Thomas

There are certain patients and clients you know you’ll never forget. Some cases that almost haunt you, arising from the subconcious on a whim. Little reminders seem to be hidden in tiny corners and crevaces of every day life. Whether its meeting a person or horse with the same name, diagnosing another patient with the same disease, or even sitting at AAEP lectures with the topic being similar in nature…a horse with a similar disposition, or sometimes just a single word on a billboard. It seems just as time has gone by, there is a reminder somewhere that brings the memories trickling (sometimes flooding) back.

This is the story of Thomas, one of the cases that for many reasons, I will not forget.

I first met Thomas in January for a routine dental and vaccines. His owner, Emma, had been referred to me by the practice that performed his pre-purchase exam only a month prior. His PPE had gone smoothly with no significant abnormalities found during the extensive work-up. The owner wasn’t able to attend this first appointment, but the trainer was present. She lead the handsome young gelding into the washrack. Just watching him walk into the washrack, I could see incoordination and exagerated gate in the hind end. His hind feet were parked oddly out from under his body, with his front feet almost ontop of one another. He stumbled and stepped on himself multiple times in the 5 minutes I spent observing. He had a slight head tilt to the left and the left side of his lower lip drooped. The nature of the appointment instantly changed, with the focus turning to neurological examination instead of a routine dental.

The findings of the neurological exam revealed cranial nerve deficits, especially noteable on the left side. Facial nerve paralysis, the head tild and decreased pupillary reflex times were the most significant CN abnormalities. On dynamic assessment, he had a grade III hindend ataxia and grade II bilateral forelimb ataxia. He had assymetrical muscling of his gluteal muscles, with the right being much more extreme than the left. He had marked weakness during the tail-pull to the right, at one point he almost fell over. Given the cranial nerve deficits and generalized ataxia, we decided to rule out a top differential of EPM. He had neck radiographs taken at the PPE, which after second review, were normal. No traumatic events were in his history.

His EPM titer results came a week later. The titer levels were high, indicating a 95% likelihood that his signs were attributed to EPM. We moved forward with a standard treatment protocol of daily Ponazuril and Vitamin E. In a month, we would return for a recheck neurological exam.

We continued the Ponazuril another month, during which his imrovement plateaued. Emma, opting to give him every fighting chance, elected to try another EPM medication called Protazil. After a month on the protazil, his recheck exam found significant improvement. His neurological signs had improved enough that now a right hind limb lameness became apparent.


5 months later

Now 5 months after diagnosing the EPM, with most of his facial nerve and ataxia signs resolved, we moved forward with his routine care. His vaccines and dental went without complications and he continued to receive his bodywork and acupuncture. I’ve held some skepticism in thepast, but the bodywork and acupuncture had a profound effect on his physical and mental state. He looked brighter, moved easier and the right hindlimb lameness was resolved.

A month later, I received a text that he had relapsed. The same day, I went out to exam him,. He was dull, quiet and his neurologic abnormalities at returned worse than before. After heavy consideration, Emma made the difficult decision to let him go. Unfortunately, for insurance to cover the costly treatments and reimberse for all the money spent, a necropsy at a certified facility had to be performed. I won’t name the insurance company, but I will say that how all the details were handled was grotesque. The insurance company required that Thomas’ necropsy be performed with 8 hours of his euthanasia. Since the only lab near by was 6 hours away, and since Thomas was not safe to transport, it took detailed coordination between all of us to meet the time constraints. In the veterinary field, you develop a way of talking about these things in a tactful, professional manner. I have never had a client involved in the details of this process, and honestly, I had never been involved in planning such intricate, time senstive logistics. The whole process was heartbreaking and gruesome for Emma, a nightmare for anyone whose beloved companion becomes an object, entity or commodity to company policies. I admire her and all of the strength she clearly showed through this painful process.

To meet the time constraints and laboratory hours, we had to euthanize Thomas in the middle of the night. After working that day, I set my alarm for 12am so that I could make it to the barn by 1 am. His transportation (provided by my assistant) would deliver him to the lab between 7 and 8 am. I set the alarm, just in case…but I definitely did not sleep. I had discussed his case with multiple internists, researched novel treatments so extensively that anytime I went onto google, it asked if I wanted to search new research in EPM. Although I was confident in my diagnosis and that the treatments we had done were the present gold standard, there was still that little voice whispering “but maybe…”

We arrived at the barn just before 1am. We placed the catheter, sedated Thomas and lead him out of the barn. Fog had crept in and it was starting to rain. Then, it started to pour. I remember the syringes being slippery, and all of us squinting through the beams of the headlamps as we laid him down under using anesthetics. He went down gently onto his side, deep in a sleep state, before Emma gave the gesture to give the final injection. Within minutes, Thomas was gone.


Answers

It was 2 weeks before the necropsy results came back. The trouble with EPM, is a definitive diagnosis is not always possible even with necropsy and microscopes. The chances of identifying the organism, especially after months of treatment, becomes slim. My fear was that the necropsy would not identify the organism anywhere, and determine the cause of his neurological disease indeterminant. When I read the results, my heart sank. No EPM organisms had been identified on necropsy and histopathology. But down, at the very bottom of the extensive report, a note said that the abnormalities found in the spinal cord were consistent with those seen in EPM.

We had all reached a point where we wanted answered. We wouldn’t get the answers as to why he suddenly relapsed, or why he didn’t respond to treatments like some horses. EPM, the heartbreaking disease that it is, can do anything at any time…making it a challenge and yet another disease warranting further research.

We did not get the answers we wanted, but we did get the answer we needed.

At a horse show a couple weeks ago, I ran into Emma. We small-talked a little, and she hugged me before we parted ways. She expresed sincere gratitude for my efforts. She said one day she might look at bringing another horse into her life, but that she isn’t ready. I returned the hug. Sometimes, at the end of it all, that’s all you can do.


Click here for information on Equine protozoal myeloencephalitis (EPM)


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When we cannot save them all, but we can save some

Like many rescues in the area,”Starfish Rescue” used to rotate through all the local vets. Almost as if going through phases. Before I eve stepped foot on the property, I was warned ahead of time. One, their bill is outstanding at over $5,000 owed. Two, overcrowding. Three, don’t be surprised if compliance is low. Four, don’t get sucked in.

My first time arriving at the rescue was in response to a horse that was down and seizing. We never determined the cause, and he never seized again. My second visit, months later, was to recheck a laminitis case that my colleague had seen a couple of weeks prior. The mare had recently had her feet trimmed, and Maureen (owner of the rescue)reported the mare was still having difficulties walking. It was difficult to focus on the laminitis over the glaring neurological deficits. After a full neurological work-up, EPM was at the top of our differential list. With titers returning at >3500 with two subspecies, we felt comfortable with the confirmed diagnosis and began treatment.

Over the next couple months, I attended several more emergencies at the rescue. Sick foals, colicking mares, face wounds, terrible leg wounds, even a sweet gelding hit by a car…cases I will never forget for both good and sorrowful reasons. And trying to make a difference, while balancing financial constraints with high quality diagnostics/treatments means a lot of advanced diagnostics went under the radar. With a limited budget composed of donations, it is a different challenge all of its own trying to negotiate and prioritize which horses to treat and which horses could not be saved…especially when the rescue’s conviction stands behind saving them all.

Early on, my recommendations based on poor prognosis (septic joints, fractured joints) was unheeded. It would take weeks for the rescue to come to the same conclusion, with the euthanasia being performed by the same person who picks up the horses afterwards. A bullet to the skull can be an effective form of euthanasia, but when it goes terribly wrong, it can be one of the most inhumane ways.

6 months in, and I have earned their trust. Early on, I would have to defend every diagnostic, medication, treatment protocol and justify quality of life concern. Now, not only am I greeted with open arms, but their compliance with my instructions and view of my professional opinion, does not waver. It is amazing what time (on and off the clock), patience and a whole lot of energy can do for a relationship, especially a professional veterinary one.

There have been cases that tugged my heartstrings, and cases that I spent night after night attending. We have lost some horses and saved some horses, but with every horse, we have always tried our best. It was some of these strange cases that I further expanded on my skill set, performing joint lavages and regional limb perfusions. With money a constant wall we are up against, I’ve put in many calls to specialists and board certified surgeons/internists. I am thankful for both their time and energy, and the helpful advice that has led me to treating cases in unconventional, yet successful manners.

So, although I didn’t know it when I showed up at Starfish Rescue the first time, it would come to be one of those places with some of the most sincerely compassionate people I have ever met…and something I have wholeheartedly become thankful for this year. And it reminds me of medicine in general, that we cannot save them all, but we can certainly save some.

Case of the Mondays

Like most things in life, do something long enough and often enough, and it gets easier. Drawing blood, placing catheters, passing a nasogastric tube, suturing…do it often, with a goal of doing it well. Then, there comes the added benefit of confidence. And there’s no better way to appreciate a skill, than to have acquired it and then lost it. About halfway through a “typical” day, I was made aware of those skills I take for granted.


BAL Gone [every kind of] Wrong

It started with performing a bronchoalveolar lavage on a gelding with intermittent coughing over the past year which fluctuated with weather, exercise and environment. With non-specific findings on ultrasound, we proceeded in our diagnostic plan to determine the nature of the cough. We elected to retrieve a non sterile sample from the lower airways to evaluate for RAO and IAD. I’ve passed an endoscope countless times, and performed it successfully and easily enough that I consider it at acquired, reliable skill.

By the conclusion of the BAL, I felt like I had rehearsed for a performance demonstrating everything that could not go right. The highlights of this performance included:

  1. BAL tubing hit the ethymoids, causing a profound nosebleed
  2. Projectile, unrelenting spraying of clots across self, assistant, owner, trainer and three innocent onlookers
  3. BAL tube entered the esophagus, rather than the trachea
  4. BAL tube retroflexed and came out the oral cavity
  5. BAL tube severed by teeth when traveling through the oral cavity
  6. BAL tube #1 ruined, retrieved BAL tube #2
  7. BAL tube positioned correctly in trachea, cuff would not inflate
  8. BAL tube #2 leaky cuff confirmed
  9. Continuation of #2 problem (Projectile, unrelenting spraying of clots across self, assistant, owner, trainer and onlookers)
  10. BAL tube in position, cuff inflated, saline injected in…unable to collect any saline
  11. Added more saline through tubing, retrieved <40 ml

I was relieved when the whole thing was done. After all the above complications, at least the sample was collected and submitted. What else could go wrong? Then, I got the lab report stating:

Sample has insufficient cells, inconclusive. Recommend collect second sample for analysis.

This was just the first appointment of the day.


Miscommunications, mistakes, mishaps and misfortune

When not a soul could be found at our second appointment, I called the owner. Turns out, the appointment had been rescheduled to the following week…news of which, didn’t happen to make it to today’s day schedule.
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Our third appointment canceled.

Our fourth and fifth appointments had the wrong addresses (showed up at a neighbor developement and then mistakenly went to the owner’s house instead of the boarding facility).

Collected the wrong blood tubes, forgot to dispense a medication refill, double-charged on an invoice, made at least 12 U-turns…

And the cherry on top? At 6pm, as we’re wrapping up at the last appointment and about to begin our 90 minute drive home through late rush hour traffic…my assistant hesitantly asks,

“Hey, have you been having problems with the gas gauge?”

I hadn’t. No one had. About 4 minutes later, the thing we were dreading came to fruition. We ran out of gas.


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Mindhunters and Midnight Calls

For my first on-call weekend, I was co-pilot to one of the associates and assistants. Around 11:30pm, as we were wrapping up our 4th emergency of the day, we got an ER call for a horse in respiratory distress. The first address we arrived at was in the middle of a suburban neighborhood, obviously the wrong address. We idled in the couldesac while the associate, Dr. Kepper, struggled to get the correct address. It seemed no one on the phone knew the address for the residence, althought they confirmed the horse was in fact at their residence.

After 25 minutes of wrong turns, u-turns, and sleuthing via google maps, we made it to the right road. We drove quickly down the paved road, passing occasional looming, dimly lit mansions. When the driveway ended, we parked in front of a run-down expansive ranch home. None of us got out at first. We just watched the events unfold infront of us. Our arrival sparked some confusion amongst the obviously enebriated residents. Enebriation, not uncommon for late night calls, usually owners who opened a bottle or two of wine before discovering their horse had a laceration or bit of colic. But it didn’t take long observing this group of random strangers, that enbriation was a little too soft a word. Their movements were, for lack of a better word, tweaky. Their speech was incoherient, thoughts scrambled. I wondered how they had managed to call us, let alone find our practice online.

I am going to preface the remainder of the story with this small tidbit: Earlier today, I had binge-watched the second half of Netflix’s season one of Mindhunters.

One man, in his mid 40s, approached us. To access the back pasture, they had to move a truck which blocked the driveway around the back of the house. We did not think much, until a scrawny young man and man in his mid 70s came wandering through the overgrown hedges of the front lawn. From somewhere in these hedges, they produced jumper cables.

Dr. Kepper wasn’t about to wait for these shenanigans. “We’ll just walk. How far is the horse?”

The central area of the house was mostly windows with a large atrium garden. With every light on inside you could see the entire layout of the home. Dark is dark, I’ll admit. But it wasn’t until I got outside that I realized just how dark the night was. No moon, no stars, just darkness above and around. I grabbed the headlamp and Dr. Kepper carried her laptop as a makeshift light source. The guy lead us around the side of the house, wading into darkness and unknown terrain. In the light of my headlamp, I saw he had his shoes on the wrong feet, the last half of the shoelace strands worn off. He wore one dirty sock. I glanced inside the house in time to see a figure of a woman sitting on the floor rocking back and forth anxiously.

Uneven steps led down the side of the house past windows of the daylight basement. One of the windows in the basement had black, metal bars on the inside of the glass. The room was empty, but I could see a jail-style door on the opposite wall. On the other side of the rod-iron door was a normal door. No one else seemed to notice the homemade “cage.”

This was the point at which Mindhunters triggered my rampant imagination. We continued in silence down behind the house, through the middle of a pasture of unknown proportion. The only noise was the sound of us slushing through damp, tall grass. After several minutes, an old barn loomed ahead in the glow of my headlamp. Dr. Kepper marched on, following a couple yards behind the man. The barn had two big doors, but the first thing I noticed were the many, many locks and bolts and chains on the outside. It as not necessary to count the number of bolts, padlocks and chains to know that it was excessive and albeit, alarming.

The man was heading straight for the barn, Dr. Kepper striding behind. The assistant shot me a “this is #$%@ing sketch look.” I mouthed back “I will not go in there.”

Just as we thought he was going to start unlatching, unlocking the doors, he turned and lead us beyond beyond broken fencing into another expansive field. If possible, this field felt even darker than the first. I couldn’t see the house behind us anymore and I kept looking over my shoulder to see if anyone was following us.

This was when I began to wonder if there even was a sick horse here.

I kept checking behind us as I followed Dr. Kepper’s laptop glow. Just as I was going to ask how much further to the horse, a shadowy figure came into view. I feel kind of ashamed to admit it, but it was a wave of relief that washed over me the moment I saw the down horse. Then that relief vanished, and we all launched into emergency care mode.

The mare, down and unresponsive, had labored breathing, no CRT, a heart rate of 80 and weak peripheral pulse. She was matted, sticky with sweat that had cooled, and her muscles were rigid. It was very apparent she had been suffering for some time. Her body was covered in wounds, the ground around her torn up from her thrashing around. After discussing prognosis and options, the owner elected for euthanasia. Although a sad ending, the ability to bring an end to her drawn out suffering was the most compassionate thing we could do. While the owner disappeared into the darkness, we sat with the mare for a few moments before confirming she had passed.

Silently, under the glow of the dying headlamp and Dr. Keppler’s laptop, we navigated our way back to the truck. After loading up, no one said a word until we had some distance.

“I know no one attacked us or threatened us, but I just have the feeling that we narrowly escaped with our lives.” I said, and a some laughter lightened the heavy mood in the truck…right before Dr. Kepper’ phone rang with the next late night emergency.


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Unsolved Mystery (Part 2)

Picking up where I left off, the last entry was about an emergency case involving a non-weight bearing lameness and unexpected penetrating wound to the abdomen. Without the financial option for referral, the owner (fictitiously referred to as Karen from here on out) opted for managing the mare (fictious name of Sugar) at home. Our aggressive antibiotic required placement of an intravenous catheter, and intense training session regarding care, maintenance, problem solving and how to use a catheter. I am always nervous when it comes to client managing catheters in the field. Luckily, Karen had previous experience working under a vet in an equine surgical center.

Sugar was started on a 5 day course of intravenous antibiotics (Kpen and gentamicin) and an anti-inflammatory (flunixin). The dime-size penetrating wound was sutured closed. I expeted that the would see evidence of complications (peritonitis, compromised bowel etc) within the first 24 hours, and was pleasantly surprised when Karen informed me Sugar was holding steady. Her appetite and energy level remained consistent, as did her severe lameness on the hind leg. It wasn’t until day 3 that she threw the first fever, a staggering 104.5 F. When the fever was unresponsive to banamine, Karen took to giving alcohol baths. I was anticipating at any moment, the downward spiral would begin…but aside from transient fevers, Sugar was still holding steady at day 5.

On day 5, Karen reported the catheter wouldn’t flush and after confirming it was no longer patent, we pulled it. To continue the antibiotic coverage, Karen was given excede and her fevers had stopped. Haunting still, was the none-weight-bearing lameness that remained unchanged, and was now making me suspect a pelvic or hip injury. With her budget depleted, no additional diagnostcs or treatments were an option…and we began discussing quality of life concerns for the severe lameness. Karen painfully drew a cut-off point for Sugar’s recovery, which was a week. If her hind leg wasn’t showing improvement by the end of the week, she would have to be let go.

I didn’t hear from Karen for a week, and when an appointment popped up on my scheduled, I assumed the worst. Much to my surprise, her lameness had improved by 50%. And after another week, she was 90% sound on the left hind. Sugar never looked back after that…she recovered completely, despite the odds.

Word on the Street

And the mystery of the penetrating injury? It’s all heresay, but on my final visit to see Sugar…a neighbor just happened to swing by.

“It’s been bothering me ever since day 1. I was working in the garden, a quarter mile down the street. And you seen those big concrete pillars? Well, that day I was pulling weeds, and saw this man park his car right next to the pillars. He got out with a big black duffel bag and I remember wondering now what is he doing. At first I thought he was just working on something for the county. But he was in normal clothes, a white t-shirt and jeans. I just kept doing my gardening and it must’ve been an hour. When I looked over, he was laying on his stomach on the top of the pillar, like they always show snipers doing. And I heard my phone ring, so I went to answer it and in the middle of my phone call, there was a gunshot. My husband and I hunt, I know a gun shot when I heard one. I thought he’s poaching! I looked out to see he was still there on his stomach. So I called the police because you can’t be firing into someone’s pasture or at farm land like that. Well, I was terrified and stayed inside…I didn’t want him to know I was in there. When I heard the police knocking and answered the door, I could see over their shoulders that other cops were walking around the pillar but the guy’s car was gone. I think that guy shot the horse!”

Seeing the Signs

This story stuck with me, because a month later, at a farm in the area there had been a couple cows believed to have been shot (they didn’t die, but had wounds similar to Sugar’s. When a dog and goat were shot a months later in the neighboring town, what originally sounded like a far fetched theory…started resonate.

It’s been a couple months now, and I have yet to hear of more animal shootings…but if this really is a person targeting animals, could the target become a human? Unfortunately, the city and state police don’t consider the events related…but it also sounds like there has been little follow-up into what could be considered early indications that we have a fledging psychopath.

They all go differently.

Euthanasia, and the process of euthanizing, is not a new concept or experience for me. My first euthanasia experiences were assisting with the euthanasia of research animals while working for the USDA and veterinary micropath department of the vet school. Horses, sheep, goats and cattle were the species involved in various research studies. There was a set protocol in place that made the process fast and efficient, which while it sounds cold, was also very humane. Some animals appeared healthy on the outside, and these were the more difficult ones to euthanize at the conclusion of a research study. Other animals were deeply affected by disease, and it was a deep relief to see them at rest and at peace.

While respectful and maintaining dignity of each research animal, the emotional element that is embedded in the relationship between owner and pet was missing. It wasn’t until I was working at a small animal hospital before veterinary school that I was exposed to the emotional elements that follow with the decision of an owner to say goodbye to a beloved pet. These cases, I will admit, tear me up. I have always linked with people’s emotions, and have an unwavering empathy for people. When an owner is sobbing or tearfully talking to their pet for the last time, I cannot help but shed tears. I’ve faced some unkind remarks from colleagues for this visceral reaction I have, but the truth is…I’m okay with it. It’s my most candid display of truely caring, both for the animal and the person attached. There is no shame in it.

Throughout veterinary school, I never had a patient that was euthanized. But I experienced my own loss in veterinary school when my 18 year old lifelong companion, my childhood cat, was euthanized after secuming to alimentary lymphoma. It was the single most significant and profound loss I’ve had in my life so far. It was traumatic, painful and was compounded by the fact that I probably waited a little to long to come to the decision. I didn’t realize this until after he was gone, and it remains a haunting realization.

Then, my internship brought forth many euthanasia experiences. I performed my first solo euthanasias in my final six months. For the most part, the process went quickly and well. The nature of euthanizing a horse appears sudden and abrupt. One minute the are standing, then they collapse. Sometimes, it is violent. There are many factors that contribute to how a horse goes down, and how quickly they are gone. Of the euthanasias that appear more difficult, or prolonged, I have noticed that these horses tended to have underlying cardiac or neurological diseases. There is individual variation, even without underlying disease (that we are aware of). On a rare occasion, there has been human error…but this is a deceiving statement. When it comes to injecting the solution, the most important part is that the entire solution enters the vein. In horses, this is the jugular vein. The Drug acts to stop the heart. The appropriate amount must enter the bloodstream, for a partial dose can render a situation fraught with danger, stress and possibly chaos. There are plenty of stories of euthanasia gone ary. It’s a haunting experience for everyone involved…and certainly the very last thing a veterinarian would ever want an owner to witness.


My first bad euthanasia experience happened on the second to last day of my internship. It was a middle-aged gelding that presented for severe colic, and Surgery was not an option. Despite medical management attempts, he became progressively uncomfortable and the decision was made to euthanize. It was the resident and I on the case, and owners were a younger couple struggling to keep their composure as they made the difficult decision. They had also decided to not bare witness, and were about to leave after final goodbyes. As they were stepping out, they changed their minds. They wanted to be present. We had to load the horse up on Pain killers and sedatives to buy me a couple minutes to grab the euthanasia supplies. Because of the horrible weather, we chose to euthanize in the work-up stall. At this point, he was being restrained in a shoot (a mobile door that swings, and keeps horses against the wall.
I injected the euthanasia solution into the catheter I had placed an hour before. All was still, while I held the door and the resident held his head. It was 30 seconds later that he started buckling and then launched forward. He took a nose dive, and his hind end almost came over his head. He started kicking within the chute, and the resident was doing everything in her power to hold him back for fear if he broke lose, he could crash into anyone or anything. Then, he had what appeared to be a seizure…rhythmic banging within the chute. The only other thing I could hear aside from his grunting and kicking was the owners gasping and running out of the room. Then, he sighed and passed away.

We don’t know this happened this way, with an adequate dose and a patent catheter into the jugular vein. There are many theories, I’m sure. But unfortunately, we’ll never know and worse yet, is that these were the last moments the owners will remember forever. I cried as soon as I got in the truck, cried all the way home, and then cried as I told my roommates what happened. It was one of those moments that brings up a barrage of negative feelings and the sense of ultimate failure. Guilt, shame, disappointment, fear, regret, remorse, confusion and shock…all in the face of failure. And I definitely started asking myself if I should even be a vet if I cannot be a good one.

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