Life changes

Been really busy lately.  Finished up my internship, and starting a new job on the west coast in a couple short weeks!  Which means selling all my stuff, cleaning my apartment, packing up my car, and heading back to the beautiful Pacific Northwest, home sweet home.

And on top of all of that, this little critter has been doing her part to keep me occupied as well… even during the wee hours of the night, when I would prefer to be occupied with sleeping…

Chronic Progressive Lymphedema

I’m getting ready to move back to Washington State next month.  I am very excited.  I will continuing my adventures as an equine ambulatory vet in the beautiful Pacific Northwest.

But for now, let me tell you a sad story.

One of my favorite clients is a quirky older gentleman who lives by himself on a fairly large property.  He owns quarter horses and percherons, and he breeds a few percherons every year.  There are few things cuter than a new-born percheron foal.  Although, being 150lbs+ at birth, they quickly become rambunctious little trouble-makers that are much heavier and stronger than you!  You just have to try and keep them from realizing that fact.

So, this older gentleman was the very proud owner of a beautiful black percheron named Joe.  Joe was his pride and joy, his favorite horse, raised from a foal.  And for many years, this gentle giant had been suffering from chronic progressive lymphedema (CPL), a disease that had left his hind legs swollen and disfigured.

There is a lot that isn’t known about CPL, and it may well be that it is a multifactorial disease.  What we do know is that it afflicts draft breeds and there is no cure.  For whatever reason, lymphatic return from the legs is compromised, resulting in swelling of the legs.  Secondary skin infections develop, leading to further inflammation and irritation.  Over time, large nodules and skin folds develop, allowing infections to thrive in the crevasses.  With very little in the way of treatment, and no cure, CPL generally progresses until the only right answer is humane euthanasia.  The best treatment for CPL is compressive wrapping of the lower limbs to keep the swelling down, like Game Ready Boots.  These boots are expensive, treatment requires dedication, and at best the disease course is slowed (but certainly not stopped).  However, with few other options, that’s the best we have to offer.

For Joe, with the advanced state of his CPL, we tried our best to keep him comfortable by keeping his legs clipped and dry, frequently scrubbing them to clean off any crusty discharge and ward off inflammation, treating him with antibiotics on occasion if his dermatitis warranted, and otherwise doing what we could to maximize his comfort.  Knowing (or at least thinking) that it would be the end of him some day.

Tragically, Joe was found down in his stall last fall and unwilling or unable to rise.  On examination it was clear that he had very severe colic, and the decision was made to humanely euthanize him.  We all miss Joe.  He was a good horse.  He taught a lot of vet students about CPL, and I will do my part to ensure that he continues to teach people about CPL for many years.

Here are some photos of Joe, as well as a clydesdale mare who also suffers from CPL.  It is a very frustrating disease, and I can only hope that future research will provide us with more treatment options.

“Non-client”

I got two calls yesterday at around 7pm, one about 2 minutes after the other.  Luckily one was a laceration on a hip that could wait until after I handled the first one (colic).  The colic was a nephrosplenic that I treated with phenylephrine, and while the phenylephrine seemed to help and he may have gotten better from there without further treatment, we all opted to send him into the hospital to be monitored overnight.  With just a bit more fluids to rehydrate him, he is doing very well today.  Yay!

The laceration was right on the point of the h ip, and there was a round flap of skin about 4cm in diameter and 1/2cm thick that was attached by only a narrow piece of skin at the bottom.  The flap was already cold and when I trimmed the edges it didn’t bleed, so it will most likely die over the next few days.  “If it’s skin, leave it in”, sometimes it surprises you and stays alive.  So cleaned it up and sutured it.  It’s funny how hard on myself I am about making lacerations look perfect when I’m sewing them up.  Being round, it was a bit awkward to sew anyway, but considering that  I am 100% that the flap will die and it will fall apart anyway, I thought it was amusing that I still wanted to make it look beautiful.  The horse’ll be fine — it’s far from the heart.

Both of these clients were very kind and we’ve seen them both before, but they only call us for emergencies when their regular vet can’t make it.  We have three tiers of emergency fees – A daytime fee, a weekend fee for regular clients, and a weekend fee for non-clients.  So, when we get these calls on Saturday night from people who don’t use us as their regular vet, we are perfectly justified to use the non-client emergency fee (though depending on the situation we sometimes cut them some slack).  For me to pull up to your barn, before I even look at the horse, costs about $190 for a non-client ($160 for a client).  Rest assured that I don’t see a dime of that.  But, that’s the life of an equine intern.  The hours can be long, and the pay is always laughably low, and you’ve gotta keep smiling.  Livin’ the dream!

These are a few of my favorite things

If I were to pick two of my favorite topics in regard to veterinary medicine, it would be reproductive medicine and toxic plants.  And hey, there are some plants that affect repro, like mustards or fescue — the best of both worlds!

The breeding season is off to a slow start this year, but we’ve got some healthy foals on the ground, a few mares bred, and several others on our schedule to watch and breed over the next few months.  Enough to keep me happy.  We worked up a “problem mare” a couple weeks ago.  She had been either not getting in foal or losing her pregnancy early.  Luckily, the problem (or at least one of them) was self-evident when we drove up and looked at her and saw that she was a good 8/9 on the body condition scoring scale, and had all the classic signs of a horse with Equine Metabolic Syndrome (cresty neck, regional adiposity behind the shoulder and around the tailhead, divergent growths rings on her hooves reflecting chronic sub-clinical laminitis).  Glucose and insulin testing confirmed that she is insulin resistant.  On uterine biopsy she had mild age-related changes that may be adding to the difficulty, but the first step toward getting that mare pregnant is certainly a diet.

On the opposite end of the spectrum, I checked a mare yesterday that belongs to an employee of the vet school, and the mare was winking at me with her vulva before I even entered the stall.  Sure enough, 40mm follicle on the left and moderate uterine edema.  Ordered the semen, shot her with deslorelin, and bred her today.  Took a sample of the “boyfriend in a box” back to the hospital, and they were certainly swimmers.  This mare has had some pregnancy difficulties in the past, but she looks clean now (without any extensive testing), so we’ll do the pregnancy dance, check her tomorrow to make sure she ovulated, and schedule that fateful exam in 2 weeks when we’ll know if she caught.

Regarding my other favorite topic, toxic plants, I have become painfully aware in the past few months that the vet school curriculum here does not have a strong emphasis on toxic plants.  Shame!  So, I’m putting together a power-point for students to use to learn and review toxic plants, and thinking about giving a 1hr informal evening talk to the AAEP club on plant toxicities in horses.  Could be fun.

My current approach : Enjoy today.  Try not to worry too much about tomorrow.

It’s better than the alternative.

Doing good

Life update : I am almost 100% certain that I will move back to Seattle this summer, with or without employment.  At this point, I think I would rather be in a place I love, with the people (and animals) that I love, and not having the “perfect job”, rather than finding a potentially-great job somewhere else.  The good thing about my job outlook is that the job I want is long-hours and hard work, and the “less perfect” jobs are actually fewer hours and maybe even better pay.  So, at least it’s not the other way around!  I’m confident I can find employment *somewhere*.

Work update : I’ve been doing my part keeping the in-hospital clinicians busy.  Have sent in a few horses recently, and so far they are all doing well. One had  a really swollen stifle, puncture wound in her ground, and was feeling dumpy (don’t blame her).  Sent her in, they knocked her down to have a good look around, and found a big stick up in the wound.  She felt better almost immediately, and has gone home!  Yay!  The other was a laceration on the back of the horse’s right hind pastern (bad spot!).  Sent him in out of concern for the tendon sheath, and it turned out that it did in fact get into the tendon sheath.  Knocked him out a few times to flush it out and treat it aggressively, and he’s been sound in it since the first night, which is a great sign.  A contaminated tendon sheath or joint is never a good thing, and it is always appropriate to send them into a hospital and treat them aggressively if there is any concern, because if you wait a couple days to see if they get more lame you are already way behind in treatment.  If you want a performance horse in the end and you have the financial means, potential over-kill on the treatment is much better than a wait-and-see approach.

In other news, because it has been kinda slow this week, I’ve been putting in some more hours on a couple teaching projects I’m working on.  They are both power-point reviews for 4th year vet students.  One is a “diagnostic challenge” of sorts, with images of horses with fairly readily-identifiable conditions, and questions are posed to the students about that condition (what is it, how would you treat it, etc).   The other is all about toxic plants.  I have found that the curriculum here (and probably other schools as well) seems to focus on memorization of the names of plants and what they do, and in the end the students still have no idea what the plants look like.  Not much help when you’re out standing in a field trying to figure out if any of the plants are toxic.  So I’m putting together a pretty simple power-point that has a couple photographs of the plant on one slide, and then next has information about the plant.  That way it can be used to study or review, and it could also potentially be used to quiz yourself.  It would be better, I suppose, if I couple put it into a program that had the slides come up randomly so your brain wouldn’t just memorize the order that the plants come in on the power-point, but I’m not smart enough for that.

That’s my life at the moment.  There’s always something I “should” be doing.

A sad story

Been a bit busier, and there are officially foals on the ground.  Definitely an improvement.

I’d like to summarize the plight of an unfortunate horse whose story has now sadly come to an end.

I first saw him a while back because he has a weepy eye.  The pupil was very constricted, but otherwise his eye was normal, so treated him with some topical antibiotics and steroids, and topical atropine.  Seemed to do the trick.  A week or so later, he came up lame in a hind foot, and we dug out a subsolar abscess.  Besides being a particularly nasty abscess, it was not overly concerning at the time.

However, it soon got more concerning.  Usually, once an abscess is opened, the horse gets better fairly rapidly, although the actual healing process takes weeks.  This particular horse remained non-weight-bearing lame on that foot even after the abscess began draining out of a whole pared out in the bottom of his toe.  Then, a few days later, both of his hind legs were stocked up and his coronary band looked like thing:

Perhaps the worst abscess ever, but certainly concerning!  At this point, he refused to move and his coronary band was very, very sensitive.  There were monetary limitations and referral to a hospital was not an option, so we treated him conservatively.  Concerned about potential separation at the coronary band and sloughing of the hoof, we took two x-ray of the foot and saw that the coffin bone was not rotated or sunken.  The coffin joint was uneven, but that is hard to evaluate when the limb is not bearing full weight.

He improved a little bit over the next week, to where he would willingly walk on that limb, and the coronary band stopped oozing and began to dry up.  Small steps in the right direction.  But all was not well, because the hole in the bottom of his foot continued to drain, and he was still very lame.  Regardless of what was going on inside that hoof, every day that he favored that limb increased the risk of supporting limb laminitis on the other side.  You can be certain I was watching him like a hawk.

Another x-ray confirmed our suspicions.  He had an infection in his coffin bone (pedal osteitis), not detectable on the first x-rays because it had been too early to see the changes in the bone.  But now it was very clear, and an infection that is set up in a bone requires debridement of the bone and aggressive local antiobiotic therapy.  That was out of the budget.  And, to make the case final, his other hind leg finally succumbed to the weight and developed laminitis.  Up until that point, he could hold his painful foot up and be relatively comfortable.  However, once his other foot began to give way, it was impossible for him to stand comfortably.  The best thing we could offer him was humane euthanasia.

Cross-sectional image of his hoof after the break.

So. slow.

Work has been slow.  I’ve been spending a bit of time tending to the horses owned by the University, patching up their cuts and scrapes.  Otherwise, it’s been very quiet, and I’m not complaining because it’s been bitter cold.  The foals are gonna start hitting the ground here soon!

The heel bulb laceration is doing great.  Going to trim off a little bit of proud flesh tomorrow, but I don’t expect any problems.

I acquired a skull a while back that I recently finished prepping.  This poor horse had some really interesting abnormalities.  He had a very severe parrot mouth, and several other marked dental abnormalities resulting from that, including a wave, ramps in the front and back, and very malaligned lower 2nd molars with large diastemas (gaps between teeth).  He had also had his right eye removed in the past, and he had a bulging forehead.  His skull shows evidence of severe facial trauma.  Poor guy.

Pictures of the skull after the break.

First Post – Heel Bulb Laceration

I would like this to be both a journal for myself, as well as an interesting read for those who may find this sort of thing… interesting.

To that end, I think I will organize it in a “case study” manner.  Each entry will discuss a case (with photos, if available), or update on a previous case.  Hopefully that will accomplish the above goals.

Let’s start with a heel bulb laceration, now about 4 weeks old.   I first saw the horse on December 6, and my first impression was not a good one.  She had caught herself on a smooth wire fence and had a deep laceration that not only cut through her lateral collateral cartilage (which comes off the coffin bone – “side-bones” are when this cartilage becomes boney), but it was also likely that it got into her tendon sheath.  It was too old and dirty to suture it, and referral to a hospital (which would have been ideal) was not an option.  Cleaned her up real well and bandaged it.  Antibiotics, anti-inflammatories, tetanus booster, and stall rest.

The next day I pulled fluid out of that tendon sheath, and sure enough the white cell count was high.   Began injecting antibiotic directly into the tendon sheath.  She did amazingly well.   By the end of the week, the white cell count had returned to normal, she was basically sound on the foot, and the wound looked good.

We put a foot cast on her for 10 days, which reduces the motion of the heels expanding and contracting.  When the cast came off, the wound had granulated over completely.  That was one week ago.  She’s had a light bandage on since then, and I’m very pleased with her progress.  It’s possible that a piece of the cartilage will need to be removed eventually, but for now she’s walking great, healing great, and she’s sick of being stuck in a stall.

Photos are after the break.  *graphic*