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.”

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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.

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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.

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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.

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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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The Bandage Debate

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

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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.

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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.

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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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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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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.

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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.

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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.

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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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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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