Update from the Mile High City

Hey all, sorry it’s been a while since my last post! A few weeks ago my schedule was switched up, so now I get to split my time between the ICU and the field. On Mondays I get to work as an assistant for Dr. Lori, who sees a mixture of general practice appointments. It’s been a really great opportunity to see a lot of variety, from lameness evaluations and suturing wounds to radiographing a fractured cervical spine. Dr. Lori is also great to work with, and he’s been really cool about letting me do a lot of hands on stuff.

On Wednesdays I get assigned to a different doctor to shadow every week. A few weeks ago I got to work with Dr. Story, who does a lot of chiropractic and acupuncture, which is something I wasn’t very familiar with before this summer. I think there are a lot of misconceptions about what acupuncture actually is and does (at least I know I had some!). There are several different approaches to acupuncture, one of which involves harmony, balance, yin and yang, etc. However, the western medicine approach to acupuncture utilizes nerve stimulation to help with a variety of conditions from musculoskeletal pain to colic. In horses that will tolerate it, electrical stimulation can be combined with the needles to intensify the effects.

On Fridays I get to float around the hospital, or if there isn’t much going on I usually end up helping in ICU. However, a few weeks ago I was able to sit in on an olecranon fracture repair surgery. The olecranon is part of the ulna, which is essentially the point of the elbow. It was really interesting to watch the surgeons implement all of the techniques for fracture repair that I just learned about in our Musculoskeletal course last semester, but that I had never seen in person before. The horse recovered from surgery well, and despite an episode of colic that ended her up in the ICU for a few days, she is now doing very well and bearing full weight on her leg.

Outside of the clinic I’ve been keeping myself a little too busy, which is part of the reason I haven’t posted in so long. Denver is incredible and I’ve been able to explore a lot of the city as well as take myself on a few adventures on the weekends, my most recent of which was skydiving last weekend! This whole summer has been such an incredible opportunity to gain both medical experience and life experience, and I’m trying to take advantage of as much as I can since this will be my last summer break before graduation (and really, my last summer break ever).

I’ll try to post a few more times this week to fill in the gaps, so stay posted!

Kiva

The Wide Variety in Ohio

           I’ve just finished off my seventh week here in Ohio and I am still loving it! I have seen such a wide variety of cases in just this week alone. I assisted in a standing splint bone surgery this week. The doctor performs this surgery standing, so the horse receives only sedation and local anesthetic. The surgery itself was very quick! The doctor uses a fork (yes, the same kind you eat with) and a small chisel to remove the section of bone, compare it to the initial radiographs, smooth off the remaining bone, places a drain, and closes. The horse then quickly wakes up and loads back on the trailer to head home.

I’ve also seen several wound cases this week. One wound exposed the entire cannon bone, stripping away a large amount of the periosteum and severing the extensor tendons. Surprisingly, the horse was still somehow able to place its foot fairly normally. When we initially saw it on emergency, we cleaned the wound, took x-rays to ensure that there were no fractures, and applied a thick bandage. This week I have also seen a large chest wound that extended along essentially the horse’s whole armpit region. This horse was lucky because there was no puncture into the chest cavity and the muscles were largely separated along the fascia plane. A drain was applied and the wound was closed with a combination of sutures and staples.

I have seen more wound cases, reproduction cases, general exams, prepurchase exams, lameness and several emergency colic cases. I am learning so much about how doctors handle the cases and work with owners to ensure that the horses have the best care while still staying in a reasonable budget. There are a lot of shadowing pre-veterinary students and veterinary students that come on their externship rotations, so it has been great to compare notes! Time is flying by here, I can’t believe that I’ve only got five more weeks left at the clinic!

 

Week Six in Somerset

It is hard to believe it is already July; time is sure flying by! This week was filled with interesting cases. To start off the week, a mare came in on emergency with a fracture of the first phalanx, or long cannon bone. We took her to surgery and placed three lag screws to draw the fracture line together. The procedure went very smoothly and we put her in a half limb cast. She has been doing well and hopefully she will be able to go home soon. Check out the pictures below.

                      

             Pre-Op, Inta-Op, and Post-Op Radiographs of P1 Fracture

We also had a horse come in with “photo head shaking”, which is an idiopathic condition that presents as various behaviors that seem to worsen in daylight. In this case, the horse began to violently toss its head and run off whenever she put her head down to graze. She did not have the same reaction when she ate grain off the concrete. Dr. Brown’s hypothesis was that her muzzle was hypersensitive and the long grass was causing her pain. Using lidocaine, we numbed her muzzle and she was able to graze on long grass without any abnormal reaction. The owners opted to try constant tactile stimulation over a surgical treatment option. Dr. Brown recommended they put a net-like or leather tassel contraption over the mare’s nose at all times to constantly stimulate and desensitize the nerve endings. If that is not effective, the owners may consider a long-term sedative or surgical treatment.

Another mare presented with dysphagia, or difficulty swallowing. After a neurological work up, Dr. Brown scoped her guttural pouch. Sitting between the internal carotid artery and nerve bundle of CNs IX, X, and XII was a fungal plaque. He put the mare on a systemic antifungal and began flushing the gutteral pouch with a LRS and DMSO solution. Once a topical antifungal suspension arrives, we will begin injecting it into the gutteral pouch through the scope once a day for about a week. If this treatment is not effective, the owners will consider a surgical option.

Fungal plaque sitting between the internal carotid artery and nerve bundle in the gutteral pouch

We also said good-bye to one of the technician, Rachel, with a trip to The Meadows, a Standardbred racetrack. I had a great time socializing with my co-workers and betting on the races. It was pretty cool to see some of the horses we have worked on (and their offspring) race.

Day at the Races

Week Five in Somerset

I am now officially half way through my Equine Summer Fellowship, and this week was still filled with plenty of new experiences. As the doctors here have become more comfortable with me, they have begun teaching me more hands-on skills. I now place IV catheters as needed when horses come into the clinic and require fluids or IV medications.  I also performed my very first palmar digital nerve block and successfully blocked the foot on the first attempt (much of the credit for that goes to Dr. Sonea and Dr. MohanKumar for teaching us different never blocks on cadaver legs in anatomy lab.) During the numerous joint flushes on the two foals last week, Dr. Brown began having me participate more and more. For the most recent flush, I did everything myself under the guidance of Dr. Brown. To say the least, it has been the highlight of many highlights so far this summer.  Dr. Brown has also given me a couple of opportunities to suture skin incisions at the end of minor surgeries. I really hope I get a few more chances to improve my simple continuous pattern and surgeon’s knot.
There were several procedures this week that were also new for me. The first case was a horse with a locked stifle. Due to the reciprocal apparatus in the hind limb, he could not flex his stifle or his hock, resulting in walking on his fetlock. His stifle was successfully unlocked after a medial patellar ligament split procedure. Dr. Brown essentially poked holes in the ligament with a scalpel to create inflammation around the patella and loosen it from the locked position. For another horse with chronic sinus issues, he placed a port into the frontal sinus by drilling through the skull. Through the port, the owner will now be able to lavage the sinus at home. We fondly called the lavage the “netti pot procedure.” Lastly, a horse came in with suspected botulism. Although botulism is not common in Michigan, Brown Equine Hospital has dealt with over half a dozen cases in the last year. When it presented, the horse was unable to swallow, so we treated him with antitoxin, IV fluids, and potassium penicillin. Unfortunately, he went into flaccid paralysis and had to be put down.

There were several new experiences outside of work as well. I was finally able to get out to the Laurel Hill State Park and do some hiking. I still cannot get over how beautiful this area is. I also took a trip out the Memorial of Flight 93, which crashed less than 30 miles from here on September 11^th. The memorial upholds the memories of the passengers and crew with a simple and beautiful dignity. I have included several pictures below.

  Laurel Hill State Park

  Cool Step-Stone Dam

The Flight 93 Memorial

Summer Continues at RREH

I’ve determined that summer in Lexington is marked by the point when the weanlings go from cute and petite to monster-size (some being well over 500 lbs…) and feisty! We’re continuing in surgery with many of the prep surgeries for the fall yearling thoroughbred sales at Keeneland, Saratoga, and elsewhere, but we are also seeing quite a few colic surgeries (even the elusive epiploic entrapment), fracture repairs, tie-back surgeries – 2 Percherons in fact!, and several more specialty surgeries (including more Baskets). In fact, over the weekend there were approximately 7 or 8 colics that came in on emergency – though not all of them had to be “cut”. We even had a few visitors from the Triple Crown races last week, though I can’t say whom out of respect for client confidentiality!

For my case of the week… We had a pretty bad fracture repair mid-week, and being an orthopedics fan, I found this case highly interesting. This filly was in her first major year of racing (probably a contributor to her injury), and had a right hind metacarpal III (cannon bone) spiral fracture - which are notoriously difficult to repair and notoriously difficult for horses to recover from safely and soundly. Dr. Embertson – a fellow MSU grad from back in the day! - was even hesitant on the fixation, given the size, type, and location of the fracture. However, he successfully plated the fracture with a 12-hole plate and lag screws (rads are coming)! The filly is doing much better here at the hospital, though the next several weeks remain absolutely critical to determining if the fracture will heal adequately to allow her to return to an active career.

Here at RREH, we have many cases where – like this filly – cost of surgery is not a concern. We’ve operated on several horses in the last week that were worth well over $1.5 million, and it’s easy to become “star-struck” by the equine celebrities that walk through the door. However, I like to remind myself that every horse here – and elsewhere – is more valuable than its weight in gold to someone, somewhere. In fact, some of the most valuable horses are the ones that are retired from competition and now spend their days helping children with disabilities, or the ones that enrich their owner’s life simply by giving them something to look forward to after a long day at work.

Okay… off my soapbox! Another aspect of my summer that I have neglected to mention is how much I have enjoyed meeting the new (and old!) RREH interns and the many externs that have come through the house this summer. I have met new friends from UGA to Texas A&M, Guelph to Edinburgh, Buenos Aires to Munich – and they all have taught me something about the path that we take in vet school, and how each opportunity shapes (or even just tweaks) our career plan. They have also shown me how universal veterinary medicine is, and how no matter where you go, you can always find at least one equine enthusiast similar to yourself!

I leave you now with a few photos:

One of the local favorites - Wallace Station, a small diner on Old Frankfort Pike that sits right in the middle of horse country. It was once featured on Guy Fieri's Diners, Drive-Ins, and Dives.

The drive to Wallace Station features some of the best views you could ask for - literally, you pass some of the world's most beautiful farms, including Donamire, Stonestreet (home of legendary Rachel Alexandra), and Darby Dan to name a few.

 

Apparently, it rains a lot here in KY - and without fair warning. Note to self: never leave the windows in the car open! Rain apparently also means that there will be emergency colics coming in (so we all knock on wood when it storms!).

Week Four in Somerset

This week was the week of foals, which has been interesting if a little bit more stressful. Most of the foals that come into the clinic have serious conditions and have to be monitored closely. Our most recent case is a week-old foal that came in on Saturday night with colic and diarrhea. She presented in so much discomfort that her owners and referring vet could barely stand her up long enough to get her on the trailer. When she arrived, we ran blood work, examined the abdomen with the ultrasound, and performed a belly tap. We found a small amount of enteritis, but no other major problem. Dr. Brown was reluctant to consider surgery as an option since young foals have a greater risk of developing adhesions. Instead, we put the filly on antibiotics, anti-inflammatories, and supportive fluids. Throughout the night, she became much more comfortable, but continued to have diarrhea. We were able to determine that the cause of her diarrhea was a clostridial infection. She was isolated in separate barn to prevent infecting the other foals. She is continuing her antibiotic treatment and will hopefully be well enough to go home in a few days.

Two other foals are staying with us this week due to septic hocks. Both foals have been treated with a series of three joint flushes, which essentially pumps and drains a large volume of sterile fluid through the infected joint to wash out bacteria. Then, antibiotics are injected into the joint to eliminate the infection. As we flush the joint, we also perform a regional limb perfusion. This procedure requires tourniquets to be placed above and below the infected region. Antibiotics are then injected into a vein (in these cases the saphenous vein) and perfuse through the tissues in higher concentrations than if they were administered systemically. Both foals have responded to their first two flushes and will be able to go home when the white blood cell count in their joint fluid is sufficiently low.

The last tiny guest at Brown Equine Hospital is the three-month old foal with the fractured calcaneus that I wrote about last week. He is doing extremely well, with no signs of infection yet. I have included a couple pictures of the fracture repair surgeries and his before and after pictures below. 

 

Pre-, Intra-, and Post- Op radiographs of the calcaneal fracture repair

Rounding Off Week Four in Ohio

It has been four weeks for me here in Ohio! I have already learned so much at the clinic. I am getting much better at reading ultrasound and radiographs. I am also learning tricks to restraining difficult horses, how to quickly and accurately do a physical exam (identified my first AV block this week), and practicing leg palpation. I am continually amazed at how hard each member of the Cleveland Equine Clinic works!

This past Saturday I rode with one of the doctors who was on the emergency cases that day. We began at about 8:30 am and drove an hour to our first call, where we were told that the horse “ripped her nose off.” When we arrived we did indeed see that the mare had somehow mysteriously ripped her entire nostril apart on one side. However, the skin and cartilage flaps were still attached and after a through scrubbing, the doctor was able to suture the flaps back together using a line of subcut and a line skin sutures. The doctor finished off the few hours of suturing by spraying the wound with AluSpray for protection. It is going to be up to the owner to ensure that the horse does not rub the stiches out, but if all goes well the wound should heal very well. The rest of the day involved preg checking and inseminating mares, another open wound exam, and an emergency colic case. Just a typical day at the Cleveland Equine Clinic!