The downfalls of routine

I have learned through my experience as an Equine Fellow that one of the most important qualities in equine field work is to be flexible. Although there may be a full schedule booked in the evening, the following morning can bring different emergencies that tend to shift around that entire schedule.

It is easy to get frustrated, but it is important that emergencies are just that: unplanned. I feel like that is one of the perks of equine medicine. I love experiencing a variety of different cases that aren’t typical of the routine visit. So far this summer, I have seen several different cases of foot abscesses. These calls have turned into guessing games on the drive. What caused this acute lameness? Is it going to be a case of laminitis, a fracture, an embedded nail, or an abscess?

I’ve learned that you need be interested in these different emergencies that are thrown in your direction instead of being so caught up in a routine schedule.

Wrapping It Up Ohio

I have finished up my twelve weeks at the Cleveland Equine Clinic. The time simply flew by! I could not have asked for a better summer experience. All the staff, technicians, and veterinarians were so hardworking and knowledgeable it was truly impressive. I was able to see such a variety, from breeds of horses, to internal medicine disease, to wounds, and to routine care. Within the last few days, I assisted with a tongue laceration (the rostral 1/3 of the tongue was literally hanging on by less than a half inch), worked up a horse with a severe pelvic fracture (initially the appointment was for a suspected abscess), worked up various lameness cases, pin-fired a horse, and assisted in an entire day of tie-back and sacculectomy surgeries. I certainly feel that I am ready or at least more prepared for entering clinics this next spring. At the suggestion of one of the vets, I've compiled at list of commonly used drugs, dosages, with quick reference info that I plan on using for equine clinics. I also think that my horse handling skills have improved. Although I have always been a horse person, there is an art form to restraining a horse for an exam or a particular procedure. I definitely feel more confident at performing flexion tests, diagnosing subtle lameness, doing a routine physical exams, and performing leg, back, and neck palpations. This program has given me an excellent look into what it will be like to work in 'real-world' equine practice.

For anyone interested in this program, I cannot say enough good things about it. For my program in particular, I think as long as you are willing to work hard, learn quickly, and go with the changes, it can be an invaluable experience!

Farewell to Somerset

Well, it has finally sunk in that my time with the MSU Equine Summer Fellowship Program and Brown Equine Hospital has come to an end. I could not have imagined a better experience and I would do it all over again in a heartbeat. The vets and techs at Brown Equine Hospital taught me so much and were so supportive, I could not ask for a better group of people to work with. I was very sad to say goodbye, but I left with many fond memories. So here it is, my final blog post:

Something must have been in the air this week, because we received four emergency colic cases in less than three days. The first to be brought in was a draft horse that had been off feed since the night before. From the abdominal ultrasound and rectal exam, Dr. Brown diagnosed him with anterior enteritis, or inflammation of the duodenum and/or jejunum. Since anesthetizing draft horses carries an even higher risk than other horses, Dr. Brown wanted to keep this gelding off the table at all costs. We started by passing a nasogastric tube to reflux every few hours and administering IV fluids with a lidocaine drip. The draft horse took a turn for the worst a couple days into treatment, refluxing up to 30 liters and going into acute renal failure. We increased the frequency of refluxing and started to bolus the IV fluids. Remarkably, the gelding pulled through and is now recovering well. We stopped refluxing completely and have started weaning him back onto solid food.

The second colic that came in was a part-Standardbred that had been acting uncomfortable for a couple days. As it turned out, this gelding also had anterior enteritis and we started him on the same treatment regimen as the draft horse. Unfortunately, our refluxing did not keep pace with the fluid backing up into his stomach. About 48 hours after being admitted, we passed a tube, but we got negative net reflux. Suspicious, Dr. Brown performed another ultrasound and belly tap. The results showed excessive fluid (reflux) surrounding the intestines, revealing that the gelding’s stomach had ruptured. Sadly, we had to put the horse down. It is surprising how such similar cases, treated the same, can end so differently.

The last two cases were also treated medically. An impaction and a right dorsal displacement were resolved with IV fluids and fasting. Both horses were slowly reintroduced to solid food and were sent home within two days of being admitted. I had always thought that all colic cases that were referred went to surgery. Much to my surprise, however, the vast majority of the colic cases we saw this summer were treated and resolved medically. Another surprise was how many of the horses that came in for colic went home healthy; it was nice to discover that colic is not a death sentence.

To end, here are a few photos of some of my favorite moments working at Brown Equine Hospital:

Repro work with Dr. Jen Brown

Surgery with Dr. Keith Brown

Scoping with Dr. Travis Tull

Week Nine in Somerset

It is so hard to believe that I will leave Brown Equine Hospital in less than a week. This summer has flown by and I have learned so much in the short time I have spent here. Like the summer, this past week sped by and we had a full caseload of horses to be scoped.

The most invasive procedure we performed with the scope was a ventriculocordectomy. A ventriculocordectomy is the removal of the laryngeal ventricles and vocal cords to enlarge the airway. During this procedure, the scope is passed through the nose to the level of the epiglottis and gives the veterinarian a clear view of the larynx as he works. The ventricles and vocal cords can then be removed through an incision in the throatlatch area. In our first case, the patient had partial paralysis of the left recurrent laryngeal nerve, which prevented him from fully opening his left arytenoid cartilage and vocal cord. Dr. Brown is confident that the ventriculocordectomy will allow him to perform at a high athletic level despite the partial paralysis.

We suspected that a second horse presenting with exercise intolerance also had laryngeal nerve paralysis. This gelding had an even more pronounced paralysis in both the left and right arytenoid cartilages and the owner was already considering a ventriculocordectomy. Upon close examination of the horse as a whole, however, severe facial muscle atrophy on the right side of the face was also observed. Dr. Brown diagnosed the horse with Equine Protozoal Myeloencephalitis (EPM), a common neurological disease. Instead of staying for surgery, the gelding went home to be treated with anti-protozoal drugs and a vitamin E supplement.

Minor muscle atrophy of the left side of the face compared to advanced muscule atrophy of the right ride

We used a gastroscope to go up the nose, under the epiglottis, down the esophagus, and into the stomach of another patient to check for gastric ulcers. Surprisingly, once we entered the stomach, we found no ulcers. Instead we found clusters of bot fly eggs (truly disgusting.) Our final scope case was the guttural pouch fungal infection that we have been treating topically through the scope for the past three weeks. We are now able to tear pieces off of the fungal plaque and inject the topical treatment directly into it. Below is a series of pictures documenting our progress.

    

The plaque upon presentation, during a lavage with dilute betadine, after two weeks of treatment

Topical treatment with an anti-fungal suspension, after three weeks of topical treatment

Despite being busy, we still found some time to have fun. One of Dr. Brown’s heavy weight pulling horses, Tank, has been staying at the clinic so Dr. Brown can work with him.  The externs and I go along for the ride when we can to add weight to the sled; we have a grand time trying to keep our balance on the moving pallet. Dr. Brown even let me try my hand driving Tank. It is never a dull day around here!

        

Time Flies When You’re Working Hard, Having Fun, and Learning Loads!

Time is flying by here at CEC! I am just finishing off my tenth week and I am still having an awesome time! I have seen so many neat cases and am learning so much. Even though, it is in the 90s this week, I love working hard and going on lots of farm calls. This week we had an interesting wound that was along the lateral canthus of the eye. Somehow the horse had avoided scratching the eye and we were able to suture the wound closed with 3-0 vicryl.  The real test will be whether the owners can stop the horse from rubbing the eye, which for this trouble-maker of a horse will be a challenge!

There have been several colic cases lately. One involved an emergency farm call out to see a draft horse 5yr mare. The mare had a heart rate of 100beats/min, respiratory rate of 80bpm, temperature of 103*F, muddy-color gums, and a severe sweat. I was able to rectal the mare and felt an extreme amount of heat, several distended loops of small intestine, and a very firm cecum. Unfortunately, because surgery was not an option for this mare, she was euthanized. We have also been seeing several impaction cases, ranging from mild to severe. We currently have an impaction colic case that has now developed severe diarrhea and a fever. A fecal sample has been submitted so we will see what it says, however I’ve been told that it “smells like Salmonella!” The horse is now on K-pen, gent, polymyxin, cimetidine, and fluids. In addition, to continuing multiple day NG tubing with different combinations of water, electrolytes, energy, Epsom salts, and mineral oil. I’ve found colic cases to be very interesting, although often frustrating (if only you could make a horse drink)!

I can’t believe that I only have two week left. I truly can’t say how much I love working here!

Hard Lessons from RREH

Hello again from the Bluegrass! As summer winds down here, I thought I’d take a moment to talk about some of the hard lessons that we learn in equine/veterinary medicine.

Yesterday started out as a pretty routine day for surgeries with Dr. Bramlage, but right around 1:00 PM, we had an emergency that came in – an internal carotid hemorrhage in the right guttural pouch… and when I say hemorrhage, I mean pouring out! This mare was a 12 y.o. TB mare that had actually been in sometime between late April and early May with a similar presentation, and had actually had her internal carotid already ligated surgically.

Initially when she came in, she left a trail of blood from the parking lot to a pool in the work-up area and induction stall. Prior to and during surgery, she had probably lost approximately 20% of her blood volume (so roughly about 10L – horses have a lot more blood than the average human). During surgery, she had part of her volume replaced with fluids, Hetastarch, and plasma, and she was eventually matched with one of the blood donor horses for a transfusion following surgery. The surgeon on the case performed a balloon embolization to stop the bleeding from that artery – which, essentially, puts a “plug” in the vessel by inflating the end of a small, wire-like catheter with saline (almost like filling a miniature water balloon that blocks the blood flow).

The surgery was successful at stopping the hemorrhage, and the mare was placed in the recovery stall and fitted with a blood transfusion set. Two of the best recovery guys were with her the entire time, and were extremely conscientious of her condition and how she was progressing. It took a good hour and a half for her to regain enough strength and come around from anesthesia to even try to stand up with their assistance – not entirely unexpected due to how she came in and how long the surgery took (about 3 hours!). The first time, she couldn’t stand up fully, and the team allowed her to rest in lateral, a.k.a. on her side, a little bit before trying to help her up again. She was still incredibly weak from all of the fluid she lost and probably some electrolyte imbalances, etc.

Once she sat up sternal (a.k.a. on her belly), the guys and an anesthetist adjusted her hooves so that if she tried to stand again, she would be in a better position for success. Again, she tried to stand with their assistance, but, she was still too weak and collapsed from fatigue – this time, it was not a smooth fall. To everyone’s dismay, when she collapsed, she also completely fractured her right tibia (for all you basketball fans, think Kevin Ware in the NCAA tourney). Tibial fractures in horses are basically fatal because they cannot be easily repaired without major complications. And, fractures during recovery are every veterinarian’s worst nightmare.

When this happened, the interns sprung to action and were able to sedate her until her owners could be reached, and quite regrettably, she was euthanized. No one was truly to blame in this situation, nor did anyone expect for this to happen. It’s just one of the unfortunate and undesirable things about equine surgery. Mostly, I feel for the surgeon and the intern on her case – it’s devastating to complete a difficult, 3-hour-long surgery and have a positive outlook for your patient, and then have something so tragic happen that absolutely no one could control.

So, this blog is in memory of the sweet mare that we lost, though please do not let it scare you – fractures during recovery are rare if the recovery team is good at what they do, and they should never be anticipated as though it will inevitably happen. Props to our recovery guys, who watch out for the safety of all surgery patients each day, and even risk their own safety for many of our horses!

Week Eight in Somerset

We started the week off with our normal cases of joint injections, lameness exams, pregnancy checks, and various other procedures. Although I have not yet discussed it, seemingly every week at least one overweight horse comes in lame with some degree of laminitis and rotation. Equine Metabolic Syndrome is something that I had vaguely heard of before, but I have gained a much better understanding of the prevalence of the problem here. EMS is developed insulin resistance comparable to Type II diabetes in humans. For some reason, changes in the sugar composition in the grass during spring and fall cause insulin resistant horses to experience bouts of laminitis. These horses also become very overweight, depositing fat around their tail-heads and developing a “cresty” neck appearance. We have seen so many cases now that I can tell by looking at these horses that they will have coffin bone rotation on a radiograph. Just like with diabetes, the solution to the problem is diet and exercise. Dr. Brown and Dr. Tull recommend switching to a low-starch grain, severely limiting access to grass, and soaking the hay before feeding to leach out the sugars. EMS is an interesting condition and I am sure I will be seeing it quite often, even after I leave Somerset.

On Tuesday, we had the surprise of not one, but two horse with P1 fractures come in. Both cases were lateral condylar factures that were repaired using two lag screws. As always, I got to scrub in! It was a long day in the operating room, but Dr. Brown set both fractures with relative easy. I finally got the hang of assisting for these fracture repairs (at first all of the hardware and new instruments intimidated me) and could anticipate what Dr. Brown would need next. In the end, he let me practice my vertical mattress suture pattern to close over the screws. We were all pretty excited over how well the surgeries went. Both horses recovered well and were sent home a few days later. 

The post-op radiographs. You can't even see the fracture line!

   

Drilling                                  Flushing                                Sewing

The twist of the week came on Wednesday, when I started experiencing severe abdominal pain and my Brown Equine family decided I needed to go to the ER. After every diagnostic test under the sun, the human doctors admitted me to the hospital for several days on fluids and pain meds. The final diagnosis was a viral infection and they released me after I had no pain or fever for 24 hours. While the nurses and staff were very nice, I am more than excited to be back at work and I am looking forward to another great week.

Weird things at RREH

Hey everyone! I hope your summers are treating you well. We’ve enjoyed some warm and sunny weather here in Lexington, with the occasional rainstorms, of course. I wanted to take this week’s post to discuss the “weird” cases that we’ve seen. The majority of these cases have come in as emergency rather than elective cases, and unfortunately the outcomes aren’t always what we hope for.

1. TB broodmare with a foal at her side presenting for a moderately painful colic:

On evaluation, nothing major is noted about her large colon (wall thickness, etc), and for the most part, the majority of her small intestine was just moderately dilated. Regardless, she was taken to surgery as she was insured and of significant value to the farm. The surgeon on her case, Dr. Embertson, found that (oddly enough) she had a moderately large diaphragmatic hernia, with protruding small intestine and the cranial portion of her spleen… quite a rare finding! The intern on the case even noted that she was able to reach through the diaphragm and feel the heart beating – which, in and of itself, was impressive. Normal repair of diaphragmatic hernias in horses often require implantation with a prosthetic mesh across the lesion, but RREH rarely keeps mesh on hand because of how rarely it is used. Dr. E repaired it by repositioning of the viscera and careful appositional suturing, and to date, the mare (with her foal) is doing well in recovery!

2. Emergency presentation of a Quarter horse gelding (yes, I did say quarter horse!), with a severe right hindlimb lameness after showing:

This gelding came in after hours on the weekend after barrel racing, and was essentially 3-legged lame. Upon radiographs, it was discovered that he had a severely communited P1 fracture. In fact, I would not even call it a fracture – I would call it a shatter. There was hardly any intact bone that could be used as a “strut” to help reconstruct the pastern, to at least allow him to live as a retired pet. He had two options: cast the limb and see how it healed on its own, or euthanasia. In all honesty, casting the limb had an extremely poor prognosis for any return to function, and it was suspected that he would develop other complications during the healing process, such as laminitis in the contralateral limb, etc. The owner reluctantly and difficultly chose to euthanize him, and we all felt for her and her situation. I can’t imagine what I would do in her situation (knock on wood that it never happens to anyone…).

3. Young TB mare presenting for an elective fetlock arthrodesis:

This mare presented as a Dr. Larry Bramlage case (the master of most things orthopedic) for front fetlock (cannon bone to phalanx 1) arthodesis, mostly as a salvage procedure. I have personally experienced Dr. Bramlage’s mastery of joints and bony structures, including one fetlock arthroscopy lasting merely 5 minutes… but even this surgery was a challenging one and it took several hours. Dr. Bramlage used a standard method of LCP plating on the dorsal surface of the bones with 4.5 and 5.5 mm screws (in this case, he used a 12-hole plate). Again, this is entirely a salvage procedure to allow the mare to be more comfortable in her fetlock in her future years, although the procedure itself does create quite a substantial amount of pain in the initial recovery period. However, like many of our orthopedic cases, she is recovering well here in the hospital and is regularly having her cast changed to prevent pressure sores.

Like most of the other fellows, I try to take the free time that I have to enjoy the culture and city of Lexington, and the different things it has to offer. There’s a lot of history here, and in my opinion, some really great “foodie” places! Here are pictures of some of my favorites thus far:

Stella's Kentucky Deli: a to-die-for homestyle brunch place with all you can eat cheese grits, stratas, orange pecan pancakes... yum. Definitely give it a try if you are in town!

The Local Taco: some of the best Mexican food I've had anywhere. The mole sauce is particularly delicious, as is the sangria, if you are old enough!

North Lime Coffee and Donuts: a quirkly little place featuring delectable espresso and tea drinks, as well as fun doughnut flavors like Root Beer Float, Strawberry Yeti, Chocolate Covered Blueberry, and Pink Lemonade, to name just a few!

 

Did you know that Lexington is actually the childhood home of Mary Todd Lincoln, wife of President Abraham Lincoln?! This is her historic house, which sits right on Main Street in downtown Lexington.

 

Week Seven in Somerset

We celebrated the Fourth of July this week by welcoming two overseas vet students to the clinic. Jenny is originally from West Virginia and is going to school in New Zealand; Sonea is from Austria and is going to school in Vienna. It is really interesting to hear about school and life in general from a foreign perspective. As I show them the ropes around the clinic, they are sharing their knowledge about the cases with me.

This week was full of new cases, exciting hands-on experiences, and very little sleep. We had two yearling Standardbreds in for arthroscopies to remove OCD lesions in their hocks. Assisting for these arthroscopies has become less daunting for me, despite all the strange instruments. I am also finally able to identify anatomical landmarks on the screen. I was pumped beyond pumped when Dr. Brown allowed me to remove OCD lesions from the distal intermediate ridge of the tibia in both hocks for one of the horses. I have a new appreciation for the coordination required to grasp a small chip with only the small view on a computer screen for guidance. Dr. Brown makes it look easy. The second arthroscopy revealed that the chip we could see easily on an x-ray was actually buried in a collateral ligament. Dr. Brown and Dr. Tull were both very excited to examine the soft tissue structures of the joint with the scope. They figure that the horse tore his deep short medial collateral ligament, which carried a chip from the medial malleolus with it. Dr. Brown was able to clean up the torn ligament and remove the chip, but he does not hold much hope for the horse’s racing career.

We also had two more foals with swollen joints come in, but neither of them turned out to have septic joints. The first has an infected physis, or growth plate, which we are treating with systemic antibiotics and regional limb perfusions. The second, Dr. Tull suspects has Rhodococcus, based on his findings from a thoracic ultrasound. Rhodococcus is a bacterium that can cause pneumonia in foals by forming abscesses in the thorax. Due to the connect blood supply between the metaphysic and epiphysis in foals the bacteria can gain access to the joint area, causing inflammation around the joint. For this reason, sometimes the most visible sign of Rhodococcus is swollen joints. We are treating the infection with targeted oral drugs that are proven to penetrate the abscesses.

        

Here are some action shots of the arthroscopy surgeries. On the far left, I am "assisting" in a whole new way. In the middle two frame, I am examing and gripping two OCD lesions on the computer screen in preparation of removal. The final picture is of my proud display of the first chip I removed. 

Update from St Johns

It has been a few weeks since my last blog entry. I have been busy working for MSU’s advising office at the Academic Orientation Program (AOP) for incoming undergraduate freshmen. This is my second summer working the program and I present the pre-veterinary and veterinary technology programs to the undergrads who have declared their major as such. Due to my prior commitment with AOP for six weeks this summer, I am only able to be with Clinton Veterinary Service on Fridays until AOP is finished.

I am incredibly thankful to Clinton Vet for being so accommodating and flexible with me for these next few weeks. I have still been able to log a few hours every Friday still assisting with checking breeding cycles and pregnancies at MSU’s horse farm, various teeth floats, changing bandages, and assorted other appointments. I look forward to being back with the clinic full time in a few weeks!

Update from the Mile High City

Hey all, sorry it’s been a while since my last post! A few weeks ago my schedule was switched up, so now I get to split my time between the ICU and the field. On Mondays I get to work as an assistant for Dr. Lori, who sees a mixture of general practice appointments. It’s been a really great opportunity to see a lot of variety, from lameness evaluations and suturing wounds to radiographing a fractured cervical spine. Dr. Lori is also great to work with, and he’s been really cool about letting me do a lot of hands on stuff.

On Wednesdays I get assigned to a different doctor to shadow every week. A few weeks ago I got to work with Dr. Story, who does a lot of chiropractic and acupuncture, which is something I wasn’t very familiar with before this summer. I think there are a lot of misconceptions about what acupuncture actually is and does (at least I know I had some!). There are several different approaches to acupuncture, one of which involves harmony, balance, yin and yang, etc. However, the western medicine approach to acupuncture utilizes nerve stimulation to help with a variety of conditions from musculoskeletal pain to colic. In horses that will tolerate it, electrical stimulation can be combined with the needles to intensify the effects.

On Fridays I get to float around the hospital, or if there isn’t much going on I usually end up helping in ICU. However, a few weeks ago I was able to sit in on an olecranon fracture repair surgery. The olecranon is part of the ulna, which is essentially the point of the elbow. It was really interesting to watch the surgeons implement all of the techniques for fracture repair that I just learned about in our Musculoskeletal course last semester, but that I had never seen in person before. The horse recovered from surgery well, and despite an episode of colic that ended her up in the ICU for a few days, she is now doing very well and bearing full weight on her leg.

Outside of the clinic I’ve been keeping myself a little too busy, which is part of the reason I haven’t posted in so long. Denver is incredible and I’ve been able to explore a lot of the city as well as take myself on a few adventures on the weekends, my most recent of which was skydiving last weekend! This whole summer has been such an incredible opportunity to gain both medical experience and life experience, and I’m trying to take advantage of as much as I can since this will be my last summer break before graduation (and really, my last summer break ever).

I’ll try to post a few more times this week to fill in the gaps, so stay posted!

Kiva

The Wide Variety in Ohio

           I’ve just finished off my seventh week here in Ohio and I am still loving it! I have seen such a wide variety of cases in just this week alone. I assisted in a standing splint bone surgery this week. The doctor performs this surgery standing, so the horse receives only sedation and local anesthetic. The surgery itself was very quick! The doctor uses a fork (yes, the same kind you eat with) and a small chisel to remove the section of bone, compare it to the initial radiographs, smooth off the remaining bone, places a drain, and closes. The horse then quickly wakes up and loads back on the trailer to head home.

I’ve also seen several wound cases this week. One wound exposed the entire cannon bone, stripping away a large amount of the periosteum and severing the extensor tendons. Surprisingly, the horse was still somehow able to place its foot fairly normally. When we initially saw it on emergency, we cleaned the wound, took x-rays to ensure that there were no fractures, and applied a thick bandage. This week I have also seen a large chest wound that extended along essentially the horse’s whole armpit region. This horse was lucky because there was no puncture into the chest cavity and the muscles were largely separated along the fascia plane. A drain was applied and the wound was closed with a combination of sutures and staples.

I have seen more wound cases, reproduction cases, general exams, prepurchase exams, lameness and several emergency colic cases. I am learning so much about how doctors handle the cases and work with owners to ensure that the horses have the best care while still staying in a reasonable budget. There are a lot of shadowing pre-veterinary students and veterinary students that come on their externship rotations, so it has been great to compare notes! Time is flying by here, I can’t believe that I’ve only got five more weeks left at the clinic!

 

Week Six in Somerset

It is hard to believe it is already July; time is sure flying by! This week was filled with interesting cases. To start off the week, a mare came in on emergency with a fracture of the first phalanx, or long cannon bone. We took her to surgery and placed three lag screws to draw the fracture line together. The procedure went very smoothly and we put her in a half limb cast. She has been doing well and hopefully she will be able to go home soon. Check out the pictures below.

                      

             Pre-Op, Inta-Op, and Post-Op Radiographs of P1 Fracture

We also had a horse come in with “photo head shaking”, which is an idiopathic condition that presents as various behaviors that seem to worsen in daylight. In this case, the horse began to violently toss its head and run off whenever she put her head down to graze. She did not have the same reaction when she ate grain off the concrete. Dr. Brown’s hypothesis was that her muzzle was hypersensitive and the long grass was causing her pain. Using lidocaine, we numbed her muzzle and she was able to graze on long grass without any abnormal reaction. The owners opted to try constant tactile stimulation over a surgical treatment option. Dr. Brown recommended they put a net-like or leather tassel contraption over the mare’s nose at all times to constantly stimulate and desensitize the nerve endings. If that is not effective, the owners may consider a long-term sedative or surgical treatment.

Another mare presented with dysphagia, or difficulty swallowing. After a neurological work up, Dr. Brown scoped her guttural pouch. Sitting between the internal carotid artery and nerve bundle of CNs IX, X, and XII was a fungal plaque. He put the mare on a systemic antifungal and began flushing the gutteral pouch with a LRS and DMSO solution. Once a topical antifungal suspension arrives, we will begin injecting it into the gutteral pouch through the scope once a day for about a week. If this treatment is not effective, the owners will consider a surgical option.

Fungal plaque sitting between the internal carotid artery and nerve bundle in the gutteral pouch

We also said good-bye to one of the technician, Rachel, with a trip to The Meadows, a Standardbred racetrack. I had a great time socializing with my co-workers and betting on the races. It was pretty cool to see some of the horses we have worked on (and their offspring) race.

Day at the Races

Week Five in Somerset

I am now officially half way through my Equine Summer Fellowship, and this week was still filled with plenty of new experiences. As the doctors here have become more comfortable with me, they have begun teaching me more hands-on skills. I now place IV catheters as needed when horses come into the clinic and require fluids or IV medications.  I also performed my very first palmar digital nerve block and successfully blocked the foot on the first attempt (much of the credit for that goes to Dr. Sonea and Dr. MohanKumar for teaching us different never blocks on cadaver legs in anatomy lab.) During the numerous joint flushes on the two foals last week, Dr. Brown began having me participate more and more. For the most recent flush, I did everything myself under the guidance of Dr. Brown. To say the least, it has been the highlight of many highlights so far this summer.  Dr. Brown has also given me a couple of opportunities to suture skin incisions at the end of minor surgeries. I really hope I get a few more chances to improve my simple continuous pattern and surgeon’s knot.
There were several procedures this week that were also new for me. The first case was a horse with a locked stifle. Due to the reciprocal apparatus in the hind limb, he could not flex his stifle or his hock, resulting in walking on his fetlock. His stifle was successfully unlocked after a medial patellar ligament split procedure. Dr. Brown essentially poked holes in the ligament with a scalpel to create inflammation around the patella and loosen it from the locked position. For another horse with chronic sinus issues, he placed a port into the frontal sinus by drilling through the skull. Through the port, the owner will now be able to lavage the sinus at home. We fondly called the lavage the “netti pot procedure.” Lastly, a horse came in with suspected botulism. Although botulism is not common in Michigan, Brown Equine Hospital has dealt with over half a dozen cases in the last year. When it presented, the horse was unable to swallow, so we treated him with antitoxin, IV fluids, and potassium penicillin. Unfortunately, he went into flaccid paralysis and had to be put down.

There were several new experiences outside of work as well. I was finally able to get out to the Laurel Hill State Park and do some hiking. I still cannot get over how beautiful this area is. I also took a trip out the Memorial of Flight 93, which crashed less than 30 miles from here on September 11^th. The memorial upholds the memories of the passengers and crew with a simple and beautiful dignity. I have included several pictures below.

  Laurel Hill State Park

  Cool Step-Stone Dam

The Flight 93 Memorial

Summer Continues at RREH

I’ve determined that summer in Lexington is marked by the point when the weanlings go from cute and petite to monster-size (some being well over 500 lbs…) and feisty! We’re continuing in surgery with many of the prep surgeries for the fall yearling thoroughbred sales at Keeneland, Saratoga, and elsewhere, but we are also seeing quite a few colic surgeries (even the elusive epiploic entrapment), fracture repairs, tie-back surgeries – 2 Percherons in fact!, and several more specialty surgeries (including more Baskets). In fact, over the weekend there were approximately 7 or 8 colics that came in on emergency – though not all of them had to be “cut”. We even had a few visitors from the Triple Crown races last week, though I can’t say whom out of respect for client confidentiality!

For my case of the week… We had a pretty bad fracture repair mid-week, and being an orthopedics fan, I found this case highly interesting. This filly was in her first major year of racing (probably a contributor to her injury), and had a right hind metacarpal III (cannon bone) spiral fracture - which are notoriously difficult to repair and notoriously difficult for horses to recover from safely and soundly. Dr. Embertson – a fellow MSU grad from back in the day! - was even hesitant on the fixation, given the size, type, and location of the fracture. However, he successfully plated the fracture with a 12-hole plate and lag screws (rads are coming)! The filly is doing much better here at the hospital, though the next several weeks remain absolutely critical to determining if the fracture will heal adequately to allow her to return to an active career.

Here at RREH, we have many cases where – like this filly – cost of surgery is not a concern. We’ve operated on several horses in the last week that were worth well over $1.5 million, and it’s easy to become “star-struck” by the equine celebrities that walk through the door. However, I like to remind myself that every horse here – and elsewhere – is more valuable than its weight in gold to someone, somewhere. In fact, some of the most valuable horses are the ones that are retired from competition and now spend their days helping children with disabilities, or the ones that enrich their owner’s life simply by giving them something to look forward to after a long day at work.

Okay… off my soapbox! Another aspect of my summer that I have neglected to mention is how much I have enjoyed meeting the new (and old!) RREH interns and the many externs that have come through the house this summer. I have met new friends from UGA to Texas A&M, Guelph to Edinburgh, Buenos Aires to Munich – and they all have taught me something about the path that we take in vet school, and how each opportunity shapes (or even just tweaks) our career plan. They have also shown me how universal veterinary medicine is, and how no matter where you go, you can always find at least one equine enthusiast similar to yourself!

I leave you now with a few photos:

One of the local favorites - Wallace Station, a small diner on Old Frankfort Pike that sits right in the middle of horse country. It was once featured on Guy Fieri's Diners, Drive-Ins, and Dives.

The drive to Wallace Station features some of the best views you could ask for - literally, you pass some of the world's most beautiful farms, including Donamire, Stonestreet (home of legendary Rachel Alexandra), and Darby Dan to name a few.

 

Apparently, it rains a lot here in KY - and without fair warning. Note to self: never leave the windows in the car open! Rain apparently also means that there will be emergency colics coming in (so we all knock on wood when it storms!).

Week Four in Somerset

This week was the week of foals, which has been interesting if a little bit more stressful. Most of the foals that come into the clinic have serious conditions and have to be monitored closely. Our most recent case is a week-old foal that came in on Saturday night with colic and diarrhea. She presented in so much discomfort that her owners and referring vet could barely stand her up long enough to get her on the trailer. When she arrived, we ran blood work, examined the abdomen with the ultrasound, and performed a belly tap. We found a small amount of enteritis, but no other major problem. Dr. Brown was reluctant to consider surgery as an option since young foals have a greater risk of developing adhesions. Instead, we put the filly on antibiotics, anti-inflammatories, and supportive fluids. Throughout the night, she became much more comfortable, but continued to have diarrhea. We were able to determine that the cause of her diarrhea was a clostridial infection. She was isolated in separate barn to prevent infecting the other foals. She is continuing her antibiotic treatment and will hopefully be well enough to go home in a few days.

Two other foals are staying with us this week due to septic hocks. Both foals have been treated with a series of three joint flushes, which essentially pumps and drains a large volume of sterile fluid through the infected joint to wash out bacteria. Then, antibiotics are injected into the joint to eliminate the infection. As we flush the joint, we also perform a regional limb perfusion. This procedure requires tourniquets to be placed above and below the infected region. Antibiotics are then injected into a vein (in these cases the saphenous vein) and perfuse through the tissues in higher concentrations than if they were administered systemically. Both foals have responded to their first two flushes and will be able to go home when the white blood cell count in their joint fluid is sufficiently low.

The last tiny guest at Brown Equine Hospital is the three-month old foal with the fractured calcaneus that I wrote about last week. He is doing extremely well, with no signs of infection yet. I have included a couple pictures of the fracture repair surgeries and his before and after pictures below. 

 

Pre-, Intra-, and Post- Op radiographs of the calcaneal fracture repair

Rounding Off Week Four in Ohio

It has been four weeks for me here in Ohio! I have already learned so much at the clinic. I am getting much better at reading ultrasound and radiographs. I am also learning tricks to restraining difficult horses, how to quickly and accurately do a physical exam (identified my first AV block this week), and practicing leg palpation. I am continually amazed at how hard each member of the Cleveland Equine Clinic works!

This past Saturday I rode with one of the doctors who was on the emergency cases that day. We began at about 8:30 am and drove an hour to our first call, where we were told that the horse “ripped her nose off.” When we arrived we did indeed see that the mare had somehow mysteriously ripped her entire nostril apart on one side. However, the skin and cartilage flaps were still attached and after a through scrubbing, the doctor was able to suture the flaps back together using a line of subcut and a line skin sutures. The doctor finished off the few hours of suturing by spraying the wound with AluSpray for protection. It is going to be up to the owner to ensure that the horse does not rub the stiches out, but if all goes well the wound should heal very well. The rest of the day involved preg checking and inseminating mares, another open wound exam, and an emergency colic case. Just a typical day at the Cleveland Equine Clinic!

Week Three in Somerset

This week began and ended assisting Dr. Travis Tull during two emergency surgeries. The first was an umbilical hernia repair on a two-month-old foal.  The owners brought him in because they suspected a part of his small intestine of being trapped in the hernia. After the initial work up and ultrasound of the hernia, Dr. Tull was confident that there was no entrapment, but we took the colt to surgery to repair it just in case. There was no small intestine entrapment and the procedure went very smoothly (I am getting quicker with identifying instruments and handing them off.) The foal recovered well and was sent home a few days later.

The rest of the week was filled with lameness exams and breeding mares. We had a wide variety of foot, fetlock, knee, hock, and stifle problems to deal with, which provided ample practice opportunities. Dr. Keith Brown is great about explaining what to look for and giving helpful hints. For example, this week he taught me that a front-end lameness that is more apparent when the affected leg is on the outside (i.e. lame on left front when turning to the right) is commonly associated with the knee. The lameness evaluations also provided practice at shooting radiographs. I am getting better and faster with my shots, but I still wind up redoing one or two in each set (always room for improvement!) It was also a full week for Dr. Jen Brown with her mare appointments. She uses ultrasound to monitor where the mare is in her cycle, if/when she needs to be short cycled, when she should be bred, and whether or not she is pregnant. I got the chance to rectally palpate one of the mares this week; I was pretty pumped that I was able to find the cervix and both ovaries, even if it took me fifteen minutes. Dr. Brown assured me that I would only improve with time and practice… Hopefully I will get more of that practice as the summer continues.

This week ended about two hours ago after the second emergency surgery with Dr. Tull. It was another foal, but this colt had somehow injured its hock and fractured its calcaneus. This was the first fracture repair (large animal or small) that I had ever witnessed. Dr. Tull warned me that it would be long and tricky, but even then, I was not quite prepared for a six-hour surgery. After much tugging, grunting, and yelling like a girl (which apparently gives you a little extra strength during orthopedic surgeries), Dr. Tull managed to coax the bone fragment back into place and secure it with a lag screw and metal plate. The foal recovered well, but he has to avoid any secondary injuries and fight off any infection before he is out of the woods. Next week begins in less than eight hours, so it’s off to bed for me.

Some actions shots of the calcaneal fracture surgery 

Circle of life and its balancing act

I’ve learned that you need to expect the unexpected when it comes to veterinary field work.

In one day, I woke up to the announcement that the foal that we were waiting for had finally been born at the clinic. The mare was at the clinic for observation due to having the tendency to retain her placenta after birth. We had been patiently waiting for this foal, even as the mare went past her expected delivery date. By three weeks. At first we had thought maybe there had been a mistake in her breeding history and she was actually bred later than had been written down. But that was not the case; she was indeed three weeks overdue. This has been a fairly common occurrence this breeding season for some reason, possibly due to the crazy ups and downs in the Michigan weather. Regardless, we were gifted with a happy and healthy, solid black Standardbred colt.

After visiting with the new addition, we went about our scheduled farm calls for the day. However, within a couple hours, it was obvious that this was going to be anything but a typical day. Emergency calls poured in one after another. The first was to a mare that was found down after what appeared to be a full night of rolling due to colic. When we arrived to the barn, she was up and walking around but clearly depressed. A rectal exam was performed and a belly tap resulted in serosanguinous (thin and blood-tinged) liquid which is indicative of a twist or rupture of intestines. The owner made the decision to put the mare down immediately instead of taking the gamble to ship the mare to MSU for colic surgery that had no significant promise for recovery. It was crushing to see the guilt that the owner had for not checking on her horses the previous evening like she always does. We cannot say when the mare began to colic or if she would have had a better prognosis if her situation had been noticed earlier. That is probably the most frustrating and scary thing when it comes to colic in horses. The fact that perfectly healthy horses can colic at any point in time for any reason is terrifying.

Another emergency following that call was up at a warmblood breeding farm. A promising imported filly had gotten tangled in a fence and cut deep into one of her hind cannon bones. When we arrived, she had layers of clothes and makeshift tourniquets around the leg to stop the bleeding. We laid her down with sedatives to get a better look at the injury. After unwrapping all of the layers, we could see that the wire had sawed through the common digital extensor tendon running down the front of the leg and through the superficial flexor tendon down the back of the leg. The damage was too great for us to repair in the middle of the field, but the filly was worth enough money that they were willing to trailer her down to MSU for surgery and aftercare. After splinting the leg for support and cutting several strands of fence to bring in the trailer, we loaded her into the trailer and sent her on her way. She is doing well and will be heading back to the farm in a few days.

The last call of the day was emotional as well. The family had scheduled two euthanasias during the same visit. The first was their family pony with a long history of laminitis and she could no longer move around comfortably. Her quality of life was suffering and putting her down was the best decision in this situation. The second euthanasia was more difficult. It was for one of their dogs with child aggression. The dog had belonged to the oldest daughter and she had trained him for 4H obedience and agility. He was the first one to meet us when we had pulled up into the driveway. He was bouncing around and as happy as could be. Unfortunately, he had bitten a few children over the past year including the family’s youngest daughter. His aggression was unpredictable and they had tried many different options, but nothing had worked. It was difficult thinking about euthanizing a young, healthy dog, but all of the other options had been exhausted.

Needless to say, having all of this happen in less than twelve hours was emotionally overwhelming. I know understand when professors and practitioners talk about “compassion fatigue”. As a future practitioner, I will have to learn how to balance this aspect of veterinary medicine.