Hello again from Michigan State University's Large Animal Hospital! I am currently in my third week of working the night shift, and things are a little different than when I was working during the days. The hospital is much quieter, and unless there are emergency patients, it is just myself and two to three technicians in the hospital. The biggest portion of my duties is hourly treatments, which includes monitoring vital signs, feeding, cleaning stalls, and administering medications. I also do some cleaning and restocking of supplies.
When an emergency comes in, I am often responsible for restraining the patient while the doctor and student on the case take a history, do a physical exam and any other testing or procedures that may need to be done before the patient is admitted and put into a stall. I also run blood work, such as a packed cell volume/total solids, and a venous blood gas. These basic tests allow the doctor to asses the patients hydration, acid-base status, oxygenation levels, and can give an indication if sepsis is a concern. During colic emergencies, I also restrain the horse during an abdominal ultrasound, rectal exam, and while the nasogastric tube is passed.
My first two weeks on the night shift were very quiet, with few to no emergencies coming in each night, and very few patients in the hospital. Last night, however, we made up for two slow weeks! A mare and foal, a colic, an alpaca, a calf, and a potbelly pig all came in on emergency, along with quite a few patients already in the hospital. The foal was a two day old Belgian filly that presented for being dull and poor nursing. On admission, the foal was found to be dehydrated with entropion in both eyelids. Entropion is a condition that causes the eyelid to roll in towards the eyeball, and the eyelashes can cause corneal ulceration. This was thought to be due to the dehydration, and not a congenital defect. The foal also had injected, tacky mucus membranes, was tachycardic, bloated with decreased gut sounds and loose manure on the tail. Initial blood work showed that the foal was hypoglycemic and dehydrated. An IV catheter was placed an a 10% dextrose drip was started to correct for the hypoglycemia while additional diagnostics were performed. A venous blood gas indicated that the foal had a decreased bicarbonate, increased lactate and creatinine, and decreased white blood cell count. These results indicated toxic changes and that sepsis was a possibility for this foal. An abdominal ultrasound was performed, which showed loops of distended small intestine. A nasogastric tube was passed and the foal produced 1 liter of reflux. Due to this, feeding was not started last night. We continued to check for reflux and a dextrose CRI was started to support the foal's blood glucose through the night. The entropion was corrected with a few sutures in the lower eyelid to hold the eyelashes away from the cornea until the condition corrects itself with adequate hydration.
Today, I am happy to report that the filly is doing much better. She is able to rise on her own and run circles around me in the stall! The reflux has resolved, and we have been feeding her 100ml of her dam's milk via the tube every two hours. IV antibiotics were started last night, and continue today. She remains on IV fluids, dextrose, and total parenteral nutrition.Her eyes look much better, and she is quite spunky. The only negative change is that she has developed some loose, foul smelling manure. If this gets any worse she will have to be moved to the Pegasus Center to our isolation unit.
This week and next week will both be short weeks for me. I leave early Friday morning for an AAEP Conference in North Carolina. I won't be back to work until Thursday evening next week. The AAEP Summer Focus Conference is offering a student track that offers dry labs in radiography, podiatry, and ophthalmology. For the remainder of the conference, students can either attend sessions on ambulatory equine medicine or lameness. I hope to use this time to review my equine limb anatomy and radiography skills. My in-laws live about an hour away from where the conference is, my wife and I are also using this trip as a mini-family vacation.
Wednesday, June 20, 2018
Clinton Vet Service: Week 3
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| Day 1 |
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| Day 7 |
One of the largest parts of my internship thus far have been reproductive cases. Not only does Clinton Vet service the MSU Horse farm, but Dr. Cynthia also assists with the breeding of a number of local, privately owned, mares. Some of the work is done on their personal farms, while others are boarded at the clinic for breeding so that we can check them daily and track their cycles. My reproductive background is in cattle, so it has been interesting to learn the different nuances involved in breeding mares. Like cattle, horses have a 21 day estrous cycle that lasts from the ovulation of the previous follicle, through the growth, development and eventual ovulation of a new follicle (see images of different sized follicles). Unlike cattle though, horses ovulate much larger follicles. Cows will ovulate follicles that are between 10-15 mm while horses range from 40-50 mm. This was a surprising find the first time I looked at an equine ultrasound and thought she had a cyst!
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| Various sized follicles with a large (close to ovulatory sized follicle on the right-hand side) |
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| Ovulatory sized follicle (approximately 50 mm in diameter) |
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| Corpus luteum after a recent ovulation (<24 h post ovulation) |
Another key aspect to timing insemination, is precise ovulation. The hormones involved in this event are GnRH or gonadotropin releasing hormone. GnRH is an endogenous hormone released from the hypothalamus and stimulates leutenizing hormone (LH) release from the pituitary gland. Today, we have synthetic formulations of GnRH that can be administered to induce ovulation of properly sized follicles within 24-48 hours of application. These formulations include deslorelin acetate (SucroMate) or histrelin (a compounded GnRH product). Ideally, we will time our breedings so that the mare receives a dose of semen 6-12 h pre and post ovulation.
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| Uterus with edema |
Once the mare has successfully been bred and been checked for ovulation she is hopefully all set to maintain a healthy pregnancy. We try and ultrasound mares 16 d post breeding to look for pregnancy. If she is pregnant we will return 30 d post breeding and do a 'heart-beat check' to ensure the pregnancy is progressing as planned.
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| 16 d pregnancy |
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| 30 d pregnancy |
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| You have to maintain a sense of humor when performing reproductive work! |
Breeding horses can be considered more of an art than a science. At times it can be extremely frustrating when things go as planned and a mare still fails to conceive. I hope to one day become proficient at equine reproduction and have been very fortunate to get to see so much repro work with Dr. Cynthia. It is hard to believe that I only have two weeks left, but I am sure they will be filled with even more adventures! Thanks for following along.
Monday, June 18, 2018
MSU Large Animal Clinic Weeks 4-6
Hello again from here at MSU! I have had an enjoyable couple
of weeks on first shift! I have been able to see an assortment of different
cases on outpatient, inpatient, and surgery.
Outpatient has been filled with a variety of different cases
from putting splints on crooked baby goat legs and bull breeding soundness
exams to lameness and neurological exams on horses. My main duties with
outpatient is helping the techs set up anything that is going to be needed for
the patient coming in. Then once the patient arrives I help restrain or if its
something like a lameness exam, I will help jog the horse. One of the first
outpatient cases I got to help with was a breeding soundness exam (or a BSE) on
a bull. This is basically to see if the bull will be fertile enough to adequately
service the cows in his herd. The BSE starts with a physical exam to make sure
the bull looks physically able to breed. This would include things like making
sure he has an ideal body condition score. It is undesirable to have a bull that
is underweight or overweight. The scrotum is also examined. The testicles are
palpated to make sure there are no abnormal lumps or bumps. The circumference
of the scrotum is also measured. The amount of sperm that is produced and the size
of the scrotum are highly correlated. So as scrotal circumference goes up so
does sperm production. The other main part of a BSE is to examine the bulls
sperm under a microscope. The bull is normally then graded as a satisfactory or
unsatisfactory breeder. Bulls with no sperm production, or too many sperm with
abnormalities (for example, bent tails or no tails) are graded unsatisfactory
and are not recommended for breeding.
Another cool outpatient case that I was able to be apart of
was a lameness/neurological exam on a horse that shows in eventing
competitions. The horse had previously fallen when going over a jump and has
been on and off lame ever since. The horse had a history of going lame 15-20
minutes into exercising and then it would resolve itself shortly after. Because
of the history, a neurologic and lameness exam were both done. When helping
with this case, I was the one handling the horse. During the neurologic exam various
test are done to try to exacerbate any neurologic abnormalities the patient may
have. These tests include walking the horse in a serpentine pattern, walking
the horse with its head lifted in the air, turning the horse in tight circles
and then stopping abruptly, stretching the horses head from side to side,
placing their legs in abnormal positions, pulling the tail while walking, and
backing the horse. For the lameness evaluation the horse is trotted up and down
a straight path. The doctor will also perform a flexion test on each of the
joints in all four limbs. This is when a certain joint is held in flexion for
30-60 seconds. Then the horse is immediately trotted off to check for lameness.
Here at MSU we also have access to The McPhail Center which has a big indoor
arena where we can lunge the horses and the doctors can access the horses lameness
while the horse is going in a circle. This
way the horse can also be observed at the canter and transitioning from one
gait to another.
For inpatient during the day, it is similar to the duties I
have when working nights. This includes hourly checks and treatments. During
the day, the clinical student on that patient’s case will do their hourly
checks and treatments so there is not as much to do for inpatient during the
day compared to nights. One of the more interesting inpatient cases I got to
see was a pony that came in on emergency with a giant wound in its
semimembranosus and semitendinosus region. The referring veterinarian did a
great job at debriding the wound. When the wound was unbandaged it looked pink
and was starting to fill in with granulation tissue. They flushed the wound
with sterile saline and betadine. The process seemed to be unpainful to the
pony and this is because granulation tissue has no nerve endings. Once the
wound was cleaned, it was rebandaged. It is unclear what caused the wound.
First thought was maybe it was from getting an IM injection but she hadn’t
recently received any injections in that area. It could also be from an abscess
or tumor. It is still unclear where the wound came from but thankfully it is
looking better and better each day.
I also got to help with surgery and that was really fun! I
helped the tech set up the surgery suite with whatever would be needed for that
particular procedure. Once the horse was dropped we would help hoist them onto
the table and get them positioned for surgery. Once the horse is positioned,
the tech and I would clip and scrub the surgery site while the anesthesia team was
intubating the patient. The first surgery I was able to observe was a tie-back.
A tie-back is done in horses that have a history of roaring. Roaring is when a
horse makes a load noise while breathing during exercise. This is normally due
to a paralysis of the arytenoid cartilages in the larynx. This causes a partial
blockage of air flow because the arytenoids close when they should be open. This
is treated by surgically “tying back” the arytenoid cartilage with suture
material. The goal of this surgery is to hopefully improve airflow to the lungs
during exercise.
Well that is all for now! I’ll keep you all updated as more
share-worthy cases come into the clinic!
Friday, June 15, 2018
Brown Equine Hospital: Week 4
This week was packed with interesting cases! I was able to
learn a lot and gain great hands on opportunities!
This week started off with two ventral cordectomies or VCs. Ventral
cordectomy is a procedure that is done for horses that are “roarers.” Roaring
is when a horse makes loud roaring noises during inhalation. This is because
the horse suffers from laryngeal paralysis. There are nerves that innervate the
muscles that help to open the arytenoid cartilage and when the horse inhales,
they stimulate the muscles to constrict, which opens up the horses air way and
allows them to breathe. With horses that have damage to this nerve it can cause
the arytenoid cartilage to not open correctly, therefore, causing the roaring
sound and making it difficult for them to breathe. This can sometimes be
apparent during strenuous exercise and reduce performance with horses. In order
to fix this problem the horses were first scoped and we observed their
arytenoid cartilage in order to confirm that the horses had nerve damage. Once
this was done the doctor made a ventral incision and cut through to the larynx.
Once they were inside they removed the vocal cords and the vestibular fold in
order to increase the ventral diameter and reduce the noise associated with
laryngeal paralysis. This procedure is done standing and with the endoscope
still near the opening of the horses larynx. This allows the surgeon to get a
better view and it allows the horse to still be standing for the procedure. I
unfortunately did not get any pictures for this week, hopefully I will have
some next week!
A yearling showed up to the clinic for a bilateral
cryptorchid surgery. When a horse is cryptorchid it means that the testicles
have not descended, they are still in the abdominal cavity. Before the surgery
started we had to safely drop the horse for surgery. During this process, the anesthesiologist
administers the drugs and guides the head of the horse, while 1-2 assistants, depending
on the size of the horse, will push the hips and shoulders of the horse against
the wall so they fall safely. We essentially guide the horse to the ground.
Once this was done, the anesthesiologist let me place the endotracheal tube! It
was so exciting! For horses you have to grab the tongue first and then place a
tube in its mouth so that the endotracheal tube can pass through the horse’s
mouth safely. Once the tube is in, you
should have no resistance when passing it into the trachea. If you have
resistance you want to pull the tube back slightly and rotate it slightly. Once
you are in the trachea you should be able to feel the horses breath. Once I did
the rotation I could feel the horses breath! Then we hoisted the horse onto the
surgical table and prepped the patient for surgery. The surgeon found the
testicles and removed them. The patient recovered well and went home.
Another colic emergency showed up to the clinic yesterday.
We ultrasounded the abdomen and took a sample of the fluid and it was blood.
The horse had a hemoabdomen. The veterinarian ran some blood work and the horse
was found to have little to no platelets. The surgeon said that the horse was
not a surgical candidate due to this issue. The plan was to give the horse
fluids and give it a transfusion in order to increase its platelets and help
stop the bleeding. We went to a neighboring horse farm and found a blood donor
and began the transfusion. I was able to monitor the transfusion. I took the
horses temperature, respiration rate and heart rate every fifteen minutes in
order to monitor the horses condition. The horse did well throughout the
transfusion and is in stable condition. We are still monitoring her status and
I will keep you posted on her outcome!
Another horse presented to the clinic for a mass on her
uterus. The owners wanted to see if this would impede her breeding abilities.
The horse was put in the stalks, rectally palpated and ultrasounded. It was
found that she had a mass on the bifurcation of her uterus and she was
vaginally scoped to further investigate the mass. The mass was not seen with
the scope and the veterinarian said that it could not be safely sampled. The
mass was on the outside of the lumen of the uterus and would not likely
interfere with future breeding if it did not increase in size. The veterinarian
suggested to follow up with the mass to see if it will enlarge further. If the
owner wanted to, surgical removal could be an option for the mare.
I was also able to rectally palpate a mare for the first
time, which was a wonderful experience. I got to palpate one of the
veterinarians horses after they ultrasounded the ovaries for follicle
development. They were trying to see if they should breed the mare and used
ultrasound to measure the diameter of her follicles on her ovary in order to
determine when to order semen to breed the mare. I was able to rectally palpate
and feel the horses aorta, uterine body, bifurcation and right and left
ovaries! It was amazing to have such an experience like that!
Other than that, I have become more comfortable with placing
IV catheters, helping to drop horses for surgery, recovery after surgery, TPR,
administering medications and scrubbing for joint injections, surgery and
sterile scrub. Dropping horses for surgery is very interesting. It takes a
couple of people, depending on the size of the horse; the anesthesiologist to
hold the horses head and guide them when they fall, one person to guide the
point of the shoulder, another to guide the hips and maybe a third to help the
horse fall safely. Recovery can be challenging, but I am glad I get opportunities
to help! Once we get them off the table we lay them down and tie ropes to the
halter and the tail. Once the horse is ready to get up on their own we will use
the ropes to help guide them up safely. This helps to limit falling and injury
to the horse. After the horse has been up for a period of time we will test
their balance. If they pass this test, we will untie the ropes from the halter
and tail and allow them to walk around the recovery suite for a bit and then
lead them down to their stalls.
So far this has been a great experience. I have learned so
much about equine medicine and I have gained so many valuable skills. Can’t
wait to see what this next week brings me!
Tuesday, June 12, 2018
Clinton Vet Service: Week 2
Hello, hello! I am back to share another week of awesome adventures with Clinton Vet. After a marvelous first week I didn't think that week two could surprise me with anything out of the norm. Boy was I wrong! Week two brought even more learning opportunities and hands on...or in...experiences.
Monday started out with pregnancy checks and health certificates for some horses going to new homes. It was an exciting start as all of the mares we checked were positive for pregnancies! Since I used to work closely with the mares at the MSU farm, seeing them get in foal is always a treat. The next farm we stopped at belongs to one of my former professors from undergrad. I had the pleasure of following this mare from when she foaled her first filly (thank you social media), throughout her breeding process, and finally getting to see her pregnancy check! The rest of our Monday was filled with some routine vaccines and a lameness exam. It was a fun day, but was just the beginning of our crazy week.
Tuesday began with a longer visit to a local farm for vaccines and dental checks. I first visited this fun farm when I was shadowing Dr. Cynthia back in 2015. Back then we were there to geld a spunky donkey, one of the first times I had seen that procedure performed. Once again I got to experience more firsts at this farm. After checking the horses (and donkeys) teeth we determined that 6 of our patients needed to have their teeth done. The first gelding we looked at had a cracked, and by the smell of it, infected tooth. Dr. Cynthia started to work on removing the tooth when she turned to me and asked if I would like to pull it. I immediately said yes! Now, I am normally quite squeamish when it comes to all things dental related. But, when put to the task of removing that nasty tooth I didn't bat an eye. After some work with the extractors the tooth came out beautifully. Our work continued as Dr. Cynthia started floating the next patient. As she finished up with her she asked if I would like to do the next one. I've watched floats being performed for a while, and have gotten to practice on cadavers during a wet-lab at school. But, I had never had the chance to complete one start to finish. Thanks do Dr. Cynthia's guidance and some willing, once they were sedated, patients I successfully performed my first four floats. It was a blast! How could this week get any more exciting?
Well, it got a lot more exciting Wednesday morning. Dr. Cynthia's mare was due to foal during the middle/end of June. Each night Dr. Cynthia would check Sparkyl for changes in her udder, milk composition, and vulva relaxation. Tuesday night she still seemed stable, but when one of the office staff was working outside she noticed Sparkyl was laying down and straining in the pasture. We all rushed out to check and saw little feet emerging. Someone ran to get Dr. Cynthia from her house and the rest of us assessed Sparkyl's condition. She was calm and contracting well but not making much progress as far as moving the foal further out. So, Michelle and I put light tension on the forelimbs and helped little Miss. Indy into the world. It was a beautiful, sunny morning and the foal stood and nursed like a champ. She followed the "one, two, three" rule almost to a T. That is a handy way to remember the post-foaling order of events that should occur. The foal should stand within one hour, nurse within two, and the mare should pass the placenta in no more than three hours. It was so much fun to be a part of foaling Sparkyl out! I have gotten to assist with foaling at MSU, but rarely from start to finish like this one. I am grateful that we were all there and that Dr. Cynthia now has a gorgeous new filly.
Monday started out with pregnancy checks and health certificates for some horses going to new homes. It was an exciting start as all of the mares we checked were positive for pregnancies! Since I used to work closely with the mares at the MSU farm, seeing them get in foal is always a treat. The next farm we stopped at belongs to one of my former professors from undergrad. I had the pleasure of following this mare from when she foaled her first filly (thank you social media), throughout her breeding process, and finally getting to see her pregnancy check! The rest of our Monday was filled with some routine vaccines and a lameness exam. It was a fun day, but was just the beginning of our crazy week.
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| Floating with an audience! |
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| Believe it or not, that impacted feed at the top was stuck UNDER the gum-line |
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| Its a GIRL! |
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| Helping her into the world |
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| First Steps! |
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| Healthy placenta |
Sunday, June 10, 2018
LEqMC Weeks 4 and 5
Hello again from Colorful Colorado! Below are my daily notes about the cases I've seen and my duties at the clinic. I couldn't be more happy to be here! The schedule is fantastic and has allowed me to take on several hiking day trips and just today I did a 20 mile (round trip) biking adventure into Denver. Thanks for reading!
Week 4
Tuesday, May 29, 2018
Over the weekend CaCa foaled and Dr. Dietz taught me how to
lay out a placenta and taught me some about assessing the placenta for health.
The placenta had a small strip of plaque. I also learned that there are three
places that can be noted as not being attached: both horns where the ovary
attaches and at the cervical star. These locations are pale/white in color and
there shouldn’t be any other notable places where the placenta is noted to not
be attached. The placenta inverts when the foal is born, gravid and non-gravid
horns should be noted. The placenta needs to be examined on both sides, so it
needs to be turned right-side-out after it has been evaluated inside-out. We
don’t typically worry about the allantoic portion of the placenta. Make sure
the placenta is all there. There should be a hole where the foal exited.
Today I was with team surgery and was able to watch the
placement/creation of a permanent tracheostomy on a 21 y.o gelding with
multiple (very large) melanomas. He was first scoped to visualize his upper
airways, trachea, guttural pouches, and esophagus. The most remarkable (and
interesting) finding was that there were multiple melanomas in the guttural
pouch, one around the internal carotid, and one around the external carotid
arteries. This is also cause for concern for cranial nerves IX, X, and XI, as
they all are seen in the guttural pouch. He presented with the complaint of
very loud breathing sounds (roaring). There was concern that he had (a)
melanoma(s) pressing on his trachea and that was occluding his airway. There
was also concern of left recurrent laryngeal nerve paralysis, causing stridor
(paralysis of one of the arytenoids.) The tracheostomy was placed and I
restrained the patient during the procedure. Restraint proved to be rather
challenging- he kept waking up.
Later in the afternoon Dr. Mullen performed a neuro exam on
an 18-hand warmblood with some mild neurologic signs/concerns. Dr. Mullen found
that it was not particularly remarkable but she noticed minor deficits in
proprioception. Cervical radiographs will be the next step to decide if there
is a problem.
The second surgery I watched was a maxillary sinus
trephination. The horse had previously had an infected tooth pulled and the
infection had traveled up into the maxillary sinus. The sinus was opened,
scoped, and flushed. A plug was made out of dental molding for the hole where
the tooth was, and the trephine was closed up.
After my shift, an emergency colic went to surgery with Dr.
Murray. The horse had a strangulating lipoma, which tied off a few feet of
ileum. The bowel was still alive, but the pulses and motility were poor. The
flick reflex indicated that the ileum wanted to move, but it was struggling. The
owner was presented with the option of resection and anastomosis or leaving the
intestine in and hoping that it would regain full function and not infarct. She
was given a 50-50 chance either way as both options had similar risks. She
elected for the later option, so the bowel was run, abdomen lavaged, and the
horse was sutured up and recovered.
Wednesday May 30, 2018
Today I was in ICU and the majority of my day consisted of
cleaning, restocking, some help with feeding and picking stalls. By the time I
was finished in ICU, there wasn’t much going on in the clinic. Dr. Duff taught
me how to test milk calcium.
Later that evening, after work, one of the post-op colic
horses’ (his surgery was Saturday, May 26) incision had partially dehisced and he had to be sent to surgery.
Inscisions can dehisce for a few reasons, mostly bad luck, but they can also
dehisce as a result of infection. We worry about dehiscence up to 5-7 days post
op, and 3-5 days for resection and anastomosis. Some pieces of wisdom from Dr.
Hill: we know we’re done checking the small intestine when we get to the
duodenocolic ligament. When you’re looking at the large colon, you can tell if
it’s straight (untwisted) if the lateral band lines up with the lateral band of
the cecum.
Thursday May 31, 2018
I worked in ICU this morning again. I cleaned one of the
stalls in the Brice barn, made flushes, spiked fluids, swept, organized,
stocked, dropped hay, and some other things. By 1 I was done with my ICU tasks
and was able to go see what was happening at the clinic. I, unfortunately,
missed the intraspinous desmotomy and ostectomy that was scheduled from last
week. There were 5 spinous processes involved, which is a lot, but the surgery
went well. I also was able to watch Dr. Swanson perform two lameness workups
and an injection of a hock and fetlock. There are two common corticosteroids
used for equine joint injections, triamcinolone and Depo-Medrol
(methylprednisolone). Triamcinolone is generally used in high-motion joints,
such as the hock or fetlock. Depo is not used in high-motion joints because it
causes more rapid bony change. Precautions include laminitis. Too much
corticosteroid in the system may induce laminitis. At the end of the day, I ran
another milk Ca on the mare Aegena, who might foal tonight. I helped make up
some oral meds, then helped adjust Angel’s hernia belt.
Later in the night I was called down to Larsh barn to see
and help with Aegena’s foaling! It was the first I’d ever seen! The newborn
filly was healthy but struggled with the concept of nursing so the next day the
Madigan Foal Squeeze was performed on her. Post-squeeze she was able to nurse
on her own with no trouble. She also needed a plasma transfusion, likely due to
her inability to nurse in that critical period where her gut was still open to
the large antibodies that are normally absorbed from colostrum and the fact
that Aegina’s colostrum was only registering as “fair” on the colostrometer.
Before the filly was born, Dr. Duff showed me how to feel for two feet and a
nose (proper presentation) early in parturition. I also was able to help by
drying the filly off postpartum.
Friday June 1, 2018
Today was field day! I spent the day with Dr. Tischer and
his vet tech Daniel. We did several lameness exams, radiographs of a recovering
P3 fracture, joint injections (stifle, hock, and fetlock), and shockwave
therapy. I had the chance to discuss Osphos treatment and
Triamcinelone/HA/Amikacin use in joints with Dr. Tisher. When we returned from
the field I watched Dr. Mullen perform a neurologic exam on a horse that had an
MRI earlier that day. The horse was found to have an extra floaty gait when
asked to walk on the flat and downhill with his head up. He struggled
especially with trot-to-canter transitions and had a difficult time keeping
himself up and steady behind. He also struggled when asked to circle in tight
circles. He will be reevaluated neurologically after some (or most) of his
lameness is resolved, as that makes the neuro exam a little difficult to
interpret.
Week 5
Monday June 4, 2018
Reportable disease: Rabies, EHV, EIA, Vesicular stomatitis.
VS is reportable because it looks exactly like foot and mouth disease when it
infects cattle. Aside from the mouth, it can effect ears, sheaths, coronary
bands.
Between scrubbing stalls and cleaning in ICU, I was able to
watch Dr. Lori inject the stifles of a horse with an excessively flat medial
condyle of the tibia. The two joints of the stifle are the femoropatellar and
the femorotibial. The two compartments of the femorotibial joint are the medial
and lateral femorotibial compartments. The femoropatellar joint is the largest
of the three compartments and it communicates directly with the medial
femorotibial compartment in about 65% of horses. Dr. Lori injected the medial
femorotibial joint. One injection site is located between the medial patellar
ligament and the medial femorotibial ligament. The other, which was used by Dr.
Lori, is the medial outpouching of the medial femorotibial joint. Advantages of
this technique are better accuracy and ability to recover synovial fluid.
Painful reactions are less likely in this technique. The site is the
indentation between the medial patellar ligament and the temdon of the
sartorius, ~1in above the tibial plateau.
Tuesday June 5, 2018
We had journal club about administration of fluids to
patients in the field. We discussed such topics as when to give fluids, how
much to give, and at what rate. We then had grand rounds, which took a while
because the ICU barn is completely full and there are several patients in Larsh
and the condos as well.
After rounds I handwalked horses, spiked fluids, restocked
fluids, cleaned the feed shed, stocked the alfalfa… Then we had a patient
leave, so I cleaned her stall. Around 1 I was relieved from stall cleaning to
monitor a foal as he was given a fluid bolus (I’m not sure what was in the
fluids, I forgot to ask). Around 2pm I had lunch and came back around 2:30.
After doing some minor cleaning tasks, another patient left, so I cleaned his
stall. At 4:45, Dr. Dykstra came in with a colic emergency and did an
abdomenocentesis. I held the red and purple top tubes for collection and ran a
lactate and total protein test. Lactate was 11.1, ridiculously high, and total
protein was 2. The mare was obviously very sick with no surgical option. I’ll
find out tomorrow if the mare is still with us. She has an 11 day old foal with
her.
Abdominocentesis is done for a multitude of reasons, colic
being one of them. Fluid analysis helps guide the direction we take these cases
medically or surgically. It is performed in a standing sedated horse to the
right of ventral midline, avoiding the spleen, caudal to the descending
pectorals. After the area has been clipped and sterilely prepped (we use
betadine and nolvosan/alcohol solutions), a stab incision is made and a teat
cannula is gently inserted through the incision to drain and collect fluid. In
the purple top tubes, the EDTA was shaken out because EDTA will falsely
increase total protein. With intestinal strangulation, TP will increase in the
first 1-2hr, after 3-4hr, RBCs are present. >6h WBCs increase gradually, as
intestinal necrosis continues. Peritoneal lactate increases with intestinal
ischemia, which was noted on this mare’s abdominocentesis. If there is blood in
the sample, it should be determined whether the blood was from contamination
during the procedure or if there is hemorrhage or dead bowel. If the sample can
be spun down and it’s clear, then it was fresh (contamination). If the sample
remains red-tinged, there is likely hemorrhage and erythrophagocytosis can be
seen and there with be no platelets. In the case of compromised bowel and
damaged capillaries, the fluid will be serosanguinous with a red supernatant
post-spin.
Wednesday June 6, 2018
Another ICU day! I stocked, cleaned, made up flushes and
spiked fluids. I saw a couple minutes of an emergency colic work up but had to
leave to go set the stall up for the horse to move into after the work up. I
gave him his lidocaine bolus IV. I also helped ICU by doing a CPDP (basically a
modified physical exam) on Pheonix (he’s back!), feeding the orphan foal, and
milking the Percheron mare.
Thursday June 7, 2018
Today I was in the clinic with Dr. Swanson. We had several
lameness exams and joint injections. I saw my first carpus injection. I enjoy
working with Dr. Swanson because he asks where I think I see the lameness and
lets me come up with my own ideas before sharing what he sees. I’m getting
better at evaluating lameness, but it’s still difficult for me when there are
problems in more than one limb.
Friday June 8, 2018
I was in the field with Dr. Christakos today. We did health
certificates for our first visit. The second visit was suture removal for a
horse that had a laparoscopic ovariectomy a few weeks ago. We did a gross prep
of the areas with betadine solution and chlorohexadine/alcohol solution to keep
the area clean and prevent introducing bacteria where the sutures would be
removed. Our next appointment was to use prostride on a horse who had
previously injured her fetlock. For more information about how ProStride works,
you can click this link! https://www.omveterinary.com/pro-stride
This particular patient hated needles near her neck and it was a challenge to
restrain her for her sedation injection. Dr. Christakos was incredibly patient and
was eventually able to sedate the mare long enough to do the treatment. Our last
appointment in the field was at a beautiful farm near Evergreen, CO. It was an Arabian
horse who had been injured almost two weeks prior during a competitive trail
riding event. He had fallen from a pedestrian bridge and has several
lacerations on his right front. The appointment was to check up on his
laceration and retake radiographs to be sure that there were no sequestrae. The
radiographs were clear but there was significant pitting edema of the lower
extremity. Dr. Christakos believes that it’s the start of a skin infection. She
removed the sutures on the largest laceration, wrapped the limb, and dispensed
SMZs to be administered twice daily to get rid of the infection. He’ll be on
stall rest at least for a few more weeks. The final appointment of the day was
a Morgan gelding with previous SI treatment, looking to be evaluated and
potentially injected again. The lameness exam indicated that injection would
likely help. Dr. Christakos used Depomedrol because the SI joints are not
synovial and also because the gelding was obese and at risk for laminitis with triamcinolone.
Weeks 2-4 Cleveland Equine
Weeks 2-4 at Cleveland Equine Clinic
Its been a busy few weeks! There have been a decent number
of 12-14 hour days on the road these past few weeks just with the regularly
scheduled appointments. Luckily a lot of the time is spent driving, so there is
plenty of time to decompress and talk with the vet between appointments. I
apologize for not posting more regularly, but since I am covering a few weeks
at once I tried to divide this up based on type of appointment instead of going
chronologically.
Lameness: I am beginning to feel more comfortable with
lameness exams in terms of knowing which limb is lame and what grade. Forelimbs
are definitely easier for me than hind limb lamenesses. Each exam follows a
similar progression:
·
Forelimbs, hindlimbs neck and back are palpated –
check for stifle laxity, Churchill response and note shoeing
·
Horse is evaluated in motion: trot in a straight
line and turning, lunge left and right, flexion (proximal and distal) of all limbs
·
If a lameness is detected a block is performed
to localize the issue (performed proximal to distal with some variation depending
on where the vet suspects the lameness is derived from)
·
Radiographs of affected area (or ultrasound is
soft tissue is suspected)
We see a very wide range of clients. Some farms we go to
because the owner or rider has picked up on a very mild gait deficit they want
checked out. Other calls are to horses that the owner just noticed getting
lame, but are actually already quite far in the progression of their developing
lameness. I have been impressed by the consistent standard of care that every
patient receives. Whether a horse is performing in shows across the country or
hanging out as a backyard pet, every treatment option presented. Then the owner
and the vet work to create a plan that is realistic and likely to be successful
for that specific patient.
Pre-Purchase exams: A similar philosophy is applied to the
prepurchase exams done by the clinics. Whether the horse is being sold for
thousands or hundreds the same packet is filled out for every horse. It covers a
physical exam (auscultation of heart/lungs/GI, temperature, etc.) basic lameness
exam (palpation, lunging, flexion tests, hoof testers), neuro exam (cranial
nerve function, etc.), looking at the eyes, ears, mouth and anything else the
vet deems necessary to develop an initial impression of the horse. Then the vet
will call the potential buyer and discuss any reservations (for example, if the
horse has a slight right front lameness lunging to the right, or if there was a
negative slap test, which evaluates arytenoid function). The vet might suggest taking
radiographs of the foot or an endoscopic exam. At this point it’s up to the
potential buyer if they want to add on to the pre-purchase exam (some buyers
want radiographs or every foot and the hocks regardless of if any lameness is
detected), but Cleveland Equine will do any diagnostic test the buyer wants and
give a professional opinion on every finding.
Repro: I have ridden with the vets the specialize in repro a
few times now. A lot of what we do at
this point in the year is preg checking (owners in this area of Ohio usually
want later spring foals to ensure the snow is gone). I generally hold the
ultrasound and, depending on which appointment post breeding it is, the vet looks
for a vesicle (14 days post breeding) or a heart beat (25 days post breeding)
or does a general check (40 days post breeding). At the 14 day ultrasound it is
important to check for twins. The mare that is owned by the clinic had two
vesicles when we checked her, and I watched one of them be pinched. Depending
on how large and close together the vesicles are this can be a difficult
procedure, but it was cool to see the clearly collapsed vesicle next to the
circular, fluid filled one on ultrasound after the vet successfully pinched
one. I’ve also witnessed a live cover (stallion and mare breed as opposed to artificial
insemination) in less than ideal conditions. It’s important to remember that
not every client will have the ideal set up for the procedures that need to be
done.
Wound repairs: Wounds are one of my favorite types of calls.
Depending on how fractious the horse is, I can help hold/restrain during the
appointment. The tech cleans the wound before the vet applies a bandage +/-
sutures. I’ve learned some hallmarks of
good bandaging, like even pressure, security and padding. I’ve also learned the
differences in medications that should be used based on the goal. For example, using
silver sulfadiazine with a steroid and antibiotic like entoderm to decrease
proud flesh versus using the silver sulfadiazine with dermagel to granulate the
wound in. I saw the progression of one wound on dorsal metatarsal 3 of a friesian
yearling over a few weeks. The common digital extensor tendon had been
completely transected, and the bone was visible. Although initially sutured,
the tension was too great, and they had ripped out after week one. With weekly
bandage changes, antibiotics and stall rest the bone stayed healthy and
granulation tissue began to form. The owner is doing the bandage changes by
herself now that the wound is under control.
Another wound we’ve been treating is from a Clostridium
infection that developed after an owner gave a vaccine in the gluteal muscles.
It’s been difficult to manage due to its location, but the patient is doing
well. One complication has been the constant need to apply Vasoline to the hind
limbs because drainage from the wound has been blistering the skin.
Castration: I saw one castration and witnessed the importance
of after care when we had to go back 10 days later because the incision site
was infected. The horse had been let out in a round pen, but no one checked to
make sure he was moving around. A standing castration heals from the inside out
and needs to be able to drain, so it is important for the patient to be walked.
We drained the infection and dispensed Baytril – aka enrofloxacin (remember
this antibiotic cannot be given to horses less than 2 years old because it
affects bone/cartilage development). For the castration Dorm and Torb were given
for sedation and Carbocaine to block incision site.
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