MSU CVM Weeks 3 and 4

The last few weeks have been busy at the MSU Large Animal Hospital. We have had many outpatient appointments for lameness exams and joint injections. My primary role is to help the technician who is working with inpatients do hourly treatments. This includes cleaning stalls, feeding and watering, monitoring vitals, hanging IV fluids, refluxing colic horses via nastogastric intubation and administering fluids, walking and grazing patients, etc. I have learned a lot the last month. Starting next week I will be moving from the day shift to the night shift, where I expect to see more emergencies.

An interesting case that has come in early Wednesday morning is a newborn foal that had experienced substantial blood loss from his umbilicus, and was also exhibiting signs of being a dummy foal. At presentation, he was in hypovolemic shock from the blood loss and had a packed cell volume of 12%. IV fluids were administered, while blood work was submitted and a feeding tube was placed. He then received a 1 L blood transfusion using his dam as a donor. He was placed in a stall adjacent to his dam, with a window between the stalls so that she could see him. We began feeding the foal every two hours via the tube with milk from the dam, while the foal continued on IV fluids. After a few times milking the mare, she became very averse to the process and nearly kicked me, so we discontinued milking her for the time being and supplemented the foal with goat's milk. Wednesday afternoon we planned to perform another blood transfusion from the dam. We sedated her for the procedure, but found that the foal's packed cell volume had increased to 24%, meaning he did not need another transfusion at this time! However, we took advantage of the dam's sedated state and were able to milk 1100 ml from her. Wednesday evening the foal was able to stand with assistance, however he continued to attempt to nurse inappropriately. Dummy foal syndrome, also known as neonatal maladjustment syndrome,  is seen in foals less than 72 hours old and involves neurological signs ranging from severe such as seizures to mild such as inappropriate behavior (Diesch and Mellor 2013). This foal was suckling very inappropriately, including attempting to nurse from the blankets in his stall, the wall of the stall, etc. Today, he is able to stand with assistance for longer periods of time. If he continues to do well throughout the day, the plan is to attempt to reintroduce him to his dam this afternoon and assist him with appropriate nursing.

Additionally, many colics have been in and out of the hospital the last two weeks. I have been able to get quite a bit of practice refluxing horses and administering fluids via a nasogastric tube. After today's shift is over, I am off work until Tuesday evening, when I begin my month on the night shift.

Diesch, T.J. and D.J. Mellor. "Birth Transitions: pathophysiology, the onset of consciousness and possible implications for neonatal maladjustment syndrome in the foal." Equine Vet J 2013 Nov; 45(6): 650-60.

Brown Equine Hospital: Week Two

Week two has brought some interesting cases and some sleepless nights, that is for sure! Here are some of the highlights from this past week! 

The week started out with a patient coming for a head tilt. This patient had a head tilt towards the right side and was ataxic when walking. This horse had been scoped at a prior clinic and was diagnosed with Temporohyoid osteoarthropathy (THO) or what is also referred to as middle ear disease. THO is a proliferation of one of the surrounding joints of the hyoid apparatus called the temporohyoid joint. The hyoid apparatus is the structure that helps to suspend the voice box and the tongue from the skull and the area where it connects is called the temporohyoid joint. This proliferation of the bone surrounding the joint can lead to joint fusion. The cause of THO is not completely understood, but it is thought that it may be due to infection or inflammation from nearby structures, such as, the inner ear or guttural pouch. THO can decrease the normal range of motion and flexibility of these structures, so swallowing and head movements can be affected. If it is not treated it can cause a fracture within the attachment of the hyoid bones and can cause symptoms to worsen (ACVS 2018). In order to treat THO the doctor performed a ceratohyoidectomy. This is a surgical procedure where the surgeon removes one of the small bones in the hyoid apparatus called the ceratohyoid bone in order to decrease pressure on the hyoid apparatus to avoid future complications like fractures within the hyoid apparatus (ACVS 2018). The surgery went well and the patient recovered well. The horse still had a slight head tilt, but the surgeon informed me that it may improve over time or that it may still be there. The recovery depends on the horse and the important part of the surgery was to relieve pressure and to avoid any future complications like fractures that could cause potential nerve damage. After about three days in the hospital the patient was discharged home.

Another interesting case that presented to the clinic was an emergency that was called in during my second solo overnight shift this week. The horse was coming to the clinic due to Banamine injections that were given in the neck muscle. Banamine is a nonsteroidal anti-inflammatory drug that is used for pain relief, inflammation or fevers in horses. Banamine can be given intravenously or orally, but not in the muscle (Teixera and Valberg 2018). If it is given in the muscle it can cause muscle damage in the surrounding area. One complication that is common is Clostridial myosititis. Once the bacteria grows it can cause Clostridial myositis that can cause swelling and crunchy areas of gas under the skin where the drug was given. This can be problematic because if the infection is severe enough, bacterial toxins can be released into the bloodstream and can make the horse very sick (Teixera and Valberg 2018). When the horse arrived at the clinic the doctor used an ultrasound to identify the gas pockets under the skin and made three incisions in the affected areas in order to drain and clean the neck. The horse was then put on IV and oral antibiotics to help clear the infection. The horse is still in the hospital and being monitored.

The rest of the week was filled with lameness exams, x-rays, joint injections and patient care. I am getting better with identifying both forelimb and hindlimb lameness. Dr. Brown and Dr. Nicholson have been amazing teachers! I am slowly but surely learning where things are in the hospital, how to run various blood tests and how to interpret the results. It has been a busy and hectic week, but very rewarding! I look forward to what the next week brings! Unfortunately, I did not get any pictures this week, but hopefully I will get some for next week’s post!

References:

“Temporohyoid Osteoarthropathy.” American College of Veterinary Surgeons, American College

of Veterinary Surgeons, 2018, www.acvs.org/large-animal/temporohyoidosteoarthropathy.

Teixera, Raffa, and Stephanie Valberg. “The Risk of Administering Intramuscular Banamine.” University of Minnesota Extension, University of Minnesota, 2018, www.extension.umn.edu/agriculture/horse/health/intramuscular-banamine-risk/.

MSU Large Animal Clinic week 1-3

Hello Everyone! My name is Elizabeth Wuopio and I am doing my fellowship in the Large Animal Clinic here at MSU! I have been working second shift (from 4pm to 2am) so the only new patients coming in during this time are emergencies. The three weeks have been decently busy! On average, we have been getting about one to two emergencies in a night, some nights three. These emergencies have been mostly horses with colic. My duties when the emergencies come in is to help the veterinary technicians and doctors with whatever is needed. This includes getting the patient registered, holding horses in the stocks, running blood work, setting up stalls, and hanging fluids. When a colic comes in, doctors and clinical students complete a full work up which includes a physical exam, blood work, putting in a I.V. catheter, ultrasounding the GI tract, rectal exam, putting in a nasogastric tube, and performing an abdominocentesis. The initial work up helps figure out why the horse is colicing and helps the doctors figure out what steps to take next.

Another common emergency around this time of year is sick foals. Some of the foals that come in don’t get adequate amount of colostrum in their first day of life. Colostrum is the mare’s milk that contains immunoglobulins, so the foal can fight off pathogens that it encounters in its environment. When the foal doesn’t receive enough of the colostrum then they can become sick very quickly. This is called failure of passive transfer, or FPT. These foals normally will get an I.V. catheter, a feeding tube, and sometimes are put on oxygen. As a working student, I get to help milk the mares and feed the foals through the tube. I also help with other treatments and giving medications.

When there isn’t emergencies coming in, I help the veterinary technicians complete hourly rounds on the patients that are in the hospital. These duties include picking out stalls, filling water buckets, feeding, giving medications, milking mares, feeding foals, refluxing colic horses, walking/grazing horses, hanging fluids, physical exams, etc.

So far it has been a lot of fun working in MSU’s Large Animal Clinic. I have one more week of night shifts then I’m switching to the day shift for the month of June!

Littleton Equine Weeks 2 and 3

The weeks are passing so quickly! These past two weeks I have kept a log of some cases and things I have been doing as an easier way to remember details and pass on my experiences. The log is below!

Week Two

Tuesday May 15, 2018

I started my shift by stripping two stalls to prepare them for cleaning. Phoenix and the French donkeys went home today. A laminitis case came in with the expectation that the mare would need to be euthanized as the owners had found blood at the apex of her frogs. Dr. Mullen and Dr. Kurkowski were on the case. Dr. Kurkowski assessed the mare by physical exam before cleaning her feet and applying hoof testers to test for pain. The mare tested positive on the soles of her feed and would not tolerate the hoof testers on her hind feet. Her forefeet were significantly worse than her hind feet, though she was sore and had bounding digital pulse x2 and increased digital pulses on her hindlimbs. Her soles were bloody at the apex of the frog bilaterally in the forelimbs. This was cause for concern that her PIII had rotated and sunk through the sole of the hoof. She had a day-old foal who was found to be relatively healthy. He has slight ALD varus but has plenty of time for that to correct itself. He also has a small umbilical hernia which also may correct itself. Dr. Hill rasped the lateral aspect of the more significantly rotated hoof. There was some joint laxity in his fetlocks, but Dr. Hill expects that to resolve on its own as the foal grows and strengthens naturally.

To assess how bad the laminitis was, Dr. Kurkowski and Dr. Mullen took DP and lateral view radiographs of all four feet. None had sunk but there was evidence of chronic laminitis and potential fracture of the tip of PIII on the radiographs. Dr. Hill came to assess the mare and foal and came to this conclusion upon assessing the radiographs. There was a necrotic smell coming from both forefeet, which Dr. Hill suspects to be a part of the disease process.

Treatment will consist of palliative care, keeping the hooves well padded and comfortable, and therapeutic farrier work. The toes will need to be trimmed back significantly and once the soles harden and thicken, the necrotic tissue should be debrided. At the moment, Epsom soaks are not recommended due to the thinness of the sole and the chance that she still could sink and rotate if the laminae are still inflamed. Dental mold material was used to pack her hooves and elasticon used to wrap them. The mare went home the same day.

I spent the rest of my shift helping with treatments and cleaning stalls. It was a day well spent.  

Wednesday, May 16, 2018

Today started with tidying, throwing hay, making up meds. At 6 I did Firefly’s “treatments” which consisted of feeding, watering, mucking, walking, and a CPDP. She was normal. I walked two other horses before an emergency came in presenting with a fever of unknown origin. His name is Jime (Jimmy), a QH gelding rodeo pony who runs flags.

He went straight to isolation on precautions. He no longer has a fever but is ADR and somewhat anorexic. Bloodwork demonstrated leukopenia and low electrolytes. The plan is to keep him on fluids until his electrolytes are better. Dr. Sauder suspects coronavirus as she has seen a few cases of that here.

Clinical signs of coronavirus consist of lethargy, anorexia, and fever. Some cases also present with GI upset, however Jime did not. Diagnosis is confirmed with PCR, electron microscopy, and virus isolation from feces. The virus is spread fecal-oral. Some cases lead to secondary bacterial infection, leading to death or euthanasia. Leukopenia is most commonly due to neutropenia and lymphopenia.

Coronaviruses affect many species. There are 4 identified variations: alpha, beta, delta, and gamma. ECoV is a betacoronavirus, more often seen in colder months. Fevers typically exceed 102 deg. F. Symptoms clear in 1-4 days with supportive care. ECoV has high morbidity and low mortality rates. Horses can shed the virus in their manure for several weeks. Biosecurity measures should be taken to prevent any herd members from contracting the virus. Due to the leukopenia, Jime is also on a few antibiotics as preventative measure. His owners are going to do what they can to implement biosecurity and monitor the other horses for signs of infection.

Week 3

5/21/2018

Case: 5 y.o QH gelding presented as ADR. The farm has had previous similar cases that ended up being enteroliths, so they requested radiographs and gastroscopy was performed. On gastroscopy, multiple ulcers were noted in the distal esophagas and cardiac region of the stomach. Tissue around the margo plicatus was noted to have some fibrin adhesions and appeared inflamed. Radiographs revealed one large enterolith and what was thought to be a smaller second enterolith. In surgery, a double enterotomy (one at the pelvic flexure, one at the dorsal colon to remove the HUGE enterolith) was performed. He is now being medically managed for both the surgery and the ulcers. Being a performance horse and living inside all the time makes for a stressful life, which is ultimately what leads to ulceration of the stomach. He has since started healing well and went home.

Mule: A 3 y.o mule on her way to California from Indiana presented for severe signs of colic- thrashing and trying to roll in the trailer. On exam she had positive reflux, distended loops of small intestine palpated rectally, and some large intestingal thickening visualized on ultrasound. Initially not a surgical option, she spent the night in isolation on supportive fluids and was refluxed a few times. The next morning, owners agreed to surgery and she went immediately. In surgery, distended loops of small intestine were found and were unable to be emptied. Large colon was very difficult to pull out and visualize. Once out, an enterotomy was placed in the pelvic flexure and large intestine was emptied and lavaged. After emptying, Dr. Hill was able to clearly palpate a thickening of the large intestine where the cecum had intussuscepted into the large intestine. The large intestine was lavaged and the first enterotomy was sutured closed. A second enterotomy site was prepared at the right ventral colon. Cecum was visualized inside of the right ventral colon, it was very dead. The cecum was dark purple and appeared to have the consistency of liver. Dr. Hill resected as much as she could. Illeum was then taken and attached directly to the large intestine to bypass any remains of the very dead cecum. Once the bypass was complete, everything was closed and the mule was brought to recovery to wake up before returning to isolation (the cause of her colic and intussusception was unknown). She has been on intense supportive care but still, almost a week later, is struggling. Considering that some cecum could not be removed and she underwent cecal bypass, it is incredible that she’s still alive and it was well known that she would become very ill before we would start to see any signs of improvement. I’m waiting to see if she will get to go home and if she will be able to pull through recovery after such an intense surgery.

Case: A rescued foal presented to the clinic for respiratory signs, dullness, and lethargy. After 1-2 weeks of treatment, he also became colicky. After repeatedly having net reflux of several hundred mLs, his owners elected for surgery due to his pain levels. In surgery, his GI tract appeared normal except for mild thickening of the pyloris. Gastric bypass was performed with no resection. He is doing well and continues to recover at the clinic.

Friday, May 25, 2018

Today was my first day in the field with Dr. French. I watched him in several acupuncture and chiropractic appointments, a colic surgery recheck appointment, and two lameness appointments. It was interesting to see the sport horses that received acupuncture and chiro act as if they were under sedation. They were sleepy, heads down, and calm. I also was able to watch and help with a neck injection appointment. The horse had osteoarthritis in several cervical vertebrae and had the injections performed to help him be more comfortable and continue performing (jumping).

Brown Equine Hospital: Week One

Hello from Pennsylvania! My name is Shelbe and I am spending my summer at Brown Equine Hospital. The hospital is located in Somerset, Pennsylvania. I have had the opportunity to work with three doctors thus far.

This first week has been a whirlwind to say the least! I have seen so many cases it is hard to keep track, so I will try and provide the highlights! My first week has been focused on teaching me the ropes and learning the ins and outs of the hospital and patient care which has afforded me many hands on experiences!

During my first day I was able to not only observe a enucleation, but I restrained the patient as well. A enucleation is a common procedure done to remove an eye. This patient in particular needed the nucleation because it presented with a tumor. This tumor formed on the third eyelid and was not only obstructing the horses view, but it began to spread to the cornea of the patient’s eye. If you wait too long to remove the tumor it can spread to the rest of the orbit and cause further damage. The surgery went phenomenally and the patient recovered and went home.

Later in the week I was in the operating room for three surgeries. I was able to provide assistance by being the surgical technician to the veterinarians. The first case was of an 18 hour foal that presented to the clinic with a possible meconium impaction. Meconium impaction is when the foal fails to excrete sufficient amounts of meconium, which is the first feces that the foal will pass after birth. The foal was examined and through ultrasound the veterinarian was able to identify fluid in the abdominal cavity and the small intestines were slightly thickened. After this examination it was though that the foal had a ruptured bladder and was taken to surgery. In the operating room the surgeons identified opaque orange-yellow abdominal fluid and enlarged mesenteric lymph nodes. The mesenteric lymph nodes are found in the mesentery which is a fold of tissue that connects the small intestines to the back of the abdominal wall. The mesenteric lymph nodes were also actively leaking the orange-yellow fluid along with thicker material. The small intestines were also found to be discolored, thickened and congested (see attached photos and videos! Hopefully the videos load!). This foal had congenital lymphangiectasia and chyloperitoneum. This resulted in the engorgement of the lymphatic vessels (chyloperitoneum) and rupture results in leakage of triglyceride- and cholesterol-rich chyle into the abdominal cavity (lymphangiectasia). In a normal foal the absorption of fats occurs through the afferent lymphatics to the mesenteric lymph nodes and then to the efferent lymphatics where they will eventually enter the blood stream (May and Good 2007). When there are ruptures or breaks in this system, the fluid will leak into the abdominal cavity and the foal will be unable to properly absorb the much-needed fats. Unfortunately the prognosis for the foal was poor and the foal was euthanized.

The second surgery was an arthroscopy. An arthroscopy is a surgical procedure that focuses on joints. You can do this to examine and treat damaged done to a joint. A endoscope is inserted into the joint through a small incision. This arthroscopy was done on the left hock joint in order to correct the osteochondrosis that was occurring on the distal intermediate ridge of the tibia. The doctor went in and excised the tissue and the patient recovered and went home.

Later a colic presented to the clinic. The horse had been experiencing episodes of colic on and off for the last couple of months without a definitive diagnosis. The horse was ultrasounded and fluid was identified in the abdomen. In order to gain more information, the horse was ultrasounded and no abnormalities were noted. The doctor also decided to do an x-ray of the abdomen and sand was found in the colon. In order to get rid of the sand, the horse was put on psyllium. Psyllium helps to collect the sand and move it through the digestive tract and pass in the feces. The horse stayed in the hospital another three days in order to be monitored safely and was discharged home.

Before Treatment:

After Treatment:

This first week has been busy to say the least, but I am learning a lot and am gaining a lot of hands on experience. I have been able to help with lameness exams and the doctor will ask me where I think the horse is lame before they say where they are lame and they have been giving me great pointers on how to identify it. I have been able to help restrain patients, take radiographs, hold the plate for radiographs, administer oral medications, scrub for joint injections and scrub patients for surgery. The staff has been very helpful and patient and I cannot wait to see what the rest of the summer brings!

References:

May, K.A and Good, M.J. "Congenital lymphangiectasia and chyloperitoneum in a foal." Equine Veterinary Education, 19, 1, 2007, pp. 16-18.