Brown Equine Hospital Holla!.....Week 3....and 4 (whoops)

Hey ya'll.

This summer is proving to be whirlwind. I'm sure you all feel the same. We had a couple of emergencies this week that set my sleep schedule off and so I was basically falling into bed every time I was in range of this laptop. 

Last week we had some ventriculocordectomies that I got the chance to assist. Below, I am scrubbing for the incision after the shave. The incision is continued through the sternothyrohyoideus and through the cricothyroid cartilage. 

                              

                                                The scope is used to guide the rest of the surgery.


                                                           

Next, the saccules are pulled out, clamped, and transected. If they come out super easy, it means the saccule has been everted multiple times as the horse was struggling to get air because of the left laryngeal hemiplagia.

Below, the first picture is the saccule being everted by a roaring bur. Forceps are then placed over the exposed mucosa to prevent slipping of the saccule back into the ventricle. They are then transected (not shown).

                               

              The vocal cords are also removed. Both removals are performed on either side when correcting left laryngeal hemiplagia. If not, the saccule on the right side could still evert, causing the same turbulence we are trying to correct.
               The incision is left open because the airway is not a sterile environment anyways. It heals from the inside out. The horses eat wet hay on the ground or mashes for the first week or so.
               The scar tissue formed will add rigidity to the paralyzed larynx and will remove turbulent airway sounds.

                                                    

                 And, here is the lovely Dr. Brown himself. Surgery is best done in socks and crocks. ;)
 
  Another emergency as I sit here and try to write this!
  Peace Friends!

Week 1 Clinton Veterinary Services!

Hello Everyone!
After a few weeks taking care of family matters, my fellowship has finally started. It was a fun first week filled with reproduction, routine vaccines, lameness and more. Each day started around 7:30 at the clinic, with care of the in house patients before packing the truck and hitting the road for the first appointment of the day. This week the in house patients were simply boarding as they were monitored for ovulation and breeding, so they only needed their stalls cleaned, fed and watered. The majority of appointments seen this week were for breeding exams. Previously, I have not had much experience with the reproductive side of equine medicine, so this has been good experience for me. Watching the rectals and ultrasounds has given me better perspective on what to look for during an exam. I can now recognize a corpus luteum on ultrasound and understand that the size of the follicle helps determine when ovulation is likely to occur. I am starting to understand the importance of looking at the cervix, uterus and ovary when trying to breed. I am slowly becoming more familiar with the different drugs that can be given to maintain one stage or help enter a different stage of the reproductive cycle. It is all very new to me.
Aside from reproduction appointments, a lot of routine vaccinations and coggins were seen. One appointment was for a prepurchase. Dr. Trombley walked me through each step of the form she has worked out for her prepurchase exams. We ended up taking radiographs of the hocks and she helped me look at them and refamiliarize myself with the various bones and what to look for. Other appointments this week included a couple teeth floats, a castration, and lameness exams. Each appointment was slightly different and the clients varied widely in background. One client insisted that I should perform the sheath cleaning on her horses. It drove home the point of how a simple action can please the client help build your rapport with them. The more willing you are to do the job that may not be the most pleasant, the better opion they are likely to have.
Although it is not equine, I also had a day riding with Dr. Bean whose focus is more on bovine. With her, I was exposed to a couple lacerations, enucleations, and goat dehorning. It was fun to work with the ruminants that I don't have a lot of experience working with. It was a good crash course in how to handle them. Earlier in the week we had also been at a farm with alpacas. It just goes to show that knowing a little about other species goes a long way!
All in all it was a great first week and looking forward to the next.

Though most places I am not able to take photos, Maple insisted I get a picture with her friendly alpaca, Stella, at North Star Alpacas. Isn't she cute, even though she is not an equine!

Week 4 at Oakridge Equine

I should really just call this post Colic Week because I think that is just about all we saw this week! So many colics!

Monday I had off to get some rest and see some of the sights around Oklahoma. I spent most of the day at the National Cowboy and Western Heritage Museum, and also made a trip to a Route 66 landmark. A man dedicated his life to remaking mini versions iconic route 66 landmarks and has them on display not far from the clinic. Although a little past their prime, it was still really neat to see.

By Tuesday we had about five colics in the clinic already and took more in just about every night. By Friday every fluid stall we had was occupied! This called for lots of late night fluid changes and tubing and a few emergency surgeries so it was a tiring week to say the least!

In addition to the colic cases, we had a mare with pretty bad founder who had just foaled. The foal was adorable and I enjoyed spending time bottle feeding her while we cared for the mom. Unfortunately it was decided euthanasia was in the mare's best interest, but the foal was placed with another mare who took her in and she is expected to do just fine.

One of the more interesting surgeries we did was a laproscopic bilateral cryptorchidectomy. This was really neat to see, and the surgery went really well. We also did shoulder arthroscopy on a foal. It turns out getting into the shoulder joint is not as easy as the distal limb joints!

This week I spent some time helping with MRIs to see how they are done and how the anesthesia is run. I am really grateful for the interns who have helped me learn more about running anesthesia and monitoring the horses and I have even been able to put some artery lines in. It is much trickier than you would think!

The rest of the week was filled with pretty routine lameness exams, lacerations, puncture wounds, arthroscopies, arthrodesis, some foals with respiratory problems, sequestrums, and rechecks from surgeries we had seen a few weeks ago. It is nice to be here long enough to not only see some patients go home, but to see how they are doing several weeks later when they come back.

Friday I got to go on a farm call to look at some fillies with a respiratory bug and do some coggins. Although it was very hot and muggy outside, it was nice to get out and see some of the Oklahoma countryside!

Week 3 RREH Ambulatory

           I can't believe it's been 3 weeks already!!! I'm learning so much so quickly! There's something new to pick up every day. This week, I think my big take away was that the clients can make bad days. We had several days of dealing with rough clients that made for a rough week even though we were having success with the patients.
           Sunday was a crazy day. The intern "graduation" party was being held at the anesthesiologist's house in the early evening, so we were all trying to make it there on time. I started out with Dr. Friend. Several of the barn managers were trying to push their times back, so they could sleep in. We also learned about a few mares that had come in from out of state that would need afternoon flushes. We got a bunch of lavages and baby treatments done by 10 am. I learned how to remove the Caslick's stitches and do infusions using a speculum instead of inserting the pipette into the cervix by hand. At 10, I was handed off to Jordan. We did some more lavages and removed a retained placenta. It was very interesting to watch how she carefully pealed the placenta from the uterus. After she got it out, we inspected it to make sure it was all there and ran some fluids through to rinse her out. Then we were called on emergency to replace a catheter in a mare that had pulled it out overnight. I got home right as the party was supposed to be starting. A quick shower and change made me an hour late. Dr. Friend pulled in right behind me. The first hour or two was really awkward for me because everyone was in their little groups catching up. I didn't want to cling to Dr. Friend, so I stood and sat by myself until Jordan got there. She had laid down for a 10 minute nap that turned into a 25 minute nap. She pulled me over to a table with a bunch of interns and Dr. Friend introduced me. After a bit, I went and played cornhole with Dr. Friend and 2 of the interns. After that, everyone was a bit more open to talking to a new person and I was a bit more comfortable with talking to them. It ended up being a lot of fun.
       

       The scenery is so beautiful here. I get mesmerized just about every morning as we drive between the first couple stops and the fog is still lifting. I finally managed to think about taking a picture of one of the beautiful views.




      Monday was Memorial Day, but that just meant more traffic for us. Jordan and I relocated a snapping turtle that was walking along the road to start off the morning in a bright light. We had an interesting day treating 2 lame horses out in their respective fields. The first had a rather unique pasture mate. She is a mammoth donkey. The owners informed me that they are a critical species.

This particular farm has a variety of fun creatures running around. In the adjacent pasture was this little stud. I had fun seeing all the different equids, but we had to run to get to our second lameness.

Our second lameness was caused by a large abscess under the hoof wall up by the coronary band. Jordan was able to pop it with minimal pressure. Despite the stubbornness of the horse, we got the foot wrapped in a soak bag and told the owner to cut the bag in an hour to drain the soak and then take the bag off. This was the first difficult client of the week. The air was much less tense as we left than it was when we had arrived.

  There was a beautiful sunrise on Tuesday. I was able to enjoy it on my way to meet Dr. Friend and his tech, Kimmy, after his resistance class. We were getting through our routine stops pretty quickly in the morning, so Dr. Friend moved his dentist appointment up to an earlier time slot. I had made arrangements to go back out to one of the farms to watch for a potential foaling in the evening. When we got to that farm, the foal had just been born. I talked with the manager and changed the plans to be at the other farm for a late night/ early morning foaling. I got to do the placenta inspection and help run plasma to the foal. I learned that it is common practice around here to run plasma to newborn Arabians before they start showing signs of needing it due to the higher risk of issues. We did a joint injection and several radiographs. It was fun to see how that process went. Kimmy and I dropped Woodrow off at his appointment and went back to stock the truck between stops. He got a nice nap in the grass under a tree while waiting for us to return. We were called by a panicked owner of the abscessed horse I saw with Jordan yesterday. Dr. Friend had to dig quite a trench in the foot to get the hole from a previous abscess from the underside of the foot to connect and drain some more pus. He put on another soak. I got to hang around with the horse to make sure the soak stayed on and the he came out of his sedation without any problems while Dr. Friend went to take care of the last 2 stops for the day. When he got back, we took off the soak boot and showed the owner how to wrap the foot to keep debris out of the trench. They informed me that the second foal had been born while I was standing with this horse. It was quite the day.

      Wednesday was another crazy day that started out normal. We did several routine ultrasounds, palpations, and lavages. The tow of our early stops were very disorganized and took longer than necessary to get the horses in place. They also both had a lot on the books for the day. I got to watch Dr. Friend band a hernia. That was interesting, but we didn't talk much about it since we were so pressed for time. This is one of the times I feel like I should know more than I do and feel silly asking questions. Jordan took care of one of our stops, so we were closer to being on track again. We did a bunch of recheck radiographs at a fancy barn with a bunch of fancy yearlings. I didn't enjoy that much because it was very fast paced and I wasn't able to do anything because the horses were worth too much. It really does make a difference to be getting your hands dirty. Even holding a tail out of the way feels better to me than just standing there trying not to be in the way. At the next stop, I got to shoot some hoof images. We did a pre-sale survey on a yearling and a pre-purchase exam on an older horse. During the pre-sale survey, Dr. Friend was quizzing me about the images. It was good to remember and have my memory jogged.

       I took Thursday off. I caught up on sleep, took a nice long shower, and filled up my fuel tank. A random guy offered to buy my truck. When I got back, I made myself some banana french toast for dinner and a couple future meals.

     Friday, I started with Dr. Friend. We had a happy start by finding several pregnancies. I'll have to try to get some pictures of ultrasounds to show the differences as the little things grow! A cast horse threw us off track a little bit. The horse seemed a little neurologic and had some swelling in the hock, so we said we would come back later and do some imaging. We did a lot of flushes. Dr. Friend taught me how to take a culture/cytology sample of the uterus. I got to take out some more Caslick's stitches, do some more blood draws and injections. I went with Jordan to see a stallion collection. We had to meet up with Dr. Friend again to get the portable x-ray machine after he imaged the horse from the morning. The leg looked fine, but there was some narrowing in the cervical spine that suggested neurological issues. We submitted the images to the radiologists for a better look. Then it was off to the circus. Kimmy came with us to help do pre-sale surveys on a couple of horses that might as well have been feral. We were only able to catch and get one calm enough to do the survey. The other hadn't gotten pre-medicated by the owner, so she was too worked up for the sedation to work. The owner seemed rather peeved that we had to reschedule, but it was not a safe situation. We still had several stops to make and didn't have time to be wrangling his yearling. We did a couple checks and breedings before doing a field castration. It was a lot of fun to put on the sterile gloves and get in there. I quickly learned that I don't have enough forearm muscle for using emasculators yet. It took a lot of convincing to get him back on his feet.

        Saturday seemed like two days. We had another rough, disorganized morning. The horse that had been cast yesterday was down again. It took several guys pulling on a rope under her bum to get her up. The next stop had a foal that had been born in the field. A mare got her foot caught in one of the panels of her holding pen. And one of their goats took off with the billing book. All that craziness set us back and pushed the limits of Dr. Friend's patience. Towards the end of the morning, I got to do a couple lavages. I stopped at the clinic on the way back to the house. I sat on the bed around 1:45 and woke up at 5. I was able to go over to the neighbor's and do my laundry before eating some leftover banana french toast.

There is so much to learn! I love being out in the truck despite the early mornings, late nights, and return to caffeine. The days off are nice but the next morning is no fun. Sleeping in throws off the rhythm of little sleep. Naps don't seem to be as bad, as long as I don't stay in bed too late. It's crazy to think I'm already a quarter of the way done!

Weeks 2 and 3 at Oakridge Equine

Weeks Two and Three At Oakridge Equine

This week started off pretty interesting with a foal we had in for Rota who ended up going to surgery for colic symptoms. He ended up having a ruptured cecum, but it was at least an interesting surgery. I also assisted with my first surgery, a fracture repair of a mandible. We also went on a farm call to preg check a mare and I got to see a little bit of the Oklahoma countryside. It sure is beautiful here!

Later in the week, we had a horse that sliced its superficial and deep digital flexor tendons and Dr Hague repaired those. We went on another farm call to remove a tumor that formed in the eye socket of an enucleated horse. Throughout the week we did many joint perfusions, septic joint flushes, hernia surgeries, cryptorchid castrations, arthroscopies, physis injections, and conjunctival flap removals.

Friday we celebrated the interns leaving for their new jobs. It was sad to see them go but I was grateful to have gotten to know them! I made some good friends that I hope to be able to visit at their new practices during my externships. Tuesday the new interns started, there are 7 of them, so this past week has been quite hectic with everyone getting acquainted with each other and the clinic.  It has been great to see what it is like to come out of school and begin your first internship though! They have been kind enough to involve me in their transition and give me advice on things they wish they had known before they started theirs! I feel very lucky to have been here for the last few weeks of one group of interns and the first weeks of the next set. I have definitely learned a lot from them!

This past week has been really busy with an assortment of cases. We have taken several horses to colic surgery, had a post foal/retained placenta infection, some septic joints, several puncture wounds including one that went through the coronet band which we cast, some sick foals, sequestrums, check ligament desmotomies, emergency tracheotomies on foals in respiratory distress(most of which came in at 3am haha), put in an SPL on a horse getting continuous eye meds, a fractured pelvis, and a horse with a blocked lacrimal duct that required catheterizing the duct. It sure has been a whirlwind but it has been an amazing experience to see and learn from a great group of surgeons and interns!

I did catch some free time this weekend and made it to a couple historical spots, I went to the town of Guthrie about 16 miles north of the clinic, most of the town was closed as it was a sunday afternoon, but the buildings were beautiful. I also went to a couple spots along route 66, including The Round Barn and Pops, a really cool store that sells all sorts of crazy flavors of soda and has a bunch of throwback brands of soda. The sell mostly glass bottled sodas and you can make your own 6 packs of any flavors you like. It was pretty neat to see, and packed with visitors!

Thats about it for now! Thanks for reading!

Sarah

Weeks 3 and 4 at RREH surgery

Weeks 3 and 4: Getting the Hang of it

               Week three marked the transition for me from what seemed like a learning whirlwind to establishing a greater comfort level that has helped me feel more helpful as a surgery tech. I’m starting to develop more of a routine; which horse to bring up to surgery, where to clip and prep based on the surgery being done, how to set up the surgery room and how to be a helpful when in surgery. By the end of week 4 I had even acted as the primary tech on a couple simple surgeries! Interesting surgeries I’ve seen in the past two weeks include a post-foaling uterine tear, a foal with a ruptured bladder, two colic surgeries, an ovariectomy, a fractured cervical vertebrae neck plate, and of course the more typical orthopedic repairs, among other things.

               The mare with the uterine tear came in as a colic case and was immediately operated on after standard colic workup. Upon opening her abdomen, all of her intestines appeared normal, but a tear could be felt in her uterus. Uterine tears often occur during foaling when the sheer size of the foal being born is enough to stretch the tissue of the uterus- the foal being in different, odd positions can serve to make this stretching worse to the point where the tissue tears. What was different about this tear is that it involved multiple layers of serosa (the outer layer of uterine tissue) and possibly some myometrium (middle muscular layer) without tearing all the way through to the inside of the uterus (through the endometrium). Most uterine tears are seen when they are entirely torn through or only one small tear through the first layer of serosa.

The tear!

In the middle of suturing the tear back together.

               The foal with the ruptured bladder came up to surgery as a case from medicine. Ruptured bladders are emergencies as the urine in the bladder has different electrolyte concentrations from the rest of the body as a result of the filtering capabilities and electron pumps in the kidneys. When the abdomen fills with urine from a ruptured bladder the electrolytes equilibrate with the electrolytes in the blood, creating life-threatening electrolyte imbalances that can severely depress the function of the heart. Medicine had worked on this foal in an attempt to deliver fluids and electrolytes to correct the imbalances to a point where the foal could survive surgery. When the foal arrived it was in critical condition and required careful anesthesia planning, a heating blanket, and immediate surgery to repair the bladder. The goal of the surgery is to find the torn area of the bladder and suture it closed to a point where it can heal on its own. The anesthetist’s role involves keeping the foal under anesthesia (“asleep”) while continuing to correct for electrolyte imbalances and keep the foal alive by administering fluids, anesthetics and additional electrolytes. This particular foal’s electrolyte values improved greatly by the end of surgery and ultimately the repair was a success. The difficulty that this foal presented to the surgeon is that the tear in its bladder was on the dorsal aspect of the bladder (closest to the top of the foal’s back) which made it difficult to access and repair!

Suturing the bladder tear.

               One of the colic surgeries was a simple intestinal volvulus (the intestine flipped around 180 degrees and essentially rolled over on itself) that was caught early enough to be a simple repair. The surgeon simply had to rotate it back to its original location and close the abdomen back up. The other colic was a foal that had an intussusception. This is where one length of intestine gets sucked inside another piece like when you roll up a sock. The tubular structure remains and is not cut off, but the vessels to and from the intussuscepted piece of intestine are blocked and that piece of intestine can die because of its lack of blood supply. In this case, there was a length of intestine that had died and some surrounding it that was relatively unhealthy. The solution in this case was to remove 6-8 feet of this compromised intestine and suture the surrounding healthy portions together-an intestinal anastomosis.

Performing the anastomosis!

 The horse that underwent the ovariectomy had her ovary removed because it simply wasn't functional any longer and had the potential to cause serious problems. An ovariectomy is not uncommon for various reasons across veterinary species.

 The removed ovary (huge!).

Weeks 1-3 at Stevens Equine

Well, these past few weeks have certainly been a blur!  I moved over here in mid-May to South Elgin where the practice is located and have been working intermittently with Dr. Marshall Stevens since then.  It has been intermittent only because a few days after I began working here, Dr. Stevens had a conference to attend in California hosted by Merial then last weekend was a long weekend with Memorial Day.  My first week began with learning the results of a respiratory panel that was conducted on two horses that had been coughing and had fevers the day before.  Fortunately they tested negative for both equine herpesvirus as well as streptococcus equi.  Those can both be serious respiratory diseases that can be difficult to contain and streptococcus equi is the causative agent of strangles, which can be a terrible disease to deal with.  The two horses that were tested were both positive for equine influenza virus.

That lead to me learning a great deal about equine influenza, and Dr. Stevens was great about sharing the information on the disease with the clients and barn manager and placing the barn under quarantine.  One of the horses had copious bilateral mucopurulent discharge and upon ultrasound of his lungs, some abnormalities with their appearance were found so he was treated with antibiotics (SMZs) for his secondary bacterial infection.  Upon followup over the past few weeks, I have learned that client compliance (in this situation, regarding the quarantine and biosecurity measures) can vary greatly and can be a major difficulty.  Based on AAEP recommendations, he requested that all horses stay on the premises, that clients practice a number of standard biosecurity measures, and that all horses have their temperature taken and recorded twice daily so that the quarantine could be lifted after three weeks of normal temperatures in the barn.  Fortunately despite some liberties taken by owners, the outbreak seems to have been limited to that barn and has subsided.

Dr. Stevens' practice is located in the midst of a number of training barns and large show facilities, so we have been working mainly on english performance horses in the area.  As the show season continues, we will go to more horse shows and work there, but lately we have mostly been making farm calls to several stables within an hour radius for lameness exams, joint injections, and dentals.  We had a break in the routine with an emergency call last week for a horse that was colicking.  After a physical exam, nasogastric intubation, and a rectal exam, the horse was then sent on to a local referral hospital.  There was another case last week for a show hunter that had just been shipped in to the nearby show grounds from Virginia and was lethargic and did not want to stand.  His gums were sticky but his physical exam was otherwise fairly unremarkable, so we treated him for dehydration.  That gave me a chance to learn about hanging the fluid bags for IV fluid administration and how to manipulate the fluid stopper and watch the catheterization of the horse.  He was also treated with a bolus of electrolyte solution and his demeanor was markedly more alert by the time that we left.

My first week began with helping with a number of dental procedures on a barn of lesson and personal horses.  I learned how to prepare and set up the dental equipment and which drugs are most regularly used as sedatives for many common procedures.  Detomidine or xylazine are commonly used with butorphanol for the dental work, and combinations of those are commonly used for other procedures as well.  I was able to restrain horses during the procedure and do cardiac assessment prior to sedation.  I also learned that I really need to review the Triadian system for teeth because I completely forget that from anatomy.

So far, the vast majority of what we have done has been lameness exams and joint injections.  Fortunately, I have gotten a lot of cardio in the past few days slogging around in deep sand arenas and jogging horses.  It has been good to see a lot of flexion tests performed on the different joints, and I have been able to watch some of the horses trot when they are being ridden through the flexion tests.  I have also gotten a great review of the different distal limb nerve blocks, from the palmar digital block to the abaxial sesamoid/basisesamoid, then low four point, etc.  A few horses have also received an abaxial sesamoid block in order to have their coffin joints injected because they were known to be difficult despite sedation.  I have gotten a lot of good practice lately on scrubbing the injection sites, which has been great especially for getting familiar with the locations and landmarks of the injections.  The most common joints that have been injected so far have been the coffin, hock (both distal intertarsal and tarsometatarsal), and stifle.  It has been really neat seeing how thin the synovial fluid can become from the inflammation, and that ultimately is a great indicator that those joints are receiving the treatment that they need.

Anyhow, I look forward to keeping you all updated and I hope that everyone is having a great summer!