Polioencephalomalacia, tetanus, any of the neurologic diseases we consider. Tetanus, they're going to be stiff. If you got a real tetanus, they're probably gonna talk about, you know, the, what do they call it? The sawhorse stance. They're really stiff. You pick them up and their legs are still sticking out straight. But those are great differentials, very legit. Good job. So here's our treatment options. Are we gonna give oral propylene glycol? Are we going to give tetanus antitoxin and flunixin  meglumine, an NSAID? Are we're gonna give broad spectrum antibiotics? Are we are gonna give thiamine, which is vitamin B1? Are we to give IV calcium borogluconate? Oh, that was another one. So small ruminants don't really get flaccid paralysis from calcium, hypocalcemia like cows do. But you know, that's a reasonable distractor. What do you guys like? All right, I see great. We see some choices. Some people are picking B, C, D. That's great. Okay, good job, guys. Here's your answer. So our treatment here is thiamine. This is polioencephalomalacia. And so thiamine is your treatment of choice. And the other things have more to do with either something we've talked about today earlier. So we talked about pregnancy toxemia. So that's your treatment there. Certainly, I consider tetanus antitoxin for a very valuable animal. In horses will sometimes use that. I'm not sure how much we treat sheep and goats for tetanus because they're often not worth that much. Calcium borogluconate IV, I think we're thinking here of milk fever in cattle. Good job, though. So if you missed that, no worries. It hurts a little bit. You might feel embarrassed. You know what, use it. We all feel that when we miss questions. The next time you get a question and you've got the dorsomedial strabismus, you got the opisthotonos, remember thiamine, remember PEM, okay? Great job, everybody. All right, let's just look at this a little bit. What we do here is initially you're giving them TID dosing IV initially and then IM and then sub-Q after. And you wanna continue your vitamin B1 for days past improvement. 

Briefly here's some notes about PEM in small ruminants. These are gonna be a fast growing calf or lamb or a goat. They're neurologic. You don't even know what it is, you look at them, you're like, I don't know what that is, but they're neuro. They're blind, they're staggering around, maybe they're down. This is a poorly understood nutritional disease in ruminants. As far as we know, it's associated with altered thiamine status and a high sulfur intake. You know, we're talking here about bilaterally symmetric clinical signs of cerebral dysfunction. It's going on up here, and you can get all these different neuro signs. Test of choice, this is basically a clinical diagnosis. You're not gonna be doing CSF taps or anything on these guys. But if you see that dorsomedial strabismus, they call it stargazing. So that the eyes, it's as if the eye of the animal is trying to look up at the stars. It's pathognomonic. If you're just simply getting a response to vitamin B1, that's suggestive that you got the right diagnosis. And you're not gonna hurt an animal giving them vitamin B one. So we often give thiamine to these animals. Early treatment is vital. You see these signs before CNS damage occurs, okay? So that's really important to keep it going. It's reversible if you catch them early. And the last sign that's gonna disappear with a successful treatment will be blindness, okay? But if it's advanced, it's a prolonged case, they've been down a long time, poor prognosis, okay, which is, you know, a common sense way to think of it. Okay, all right, great job. You wanna try another one? 

Here we go. Three month old, thoroughbred foal, presents with lethargy, decreased appetite, tachypnea, nostril flaring, has mild fever, and tucks his abdomen on inspiration, on breathing in. Gram stains from a transtracheal wash show large pleomorphic rods. Here's your hematology blood work. Now remember we've talked about this before. When you get presented with blood work, Don't panic. Don't freak out trying to read all the numbers. Home in on some things you're most concerned about. We have a young animal. Let's see, did he have fever? Let's go back. I forget. Three month old. He's lethargic. He's not eating. He's breathing fast. Mild fever. We've got pleomorphic rods. We've something sounds bacterial in a transtracheal wash. What are you gonna look for in blood work in a CBC? What are concerned about? Like before you look at the blood work, what are we a little worried about here? Probably an infection, right? Yeah, so we're maybe wondering, do we have a viral infection or a bacterial infection? Well, this suggests bacterial, pleomorphic rods. All right, now we look at blood work and does anything here jump out at you? Well, he's not anemic. Let's see. You know, red cell indices look more or less okay. What do you guys think about the white blood cell count? Pretty high, huh? Yeah, we have a great big sky high white cell count. Neutrophils are way up. So, these are pretty big signs of something. Look down here at Fibringen and Siramacute Albumen I think it is. I have to look it up. Those are sky high. So we have some pretty big clues here about what we're worried about. And the question's not, what is your diagnosis? This is a very common clinical scenario where you have some preliminary clin path results, and it's gonna hopefully point us in the right direction because we don't know what this is. Are we looking here at failure of passive transfer? Is this hypoxia secondary to anemia? Is this a marked bacterial infection? Is this an example of neonatal encephalopathy? Or is this a case of summer fescue toxicosis in the mare and secondary post-maturity in the foal? All right, chat room says, okay. Excellent, you guys are doing a great job tonight. Excellent, good job. So I'm seeing A and I'm seeing C, which I completely agree are the two best answers. With failure of passive transfer, certainly we worry about secondary bacterial infections, okay, or any kind of infection. And then C, marked bacterial. The fact that we're finding transtracheal wash with pleomorphic rods in it, and we're seeing this huge spike in white cell counts, mostly driven by the high neutrophils. This is screaming at us, we have probably got a bacterial infection. If you said FPT, failure of passive transfer, not bad. That's a pretty good guess. If you narrowed it down to those two, I like that. Okay, good job. So you got the high cell, white cells, neutrophils, fibrinogen, and the serum amyloid A, excuse me. That's an acute phase protein. It's very sensitive and very specific for infection. It's got a short half-life, so it changes rapidly, okay? So whatever's happening happened fast. Anybody want, I know what this is. Any of you guys want to take a wild guess what we might be looking at? Respiratory disease, bacterial, young foal, pleomorphic rods, and the TTW. What are you thinking? Oh yeah, there it is. Dr. Webb. Dr. Blickenstorfer. Yeah, very good. Very good. Yeah. Dr. Magel. Dr. Ribeiro. Dr. Lind. Great answers here, guys. Yeah. So what we're looking at, Dr. Krug. Good job, Dr. Aquino. Yeah, this is rotococcus. This is a classic rotococus case. Uh, it looks like I just gave you the answer to that one. Well, but you, you got it without seeing these answer choices. Um, you wouldn't have said viral because we've got these neutrophils coming up. Could it be salmonella sepsis? These rotococcus foals do get sometimes diarrhea, but honestly, that wasn't a sign that we were told about in the case, so I don't think I'd try to make something up. It's not Lysonia enteropathy because we have the wrong signs for that. We've got a respiratory problem. Inflammatory airway disease is another fancy way of saying asthma or heaves. It's not that. You wouldn't see the neutrophils up with that. Good job. 

So here's Rhodococcus equi, a classic case, tends to be a four-month-old foal, lethargy, decreased appetite, tachypnea, and nostril flaring. It's one of the most serious pneumonias in foals. All farms probably have this floating around somewhere. It's ubiquitous in soil and it's shed in the manure of the foals, okay? So here is a happy foal exposed to a lot of dust and dirt, you know, could be a risk. You can have an insidious onset. You may not notice it until it gets really bad. It can progress to a bronchial pneumonia with all the signs that go with that. As I mentioned, 50% of these foals on necropsy will have no clinical signs, and yet you can see evidence of infection in the intestine, pyrus patches with ulcerative things going on, stuff like that. You can get a non-septic polycynovitis, okay, in these foals. It's thought to be immune mediated. All kinds of different ways these guys present. Now I'm not here to educate you too much on rhodococcus, I'm mostly here to talk about guessing and being okay when you miss them and learning from the ones you miss. 

All right, everybody, we are at the home stretch here. I wanna thank you all for coming. What we're gonna do now is what we do every session. We're gonna a low-stakes quiz on the topic of the night. Remember what our topic was with Dr. Reiss. Here we go. Four-year-old male-neutered indoor cat presents with signs of urethral obstruction. After stabilization and catheterization, urinalysis reveals sterile struvite crystals. Which of the following is the most likely underlying etiology of the cat's obstruction? So we're looking for etiology. Is it neoplasia, idiopathic urethral plug, bacterial urinary tract infection, calcium oxalate urolithiasis, ammonium urate crystals due to portisystemic shunt. Good job, so a few guesses around the map here. But the correct answer in this case is idiopathic urethral plug. That's your answer there. If you missed it, this is something to study for next time. It's something to remember. And you get a lot of value for guessing wrong and remembering it. 

Question two. A six-year-old obese, indoor male, neutered cat presents with lethargy, vomiting, and a history of straining to urinate. You suspect urethral obstruction. You attempt catheterization, but the urethra remains obstructed after sedation. What is the most appropriate next step? Administer NSAIDs and attempt cathetization again. Immediate surgery to create a perineal urethrostomy. Recommend euthanasia due to poor prognosis. Administer furosemide and reattempt catheterization. Perform decompressive cystocentesis under sedation. All right, chat room. Oh, you have trained them well, Dr. Reiss. You've trained everybody well tonight. Everybody's getting this one. Great job. Yeah, you wanna perform decompressive cystocentesis under sedation. Remember, Dr. Reiss told us, you don't need to be afraid of this and you can do a lot of good. So, excellent job everyone, well done. 

Question three, you are attempting to stabilize a hypothermic and bradycardic cat with urinary obstruction and have started IV fluids and analgesia. Blood work confirms Hyperkalemia, which treatment is best to protect the myocardium? Hypertonic saline bolus IV, fentanyl CRI, dexmetomidine, IM, calcium gluconate IV, albuterol nebulized. Once again, you guys are knocking it out of the park. 100%, great job. And the answer is? Calcium Gluconate IV. Notice how well you're doing everybody, okay? If you missed them, remember we're here to learn from the ones we miss. But if you're not missing them, part of the reason is you're retrieving stuff you've just heard about. It seems almost too good to be true how easy it is to remember it, but this active quizzing yourself is the key to success. 

Here's your final question for tonight. Which of the following is the most important long-term home care recommendation to prevent the occurrence of feline urethral obstruction? This is what's the most important thing you send the owners home with for advice. Increase water intake. Daily sub-q fluids, monthly urinalysis and culture, daily phenoxybenzamine, add urinary acidifiers to the diet. All right, chat rooms going crazy. Right guys, and Dr. Lind and decrease stressors. Good job, good job. So the best thing you can tell the owners is do everything you can to increase water intake. If it means you get one of those little cat waterer things with a little stream of water coming in because some cats like to lick it or they like ice cubes in the water or with Dr. Reiss's cat likes the bowl in the sink. Whatever it takes to help them increase their water intake, excellent job. Environmental enrichment, that's a good thought. And also remember decreased stress. Good job. 

All right, and here is your assignment for next Sunday. Remember, we're gonna meet again in the morning. We'll be talking, let's see, that says feline urinary obstruction. We are not talking about that. Oh, no, you're gonna review, yeah, you're going to review feline urinary obstruction for five minutes. And then tune up topic for Sunday is equine laminitis. Okay, what I'm looking for is I want you to be able to recite to yourself a classic case description. Your test of choice, and your treatment for equine laminitis. Don't go to ChatGPT, look it up yourself, do your own homework, it'll help you. Thank you, everybody. I was so glad you came tonight. I really appreciate it. This is the point where I wanna give my big shout out to Dr. Reiss. Dr. Reiss, if you're still with us, thank you so much. Absolutely. Thank you guys. That was a great topic. That was excellent coverage. I really appreciate it.