Q&A with an emergency veterinarian on critical care and common ER misconceptions

Emergency and urgent care practice asks new graduates to make decisions alone, often overnight, on cases that veterinary school taught them to work up with a full specialty service down the hall. Tripp Oliphant, DVM, a small animal veterinarian who graduated in 2023 and practices primarily in urgent care while doing relief emergency work, spoke with dvm360 about the gap between the two.

In this Q&A, Oliphant discusses the cases that drew him to emergency and critical care, a cardiac misconception he sees repeatedly in the emergency room (ER), and what he wishes he had understood as a new graduate.

Editor's note: This dvm360 Q&A has been edited and consolidated from a verbal interview to better fit a written format while retaining the substance of the original conversation.

dvm360: What aspects of veterinary school prepared you for emergency practice, and what were the biggest learning curves once you started seeing cases?

Oliphant: I think the biggest thing that veterinary school prepares you for, I always say, is the diagnostics. You're in the ivory tower of veterinary school, and you have everything to your access, [including] the specialty services and your mentors or your professors there that you can talk to, and your colleagues. So I think it prepares you for the differentials and differential diagnoses, but it doesn't necessarily prepare you for being on your own.

If you're on that overnight shift and it's just you and the technician, that's where that challenge starts.

But I think that it did prepare me for seeing more intense cases, because you have people coming to the veterinary school for things that the normal practitioner may not [handle] or may not want to handle. That's where my interest started with emergency critical care. You're seeing those things that are a little bit more critical, and you get to work them up and figure things out.

dvm360: What types of cases or clinical challenges have captured your interest the most?

Oliphant: I really love critical care. If things are coming in, the crashing and burning patients, they're definitely intimidating, especially as a new grad veterinarian. But as you get more comfortable with just dealing with the situation, and you trust your team, then it becomes a little bit [more familiar]. It's like repetition, that you see trends and you're like, Okay, I think I can handle this. This looks like a pretty severe GI case, or this looks like an endocrinology case, something like that.

One of the things that most interests me is [that] I love stabilizing patients, but also long-term ICU management. [I love] our chronic kidney disease cases, our cardiac cases, [and] respiratory cases [like] aspiration pneumonia. Doing high-flow nasal cannulas, all of those things really, really intrigued me, and I really loved having access to that when I was in specialty ER. I found a niche or an interest in that whenever I was there, and really do enjoy that aspect of it.

dvm360: Are there recurring presentations or misconceptions coming through the ER that you think veterinarians should be paying closer attention to?

Oliphant: One of my biggest pet peeves [came] from one of my mentors, an amazing cardiologist who I think so highly of. She taught me never to monitor a heart murmur.

I think it's getting better, but there was an older set of thinking that we are going to monitor a heart murmur. I always tell the technicians, "What are we monitoring for?"

We can't necessarily listen to a murmur. Yes, we can grade it, but we can't say the extent of cardiac disease without truly having an echocardiogram with a cardiologist.

So usually what I tell owners is, I never am going to talk poorly about the referring practitioner, but [I say], "Okay, well, your dog, I hear today it does have a heart murmur." And they're like, "Oh yeah, they said to monitor." At that point, I'm just going to say, "Well, I would recommend getting them seen by a cardiologist."

The reason I say that is [that] there's a lot of cases that will come in that are in congestive heart failure, and they've been having a murmur for 3 to 5 years, and a lot of times it's cats. They are coming in and [the clients] are like, "Oh yeah, we are monitoring the heart murmur."

In my opinion, and also what I've been taught by the cardiologist, we can get these cats and dogs on medications that hopefully are going to prolong their life, and we're not having to put them in oxygen therapy. So, that's one of the biggest things that I see come through ER. I don't mind managing them, but it's just something that I've seen.

dvm360: For students interested in emergency and critical care, what habits are most important to develop early?

Oliphant: In vet school, they teach you to go through the gamut of differentials and think of everything, and that's great whenever you have a scheduled appointment. But whenever you're in the throes of it, that's just sometimes not possible. That being said, I think the biggest thing is to learn how to think and not always just [take] action. If you need to take a step back, just tell your technician, “Hey, how about you guys get a blood pressure on this," and take a step back and really think about what this patient needs.

There’s going to be the times where the patients are crashing and they need to be emergently managed, and in that case, if you're not comfortable, then I would venture to say, reach out to a mentor, reach out to someone that you do feel comfortable with.

When we graduate veterinary school, especially for me, one of my biggest things was trying to know everything all at once, and you just can't. I think that there's a misconception that the best ER doctors know everything, and that's not necessarily true.

I think that the calmest person in the room, the most confident person in the room, should be the doctor, and should rely on their team and their staff. And when they're not comfortable, they should be asking questions, doing that research, and trying to learn from that case.