Take Me Home Country Roads

            Well this week was a different kind of adventure… I went down to West Virginia for a full day of racetrack medicine and made several trips out to Amish country.  Each week, Dr. Berthold and Dr. Allison each spend one day servicing trainers at and near the Mountaineer Thoroughbred Racetrack in West Virginia. I tagged along with Dr. Allison for his weekly visit this week. Everyone joked and warned me about how West Virginia is a whole different world, but it provided a great learning experience. Due to the nature of racetrack medicine, very little diagnostic work is performed. The vets have to diagnose lamenesses solely based on abnormalities detected on palpation and analysis of motion. This “jog and inject” style was a perfect way to hone my palpation and flexion skills. It was very satisfying each time Dr. Allison asked me what I thought and concurred with my tentative observations. Next, we would “tap” or inject the joint in question with a steroid or a combination of steroid and hyaluronic acid. For a couple trainers, we looked at almost every horse just to make sure they were sound before their next race. We did radiograph a horse that came up non-weight-bearing during a gallop due to suspicions of a slab fracture in his knee. Unfortunately, this is a common and detrimental injury in racehorses. Fortunately for this horse, the slab fracture was sagittal instead of frontal and non-displaced instead of displaced. Dr. Allison bandaged the knee and recommended strict stall rest until the fracture is healed. Although the horse will never race again, he may retain function of that knee.

            Working in Amish country is actually not all that different from working on the racetrack. Partially due to economic restraints and partially due to unreliable electric sources for the fancy toys, most of the diagnostic work is done with eyes, ears, and hands. The Standardbred buggy horses are tough animals that are somehow able to handle a variety of lamenesses, wounds, and illnesses while continuing to work. This stoic demeanor, along with the fact that many of the Amish know as much about their horses as I know about my car, means that the cases we see tend to be more chronic and severe. Although these Amish clients don’t always know a lot about horse medicine, they are very interested in being educated: from learning the anatomy of different joints to learning how to administer IV shots. When finances allow, we take radiographs and perform ultrasounds, which provides even more opportunities for client education. My favorite Amish case has been a buggy horse that somehow got himself tangled in the shafts while his owner was at a horse sale. He gave himself a couple lacerations on his hind gaskin and cannon bone. The own said someone came over the loudspeaker saying that a horse was down, but he never thought it was his horse. All I could think of was the feeling when someone announces that a car has its lights on in the parking lot. Anyway, he had the horse trailered home and called us out on emergency. Dr. Hill evaluate the wounds as well as the rest of the horse (he had some traumatic uveitis as well.) Luckily no major structures were injured and there was limited muscle damage. To cut down on cost for the client, he agreed to let me suture up the wounds. Under the careful supervision of Dr. Hill, I placed a drain and closed the wound with tension-relieving sutures. Both the client and I were impressed by how well it turned out. Now we just hope it heals well!

acupuncture at LEqMC

Last week, I spent my field day with Dr. French who does a lot of lameness, chiropractic, and acupuncture.  We spent most of the day at a barn doing acupuncture.  All the horses at that particular barn receive acupuncture on a regular basis as a part of their maintenance program.  Before placing needles in a horse, Dr. French would run his hands over it looking for areas of tightness or soreness.  He would then watch it walk and trot to look for baseline lameness.  These initial assessments gave him an idea of where to focus the therapy to address that particular horse's problem areas.  Some of the horses seemed to enjoy the whole process while others were nervous about the needles.  After a few minutes, though, each horse would visibly relax, their heads would drop, and they would begin licking and chewing.  In addition to acupuncture, a couple of the horses also received laser therapy to help relieve pain and reduce inflammation.  The process looks like something you might see on Star Trek: passing a device emitting a red light over a patient.   The benefit, however, is far from fictional.  The horses became more relaxed and seemed to enjoy it as the laser was applied to problem areas. 
About a month ago, I posted about a mare that had shattered P2 after coming off a jump.  She recently had her cast changed and check-up radiographs taken. She is healing well, and the surgeon is pleased with her progress.  It is, however, unlikely she will return to performance.  Right now, the goal is to get her sound enough to breed. 

Weeks 8 and 9 at SVEC

            The last two weeks have been very busy at Saginaw Valley!  This past week we had Dr. Williams, a board certified equine surgeon who completed her residency at MSU start working at our clinic.  We jumped right in and had four surgeries her first week – a neurectomy, a cryptorchid castration, an umbilical hernia, and a splint bone fracture.  The splint bone fracture was anything but ordinary as the mare had been kicked and a piece of the other horses’ hoof became embedded in her leg.  She came into the clinic several weeks ago after the piece of hoof had been pulled from the leg by the referring veterinarian.  She had a bad cellulitis and infection in her leg (including the bone), so we spent much time sweating her leg trying to get the swelling down and antibiotics to control the infection so we would have a better chance of success with surgery.  In surgery, there were additional small pieces of hoof debris that had to be flushed out and the diseased portion of the splint bones was removed.  Despite the 6 inch incisions on both sides of her leg, she came out of surgery well and is on the road to recovery.

            We also have had many interesting medicine cases as well.  A 3 month old Standardbred colt came in neurologic.  The owners found the colt down in the pasture that morning.  He could not stand and was also acting “spacey”.  Their local veterinarian came out and gave him IV DMSO and dexamethasone.  There was no history of trauma, although the owner did see a neighbor’s dog chasing the horses the day before.  When he got to the clinic later that afternoon, he was already significantly improved and could get up and walk but he still didn’t seem right mentally.  He didn’t respond much to the new environment, which was very strange given that he has grown up out on pasture with little handling.  We pretty much just observed him for a few days and gave him dexamethasone and he continued to improve, acting more and more like a feisty young colt.  It was likely trauma versus some sort of encephalitis as he improved with time and steroids, but we will never know exactly what happened.

            Another mare was seen on a farm call with a swollen eye.  Her eye was so large, you couldn’t see the globe and the conjunctiva was protruding from beneath the eyelid.  She was brought into the clinic the next day where the swelling was already much improved.  Upon examination of the eye, we could see she had a severe corneal ulcer and her eye was infected (the cornea was cloudy).  We put a lavage system with a pump in so the medication is continually administered.  She is being given an antimicrobial, an antifungal, and her own serum to help with the healing.  She is also being given banamine orally to help with the pain.  Her eye is healing but still has a long way to go.  I can’t imagine treating such a bad case without the lavage, as their patience for eye meds seems to diminish quickly!

Week 11 at BEH

Since Brown Equine Hospital offers 24/7/365 emergency services, I have seen my fair share of emergency cases, but one patient that came in this week brought new meaning to the term "urgent".  Castrations, while usually considered a "routine" surgical procedure, can still experience serious post operative complications.  The serous membrane that lines the inside of the abdomen (the peritoneum) is continuous along the inside of the scrotum, which means that it is possible for parts of the gastrointestinal tract (especially the small intestines) to pass out of the abdomen through the inguinal ring and into the scrotum.  If there is an opening in the scrotum, such as with castrations, the intestines can essentially fall out of the horse (NOT GOOD!).

This unfortunately was what happened to this patient.  He was castrated "in the field" (Meaning not in a surgical suite.  This is a common way to do castrations) by another vet and upon getting to his feet, the incision opened and began to eviscerate! The referring vet acted quickly, temporarily replaced the small intestines, and the owners raced the horse to BEH.  Upon arrival the patient was in shock and we took him to surgery immediately.  We had our work cut out for us.  In addition to blood loss and low blood pressure, the part of the intestines that had passed through the inguinal ring were dead and the horse was still bleeding from vessels in the abdomen.  Dr. Brown worked quickly and meticulously to find and close the bleeding vessels, cut out the dead portion of intestine, and then suture together the healthy ends.  This was truly a team effort to save our patient: Dr. Moschgat assisted Dr. Brown by passing him surgical tools, gripping suture, and holding the intestines in the appropriate position, I retrieved additional supplies that were needed throughout the surgery and poured sterile saline over the intestines to keep them from drying out, and the tech worked tirelessly to stabilize the patient while under anesthesia.  After repairing the damage to the intestines, the next step was to address the inguinal ring where the intestines had passed out of the abdomen into the scrotum.  The inguinal ring had ripped open, which caused quite a bit of damage and made the repair even more difficult.

Dead intestine (dark) next to healthy intestine (lighter pink)

The dead portion of the intestine that was removed

Suturing the healthy ends of the intestine back together 

The repaired small intestine

After 5 hours under anesthesia, Dr. Brown had done everything he could and we moved our patient to the recovery stall.  And then we anxiously waited...  Because he had been in surgery for so long (in addition to blood loss, being in shock, and having surgery earlier in the day) it took 3 hours for the horse to recover and get to his feet.

That was 3 days ago.  We have kept a close eye on his heart rate, gastrointestinal motility, and pain level as a way to assess his status after the life saving surgery.  So far, he has been doing great (knock on wood)! He is by no means out of the woods, but with each day we are more optimistic about his recovery.

This patient has been a grim reminder that no surgical procedure is without risk, no matter how "routine" it may be.  Hopefully, with the help of the amazing doctors and technicians at BEH caring for him, this patient will make a full recovery.

As I head into my last week of BEH, I am honored to have been able to work with such a great team, and in awe of how much I have learned.  The time has flown by and I have had such a wonderful experience.  I am truly grateful for Brown Equine Hospital for providing me with this opportunity and know that I am that much more prepared for entering clinics in a few months.

What will my last week bring? Who knows, but check back next week for my final post from BEH in Somerset, PA!

Snip Snip

Seemed like it was the week of castrations, both field and in clinic.  Most colts are castrated at less than a year old, however we had a 4 year old come into the clinic and boy did he have some big testicles.  

It's important to note that the type of drug used to induce anesthesia has an impact on how well the patient recovers.  Torbutrol has a very smooth recovery, the horse first rolls sternal and then stands up without much flailing around.

While going out for a field castration, one of the owner's other horses had badly injured her left eye.  There was a gash on the lateral canthus of the eye and it was so swollen her globe wasn't even visible.  After a couple days she developed a melting corneal ulcer as you can see in the picture below (the cornea is stained with fluorescein).   The cornea is the transparent structure at the front of the eye that allows light to enter.   Traumatic injuries, like the one this horse had, can damage the cornea and lead to corneal ulceration.   

To treat this we used a subpalpebral lavage system which delivers medicine to the horse's eye continuously.  It is passed through the upper eyelid and attached to flexible tubing that connects it to an injection port where medication is introduced.  It's a very easy, safe, and effective way to treat ocular damage.   

A Collection of Colics

            With the big changes in the weather over the past couple of weeks, we have seen a huge upswing in colic cases. The initial colic evaluations follow this basic pattern… 1) Take a full physical exam 2) Rectal palpation, with sedation if needed 3) Pass a nasal-gastric tube to administer oral fluids with drawing agents, electrolytes, or mineral oil depending on each vet’s preference 4) Further work up as indicated (blood work, diagnostic ultrasound, sedation, etc). Depending on the findings, patient comfort level, and option for surgery, we discuss the next steps of treatment with the clients (surgery, on-farm management, bringing to the clinic). In the dozen or so cases we have had over the past couple weeks, I have been able to observe the treatment plans for the common cause of colic.

            We treat impactions by removing feed, providing free choice water, and tubing once or twice daily with a combination of water to maintain hydration, electrolytes to replace what is lost, and Epsom salts to draw fluid into the lumen of the gut and help pass the impaction. As long as the horse stays comfortable, we can manage impactions on the farm, but we will bring it into the clinic if the farm is far away or if we want to tube more frequently. I have gotten quite a bit of practice passing the tube on the horses in the clinic. This procedure has a pretty high success rate as long as there aren’t any complications. As I discussed before, one horse developed a displacement after he passed his impaction and another’s impaction created a build up of gas in the gut that became persistently painful. We referred both of these cases to OSU; the first went to surgery, the second was treated medically, and both did very well. Unfortunately not all have happy endings. A call to see a 27 year old gelding that “had ripped something off of his testicle” turned out to be a colic. The horse was sweaty, covered in mud when we arrived and had torn a squamous cell carcinoma tumor off of his sheath. Dr. Hill examined and cleaned the area, but decided to do a rectal when his heart rate remained elevated despite sedation. The rectal revealed dilated loops of small intestine, which is surgical in most cases, so the owners elected to euthanize. I was able to palpate the gelding before we put him down and the dilated loops truly felt like long carnival balloons. Although we did not perform a necropsy for a definitive diagnosis, his age makes a strangulating lipoma very likely.

            When the rectal reveals a displacement, we try to refer for further monitoring and surgery if needed. One gelding we sent in for a left dorsal displacement has had two previous surgeries for displacement, so Dr. Hill encouraged the owner to consider a colopexy to tack a part of the colon to the body wall to prevent future displacements. The last case I will mention was a surprising displacement. On the rectal, Dr. Hill thought that she could follow the large colon up between the spleen and the body wall (the spleen should be flush with the body wall.) Since all we had on the truck was a repro ultrasound, she performed a rectal ultrasound and found dilated, non-motile loops of small intestine. She could not visualize colon between the body wall and spleen, she knew that something was preventing the flow of ingesta and was suspicious of a nephrosplenic entrapment. We administered some IV fluids and put the horse on a trailer for Ohio State. When she arrived there she was much more comfortable, her rectal was within normal limits, and the small intestine on ultrasound was large and sluggish but not completely non-motile. It goes to show how therapeutic a trailer ride can be.

A deviation from the "normal" at BEH

Wow! What a week it has been!  In addition to the usual cases (lamenesses, joint injections, and arthroscopy surgery), we had some non-equine patients visit the clinic.  Our first visitor was a one-month-old calf that was non-weight bearing on one of its hind legs for the past few weeks.  Upon physical exam, the calf was painful to palpate over its femur.  We took numerous radiographs and even ultrasounded a bump that was over the painful area, but could not find any abnormalities other than her lameness and the bump.  The owner reported that the calf has been gradually improving and can rise on her own, so we sent her home with her owner with the instructions to keep an eye on her and bring her back if anything gets worse.  Our other “abnormal” visitor was a dog that came in for radiographs.  He had a suspected foreign body and the clinic he was being treated at had a broken x-ray machine, so they brought him to BEH to borrow ours.  It was a great reminder of how helpful our profession can be when our colleagues are in need.

Examining the calf.

In lateral recumbency to take radiographs.

Dr. Provost also has taken in a new kitten and he spent the day at the clinic on Friday.  Who doesn’t like having a cute kitten to play with in between lameness exams?!

Dr. Provost's new kitten!

A couple weeks ago, I accompanied Dr. Hackett to the racetrack to perform a dynamic endoscopic exam (You can read the blog post here http://msuequine.blogspot.com/2014/06/lamenesses-galore-at-beh-and-trip-to.html).  After reviewing the footage Dr. Hackett confirmed that the horse did have dorsal displacement of the soft palate (DDSP), and this week the horse came in to have the surgery to correct this condition.  This procedure, known as a “tie forward”, involves the placement of a permanent suture around the larynx and bones of the hyoid apparatus in order to bring the larynx forward. This forms a tighter seal between the epiglottis and the soft palate and significantly decreasing the likelihood of the soft palate displacing over the epiglottis.  The surgery went very well, and the horse has a great prognosis for returning to racing after he recovers from the procedure.

Photo from VM 547-Respiratory diseases lecture (Dr. Susan Holcombe)

Closing the subcutaneous layer of tissue on the tie forward procedure

At the end of this long week, we had a colic come in late Friday night.  After our initial workup, which showed a great deal of gas distention and likely a displaced large colon, we put the patient in a stall to observe while we gave a bolus of fluids.  She showed us very quickly how painful she was, and after about 30-45 minutes of unsuccessfully trying to control the pain, we rushed to surgery.  This patient had colic surgery at BEH back in 2009 for a small intestinal problem, but this time we found that she had a right dorsal displacement of large colon and significant gas distension.  In surgery Dr. Provost relieved the excess gas and placed the colon back in its proper position.  

Friday night colic surgery with Dr. Provost and Dr. Moschgat

Distended cecum and large colon

Moving gas through the intestine to the cecum in order to suction it out.

Even though it was a long night (Finished surgery a little before 3:00 am, patient recovered from anesthesia about 4:15 am, and we finished cleaning surgery about 5:00 am), it was so rewarding coming back in to the hospital after a quick nap and seeing how comfortable our patient was after surgery!  She is already eating bran mashes and doing great.  She will be staying several more days with us as we monitor her and re-introduce hay into her diet, but Dr. Provost is optimistic that she will make a full recovery.

Just finished surgery... yes that's 2:55 AM!

This week has certainly reinforced the variety of cases that we experience in veterinary medicine; “Routine” is an illusion. I only have 2 weeks left here in Somerset, so we will see what kinds of interesting cases come in to the clinic before I leave.  Until next time!