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.

Surgery at Rood and Riddle Equine Hospital

 

 

Hello again from the great Bluegrass state! The last two weeks have been pretty full, and I apologize for my blog absence. Hopefully this week I’ll be able to get in 2 blogs for y’all!

On any given day here at RREH, we see as many as 20-25 surgeries a day. We are fortunate to have the staff capabilities, as well as multiple boarded surgeons, to be able to drop and complete as many as 3-4 surgeries or anesthetized procedures at one time. If you have never seen an equine surgery from start to finish, you may or may not realize how much of a production the whole process is, and how skilled of a team it takes to get a horse safely in, through, and out of surgery. At RREH, the team may consist of 3 surgery technicians (it takes that many bodies alone to get the horse from standing to recumbent, but usually only 1 actually “techs” the surgery), an anesthetist (usually a trained RVT/LVT or an anesthesia intern), a surgical intern, the surgeon himself, and a team of 2-3 recovery guys.

Currently, we are in the middle of “weanling and yearling” season, meaning that many of our surgeries are done on yearlings (>1 yr of age) or weanlings (usually <6 mos age) to correct minor to moderate angular limb deformities prior to the major fall thoroughbred sales. The main ones, which comprise maybe 50-75% of our daily caseload , include:

1. transcutaneous periosteal transection (“periosteal stripping”): A basic “outpatient” procedure that is done to correct angular limb deformities in younger foals, a.k.a. the weanlings. This procedure is done in an effort to encourage accelerated long bone growth on the concave side of the bone. These can be done in both the carpi (“ front knees”) and fetlocks (“ankles”).

2. transphyseal screws: Again, another basic “outpatient” procedure that is done in both weanlings and yearlings in an effort to retard long bone growth on only the convex side of the bone. The screw is placed in an diagonal fashion through the growth plate, and essentially slow the growth on that side while allowing the other to “catch up”. These can be done in both the carpi and fetlocks as well.

3. transphyseal screw removals: The reverse of #2 – once the long bone has corrected itself, the screws have to be taken out in order to not “overcorrect” and cause a deformity in the opposite direction.

4. joint arthroscopies: These surgeries usually require at least an overnight stay at the hospital and are most commonly done on mature yearlings or current adult racehorses. The most common joints that are “scoped” tend to be the stifles, hocks, and fetlocks, but occasionally we see a carpus or two that require arthroscopic evaluation. The most common reason that we scope joints are to remove osteochondral fragments (“chips”), to resurface the joint cartilage following damage, to remove osteochondral lesions (OCD), or to remove subchondral cystic lesions (“bone cysts”). The goal of these procedures is to eliminate a source of pain in the joint or to prevent severe arthritis from developing because of an existing lesion. These procedures are minimally invasive and involve the use of a camera and light source inserted into the joint pouch itself by means of a trocar and cannula. These instruments allow the surgeon to see the joint on a TV screen and operate based off of that image.

Some of the other surgeries we’ve seen in the last week have been tie-backs (arytenoid chondroplasty and arytenoidectomy), cryptorchid castrations, arthrodesis, more Basket surgeries, and long bone fracture repairs. Hopefully I’ll be able to get some pictures of these and other surgeries for you in the future, but for now, I’ll leave you with some images from my trail runs. Again, I am so blessed to be in a place that values its equine industry, and has so many rolling hills and green pastures! Once surgeries slow down and I can head out on farm calls, I’ll post some farm pictures for you.

 Runs on the Legacy Trail in Lexington, KY

 

The entire city is gearing up for the Belmont this weekend, and that may be the topic of my next post – so stay tuned. Best of luck to all of the amazing athletes running this weekend!

Look closely - you'll see my double rainbow!

Week Two in Somerset

After jumping head first into a busy week when I first arrived, my second week was more manageable. I was surprised how quickly I settled in to the routine and how well I am fitting in here. It is all thanks to the people I work with; they made me feel right at home. This week, we said goodbye to Dr. Jason Dickey as he has completed his internship year and has accepted a position in Ohio. Dr. Keith Brown also turned 40 this week, so we had two things to celebrate. On Wednesday, we took the afternoon off and threw a party at the clinic for them. It was nice to relax with good food and good company.

Since Dr. Dickey left, I have taken over most of his responsibilities. I start of in the morning by performing short physical exams on all of the in-patient horses and helping the technicians administer morning medications. Most medications are antibiotics or pain meds given orally or intravenously through a catheter. The rest of my day is spent assisting the veterinarians during appointments and surgeries. Assisting can mean anything from restraining, sedating, and drawing blood to shooting radiographs and scanning the plates. I still need a lot of practice shooting radiographs (it took me seven tries to get an acceptable navicular skyline), but everyone assures me that I am getting better.  I am also getting really good at pulling blood and giving IV sedation. At this rate, I will be a pro by the end of the summer!

Probably the most exciting aspect of this week was that I got to scrub in on another surgery. This week, it was a bilateral palmar digital neurectomy. Neurectomies are fairly common surgeries as a last resort for horses with hoof pain that does not respond to special shoeing or joint injections. During the surgery, I accidentally contaminated myself (major whoops), but Latasha the technician on anesthesia came to my rescue with a new set of sterile gloves.  Besides that, the hardest part for me was identifying each instrument Dr. Brown needed and quickly giving it to him (apparently my hand-off needs a lot of work.) I hope I get a lot more opportunities to improve.
Here is a mini virtual tour for those interested in what Brown Equine Hospital looks like:

Work-up area, Stocks, and Lower Barn for the critical patients

Preparation Room and Recovery Stall of the surgery suite

             

Surgery Table and Room

Upper Barns- outside and in