Week 4
Tuesday, May 29, 2018
Over the weekend CaCa foaled and Dr. Dietz taught me how to
lay out a placenta and taught me some about assessing the placenta for health.
The placenta had a small strip of plaque. I also learned that there are three
places that can be noted as not being attached: both horns where the ovary
attaches and at the cervical star. These locations are pale/white in color and
there shouldn’t be any other notable places where the placenta is noted to not
be attached. The placenta inverts when the foal is born, gravid and non-gravid
horns should be noted. The placenta needs to be examined on both sides, so it
needs to be turned right-side-out after it has been evaluated inside-out. We
don’t typically worry about the allantoic portion of the placenta. Make sure
the placenta is all there. There should be a hole where the foal exited.
Today I was with team surgery and was able to watch the
placement/creation of a permanent tracheostomy on a 21 y.o gelding with
multiple (very large) melanomas. He was first scoped to visualize his upper
airways, trachea, guttural pouches, and esophagus. The most remarkable (and
interesting) finding was that there were multiple melanomas in the guttural
pouch, one around the internal carotid, and one around the external carotid
arteries. This is also cause for concern for cranial nerves IX, X, and XI, as
they all are seen in the guttural pouch. He presented with the complaint of
very loud breathing sounds (roaring). There was concern that he had (a)
melanoma(s) pressing on his trachea and that was occluding his airway. There
was also concern of left recurrent laryngeal nerve paralysis, causing stridor
(paralysis of one of the arytenoids.) The tracheostomy was placed and I
restrained the patient during the procedure. Restraint proved to be rather
challenging- he kept waking up.
Later in the afternoon Dr. Mullen performed a neuro exam on
an 18-hand warmblood with some mild neurologic signs/concerns. Dr. Mullen found
that it was not particularly remarkable but she noticed minor deficits in
proprioception. Cervical radiographs will be the next step to decide if there
is a problem.
The second surgery I watched was a maxillary sinus
trephination. The horse had previously had an infected tooth pulled and the
infection had traveled up into the maxillary sinus. The sinus was opened,
scoped, and flushed. A plug was made out of dental molding for the hole where
the tooth was, and the trephine was closed up.
After my shift, an emergency colic went to surgery with Dr.
Murray. The horse had a strangulating lipoma, which tied off a few feet of
ileum. The bowel was still alive, but the pulses and motility were poor. The
flick reflex indicated that the ileum wanted to move, but it was struggling. The
owner was presented with the option of resection and anastomosis or leaving the
intestine in and hoping that it would regain full function and not infarct. She
was given a 50-50 chance either way as both options had similar risks. She
elected for the later option, so the bowel was run, abdomen lavaged, and the
horse was sutured up and recovered.
Wednesday May 30, 2018
Today I was in ICU and the majority of my day consisted of
cleaning, restocking, some help with feeding and picking stalls. By the time I
was finished in ICU, there wasn’t much going on in the clinic. Dr. Duff taught
me how to test milk calcium.
Later that evening, after work, one of the post-op colic
horses’ (his surgery was Saturday, May 26) incision had partially dehisced and he had to be sent to surgery.
Inscisions can dehisce for a few reasons, mostly bad luck, but they can also
dehisce as a result of infection. We worry about dehiscence up to 5-7 days post
op, and 3-5 days for resection and anastomosis. Some pieces of wisdom from Dr.
Hill: we know we’re done checking the small intestine when we get to the
duodenocolic ligament. When you’re looking at the large colon, you can tell if
it’s straight (untwisted) if the lateral band lines up with the lateral band of
the cecum.
Thursday May 31, 2018
I worked in ICU this morning again. I cleaned one of the
stalls in the Brice barn, made flushes, spiked fluids, swept, organized,
stocked, dropped hay, and some other things. By 1 I was done with my ICU tasks
and was able to go see what was happening at the clinic. I, unfortunately,
missed the intraspinous desmotomy and ostectomy that was scheduled from last
week. There were 5 spinous processes involved, which is a lot, but the surgery
went well. I also was able to watch Dr. Swanson perform two lameness workups
and an injection of a hock and fetlock. There are two common corticosteroids
used for equine joint injections, triamcinolone and Depo-Medrol
(methylprednisolone). Triamcinolone is generally used in high-motion joints,
such as the hock or fetlock. Depo is not used in high-motion joints because it
causes more rapid bony change. Precautions include laminitis. Too much
corticosteroid in the system may induce laminitis. At the end of the day, I ran
another milk Ca on the mare Aegena, who might foal tonight. I helped make up
some oral meds, then helped adjust Angel’s hernia belt.
Later in the night I was called down to Larsh barn to see
and help with Aegena’s foaling! It was the first I’d ever seen! The newborn
filly was healthy but struggled with the concept of nursing so the next day the
Madigan Foal Squeeze was performed on her. Post-squeeze she was able to nurse
on her own with no trouble. She also needed a plasma transfusion, likely due to
her inability to nurse in that critical period where her gut was still open to
the large antibodies that are normally absorbed from colostrum and the fact
that Aegina’s colostrum was only registering as “fair” on the colostrometer.
Before the filly was born, Dr. Duff showed me how to feel for two feet and a
nose (proper presentation) early in parturition. I also was able to help by
drying the filly off postpartum.
Friday June 1, 2018
Today was field day! I spent the day with Dr. Tischer and
his vet tech Daniel. We did several lameness exams, radiographs of a recovering
P3 fracture, joint injections (stifle, hock, and fetlock), and shockwave
therapy. I had the chance to discuss Osphos treatment and
Triamcinelone/HA/Amikacin use in joints with Dr. Tisher. When we returned from
the field I watched Dr. Mullen perform a neurologic exam on a horse that had an
MRI earlier that day. The horse was found to have an extra floaty gait when
asked to walk on the flat and downhill with his head up. He struggled
especially with trot-to-canter transitions and had a difficult time keeping
himself up and steady behind. He also struggled when asked to circle in tight
circles. He will be reevaluated neurologically after some (or most) of his
lameness is resolved, as that makes the neuro exam a little difficult to
interpret.
Week 5
Monday June 4, 2018
Reportable disease: Rabies, EHV, EIA, Vesicular stomatitis.
VS is reportable because it looks exactly like foot and mouth disease when it
infects cattle. Aside from the mouth, it can effect ears, sheaths, coronary
bands.
Between scrubbing stalls and cleaning in ICU, I was able to
watch Dr. Lori inject the stifles of a horse with an excessively flat medial
condyle of the tibia. The two joints of the stifle are the femoropatellar and
the femorotibial. The two compartments of the femorotibial joint are the medial
and lateral femorotibial compartments. The femoropatellar joint is the largest
of the three compartments and it communicates directly with the medial
femorotibial compartment in about 65% of horses. Dr. Lori injected the medial
femorotibial joint. One injection site is located between the medial patellar
ligament and the medial femorotibial ligament. The other, which was used by Dr.
Lori, is the medial outpouching of the medial femorotibial joint. Advantages of
this technique are better accuracy and ability to recover synovial fluid.
Painful reactions are less likely in this technique. The site is the
indentation between the medial patellar ligament and the temdon of the
sartorius, ~1in above the tibial plateau.
Tuesday June 5, 2018
We had journal club about administration of fluids to
patients in the field. We discussed such topics as when to give fluids, how
much to give, and at what rate. We then had grand rounds, which took a while
because the ICU barn is completely full and there are several patients in Larsh
and the condos as well.
After rounds I handwalked horses, spiked fluids, restocked
fluids, cleaned the feed shed, stocked the alfalfa… Then we had a patient
leave, so I cleaned her stall. Around 1 I was relieved from stall cleaning to
monitor a foal as he was given a fluid bolus (I’m not sure what was in the
fluids, I forgot to ask). Around 2pm I had lunch and came back around 2:30.
After doing some minor cleaning tasks, another patient left, so I cleaned his
stall. At 4:45, Dr. Dykstra came in with a colic emergency and did an
abdomenocentesis. I held the red and purple top tubes for collection and ran a
lactate and total protein test. Lactate was 11.1, ridiculously high, and total
protein was 2. The mare was obviously very sick with no surgical option. I’ll
find out tomorrow if the mare is still with us. She has an 11 day old foal with
her.
Abdominocentesis is done for a multitude of reasons, colic
being one of them. Fluid analysis helps guide the direction we take these cases
medically or surgically. It is performed in a standing sedated horse to the
right of ventral midline, avoiding the spleen, caudal to the descending
pectorals. After the area has been clipped and sterilely prepped (we use
betadine and nolvosan/alcohol solutions), a stab incision is made and a teat
cannula is gently inserted through the incision to drain and collect fluid. In
the purple top tubes, the EDTA was shaken out because EDTA will falsely
increase total protein. With intestinal strangulation, TP will increase in the
first 1-2hr, after 3-4hr, RBCs are present. >6h WBCs increase gradually, as
intestinal necrosis continues. Peritoneal lactate increases with intestinal
ischemia, which was noted on this mare’s abdominocentesis. If there is blood in
the sample, it should be determined whether the blood was from contamination
during the procedure or if there is hemorrhage or dead bowel. If the sample can
be spun down and it’s clear, then it was fresh (contamination). If the sample
remains red-tinged, there is likely hemorrhage and erythrophagocytosis can be
seen and there with be no platelets. In the case of compromised bowel and
damaged capillaries, the fluid will be serosanguinous with a red supernatant
post-spin.
Wednesday June 6, 2018
Another ICU day! I stocked, cleaned, made up flushes and
spiked fluids. I saw a couple minutes of an emergency colic work up but had to
leave to go set the stall up for the horse to move into after the work up. I
gave him his lidocaine bolus IV. I also helped ICU by doing a CPDP (basically a
modified physical exam) on Pheonix (he’s back!), feeding the orphan foal, and
milking the Percheron mare.
Thursday June 7, 2018
Today I was in the clinic with Dr. Swanson. We had several
lameness exams and joint injections. I saw my first carpus injection. I enjoy
working with Dr. Swanson because he asks where I think I see the lameness and
lets me come up with my own ideas before sharing what he sees. I’m getting
better at evaluating lameness, but it’s still difficult for me when there are
problems in more than one limb.
Friday June 8, 2018
I was in the field with Dr. Christakos today. We did health
certificates for our first visit. The second visit was suture removal for a
horse that had a laparoscopic ovariectomy a few weeks ago. We did a gross prep
of the areas with betadine solution and chlorohexadine/alcohol solution to keep
the area clean and prevent introducing bacteria where the sutures would be
removed. Our next appointment was to use prostride on a horse who had
previously injured her fetlock. For more information about how ProStride works,
you can click this link! https://www.omveterinary.com/pro-stride
This particular patient hated needles near her neck and it was a challenge to
restrain her for her sedation injection. Dr. Christakos was incredibly patient and
was eventually able to sedate the mare long enough to do the treatment. Our last
appointment in the field was at a beautiful farm near Evergreen, CO. It was an Arabian
horse who had been injured almost two weeks prior during a competitive trail
riding event. He had fallen from a pedestrian bridge and has several
lacerations on his right front. The appointment was to check up on his
laceration and retake radiographs to be sure that there were no sequestrae. The
radiographs were clear but there was significant pitting edema of the lower
extremity. Dr. Christakos believes that it’s the start of a skin infection. She
removed the sutures on the largest laceration, wrapped the limb, and dispensed
SMZs to be administered twice daily to get rid of the infection. He’ll be on
stall rest at least for a few more weeks. The final appointment of the day was
a Morgan gelding with previous SI treatment, looking to be evaluated and
potentially injected again. The lameness exam indicated that injection would
likely help. Dr. Christakos used Depomedrol because the SI joints are not
synovial and also because the gelding was obese and at risk for laminitis with triamcinolone.
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