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.

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.

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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.

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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.

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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

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

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KITS AND CARTS FOR AN EQUINE FIRST AID KIT

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.

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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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Colics for Days

The C-Word No One Wants to Hear

The list of causes for colic is endless. Sometimes I say it could be due to a cloud moving across the sky in a particular way…meaning it could be anything. The most common type of colic I see is gas (spasmodic) colic. These tend to resolve quickly, especially with the help Banamine (anti-inflammatory). Most of the time, to the frustration of many clients and equine effianados, the cause of a particular episode remains a mystery. While spasmodic colics can strike at any moment, I see more cases during the changes in seasons and during drastic weather/temperature fluctuations. Hottest days and coldest nights. Colic, simply defined, is abdominal pain. Pain associated with the gastrointestinal tract (the gut) can be due to gas (we all know what gas cramps feel like!), shifting of part of the tract into an abnormal position and therefore displaced, imbalance of natural GI bugs, diarrhea, impactions, twists in the gut or due to other diseases in the abdomen (tumors, infection). While 90% of the colics I see are simple gas colics…the past 2 weeks have really thrown a statistical curve ball.

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Impactions

Last year, I had 3 cases of colic that were due to impactions in the gut. Impactions can be complete (nothing is passing through the clogged pipe) or partial (mostly just liquid passing through, sometime small amount of manure). In the past 2 weeks, I have diagnosed 7 impactions. Usually, I see impactions in the fall. This year, the transition to spring definitely brought in the new. Impactions (basically something in the colon or small intestines that impedes flow, like poorly digested/broken down feed material) can occur anywhere in the GI tract, but particular parts of the horse’s anatomy predispose certain areas to become blocked. These are areas where a large diameter is going to a small diameter, or where the gut suddenly takes a hairpin turn. The most common location is called the pelvic flexure, and accounts for 5 of my 7 recent cases. I think one of the most astounding and stressful aspects of impactions is that they can go either way…as in, some can be managed fairly easily in the field, some may be fatal without surgical intervention. Sometimes, even surgical intervention is not enough.

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Working the Cases

Of my 7 cases, 3 were referred to our local hospital for surgical or intensive management. For the two cases that did not have a referral option (finances, owner choice etc), one made a full recovery over the course of a week. Unfortunately, the other one had to be euthanized within 12 the following 12 hours. All of the impactions were diagnosed by performing a rectal palpation. After identifying the impaction, I assessed how impressionable it is. Some impactions are so firm that I cannot make an impression or indent (feels like a baseball). Others, I can almost mold with my hand (like dough). The more impressionable the impaction, the more likely we will be able to resolve the issue in the field…which becomes a labor-intensive endeavor for vets and owners alike! After identifying where the impaction is, how impressionable it is and how large it is, the next assessment is comfort. If pain cannot be managed, referral becomes the next avenue. Otherwise, the mainstays of treatment in the field is tubing (passing tube from nostril to stomach) in order to administer fluids/laxatives/electrolytes…sometimes requiring 3-4 return farm visits a day for 2-3 days. Discomfort is managed with NSAIDs, and horses are held off feed until they are passing manure and recheck rectal palpation confirms that impaction is gone. In some cases, IV fluids are necessary.

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Additional Info for the Curious at Heart

Vetstream has a great client hand-out about colic that I have included below…for those who want to learn more or brush up on the colic basics.

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On-Call Days

Down-time and Silent Days

Making the most of it

There are on-call days when the phone is silent. This silence comes with its own secret recipe for stress…4 parts foreboding for 1 part paranioa. It can feel like the longer the silence, the more intense the impending ER storm is going to be. It took me awhile to figure out what to do, or not do, during down-time while “on-call.” After trial and error, I have developed strong on-call-but-not-on-a-call habits. When I first started taking on-call, it felt normal to be poised by the cell phone just waiting for it to ring. When an ER did ring, I could spring into action and be out the door in less than 5 minutes. But when the phone didn’t ring, a faint feeling of regret would creep in. Not only did I feel that the day was (personally) wasted, but I also felt (professionally) unfulfilled.

For me, utilizing down-time while still on-call is essential for avoiding burn-out, promoting work-life balance and reinforcing the truth that work has not become my life. When I say utilizaing, I mean being productive enough that time doesn’t feel wasted in wait for an ER than never comes. On the other hand, any project that is started has to be one that can be dropped at a moment’s notice. But on silent days…I still check my phone a minimum 5 times/hr, confirm max volume 2 times/hr and check that airplane mode is not activated once/hour.

My most recent day on call was anything but silent. Between 7:30am and 11:30pm, we had attended 7 emergencies and saw 2 add-on appointments. That’s a full day, especially during the slow season. As I drove home at 1am, I found myself running through the day’s events and eventually mulling over two emergencies in particular. It wasn’t that these two emergencies were clinically distinct, fascinating or dangerous…in fact, they are both circumstances that I would normally shrug off as inconveniences of the job. However, I think the nature of the two circumstanaces is important when gaining perspective into a day-in-the-life of a veterinarian.

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The “Nevermind” Emergency

The ER call rang 15 minutes before the start of our doctors’ meeting. Susan, who was not a current client of our practice, was frantic over the phone. While in the midst of explaining what was happening with her mare, she repeatedly interrupted herself to say

“My vet’s not answering. I can’t get ahold of my vet. I don’t understand why she’s not answering.”

I can imagine how confusion, fear and panic in the moment, is exacerbated when a client’s trusted lifetime vet of 15-20 years is MIA. Tone of voice, pitch, inflection and word-choice can paint a vivid emotional picture, especially of the client feeling pain and confusion brought on by a sense of abandonment. On rare occasions, bitterness and resentment are aimed at whichever vet does respond to the call. From firsthand experience, this type of treatment from clients is hard to swallow.

“Shelving” Client Mistreatment

When it comes to professional advocacy, I think simply swallowing mistreatment from clients does the profession a disservice. In my opinion, having the issue temporarily “shelved” vs. simply swallowed, establishes a line between acceptable and unacceptable behavior. While I don’t think disrespect is something to just “put up with,” having an open discussion requires a particular environment and mindset that emergencies cannot always afford. Bottomline: In order for me to do my job, I have to focus on the reason I am there. This means “shelving” issues that are not imminent or critical.

On the otherhand, I know some vets get upset when they are called only as a “last resort.” Sometimes, clients say that.

“I am only calling you because my vet is out of town.”

“I just need a vet, any vet.”

“I wouldn’t be calling you if I had other options.”

I take these comments in context of the extremely difficult circumstance the client is in, the difficult spot this puts their vet in and the fact that I’m here to help. This thought process keeps the negative thoughts at bay. It also helps that I am an empath by nature.

8 minutes away

Returning to the ER at hand…I kept Susan focused, making sure she was in a safe situation, the mare was contained, and gave her a few minutes to call me back with their physical address. Caught up in overwhelming situations, sometimes you can’t remember how to spell your own name. In this instance, she had to find a piece of mail so she could read off her home address. According to GPS, we would arrive at Susan’s in 45 minutes. During the first half of the drive, the office relayed two other ERs to respond to. When my phone rang again, I recognized the number as Susan’s.

In my experience, when a client calls while you’re still in route, it is for one of three reasons:
– The situation has become dire, they are panicking and have lost all sense of time
– To find out where you are because it’s past your original ETA
– They are canceling the farm call for one reason or another

I answered the phone as google maps’ estimated ETA read 8 minutes.

“I actually don’t need you to come out. My vet just got here.”

This isn’t too uncommon that another vet beats you to a call, either because the client called other vets to see which would arrive fastest or because their regular vet returned their call. I will be honest, this is frustrating. I wished Susan and her horse the best.

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Order of Operations

Determining Which Emergency to See First

When faced with multiple ERs, I prioritize based on severity, urgency and the potential risk to human safety. Numerous times, I’ve been less than 5 minutes from the ER when the client calls to let me know that another vet showed up. This ultimately ends up in re-routing, lost time and money, but most importantly, an unnecessary delay in rendering aid to other patients and clients. Our policy is to bill an in-route cancelation fee, but I have yet to follow through with this. With new clients that don’t have established payment methods with us, pursuing payment is nearly impossible.

I understand the panic and desperation owners feel when their horse is injured or sick. In a situation of overwhelming helplessness, the only help they can provide is getting a vet on the premises. For this reason and out of empathy for clients in these scenarios, I have not had it in me to bill them a cancelation fee. And then there are those rare occasions when the driving force behind a client’s actions are not driven by shear concern, fear and panic. There are times when a client’s motives and intentions are not upfront or even honest…

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ER Disguises

Critical, urgent and not-so-urgent cases

The second emergency was located 45 minutes south, within a mile of our office. It was a choke, which resolved mostly on its own by the time we arrived. As we were finishing up this second ER, the office alerted us to another emergency. Now, the ER waiting list included a mildly painful colic, a moderately painful colic that did not improve with banamine, and a laceration that had significant, uncontrolled hemorrhage. Despite pressure wraps, the owner could not get the bleeding to stop and she feared the horse would bleed out soon. We headed straight to the laceration emergency, ready to face a chaotic, blood-soaked scene upon arrival. As we pulled up to the barn, I could hear laughter and followed the voices to a small group of people standing around a bay polo pony in the wash rack. There wasn’t a drop of blood in sight, and pony appeared healthy enough.

“I’m here for an emergency, do you know where the horse with the laceration is?”

A middle-aged woman and what I presumed was her daughter, nodded.

“This is him. This is Emo.”

For a moment, I thought I had made a grave mistake and navigated to the wrong emergency (the mild colic). I reached out for something to say, still confused and mortified that I had made this profound error. The woman turned to look at Emo, walked over to his right front cannonbone and pointed at a scrape…a two inch long superficial abrasion with only the hair missing.

“I don’t know how he did it, but he managed to lacerate his leg here.”

I thought I had gone crazy, but was much more horrified upon realizing that this scrape was the previously described uncontrollable hemorrhage. She must have read my face.

“I didn’t want to be waiting around the barn all afternoon, so I might have exaggerated a little over the phone.”

She chuckled sheepishly. The other people started to dissipate once the uncomfortable silence kicked in. On an untimely cue, my assistant came huffing down the barn aisle with arms full of wraps, suture and scrub kits, fluids, clippers and even a tourniquet tucked into the v-neck of her scrub top.

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You never know what you’ll find

Prefacing this post with a disclaimer: Graphic wound images are contained in this post.

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After working with particular clients enough, you get a feel for what kind of emergencies they do and do not call about. Depending on experience, knowledge and comfort level, some may call for a tiny cut or they may only call when it appears their horse may bleed-out. And with others, you never know what you’re going to find.

One of our clients left a message on the office phone the night before. Her mare had sustained a wound to her haunches that she thought might heal well on it’s own. She described the wound as superficial, probably a kick from a pasture mate. She said the wound was not bleeding and you couldn’t see any real obvious wound. She didn’t want to pay an emergency fee because finances had been tight, so the office asked if I was willing to work her into the busy day. Fortunately, we were running early and finished up with the day’s appointments a couple hours sooner than we thought.

On arrival, the small palomino mare was in a pen. I had seen her a couple months ago for a face laceration, and before that, an episode of choke. The mare was always suspicious as we approached her with a tote of supplies. Almost an entire roll’s worth of tape had been used to secure a bandage over the right gluteal muscles. As I pulled the sheet of tape off, I saw the soaked maxi-pad that the owner immediately commented on. “I figured, what’s more absorbant than a maxi pad, right?” I removed the maxi-pad and was surprised at the severity of the wound. It was definitely a wound requiring attention, and not superficial in the least.

The wound at first glance.

An L-shaped laceration resulted in a large flap of skin. Beneath the flap of skin, was a deep gaping wound extending several inches into the underlying musculature. The owner must have read my expression because she soon asked “It’s bad, isn’t it?”

“It is big, and it is deep. But luckily, this is fairly fresh.”

After clipping some hair, the large triangular skin flap became apparent

We set about clipped the area, scrubbing the wound and exploring the extent of the damage. Meanwhile, the owner wracked her brain about what could’ve caused the wound. Most of the time we never find out what happened. It is unnerving, knowing that what sharp object inflicted the damage, still lurks in the field with the possibility of a second offense.

Determining the extent of the injury

The front half of the laceration was sutured together easily enough. Dead space was minimized with a deep layer of sutures, and the skin was re-opposed with simple interrupted. Since some dead space existed, and considering the extent of the wound, a Penrose drain was placed. The mare was started on Excede, with the plan to add SMZs due to expense. Bute and SSD were also dispensed. The owner would continue on-farm care involving flushing the wound and readjusted the drain daily. Vaseline was applied to prevent scalding of the back leg from constant drainage that was sure to ensue.

Based on the location, a simple bandage was not possible. We put in 8 stay sutures that would allow us to feed a shoelace through just like you would a tennis shoe. This shoelace method, a tie-over bandage, would secure a clean towel or pad to the wound. Unfortunately, I did not remember to take pictures of the finished work.
In 4 days, the drain will be removed. If the skin flap survives, the owner will continue to flush the wound daily and may also end up packing some of the wound with gauze. However, profound swelling and reduction of dead space, did not allow for room to pack the wound.

It has been a couple days now, and due to financial concerns, the owner could not afford for a recheck. We will be back to remove the external sutures in 10-14 days, and next time I’ll be sure to take more pictures.

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The Doctors’ Meetings

Every other Friday, before each doctor sets out for the day’s appointments, the four of us meet at the only diner in town. Our practice sits on the edge of a quaint town with no need for a single stoplight or stop sign. One of only two restaurants, the diner is nestled in a row of buildings that look straight out of a stagecoach western. State patrol frequently choses this humble eatery as the location for their change-of-shift. On those particular mornings, the diner’s small gravel parking is overrun by patrol cars. This is also the only time when the town experiences traffic as a result of overly-cautious commuters going 10 below the 25 mph speed limit.

Our doctor meetings are held over breakfast, with discussion prompted by 2 or 3 items on the “doctors meeting list” or DML. Items that make it onto the DML come from a wide range of topics, vary in importance and certainly are not guaranteed to stimulate rivoting conversation. Over the past couple months, items on the DML have include updated pricing, barn packages, changes to inventory, on-call schedules, charging tax on products, assistant performance issues, standard protocols for packing equipment, damaged or missing equipment, new drugs we’d like to have on hand…etc.

Once the items on the DML have been checked off, there is an end to the meeting formalities. This is when the meetings get interesting. This is my favorite part of the doctors meetings, when I get to revel in the hard-earned wisdom of seasoned vets.

Case discussions.

It starts off with one of us seeking input on a particularly challenging case. Without fail, it leads to the opening of the case discussion floodgates. In discussing one case, someone inevitably remembers a case they would like insight on…which triggers another doctor to bring up their recent patients and so on.

I call it the case dominos effect.

These dominos turn half-hour meetings into 1.5 hour meetings, subsequently making us all late to our first appointments and causing a chaotic post-meeting scramble in the office. While fascinating and rich with info, there is another reason I look forward to these talks. Its the environment that has been created for the conversations. The table is a safe place to talk openly and without fear. There is no room for judgment, shaming or belittling. These moments are key to nurturing a honest, sincere comradery between colleagues and fosters a strong sense of moral and unity…things I have rarely seen in multi-doctor practices. In an effort to net suggestions or help from our combined 48 years of experience, we also create a robust support system and receive encouragement.

And there have rare occasions when our conversation divulges to less professionally astute topics in veterinary medicine, like the newest gossip about neighboring vets and practices. That’s a subject for another time, and a deserves it’s own blogpost.

And if the DML is blank? We still meet for breakfast because that’s just a pleasant way to start the day.