Salem’s Story, Saving a very special horse
By Dr. Janet Han, Great Lakes Equine Wellness Center, Inc.

The veterinary profession lends itself to many challenging cases that often require intense medical management, diligent care, close client relationships, and cooperative patients. Despite these efforts, sometimes the prognosis for the condition remains guarded. However, with recent medical advancements, the outcomes of these cases are becoming more and more favorable. Occasionally there are cases that epitomize the importance of each of these components resulting in a successful outcome: this is the story of Salem.

Salem came to the Great Lakes Equine Wellness Center after an approximately one week history of being depressed and not having a good appetite. Salem received veterinary treatment at home consisting of intravenous fluids but remained depressed and was brought to our clinic. One of the first things done following an initial physical exam was a complete set of bloodwork. This had also been done on the farm and had shown a very high creatinine level. Creatinine can become increased due to dehydration but can also increase due to renal (kidney) disease. Salem’s creatinine was decreased from before, but still remained significantly elevated at 4.5 mg/dL (<2.0 mg/dL is normal). Calcium was also increased on the bloodwork, which can be another sign of renal disease. A sample of urine from Salem was also analyzed, and the specific gravity, which is a measure of the kidneys’ concentrating ability, was abnormal. This indicated that his kidneys were not concentrating the urine like they should, and further supported the diagnosis of acute renal failure.

Treatment for acute renal failure was initiated, which included constant intravenous fluids and a furosemide and dopamine infusion. Furosemide is a diuretic and is also thought to reduce the workload on the kidneys. Dopamine is believed to improve blood flow to the kidneys at certain rates. Anti-ulcer medication was also added to the treatment regimen. Ultrasound of the kidneys was performed and no abnormalities visualized. Salem’s attitude and appetite improved on therapy, and creatinine decreased to 3.7 mg/dL over the next several days. However, this improvement was not as pronounced as desired, and it was decided to start peritoneal dialysis.

Peritoneal dialysis is a therapy that has been used for a long time in human medicine for renal failure. It has also been used fairly extensively in small animal medicine, particularly in cases of renal failure that are refractory to conventional medical therapy. However, it is still a relatively new therapeutic option in equine veterinary medicine for treating renal failure. To perform peritoneal dialysis in horses, a dialysis catheter (a chest tube) is placed into the abdomen. Peritoneal dialysis utilizes the peritoneum, a thin membrane that lines the abdominal cavity. The peritoneum acts as a membrane across which fluid and certain substances flow and are filtered and cleared from the blood, thereby taking up part of the workload of the kidneys. Fluid (in this case a balanced electrolyte solution known as Lactated Ringers) is infused into the abdominal cavity via the dialysis catheter. It is then allowed to sit in the abdomen for a certain amount of time and then drained.

Peritoneal dialysis was performed for several days on Salem. He was also placed on broad spectrum antibiotics to prevent any infections that might occur from the catheter being in his abdomen. Creatinine eventually decreased to 2.8 mg/dL at its lowest point. At this time, it was decided by the owner that Salem should go home, as he could not remain on peritoneal dialysis and intravenous fluids indefinitely. As Salem had received over a week of intensive medical therapy for renal disease, it was hoped that this had allowed his kidneys enough time to heal and that he could complete the remainder of the recovery process at home. Although his creatinine increased somewhat after discontinuing medical therapy, Salem continued to remain very bright with a great appetite and was discharged into the care of his owner.

Recommendations for Salem included changes in diet and management to prevent worsening of renal disease. It was recommended that alfalfa hay and feeds high in protein be avoided, as these would increase the workload on the kidneys. Also, it was very important to ensure Salem drank well, for example by supplementing him with electrolytes to stimulate thirst. Regular recheck exams along with repeat bloodwork to be performed by the owner’s regular veterinarian were also recommended. 

To everyone’s delight, Salem did well at home and his creatinine eventually returned to normal over the course of several weeks; due to his promising recovery, he will be able to return to competition this year.  Overall, this case is a prime example of how client commitment and applied medical advancements saved the life of one very special horse.

Memorial Day Miracle
by Dr. Julie Bryngelson

While serving as the on-call veterinarian on Memorial Day, I received an early morning page requesting a response to a trauma situation.  I quickly contacted the individuals to discover that two horses had collided in a pasture. One of the horses, we’ll call him Trigger, was stuck on his side and flipped over onto the ground. The impact was so great that his withers had dug into the dirt several inches. Following the incident, Trigger was standing, but not breathing well and in need of veterinary care.

Upon arrival at the farm, Trigger was quiet, but had a very difficult time breathing. His temperature, pulse, and respiratory rate were within normal limits.  However, crackles were detected in the left lung field and there was a large painful swelling on the left chest approximately 12” X 12.” The lung sounds were also decreased in several areas of the lung fields. Due to the painful swelling and the abnormal lung sounds, a thoracic and abdominal ultrasound were performed by our internal medicine specialist, Dr. Janet Han. Blood samples were also submitted for a complete blood cell count and chemistry profile.

During the ultrasound examination, we discovered fluid accumulating in Trigger’s belly and chest.  We also detected a mild pneumothorax (entry of air into the pleural cavity). However, no rib fractures were detected.  An abdominocentesis (“abdominal tap” or “belly tap“) was performed to collect and further evaluate the fluid accumulating in the abdominal cavity. The fluid was blood. Trigger was bleeding internally into his abdomen (hemoabdomen). Ultrasound evaluation of the spleen was normal, and the source of the bleeding could not be determined by ultrasound examination. At this time, Trigger was transported to the hospital for intensive care therapy. 

After arriving at the hospital, Trigger received intravenous fluid therapy infused with a medication to stop the hemorrhaging. He also received an anti-inflammatory pain reliever, intravenous antibiotics and 100% oxygen via a nasal cannula. His complete blood cell count and chemistry profile were normal, but he was placed under intense monitoring. After arriving at the hospital, a re-check ultrasound revealed additional accumulation of fluid in the thoracic cavity, mainly the left side, but no change in the amount of fluid in the abdomen. The large amount of fluid in the chest was making breathing a very difficult chore for Trigger. A chest tube was carefully placed in the left thorax to drain the fluid from the thoracic cavity. A large percentage of the volume of fluid was blood. Trigger was also bleeding into his thorax (hemothorax)! 

In order to prevent a pneumothorax (air accumulating in the pleural cavity-which can lead to collapse of the lung), a one-way valve was placed on the end of the chest tube.  The valve allowed drainage of the fluid, but prevented air from entering through the tube.  At this time, the packed cell volume (PCV-percentage of the volume of whole, unclotted blood occupied by the red blood cells) and total protein values were re-checked.  The PCV was decreasing to significantly lower levels due to the internal hemorrhage. Trigger was closely watched and his PCV was evaluated several times that evening. Finally around midnight, Trigger’s PCV has decreased significantly enough to warrant a blood transfusion. I called Dr. Blohowiak to ask if we could use one of his horses as a blood donor and made the trip to his farm. 8 liters of blood was taken was taken from his horse, Billy, and collected in bags with anti-clotting fluid in them. Once back at the clinic, this blood was slowly administered to Trigger. Trigger was closely monitored during the transfusion to be sure he would not have a negative immune response. The transfusion went very well. Interestingly enough, any healthy gelding can potentially be a blood donor for an initial blood transfusion. Subsequent transfusions require typing and cross matching.

Throughout the following six days, Trigger’s PCV was checked 2-4 times daily, he received around-the-clock monitoring and treatments, and his condition gradually began to improve.  The chest tube was removed when the fluid draining through the tube stopped, and ultrasound examinations were performed to ensure fluid did not accumulate in the thorax following removal of the tube.

When he was stable enough to go home, his dedicated owners continued medical therapy with antibiotics every six hours and anti-inflammatory pain medications every 12 hours.  He also received daily oral medication to prevent ulcers that can occur as a result of long-term therapy with non-steroidal anti-inflammatory medications.          

Boomer’s Trauma
Acupuncture for Facial Nerve Paralysis
by Dr. Patty Glover

The world is an ever-changing place. The daily advances we make in our thoughts and technology simply amaze me! Not that long ago people believed the world was flat, we’d never walk on the moon and in home personal computers might show up by the year 2020. It seems to me, with things changing so impressively all the time; it pays to keep an open mind. It certainly paid off for a client of mine!
           
In the spring of 2007, a beautiful young paint horse stallion named Boomer started showing some unusual symptoms. At first his owner, Becky Wickesberg, noticed that she thought his lips were just a tiny bit droopier than normal. It was a very subtle change (one that I am not sure I would have noticed!), so she decided to watch it carefully. Then a few days later it seemed like his nose was slightly tipped to the side. The next day it his nose was definitely tipped to the side, so Becky called her veterinarian right away.
           
Dr. Paula Valeria came to examine the horse and discovered he had facial nerve paralysis. When a horse has facial nerve paralysis the motor function to one side of their face is impaired. The facial nerve starts at the “brain stem” or the base of the brain at the back of the head and it travels to the muscles of the face. The facial nerve’s job is to tell the muscles what the brain wants them to do. These muscles cause movement in the eyelids, ears, nostrils, cheeks, nose and lips. When the nerve is damaged, the messages don’t get sent and the muscles subsequently don’t work correctly and often appear paralyzed.
           
Facial nerve paralysis is usually the result of trauma. A horse could hit their head very hard, be hit by something, cut the nerve through a bad laceration or simply lay for a long period of time on the side ring of a halter to damage their facial nerve. The amount of trauma will indicate how severe the paralysis is and whether or not it is permanent. To this day, we are not certain of the cause of Boomer’s facial nerve paralysis.
           
There are no standard traditional facial nerve paralysis treatments. If there is obvious trauma, we attempt to treat that with anti-inflammatories and reduce any swelling that may put pressure on the nerve. But often we must simply wait and see what happens. Ideally, as the damaged nerve heals, the facial function will slowly return. Unfortunately for Boomer, this “tincture of time” was not accompanied by any improvement. In fact, his condition was still actively worsening!

As luck would have it, Dr. Paula suggested they find out whether or not acupuncture might be able to help him. Acupuncture is an ancient treatment method, originally used in China, as part of a complete health care system known as Traditional Chinese Medicine. During an acupuncture treatment needles are inserted into special spots on the body called acupoints, or acupuncture points, to cause a desired healing effect. These needles work to balance an energy network in the body, or one’s qi (pronounced “chee”). At the time, I had recently completed the Veterinary Acupuncture training at the Chi Institute in Florida. I knew that many diseases were successfully treated with acupuncture and facial nerve paralysis was one of them.

Becky was only too happy to try the acupuncture treatments, as she was desperate to give her favorite riding horse some relief. Facial nerve paralysis not only causes an odd appearance of the face, but it is also actually quite dangerous for the horse. As in Boomer’s case, his left eyelid was unable to blink and he was not producing tears. His left eye was completely unprotected from the environment. Just imagine if your horse rolled in their favorite sandy spot or dove into a deep hay pile for a snack, but was unable to close his eye to protect it from the sand or hay. For these cases, it is only a matter of time before the horse accidentally damages their eye.

Three weeks after the start of Boomer’s condition, we started acupuncture treatments. Typically, we prefer not to sedate patients for acupuncture. The sedation drugs can interfere with the chemical response in the body that happens during acupuncture and thus make the acupuncture less effective. But Boomer thought sticking needles in his face might very well be the stupidest idea in the whole world, and thus he was sedated for every treatment.

During each treatment, acupuncture needles were inserted into his face, back and legs. An electro-acupuncture unit was used, which allowed us to hook wires to certain pairs of needles and generate electric pulses between them. An electro-acupuncture unit is similar to a tens unit that you might find in a doctor’s or chiropractor’s office.

When we started Boomer’s treatments the left side of his face was completely droopy. He could not blink his left eye, his left ear hung limply to the side, his muzzle was dramatically twisted to the right and his lips hung loosely. We were ecstatic after Boomer’s first treatment, because he could create a partial blink response in the left eye. By his third treatment, he could blink normally and move his ear! By the fourth treatment, Boomer looked nearly normal. This is where we started to get picky! Boomer’s upper lip was still a little tilted and we wanted him to look his best for the ladies, so we completed two more treatments to totally restore his muzzle function. By the end of his treatment regime Boomer’s face looked completely normal.

Boomer’s case is an excellent example of how complimentary medicine can effectively fill a gap left by traditional treatment methods. Even if complimentary medicine is foreign to you, Boomer proves that keeping an open mind can pay off in the end!  

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MAGGOTS IN THE FOOT... A GOOD THING?
by Dr. Amy Ehrmentraut

Usually all it takes is the word “maggot” to turn a stomach. The mere site of them causes many to flee in disgust. So how it is possible that these unattractive fly larvae can be the key to recovery for an 1800-pound Percheron gelding named Thunder? 

Thunder was seen at his home for a severe lameness of his left front leg. A thorough examination of his leg and hoof revealed a common culprit of severe lameness in draft horses- a foot abscess. An abscess is an infection that occurs when bacteria gain access to the inner tissues of the foot through defects in the white line. The abscess was treated by establishing drainage, soaking the foot in Epsom salts, poulticing and bandaging. Thunder was sound for a few weeks, but then he became extremely lame on the same leg. At the second visit, it was clear that the foot was again the source of pain. Radiographs of Thunder’s foot showed that the infection had not resolved, and in fact had gained access to the deeper structures of the foot. Deeper infections are more serious and can cause permanent lameness if left untreated.

Thunder was admitted to Great Lakes Equine Wellness Center for treatment of the infection. He was in so much pain, he did not move at all in his stall.  We were very worried about laminitis in his right front foot because he was bearing all of his weight on that limb. He was treated with intravenous antibiotics and underwent anesthesia to allow surgical debridement of the infection. An astounding amount of foul smelling pus drained from the foot! In order for the infection to be eradicated and the tissue to begin healing, all necrotic (dead) tissue must be removed. As you can imagine, extensive tissue removal is not feasible for the horse’s foot because it can cause structural damage and they need to bear weight on the foot. Aha! This is where the maggots come into play. 

Maggot debridement is a non-traumatic, minimally invasive method to remove necrotic tissue from an extensive foot infection¹. Newly hatched maggots have a voracious appetite and will happily eat away necrotic tissue.  Not only do they debride the wound, they also stimulate healing by encouraging new vessel growth. Maggot therapy had been used extensively at Rood and Riddle Equine Hospital’s Podiatry Center (Lexington, KY) in a variety of wounds and has been shown to decrease healing time significantly. Medical grade sterile maggots (500 recently hatched darlings in sterile cotton gauze) are available for overnight shipment from California. The maggot-imbedded gauze is placed directly into the foot and a light bandage is placed over the top. The foot is protected by a custom-made treatment plate that attaches to the specially-designed shoe. The plate can be easily unscrewed for inspection of the wound, maggot growth and bandage changes. The maggots stay in the wound for 5-7 days at which time they have grown significantly and no longer have an appetite. Thunder’s maggots had finished dining in his foot within five days, and by that time he was walking so well!  He was sent home with the treatment plate in place to protect his foot until the defect heals. We are happy to report that Thunder is doing well and enjoying being back at home.

¹ Morrison S.E.  How to Use Sterile Maggot Debridement Therapy for Foot Infections of the Horse   AAEP Proceedings/Vol. 51/2005

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TUCKER’S SURVIVAL STORY
by Dr. Amy Ehrmentraut

We all hope our horses never get sick enough to need to stay in the hospital… but sometimes horses require intensive care to survive potentially fatal illness. 

This is the story of Tucker, a palomino gelding pony, who was owned by a very loving twelve-year-old boy. Tucker lived a great life at his stable in northeastern Wisconsin. He shared a paddock with a couple of good horse pals, and loved to jump and compete at shows with his owner. Unfortunately, one cold February day, Tucker became depressed and showed signs of illness. Tucker would not eat his hay or grain. His gums were pale and dry, his heart rate was elevated, and he developed diarrhea. 

Tucker’s owners and referring veterinarian knew that he was very sick and needed to be in a hospital where he could be treated and constantly monitored. I was on duty when the call came to Great Lakes Equine Wellness Center. I remember when Tucker arrived that he walked very slowly and his eyes had no sparkle. He was showing signs of being in endotoxic shock-which means that his body was having a reaction to a certain component of bacteria.  After examining Tucker thoroughly, we immediately we put an intravenous catheter into Tucker’s jugular vein and began to rehydrate him with fluids. To figure out why Tucker was endotoxic we ran bloodwork, sampled his abdominal fluid and urine, ultrasounded his abdomen, passed a nasogastric tube, and performed a rectal examination.  The laboratory tests revealed that Tucker was severely dehydrated, and had electrolyte disturbances. We continued to run fluids into Tucker’s vein…it takes a lot of fluid to rehyrate a horse!  (When horses are not feeling well, they sometimes will not drink water on their own.) 

Tucker had to stay in the isolation barn at GLEWC due to his diarrhea. Sometimes diarrhea in horses is caused by contagious pathogens such as Salmonella bacteria, so we had to keep Tucker separate from other horses to be safe.  We submitted samples of Tucker’s manure to be tested for Salmonella, and his paddock mates were tested as well. 

Overnight, Tucker spiked a fever and his blood work showed that he had very low white blood cells. His diarrhea became worse, and we needed to act fast to keep Tucker alive. In order to keep his head and limbs from swelling with fluid, Tucker needed large volumes of plasma and hetastarch (products that help keep the fluid in Tuckers blood vessels because he had lost most of his natural proteins throuh diarrhea). He was given antibiotics, anti-inflammatory medicine, anti-diarrheal products, and probiotics. His feet were iced and padded with Styrofoam to prevent laminitis, which can occur secondary to diarrhea and endotoxemia in the horse. Tucker was feeling much too sick to eat and he was losing weight.

Over the next six days, Tucker was visited often by his owners and he continued to receive intensive treatments for his condition.  Fortunately, things started to turn around for Tucker. He and his paddock mates tested negative for salmonella, and he did not develop laminitis. He began to have more solid manure and even nibble on hay and grass!  We were overjoyed to see him feeling better.  After one week in the hospital, Tucker was cleared to go home on some medication. He continued to do well and made a full recovery. Tucker is now back to being a horse and doing what he loves. 

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STUCK IN A RAVINE
by Dr. Rob Blohowiak

It was late June of 2005 and I was enjoying a lazy, hot Tuesday afternoon with few appointments. Then the call came in... "Horse Stuck in Ravine". I didn't even know that we had ravines in Wisconsin. As I listened to the information, I started a mental list of the things that I may need – rope, chains, sling, helicopter, tractor, more muscles, shovels, skid steer, crane, someone else to take this call! I gathered 2 technicians and an intern and as many of the things I could imagine needing and headed off, not knowing exactly what to expect at the scene.

Upon arrival, all I could see was a group of people down near the middle of the property. They motioned for me to drive down, and sure enough, there was a large ditch. I got out of the truck to look over the situation and what I saw was absolutely amazing. InstaMary, a 7-year-old Trakehner, was buried in mud and stuck up against this ravine, approximately 12 feet deep. She had gotten out of her pasture with a few other horses, and while running freely, forgot to cross the ditch at the driveway and flipped into it. She was all done fighting at this point and was exhausted and in shock. We immediately began to treat Mary in the hopes of stabilizing her as we made a plan to get her out.

An IV catheter was placed and she was given steroids, non-steroidal anti-inflammatories, antibiotics, hypertonic saline and then fluids. In attempt to deliver faster fluids, we discussed a second catheter, but Mary was holding her own, and we needed to get her out as soon as possible!

Her heart rate was 72, respiration 20, temperature was 101.9. She was sweaty and exhausted. As her fluids ran in, we began to dig for her legs and assess her musculoskeletal system and look for fractures or other open wounds. I decided that the safest way to get her out was to anesthetize her and pull her out by her legs with the tractor.

By this time, we were all in our socks as the mud had sucked off our shoes. We found all of her hooves and they appeared to be attached to the rest of her body! After 20 liters of fluid, I anesthetized Mary with ketamine and valium. We placed hobbles on her legs and attached them to a tow rope and slowly pulled her out with the tractor.

I carried her head so it would not drag along the tall grass and we dragged her to an open field. I probably dragged her further than necessary, but I wanted to ensure that she didn't wake up and fall back into the ravine.

She lay in the field for almost an hour and a half! Finally, she stood up! I examined her while my technician rinsed out her eyes and held her steady. We made our way back to the barn, slowly, and set Mary up with fluids spiked with DMSO and KCl in her stall.

I made daily trips out to the farm over the next 3 days. Mary made a spectacular recovery. No serious injuries except the loss of sight in her right eye. She improved daily and actually was bred in July for a June 2006 foal.

This was no doubt a remarkable event. A tragedy with a wonderful outcome thanks to the quick action of a team of folks dedicated to patient care. It truly is all about the health of the horse.