Weeks 8 and 9 at Brown Equine Hospital

Happy Independence Day, everyone!   Things have been rolling along at Brown Equine.  Dr. Provost (the new surgeon), and Dr. Moschgat (the new intern) have assumed their new roles and quickly become part of the BEH Team.  Over the last couple weeks, we’ve had fewer externs rotating through, so in that sense, things have calmed down a bit.  Also, breeding season in coming to a close for Dr. Jennifer Brown, so the barns have been relatively free of overnight patients (but still very full with outpatients during the day). 

In the last few weeks I have had the amazing opportunity to scrub in on several arthroscopic procedures.  One in particular was a horse with an apical fracture of her lateral proximal sesamoid bone. 

There are several types of fractures that can occur the proximal sesamoids – Apical, mid-body, basilar, abaxial, axial, or comminuted – which refers to the location of the fracture, and each carries a different prognosis.  Apical fractures like this patient had usually carry a good prognosis if removed early before causing damage to the suspensory ligament.  It was a great experience getting to scrub in, work with Dr. Brown, help pull out the bone chip, and even put in a couple sutures!

Pulling out the bone chip from the fracture

Looking at the screen to assess the surface of the bone where the chip from removed

Putting in some sutures

The bone chip.  A little over 1 cm long.

At BEH, Dr. Brown likes the interns/externs to take an active role in cases to help the learning process.  While Dr. Brown oversees the entire case, this gives the interns/externs the opportunity to analyze patient findings, propose which tests should be run, and discuss a treatment plan for our cases.  It is extremely nice to have the guidance while I am still learning, but still have the chance to start thinking like a vet (which will be VERY important once I enter my clinical rotations in January).  One case that I worked on was a horse that came in with a severe case of gas colic.  Usually we don’t see many cases of gas colic because, if they are a mild form, they usually resolve with administration of banamine and never have to come to BEH.  Unfortunately for this case, he did not get better after getting banamine, and had to come to us.  He abdomen was so distended upon presentation that Dr. Brown couldn’t even get his arm in the horse to rectally palpate the GI tract.  Based on the signs, Dr. Brown thought the horse had a displacement of some kind of his large colon.  Surgery was not an option for these owners, but they asked us to do what we could to manage his medically.  We began by relieving some of the gas distention by trocharizing his large colon, which involves sticking a large needle in near the top of the flank to vent the gas out of the colon.  This helped for a few hours, but soon the gas built up again, and our patient was painful.  After discussing options with Dr. Brown, we tried adding additional pain management medications to the horse’s treatment plan.  When I left the hospital that night, I was sure I would receive a call in the middle of the night to tell me his condition had deteriorated.  I woke up repeatedly throughout the night and checked my phone, convinced that I had missed a call (I hadn’t).  Upon arriving at BEH the next morning I found that my patient was much more comfortable and had actually passed some feces!  It was a great feeling, but I knew we still had a long road ahead.  Over the next few days we were able to wean our patient off of pain medications, then IV fluids, and then gradually re-introduced him to food.  After almost a week in the hospital, I’m happy to say that the horse recovered and was able to return home.  Since this patient in particular had a history of gas colic episodes, we discussed diet changes with the owners, especially decreasing the amount of grain given in an attempt to decrease the amount of fermentation and gas production in the colon.  We prepared the owners that this may happen again, but for now they are thrilled to have their companion back home and healthy.

It’s hard to believe that I’m in my last few weeks at BEH; time has really flown by.  I look forward to seeing all that I can in my remaining time here.  I hope everyone has a safe and happy Fourth of July!  Until next time…

Beautiful view from BEH as I worked the night shift last week. 

Changing of the guard

The interns I spent the first part of my fellowship with recently finished out their year here.  While they are all happy to be moving on to other things, they were glad for their experience at LEqMC.  You hear a lot about internships and residencies at school, but it was nice to here an insiders perspective.  They agreed, the internship made them much more confident about their skills, and they felt much more ready to go out into practice than they did after graduation.  Not everyone who goes for an internship is planning on doing a residency; you just have to find an internship that gets you ready for what you do want to do.
Just as we said goodbye to the old interns and welcomed the new, things suddenly became very busy here at Littleton Equine.  We have had quite of few colic cases come in for management in ICU.   One Arabian mare came in with severe gas distention making the doctors suspected a torsion.  In the time it took to get permission to take the horse to surgery, however, the horse passed most of the gas.  She stayed in ICU for a couple days but did not show any further signs of improvement.  The doctors began to think she may have sand colic since she was housed in a sandy pasture.  When a horse eats off sandy ground, the sand settles in the ventral colon and can gradually build up and cause an impaction.  I did not get to see it, but the mare was taken to surgery, and the surgeons removed several gallons of sand from her ventral colon.  She has been recovering very well so far.  She receives psyllium to help her pass the remnants of the sand.  Sand colic is relatively uncommon in this region, but this case is a good reminder to take the horse's individual living conditions into account.

A Slew of Surgeries

            Although Cleveland Equine does not staff a full time surgeon, I have found myself in the surgery suit quite often lately. Dr. Robertson, a retired surgeon from Ohio State, flew in for a day to take care several elective procedures. His surgery team consisted of Dr. Wilson (for anesthesia), Dr. Hill (to assist), two technicians, and me. We started the day by scoping the horses with respiratory complaints. One turned out to have infected, pus filled guttural pouches, which we flushed and put on antibiotics. The next was a classic example of epiglottic entrapment- the epiglottis was caught in the aryepiglottic fold, causing an airway obstruction. The epiglottis had been entrapped for so long that the exposed aryepiglottic fold was ulcerated. When Dr. Robertson cut the fold with a hooked bistoury to release the epiglottis, we were able to see that the area under the fold was also disrupted. The final respiratory case came in with the concern of dorsal displacement of the soft palate, so Dr. Robertson performed the palate lasering and myectomy that I described earlier this summer.

            After the respiratory horses were taken care of, we moved on to three closed castrations. Here, “closed” not only refers to a castration that does not open the vaginal tunic, it also refers to a primary closure of the skin. Some clients prefer the closed castration for the cosmetics, the minimal aftercare required, or the reduced concern about flies. Since the scrotum is sutured, closed castrations need to be preformed in sterile conditions instead of standing. Although Dr. Hill assisted Dr. Robertson for his three closed castrations, I assisted Dr. Genovese the following day when he performed a closed castration. He even let me man the emasculators and throw in some horizontal mattress sutures for the skin closure.

            The final surgeries for the week were two foals with umbilical masses. The first was a typical umbilical hernia, soft and reducible. Dr. Genovese freed the hernial sac from the surrounding tissues without cutting into the sac itself. He then reduced the hernia back into abdomen and closed the body wall with a “Vest over Pants” suture that I was not familiar with. This method avoids opening the abdomen, so abdominal adhesions and infection are less of a concern. The second umbilicus was firm and non-reducible - an infected umbilicus. The body wall had closed properly, but the remaining cord had become a well-encapsulated pocket of pus. Dr. Genovese removed the mass with Dr. Hill assisting and then Dr. Hill closed with me assisting. The doctors here also do a myriad of standing procedures from open castrations to screwing in fracture lines, but there is just not enough time to discuss them all.

Region 13 Show

This past week we were in Ohio for the region 13 Arabian Horse Show. It was a relatively slow show for us, but we got a bit busier at the end of the week. It was very hot at the show so we had a few horses that coliced and we tubed them and gave them fluids. There were also a few horses at the show that appeared foot sore. Dr. Hill used hoof testers to determine how foot sore the horses were, and we would take x-rays of their feet to see if any of them had rotation of the distal phalanx. Rotation is a big concern for laminitic horses, and it is important to catch it quickly so the horse has the best chance at recovery with very minimal rotation. If there is too much rotation the distal phalanx can come through the sole of the foot. After checking the x-rays we administered one liter of  IV fluids with DMSO. The DMSO is a systemic anti-inflammatory and seems to help laminitic horses. Dr. Hill recommended that the horse lose weight in order to decrease his chances of becoming more laminitic, or having problems in the future. Dr. Hill also drained a set of boggy hocks at the show. The horse had big painful hocks with a lot of increased joint fluid in the tarsocrural joint, which is the top joint space in the hock. It is common to see that kind of effusion if the horse has bone chips in the joint. This was a horse that Dr. Hill has worked on before and they have checked it for bone chips, but there weren't any present. This is why he simply drained the fluid and injected the horses hocks with some steroids and polyglycan. The most interesting case of the week was one horse we have previously seen on its farm. The horse was base line lame on its front right, and was known to have previous problems with that coffin joint. We did a nerve block and the horse blocked sound to a palmar digital block which is the lowest block on the leg and blocks that back third of the foot. We then took x-rays of the joint, and Dr. Hill was not unhappy with what he saw. He then injected the horses right front coffin joint with steroids. This all occurred at the farm at the beginning of the month. The horse was at the show for us to re-check, and her lameness had not changed. She was still base line lame on the right front. Dr. Hill wanted to do another block to ensure the horse blocked the same as it had at the farm, but he later decided he would start with blocking the coffin joint. The horse was much improved after blocking the coffin joint. The owners wanted a more aggressive treatment, and chose to have us pull IRAP on the horse. IRAP is a regenerative therapy and stands for  Interleukin-1 Receptor Antagonist Protein; it is a protein that inhibits interleukins, or inflammatory proteins. The treatment involves drawing blood from the horse, and then processing it so that you obtain the plasma that is rich in the Interleukin-1 receptor antagonist proteins. Once the plasma is obtained it must be frozen; it can then be thawed to inject into the affected joint. We injected the horses coffin joint with one syringe of the IRAP we harvested, and Dr. Hill has scheduled the horse to go in for an MRI to determine what is going on with the soft tissue structures in the hoof around the coffin joint. This will help determine the extent of the injury and the course of treatment. We are now down in Kentucky for the Region 14 horse show. I'll fill you in on that next week.

Dr. Hill filtering the IRAP plasma. 

The IRAP being injected into the coffin joint. 

A halter horse being presented in its class. 

Lamenesses galore at BEH and a trip to the track

With the weather FINALLY warming up and the show season getting into full swing, that means that we have an abundance of lameness exams over the last couple of weeks.  We have had at least 4 lameness exams every day, and sometimes as many as 8!  From barrel racers and western pleasure horses, to pacers and pulling drafts, we have seen the many different ways a horse can be painful and lame.  Dr. Brown prefers to watch the horse trot in hand in a circle each direction on asphalt, and then in a straight line to and away.  During this time we try to determine two things: 1) Is the horse lame? (The answer is usually yes, otherwise they wouldn’t be here), and 2) In which leg (or legs) is the horse lame?  Once he has determined which leg he suspects is the problem he then asks the client for a history.  I like this method of determining lameness because it allows assessment of the horse without being biased by the history or palpation of abnormalities that may be a “red herring”.  After taking the history, Dr. Brown palpates the horse and then does a series of flexion tests to localize the lameness to a specific area.  The next steps vary depending on the horse and owner, but it usually involves a series of nerve blocks to further confirm the problem area, some sort of diagnostic imaging (usually radiographs and/or ultrasound depending on the type of tissues involved), and then the appropriate treatment depending on the type of injury.  One of the common methods of treatment is injection of the joints with hyaluronic acid (which simulates joint fluid) and/or corticosteroids. Last week I got to inject the tibio-tarsal joints on one of our patients!   Assessing and treating lamenesses is very methodical, but can also have a lot of variety that always keeps us on our toes. 

Injection of the tibiotarsal joint with hyaluronic acid and corticosteroids

This week I was also fortunate enough to be able to go over to the Standardbred racetrack nearby with Dr. Hackett to do a dynamic endoscopic exam.  We do endoscopies of horses regularly at BEH to look at their upper airways, but sometimes we can’t find a cause for what the trainer/driver/owner has noticed because we are examining the horse at rest as opposed to during extreme physical exertion.  The dynamic endoscope allows us to do just that.  A more rigid scope is inserted into the horse’s nostril and secured in place so that we can visualize (in this case) the larynx while the horse is exercising. The image is broadcasted to a remote screen as well recorded while the horse works and is then reviewed by the vet after the horse finishes exercising.  The horse we were examining had a history of making noise while working and some exercise intolerance.  Through the dynamic endoscopic exam, we were able to confirm that the horse was dorsally displacing his soft palate over his epiglottis.  This causes the horse to breath through his mouth as opposed to through his nose.  For humans this doesn’t seem like it would be much of a problem, but because horses are obligate nasal breathers, suddenly having to breath through their mouth can cause decreased air intake and poor athletic performance. Going to the track and helping with the dynamic endoscopic exam was something new and different, and it’s always interesting to see the ways technology allows vets to evaluate and treat our patients. 

The saddle pad holds the computer and other components of the endoscope

The endoscope runs from the saddle pad, up between the ears, into the nostril and allowed up to visualize the larynx

The endoscope records and transmits the images to a remote viewing screen.  If the screen was outside of the transmittable distance of the dynamic endoscope, we were unable to see the images in real time, so we had to review them afterwards
  

Our patient doing his job

Reviewing the video after our patient finished exercising

Until next time!

A Taste of Internal Medicine

            This week brought a couple of cases that fall into the “things you don’t see every day” category. Dr. Hill and I were called out to an emergency late one afternoon for a horse that was lethargic and had spiked a fever. Anticipating some kind of infectious- probably respiratory or GI- cause, we greatly surprised by what we found. Upon arrival, the horse’s head was hanging and swollen to about twice its normal size and he had visibly strong jugular pulses as well as ventral edema. The physical exam revealed an obvious heart murmur, thoracic auscultation of pleural effusion, and an elevated temperature.  Since no one had suspected that a horse with a fever would turn out to be a horse with congestive heart failure, Dr. Hill tried to break the news to the owners slowly. She gave them enough Lasix and Ace make the horse comfortable for a couple days while we ran some bloodwork and the owners came to terms with the news. When his bloodwork returned with a hematocrit of 5% (severely anemic) and evidence of liver distress, the euthanasia was scheduled.

            The second strange case had a happier resolution. This gelding had been diagnosed with renal tubular acidosis by Ohio State four years ago and came back into the clinic for care and monitoring while the owners were out of town. In this case of renal tubular acidosis, the proximal tubules of the kidney are damaged and unable to resorb bicarbonate from the urine back into the bloodstream. The large amounts of bicarbonate lost through urination makes the horse acidotic while the urine becomes inappropriately alkaline. To manage the acidosis, a permanent esophagostomy tube was placed and the owner administers a slurry of baking soda and water through the tube four times a day. She uses a pH strip on his urine and saliva to crudely monitor the bicarbonate levels and adjust the routine as needed.  While he was here, I took over the baking soda treatments and ran a chemistry profile every day to monitor the bicarbonate level. Despite his condition, the horse has been doing well these past four years and is competing in dressage at the Prix St George Level.

Projectile Diarrhea

The last two weeks have been busy busy busy!  The ramping up of show season has brought a lot of lame horses into the clinic.  We are constantly doing lameness exams, taking radiographs, ultra-sounding tendons, and injecting joints with a combination of steroids and hylauronic acid.  With these long days my life has basically become eat, sleep, work, and repeat.  

Now about that projectile diarrhea... When you are doing equine reproduction work everyday and  assisting with trans-rectal ultrasounds you are bound to get pooped on sooner rather than later right? Unfortunately, it only took two weeks for me to get covered in it...yuck!  We were ultra-sounding mares like we do every morning to check for ovulation, but this time when Dr. Rapson pulled her arm out of the mare's rectum, diarrhea came flying out with it and covered us.  I now bring an extra pair of clothes to work every day.  Lesson learned.

This past week we had two foals come in with umbilical hernias that had to be fixed surgically.  The great thing about being at Saginaw Valley is that they include you in the whole process from handling the colts pre-medication, to helping safely lay them down once they are anesthetized, and get them into the surgical suite.  Which, by the way, we use a huge crane to lift the horses from the padded recovery room where we place the foals under anesthesia to the surgical suite where the actual operation is performed. 

Unfortunately, not every case that comes into the clinic has a happy ending.  Late last week an adorable one month old foal came into the clinic with a badly fractured third metacarpal bone.  His mom had accidentally stepped on him a week prior.  The first veterinarian who examined him only put a cast on it.  Take a look at the radiograph below...that fracture won't heal with just a cast, that fracture needed surgery.  Not to get too graphic, but the foals leg was essentially dangling and you could see it move when he put even the slightest bit of weight on it. 

Not only have I been learning veterinary medicine, but I have also been gaining valuable experience in horse handling.  Yes I have been around horses since I could walk and have had two of my own, but with the large volume of horses we see here I have gotten a lot of exposure working with the difficult, crazy horses that we need to make stand completely still to work on.  It's honestly the little tips and tricks you pick up that make the difference.  I personally have not had a lot of experience handling foals coming into this experience but 3 weeks in and I'm already feeling confident handling even the most difficult of foals. 

Well here's to another week and hopefully I can keep the poop off me!