Equine Athlete: Week 7-8

Hello once again! I just got back from a Lexington Kentucky and we are now starting to prep horses for the 2018 Arabian Youth Nationals! I learned a lot these last couple of weeks at the horse shows.

 

Everything that we have done this summer relates to anatomy is someway. I am so glad I learned so much anatomy my first year, without it I would be lost. We do a lot of joint injections, which have challenged me to refresh my knowledge of different anatomy topics. One injection that I struggled with understanding the logistics of was the sacroiliac joint injection. Over the last few weeks I have been able to get a better understanding of how the procedure is done.

The sacroiliac joint injection is done ultrasound guided to guarantee that the steroids are injected in the correct location. There are four different injection sites, two on each side.

The first injection is at the cranial portion of the pelvis, you place the ultrasound probe parallel to the vertebra just off the midline (pictured). Once you can clearly see the ileum on the ultrasound (green circle) your goal is to place the needle below and parallel to the ileum (needle is circled in purple), ultrasound is real time so you are able  

to watch the needle go into the correct location.

The second injection is caudal to the first and the probe is  positioned more perpendicular to the vertebra just off midline (pictured). With this positioning you are able to see where the ileum and the sacrum articulate (circled in yellow), that is your target point. Again you are able to watch the needle go into place. With that, steroids are injected from two different entry site of the same joint, this helps to assure adequate results. This type of joint injection really helped me to understand the anatomy of the pelvis as well as help to become more familiar with ultrasound imaging.

I will be back soon with more exciting cases! Thanks :) 

Brown Equine Hospital: Weeks 6 & 7

BEH Week 6 and 7

Week 6 and 7 have been filled with a lot of cases and hands on experience here in Somerset. I apologize for my lack of posting, but I have been getting called on quite a few emergencies, which means I have had a few sleepless nights. On the bright side, I have been able to learn and see what an internship could possibly look like for myself. I will try and provide some of the highlights of the last two weeks.

The first big event of the week for me was when I got to scrub in for a bilateral arthroscopy with Dr. Brown! While the patient was being prepped for surgery, the technician taught me how to properly scrub in. Once I finished I was able to run the surgery table for Dr. Brown and hand him the surgical instruments he needed. After he finished with the right hind limb, he let me drive the scope and identify anatomical structures within the hock! It was an amazing experience! The scope was not easy to drive at first, but after a tutorial from Dr. Brown, it was significantly easier! Once we moved on to the left hock Dr. Brown let me remove a piece of cartilage that was causing the OCD in the hock. I was able to grab the fragment and remove it in one try! Here are some pictures of this amazing experience!

A horse presented to the clinic upon referral from another veterinarian. The horse was having issues chewing and quidding its hay and grass. The veterinarian took some radiographs and found a fracture on the mandible near the interdental space. This made it painful for the horse to chew and was therefore the source of the quidding. We took the horse to surgery and placed a wire in the jaw to help it heal. The surgery went smoothly and I was able to assist the surgeon. (sorry I did not get any pictures for this!)

After surgery x-ray:

After surgery the horse was still having issues chewing its food and was still quidding its hay and grass. The veterinarian wanted to investigate the issue further so we scoped the guttural pouch of the horse to see if there was any complications there. Both guttural pouches looked good so we took additional x-rays of the mandible and found an additional fracture on the ramus of the mandible that was causing the issue. The horse was monitored for a couple of more days and discharged home.

Additional x-ray:

The first emergency I had for week 7 was a colic emergency. The horse was very painful upon arrival and after a physical and ultrasound, it was decided that the colic could not be treated medically and went straight to surgery. Once the horse was prepped the surgeon made the incision on the midline of the abdomen. When making an incision on midline one of the first anatomical structures of the gastrointestinal tract you should see is the cecum. For this horse the large colon was visualized. This horse had a 360 degree turn in its large colon, this is called a volvulus. This can be a detrimental problem to the horse as it can cut off circulation to the portion of the GI tract and can cause ischemia in the colon. This horse was referred in time and there was no color change to the tissue. The horse recovered well from surgery. Food was slowly re-introduced to the horse to minimize the reoccurrence of colic and fecal output was monitored. The horse did wonderfully with recovery and was discharged home.

Another colic came into the clinic that also needed to be treated surgically. Once the midline incision was made, the cecum was also not visualized like it normally should be. When the surgeon further explored the GI tract, it was found that this horse also had a volvulus of the large intestine. Unfortunately, this volvulus had caused ischemia of the colon. The surgeon performed an enterotomy on the large colon and the mucosal tissue of the large intestine was ischemic and beginning to slough off. Unfortunately resection of the large colon was not an option because the entire large intestinal tract was ischemic. The horse was euthanized on the table.

Picture of the enterotomy:

The third emergency was a laceration. A horse presented to the clinic with a fairly large laceration that extended from the left flank of the horse to the inguinal area. We clipped the area, scrubbed and numbed it with carbocaine (Mepivacaine). The veterinarian placed some vertical mattress sutures to help bring the tissue together nicely. He then let me place some simple interrupted sutures in between his sutures! Once we placed all of the incisions, we placed a drain in order to help removed fluids that build up after the trauma and to decrease infection. After the drain was placed we put a over the stitches in order to decrease tension on the sutures we placed.

Before:

After: 

We had two more additional laceration emergencies early in week 7. The first laceration was on a miniature horse. The laceration was on the left hock and was fairly deep. We did a contrast study in order to see if the laceration had gone deep enough to get into the joint space. After we did administered the contast, x-rays were taken. Unfortunately the laceration went all the way to the tibotarsal joint. The hock was flushed and amikacin was administered to help with infection. The horse was discharged home and has been doing well since then.

Here is a picture of the contrast study:

The second laceration was in a similar location, oddly enough, but it did not go to the joint. We did a contrast study for this horse as well and it was found to be in the tendon sheath of the long digital extensor. The wound was sutured shut and antibiotics were given. The horse was discharged home and has been doing well.

Speaking of emergencies, I am getting called in for another one as I type this! I apologize for the brevity of this post. Wish me luck on getting some sleep eventually!

Littleton Equine Week 8

This week was a hot one here in CO! On Tuesday, I observed a pleuropneumonia work-up. A 6 y.o Thoroughbred presented for evaluation of pneumonia, previously diagnosed by a referring veterinarian. She was raced in TX approximately a week prior to presentation. She was quiet, tachypnic, and tachycardic on presentation. She had decreased lung sounds with occasional crackles and wheezes. After ultrasound demonstrated significant fluid in the pleural space, it was determined that a chest tube should be placed to drain off the fluid, and that it would remain until it stopped draining. Six liters of serosanguinous fluid drained from the pleural space at the time of tube placement. In some cases, you would worry about having hit an artery when you see blood in the draining fluid, but fluid from an artery would be frank and would clot, where the fluid draining was not and it did not clot. The mare had concerning hyperechoic spots showing up on ultrasound, which could be small abscesses. The tube was placed on the left but the fluid was ultrasonographically determined to be decreasing on the right side as well. A transtracheal wash was performed as well. Fluid from the chest tube and from the transtracheal wash. Culture grew a Strep and Klebsiella (resistant to most things). This case demonstrated the importance of performing a transtracheal wash because the pleural fluid only grew the Strep, where the wash culture grew Klebsiella and Strep. Klebsiella is associated with hemorrhagic pneumonia, explaining the serosanguinous fluid, and a poor prognosis in adult horses. This Klebsiella was only resistant to Chloramphenicol and Amikacin. Her prognosis is very poor as ultrasound is now demonstrating a large abscess in the thoracic cavity. She was placed in ICU for monitoring and to begin her course of antibiotics. After some discussion with the HR/PR team, I've had a few photos approved to share! Below is the chest tube and the fluid drained. (The foam is formed by proteins.) It's fairly common for racehorses to develop pneumonia, due to the nature of racing. These equine athletes are likely to inhale a fair amount of dirt and dust when they run due to the dirt and dust kicked up by any horse running in front and the need for their airways to be as open as possible while racing. 

 

I spent the majority of my day Wednesday in radiology, helping with my first bone scan! It took a number of hours, but it was interesting to see nuclear scintigraphy in action. I pulled my first catheter when we were done!

Thursday and Friday I spent time at the Colorado Horse Park with Dr. Pearson and Dr. Tisher. We had a few clients need shockwave therapy and some that needed joint injections. I jogged for a few lamenesses and a pre-purchase exam. We had one horse come in that landed a little funny after a jump and tore its deep digital flexor tendon. The photo demonstrates the lesion visualized on ultrasound.

On Friday, we saw two colic cases immediately after arriving to the horse park. One was sent directly to the clinic after we worked it up. It was soon thereafter sent to surgery, and is now recovering in ICU. When we work up a horse for colic, we take vital signs, listen to borborygmi, pass a nasogastric tube to check for reflux, and do a rectal exam. In this particular case, Dr. Tisher decided that a trip to the clinic would be necessary after completing the rectal exam. He felt tight bands and gas distension, and suspected there was a nephrosplenic entrapment. In surgery, it was confirmed that there was, in fact a nephrosplenic entrapment.

To wrap up, I'll leave you with a quote that I've heard before, but have found so much truth in during my time here at Littleton: "More is missed by not looking than not knowing."

Clinton Vet Service: Week 4

Another week filled with more interesting cases has come and gone at Clinton Vet.  I would have to write a small novel in order to encompass all of the unique cases that I have had the chance to be a part of during my time with Clinton.  I have chosen two of my favorites to review in this weeks post.  Thank you all for following along this month, enjoy!

Eye ulcers can be a frustrating and drawn out battle for horse owners.  They can have multiple causes, including abrasions, foreign body, and neoplasia.  This particular gelding has been battling ulcers on and off for almost two years.  In the past he has gotten them in the winter time, this being the first time he got one in the summer.  A week prior to our first encounter, one of the associate veterinarians had performed a corneal scraping and sent it into MSU for evaluation.  Surprisingly the sample came back positive for squamous cell carcinoma, with a note that a full thickness biopsy would be needed to confirm.  The owner was extremely worried that a positive cancer diagnosis would result in the loss of his eye.  After looking at the eye we did not suspect that it was squamous cell, as there was no appearance of outer eye involvement or cancer-like behavior. 

Ulcer taking up stain
on our first visit

No stain uptake after
biopsy and treatment

        We began our exam by looking at the eye with an opthalamascope and light.  Then we stained the eye fluorescein, a dye that is taken up by damaged or inflamed cells in the eye. So we put him back on daily ulcer treatment, in this case a triple antibiotic, atropine, and an anti-fungal just in case.  The owner was willing to bring him into MSU for an ophthalmology consultation and biopsy so we got him in as fast as possible.  MSU took a biopsy and instructed her to continue treatments.  All of the tests came back negative; which was both encouraging and frustrating.  We were back the drawing board as there was not evidence of bacteria, fungus, a virus, or cancer.  Two weeks later we returned to the farm to a welcome sight.  The eye no longer took up stain and the biopsied portion was healing well.  For now we are discontinuing treatment and crossing our fingers that we have cleared his ulcer woes once and for all.

Cytology showing abnormal lymphocytes

The next mare that we visited was on the schedule for "bumps on her body" and weight loss.  A long time client of Dr. Cynthia's, the owner just wanted to trouble shoot what could be causing her problems.  The mare is older and has been struggling with weight loss for some time.  Dr. Cynthia palpated the area, near the mares right flank, and noted that it was well attached to the underlying tissue, a sign that it might be neoplastic in origin.  We took a fine needle aspirate of the area and brought it back to the clinic for cytology.  Unfortunately, we noted a number of abnormal lymphocytes.  Our most likely diagnosis was cutaneous lymphoma.

Taking a punch biopsy

The "lumps", more on underbelly

When you hear the word lymphoma you immediately think the worst, as we did at first.  But, after substantial research we found a few recorded cases of cutaneous lymphoma in horses that received treatment.  The owner did not express interest in treating the horse with chemotherapy, the most common treatment for lymphoma.  With the horses age and condition we agreed that this wasn't a feasible option.  Instead, we found positive evidence of remission with intralesional steroid treatment and oral administration of progesterone.  As this treatment was cost effective and easy to execute (the steroids were a one time treatment and the progesterone is given once daily on top of grain) we chose to give it a shot.  So we visited again, took a punch biopsy, and administered the steroids diffusely around the tumor areas.  That evening the owner messaged to say that the areas had softened up throughout the day and seemed to be getting smaller already.  We are awaiting biopsy results and typing of the lymphoma, but for now we are optimistic that we can keep the mare comfortable for a good long while.

Injecting dexamethasone into region

It is hard to believe that I am heading into my last week with Clinton Vet.  I have seen so many unique cases and met some fantastic clients.  I am so fortunate to have gotten this opportunity and I cannot wait to see what my final days have in store.  Thank you for following along!