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Chokes, Nosebleeds and Birthday Parties

The Call

Charlotte didn’t sound particularly worried in her voicemail as she recounted the events of the evening. Calmly, she explained how this evening’s feedings went as usual. She disclosed that all three geldings were overdue for dentals, and were otherwise a picture of perfect health. Until right before she made this call.

Around 6 pm, Charlotte’s daughter alerted her that Nike was coughing, drooling and running frantically around the paddock. He refused to be caught, and uncharacteristically showed no interest in the treats that were offered to him. “Nike never says no to a treat, so something is wrong.”

Thinking of choke and colic, I emphasized the importance of not feeding him anything. No treats, hay, water or anything else in the mouth until I could examine him. Charlotte reiterated this sternly to her daughters before lowering her voice in the phone, “Just a heads up, my daughter is having her birthday today so there’s a dozen 9 year olds running around the place.”


A Few Words on Choke

Most owners can list the classic signs of choke such as food coming out the nostrils, drooling, coughing and acting stressed. There is also a common misconception that “choke” is the same in horses and people.

In horses, choke refers to obstruction of the esophagus. Usually, feed becomes lodged right after it is swallowed, or right before the esophagus enters into the stomach. In people, choking occurs when something obstructs the trachea or “wind-pipe.” In other words, inhaling one’s food or drink. Horses choke because food became stuck on the way down, never reaching the stomach. Their signs of distress are not because they can’t breath, but because of the pain from the esophagus spasming around the obstruction. Most chokes resolve before I can get there. Those that haven’t, usually resolve after passing a tube down the esophagus and pushing the bolus into the stomach. In some rare cases (especially when the choke has been going on for days before being seen by a vet), there is too much damage to the esophagus for the horse to recover…and in those cases, owners usually elect for euthanasia.


Nike

On my way down the driveway, I passed the backyard teaming with children hyped-up on sugar. I pulled into pasture surrounding the tidy little barn. A forelorn girl stood patiently with a grey pony at the end of the leadrope. Except for the drool, he appeared relatively normal. It appeared that Nike’s choke episode had likely resolved in the 30 minutes it took for me to arrive. However, unlike the usual feed-pasted nostrils, Nike’s nostrils were clean and dry.

“Do you mind if they watch? Some of them want to be vets.” Charlotte asked. A classroom-sized gathering of nine-year-olds stared intently from outside the stall. I didn’t mind, but paused for a second to provide a disclaimer for what I was about to do.

To rule out choke, a nasogastric tube is passed up the horse’s nostril. With finess and timing, the horse swallows the tube. The tube is then advanced down the esophagus until it either collids with the obstruction or enters the stomach. This is the same technique used to administer fluids and electrolytes in cases of colic. While a relatively safe procedure, there is one complication in particular that can lead the unsuspecting spectors traumatized. A nosebleed.


Nosebleed Criteria

There is a small area in the nasal cavity that contains the most sensitive and fragile blood vessels in the horse. In the event that the tube touches, scrapes or bumps this area, all hemorrhagic hell can break lose. We are talking substantial bleeding from the nose. The nosebleed isn’t life threatening, but it can be difficult to convince people of this when they see the blood cascading out like a waterfall. If the blood pouring out their horse’s nostril doesn’t freak them out, the snorting of golf ball-sized blood clots across the stall and splatter across everyone within a 6 foot radius will.

I’ve tubed over 300 horses since graduating vet school. I have come to believe in the Nosebleed Criteria. Although nosebleeds are rare, you can guarantee one if the following criteria are met:

  1. Grey or white colored horse
  2. 3 or more people watching
  3. Someone insists the horse won’t get a nosebleed

It just so happened that all three criteria had been met in the middle of this birthday party. So when I felt the tube nudge up against the ethymoids, I wasn’t the least bit surprised when blood came rushing out of the nostril. The steady stream of blood pooled in the shavings below Nike’s face. I dodged golf-ball sized clots with every snort Nike made.

No one could dodge the blood splatter.

I felt pressure on the tube give as I advanced the final 6 inches into the stomach. If Nike had choked, it had cerrtainly resolved by now. Unfortunatrely, his nosebleed had not resolved yet. When I gave the good news to Charlotte, she didn’t seem to hear me. Her eyes were fixated. Her expression was purely mortified. Not a single attendee of her daughter’s birthday party was spared. Evidence of the emergency and the nosebleed was all across the girls’ faces and outfits.


20 minutes later, Nike’s nosebleed had slowed to a trickle. And I pulled out of the driveway leaving Charlotte to wonder how on earth she was going to explain this to the parents that would be arriving any minute.


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Prepare for [almost] Anything

That-which-shall-not-be-said Rule

We learn through social cues that there are certain things you just don’t say and questions you just don’t ask. Like “taboo” topics at dinner, there is a list of phrases that never have a place at the table. This code of conduct was born out of superstition and irony, particularly in emergency situations. Breaking this unspoken rule is a punishable offense, earning the perpertrator anything from a glare to absolute discontempt.

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The most grevious offenses are those commited on a Friday with an hour left on the clock, or at any emergency. Any mention of it being a quiet day on call willl surely be met with a hefty dose of animosity from co-workers. Point out that the work-day was slow, and 5 minutes later there will inevitably be an emergency flying through the front doors.


The Law of Impecable Timing

Along the same lines as the “jinxed” list, emergencies follow the law of impecable timing. If you want to guarantee you receive an emergency call, make any sort of plans. Schedule a haircut. See a movie. Tell a friend you’ll call them at 6. Schedule an oil change for the car. Set a 10pm bedtime. You can even think to yourself, ‘I’ll finish that load of laundry when I get home.’ That load of laundry will be mocking you six hours and two ERs later.

The law of impecable timing – it’s a thing.


The Art of Preparedness

I was on call last weekend, but made plans to meet friends for coffee at 9AM. And like clockwork, mid-order, I received an ER call at 9:04. The barista mouthed the words, “your usual?” She knew the deal.

The hysterical voice was difficult to understand, cutting in and out with fragments of sentences. I caught snipits as she recounted events: police siren, car honking, horse reared again, fence broke, bolting around, fence attached, cut up, blood, painful, shock, trembling, wounds, won’t put weight on the leg.

Monroe, a 7 year old paint gelding, had been tied to a fence. Spooked by the police sirens racing by, he reared back and broke off the part of the fence he was secured to. He bolted, the section of the fence chasing him through the paddock. I left the coffee shop, triaging with the owner over the phone. We were coming up with a plan she could put into action while I made the 30 minute drive to her house.

He was bleeding. No bandaging material.

He was pacing, unwilling to bear weight on one leg. No extra lead rope.

He was trembling. No banamine. No bute.

Only one laceration required stitches, and the remainder of the wounds were small, superficial cuts and abrasions. By the time I arrived, he was also willing to walk on the injured leg. After the initial assessment and treatment, there didn’t appear to be any life-threatening injuries and he was already looking more comfortable. As we were getting ready to depart, the owner approached my window. “Do you guys have an emergency kit or something that I can buy? I’ve never needed one up until now and I want to be prepared next time.”

The list I gave her sparked the idea for this post.


Equine Emergency First Aid Kits

You can spend a pretty penny buying ready-to-go kits. A quick google search will show you that kits range anywhere from $75 to $1,000. I put together a list of supplies that I would recommend for a fairly comprehensive emergency kit.

Most of the medications are prescritption and would require a vet to sign off on dispensing them. These are medications that I would be okay with clients having on hand, so long as they were routinely seen for annual exams (established doctor-patient relationship regulations).

ESSENTIAL SUPPLIES OF AN EQUINE FIRST AID KIT

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KEY ITEMS

  • Thermometer
  • Stethoscope
  • Headlamp
  • Spare Halter & Lead Rope
  • Gloves
  • Clippers
  • Hoof pick
  • 60ml dosing syringe

BANDAGING

  • Bandage
  • Scissors
  • Non-Sterile Gauze – 4″x4″ Squares (1 package)
  • Elastic Adhesive Bandage (Elasticon®) 3″ (2 rolls)
  • Cohesive Bandage (Vetrap®) 4″ (2 rolls)
  • Non-Adhesive Wound Dressing (Telfa® pads)
  • Non-Sterile Gauze – 4″x4″ Squares (1 package)
  • Elastic Adhesive Bandage (Elasticon®) 3″ (2 rolls)
  • Cohesive Bandage (Vetrap®) 4″ (2 rolls)Non-Adhesive Wound
  • Dressing (Telfa® pads)
  • Rolled cotton
  • Brown gauze (2 rolls)
  • Baby diapers
  • Duct tape

SOLUTIONS AND SCRUBS

  • Betadine® Solution (4 oz)
  • Chlorhexidine solution
  • Bottle of isopropyl alcohol (1/2 gallon)
  • Paper Towels (1 roll)
  • Chlorhexidine solution
  • Bottle of isopropyl alcohol (1/2 gallon)
  • Paper Towels (1 roll)
  • Sterile saline (1 liter)

MEDICATIONS

  • Electrolytes (paste or powder)
  • SSD ointment
  • Bute
  • Banamine
  • Trimethoprim-Sulfa Tablets (SMZs)
  • Acepromazine tablets
  • Dormosedan gel
  • Mag60 paste

KITS AND CARTS FOR AN EQUINE FIRST AID KIT

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The other part of the emergency kit is the actual kit itself. I prefer to use hard-sided containers or carts, because bags and cloth can easily become wet/mold. Replacing everything in the kit because of a water leak, spills, manure etc.. would be quite costly. I don’t recommend cutting corners on whatever carrier you use. I’ve seen some barns buy surplus medical crash carts, stackable tool organizer kits from Home Depot etc…the nice thing is all the supplies can easily be moved by one person, vs. grabbing individual bags/boxes.


Other considerations …

On the subject of preparedness, I would recommend having “cheat sheets” or info-posters reviewing what constitutes an emergency and very brief info on what common horse emergencies are. A diagram of basic horse anatomy and vitals would also be helpful. Below are some examples of these materials.


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*New Resource* Horsedvm.com


A novel online horse resource

I stumbled upon this website awhile back and found its contents especially interesting. I’ve yet to find a great resource for poisonous plants, and was impressed by their toxic plant section!

The site is full of visually pleasing infograms, summaries and overviews of diseases, conditions and their symptom check was quite interesting.

Want to kill a little free time and learn while doing it? Check out this site.


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The Bandage Debate

The subject of bandaging technique and ettiquette can spark some fiery debates among equine enthusiasts.


The potential dangers behind “bad” bandages

Bandage bows are injuries to the tendons/ligaments on the leg that result from improper bandaging. The tendons at risk are critical structures required for flexing joints, and are located on the back of the leg. Damage to these tendons can be serious and cause long-lasting effects on performance. I’ve seen my fair share of bandage bows resulting from the use of poor quality materials, insufficient materials or benign negligence. Most times, it has resulted from a novice horse owner applying pressure wraps or standing wraps improperly.


90% material, 10% technique

When wrapping around a leg, if the tension as maximized back-to-front, it can result in excessive tension on the back of the leg..right where those critical structures are. If the tension (effort to remove slack from the bandage) is maximized from front-to-back, then the maximum tension rests across the front of the cannonbone where less “susceptible” structures are.


Standing Wraps

The common pressure bandage or standing wrap provides structured support and even pressure on the leg.

And what is the key material?

It’s all in the fluff.

Gamgee, combi-rolls and cotton are all materials that serve as “fluff.” They serve as a buffer, a way of preventing particulr area from too much compression. The material that wraps around the “fluff” are materials that create the pressure around the leg. The fluffy layer is insurance, ensuring that no matter how much tension you create in either direction, you won’t be able to put the constricting layer on too tight.

In other words, since there is no absolute “right” direction, you can rest easy in either direction so long as you have the protection of the fluff.


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First Foal of the Season

In the beginning…

Reproductive work makes up less than 5% of our cases. Foals have always been a special area of interest to me, largely because my first veterinary-related job was with a university and USDA breeding herd. For 3 years during my undergraduate studies, I spent the summers orchestrating and managing a breeding program consisting of 30 mares and 3 stallions. It was during these summers that I thought to myself for the first time

‘I can’t believe I’m getting paid to do something I thoroughly love and enjoy.’

I felt like this every day. Although the actual cycling and breeding  (AI and livecover) was interesting, without-a-doubt my favorite part was the foals.  Foals were the heart and soul of the job. From their first day to their last  day, they were both the most challenging and rewarding aspects of my job.


In the present…

Since there is definitely a professional void that foals used to fill, I jump at any opportunity to work with them. Last year, I inherited a big client with a small breeding program. We delivered 6 foals last year, and with the exception of one FPT, they were all healthy. This client also became one of my favorites, and I was filled with mixed feelings when she shared the news she was moving out of state. Part of me was sad at the thought of never working with her and her horses again, while the other part was excited for her new opportunity. The odds of working with mares and foals drastically dropped.

However, another client happened to have a pregnant mare that was rescued off a reservation last summer, She was pregnant, feral and has been a ticking time-bomb for the last 4 months. Since it was impossible to ultrasound or examine her, her due date was a complete mystery. As a 2 year old, she was facing a heightened risk of foaling complications (specifically, dystocia),

The client placed cameras in the stall for constant monitoring, and we all spent many evenings obsessively glued to these cameras. I even found myself checking the cameras while driving between appointments, grocery shopping and every night before bed. Over the past 2 weeks, curiosity turned to obsession as the rescue thought labor was underway any time she laid down, swished her tail, took a break from her feeder or circled her stall.


After the long wait…

It was on a Wednesday, which happens to be one of the weekdays I am not on call for emergencies. When my work phone rang, I didn’t have to look at the caller ID to know that it was the owner of the rescue.

“We’ve got wax!” 

I actually squeel-yelled into the phone with excitement and then apologized for blasting her eardrum. Waxing, in 95% of cases, means impending parturition (birthing process) in the next 6-48 hours. From my previous experience a breeding program, I guessed she would deliver her foal in the middle of the night, between 12am and 3am.

At 11:30pm, I was already out the door before I knew who was calling. This time there was a panicked tone on the other end of the line.

The foal is coming and there’s something wrong! Come quick!”

I live 8 minutes away from the rescue. I was there in exactly 7 minutes. During that handful of time, the foal was born. He lay sprawled on the ground, soaking wet. His dam, while curious about the new arrival, was equally suspcious and reluctant to approach. After passing a physical exam without a single abnormality, I spent a little time soaking up the moments. The adrenaline rush was replaced with heavy exhaustion. My colleague, the official doctor on call, was due to arrive any moment (she lived 30 minutes away). The foal was now in her care until 6 the next morning.


A note on exhaustion, fatigue and sleep deprivation

While I treasure foals, and welcome the surge of emotions that come with the entrance of a new horse life, I was also entering zombie mode. I had spent the previous two nights handling emergencies and then worked two full days with no sleep.

During vet school and the internship, mental/emotional/physical exhaustion is a very real problem. Going without sleep for 36+ hours takes sleep deprivation to a dangerous level. It wasn’t uncommon to wake-up in the driver’s seat, engine still idling and suddenly realizing you don’t remember the drive home.

In the middle of my fourth year of vet school, I remember jolting awake to the sound of someone knocking on my window. My neighbor’s worried expression was followed by

“I wanted to make sure you were okay. My husband said you’ve been idling here for 4 hours. Are you okay?”

It was 4:30 am. I assured her I was okay, just tired.

And during the internship, I even fell asleep standing up. After 42 hours without sleep, I was watching our clinician perform an abdominal ultrasound on a very sick patient. Before I knew what was happening, I felt myself suddenly fall forward…stumbling into the ultrasound and doctor trying to perform it!

Nothing will make you treasure and value sleep like an internship, vet school or any other inordinately demanding job. Looking back now, I shake my head in disbelief that any employer, program or profession would even consider asking or expecting someone to reach this extreme level of fatigue. It’s not only dangerous to the individual, but the patients as well!    


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Reader opinions wanted!

First, I want to say thank you to all the wonderful readers who comment on my posts. I have received heartfelt, supportive, insightful, constructive and empathetic comments and messages…and on difficult days, these notes easily become the most encouraging and inspiring part of my day.

Thank you!

As much as I ramble, rant and randomly post about the various aspects of vet life…I am curious what readers would like to hear more about? So I created this little poll, just to gather some feedback and help take this blog in different directions.