Equine A&E

Teeth re­moval, laser surgery, an emer­gency colic op­er­a­tion and much, much more — it’s all in a day’s work at Pool House Equine Clinic, finds Aimi Clark

Your Horse (UK) - - Editor’s Letter - For more in­for­ma­tion about Pool House Equine Clinic, visit pool­hou­se­vets.com.

Be­hind the scenes at Pool House Equine Clinic

VET GIL RI­LEY IS on his first lame­ness in­ves­ti­ga­tion of the day. Pink, a 14-year-old mare used for grass­roots event­ing, is lame and her own­ers want to know why. A dif­fer­ent horse has al­ready been in and out of the the­atre for a sus­pen­sory neurec­tomy while an­other, a vet­eran strug­gling in his later years, has been put to sleep. All that and we’re only an hour into the nor­mal work­ing day at Pool House Equine Clinic in Lich­field, Stafford­shire. But a ‘nor­mal’ day doesn’t re­ally ex­ist here. Life as a vet is un­pre­dictable. Any­thing and ev­ery­thing can (and of­ten does) hap­pen — usu­ally when it’s least ex­pected.

First-hand as­sess­ment

Pink’s owner watches from the side­lines as Gil, a part­ner at the clinic for 18 years, as­sesses the mare be­ing rid­den in the mé­nage by his team mem­ber Lucy Ire­land. Af­ter rid­ing the mare in walk, trot and can­ter, Lucy re­ports the left hind isn’t step­ping through prop­erly, as well as con­firm­ing the main lame­ness is in the off fore. It’s show­ing pre­dom­i­nantly on the right rein, but Lucy can feel it in the other di­rec­tion too. “The two of us work as a team, to­gether with the horse’s owner, who knows what’s nor­mal for the horse bet­ter than any­one,” ex­plains Gil. “They both bring a lot of in­for­ma­tion to the ta­ble. With­out it I’m re­duced to an

ed­u­cated guess and I want cer­tainty.” Gil opts for a pal­mar dig­i­tal nerve block first — es­sen­tially numb­ing the mare’s heels. “Lame­ness is a gait change to min­imise pain — that’s what a limp is,” he says. “So, if we can iden­tify which area the pain is in by block­ing it out and show­ing an ob­vi­ous improve­ment in the horse’s move­ment, we can nar­row down where the ac­tual cause is.” At 10.30am, Gil in­serts the nerve block. There’s a 10-minute wait be­fore Pink is as­sessed un­der sad­dle again. “When nerve block­ing, we start from the bot­tom and work our way up the leg. If you start at the top, it blocks out all the leg be­low it and doesn’t give us an ac­cu­rate read­ing.” There’s no improve­ment, so nerve block­ing moves to the fet­locks, block­ing the sus­pen­sory lig­a­ments of the hind legs. The lat­ter makes a dif­fer­ence to the tight­ness be­hind and so Pink is booked in for a scan.

Tan­gled in a gate

In ex­am­i­na­tion room two, a bay horse is hav­ing ban­dages re­moved by vet in­tern Kris­ten Hol­land, who lives on site. The mare has been at Pool House since get­ting stuck in a me­tal gate 10 days ago. The fire bri­gade was called and once a vet had at­tended to give the mare a gen­eral anaes­thetic, they cut off the gate. “She’s had surgery to flush her hock joint and de­bride the wounds so they heal bet­ter,” says Kris­ten. “The gate cut right down to the ten­don on her left hind.” The mare is on box rest with dress­ings changed ev­ery two or three days. An X-ray ruled out any bone frac­tures — the vul­ner­a­ble splint bone was a par­tic­u­lar con­cern — and so now keep­ing the legs clean and as still as pos­si­ble is top pri­or­ity for a good out­come.

Pa­tients and pa­tience

Gil’s sec­ond pa­tient ar­rives — 11-year-old Vin­nie, who is lame be­hind. He’s been trans­fered to Pool House for a sec­ond opin­ion, af­ter be­ing rec­om­mended a sus­pen­sory neurec­tomy at an­other equine clinic. Lucy feels it is worse when the painful leg is on the in­side rein. Gil sus­pects a sus­pen­sory is­sue, which are in­creas­ingly com­mon in com­pe­ti­tion horses who are be­ing asked to en­gage their hind ends a lot. Vin­nie is nerve blocked out­side the ex­am­i­na­tion room as he is claus­tro­pho­bic. Gil knows from treat­ing Vin­nie pre­vi­ously that he’s more re­laxed when han­dled out­side. “I al­ways say I’m here to find out why a horse is lame, not fry its brain. I give them lots of car­rots and treats and do things in a way that bet­ter suits them, as far as I can. If they are more re­laxed, they’re eas­ier to work with.” Gil in­jects lo­cal anaes­thetic into the skin to numb the area. “Then, when the big­ger nee­dle goes in, we pre­fer he doesn’t know any­thing about it.” Lucy ban­dages Vin­nie’s tail to keep it out of the way and then cleans — and re­cleans — his leg us­ing Hibis­crub. Gil puts in the lat­eral plantar block.

Ten­don trauma

Marco Mar­catilli is ban­dag­ing the front leg of a Thor­ough­bred chest­nut mare in ex­am­i­na­tion room one. The race­horse came straight to Pool House off the track a week ear­lier af­ter strik­ing her front leg with a hind hoof and sev­er­ing the su­per­fi­cial flexor ten­don. Sadly, it’s a ca­reer-end­ing in­jury. “She’s been in a cast un­til to­day and now it’s be­ing bandaged,” ex­plains Marco. “She’ll be with us for a while yet and will then go home to be a brood­mare.” Next door, vet in­tern Gi­u­lia Rapez­zano is ex­am­in­ing a mare to check where she is in her fer­til­ity cy­cle. Her owner hopes she will have a foal by ar­ti­fi­cial in­sem­i­na­tion (AI). A pre­vi­ous at­tempt has al­ready failed. A cam­era is in­serted in­side the mare, so the vet can ex­am­ine her re­pro­duc­tive sys­tem on a big screen. A de­brief with the owner fol­lows and it’s good news — the mare will be ready to un­dergo AI in three days’ time.

Pos­i­tive find­ings

Out­side, Vin­nie is back in the mé­nage. Lucy re­ports a huge improve­ment fol­low­ing the lat­eral plantar block and it’s no­tice­able from the ground too. “You’ve let the hand­brake off,” she tells Gil. “We’re al­most get­ting medium trot — he’s got an ex­tra push in his stride now, which wasn’t there be­fore.” This is a pos­i­tive find­ing be­cause it nar­rows the pain down to the sus­pen­sory lig­a­ment, as ini­tially sus­pected. “If I numb the sore struc­tures, it en­ables the horse to go back to the gait he used to have,” ex­plains Gil. “Horses don’t want to be un­sound. DNA tells a horse that if he’s lame, a lion will spot the weak­ness and eat him for din­ner. Ev­ery horse wants to be as sound as they pos­si­bly can be.” As a re­sult of find­ing lame­ness in one hind leg (uni­lat­eral), Gil ad­vises book­ing the horse in to have both legs ul­tra­sound scanned in the morn­ing. It can’t be done im­me­di­ately, be­cause the block needs to wear off first. “It could be that the prob­lem is bi­lat­eral [oc­cur­ing in both legs], but at the mo­ment only one side hurts. A scan will tell us that.” Vin­nie is given a pad­dock for the af­ter­noon and he will spend the night in one of the clinic’s 21 sta­bles. He won’t be alone — other horses are around, in­clud­ing a pony wear­ing a belly ban­dage fol­low­ing suc­cess­ful colic surgery, and Harold the blood donor, who lives in a neigh­bour­ing pad­dock. “This is a re­sult,” says Gil. “If to­mor­row’s scan shows the in­jury is to­wards the top of the lig­a­ment, surgery will be ad­vised and it can be done on site straight­away. If the in­jury is at the bot­tom, in the lig­a­ment branches, a strict re­cov­ery rou­tine will be put into place. Ei­ther way, by the end of to­mor­row we’ll have a treat­ment plan.”

Tricky teeth

Af­ter a morn­ing out on the road, Sam Hole, one of the UK’s few recog­nised Euro­pean equine den­tistry spe­cial­ists, is spend­ing the af­ter­noon ex­tract­ing an in­fected tooth. It’s tooth 209, the fourth cheek tooth on the top left jaw — a tricky and time-con­sum­ing job due to lim­ited space and vi­sion. The horse is se­dated and stand­ing in

stocks, and has been given a nerve block so he doesn’t feel any pain. The tooth is wob­bling and Sam uses clamps to move it from side to side, en­cour­ag­ing it to loosen. “Slow and steady gen­er­ally wins the day when it comes to get­ting these out,” he says. “The aim is a clean ex­trac­tion, where all the roots come too, but it doesn’t al­ways hap­pen like that.” Suc­cess. Sam pulls the tooth free and all three roots come with it. He in­serts a small cam­era in the horse’s mouth to ex­am­ine the large hole left be­hind by the long tooth (it’s a good 3in in length). Sam flushes the hole to clear out any de­bris, then packs it with crushed an­tibi­otic tablets and an im­pres­sion ma­te­rial. “You shouldn’t be able to press into a tooth with a nee­dle — it should be rock solid,” says Sam as he ex­am­ines the re­moved mo­lar. “It hap­pens be­cause the tooth has died and stopped pro­duc­ing min­er­als, so it’s weak.”

Fill­ing a hole

Sam spots an­other tooth in the poor pa­tient show­ing signs of den­tal de­cay. He drills into the in­fected part and dirty wa­ter spurts out. “That’s ab­nor­mal — it should be clean wa­ter,” he says. Drills suit­ably sized for horses’ teeth don’t ex­ist. That means the long­est hu­man drill-end has to be used and it’s too short to do a com­plete job. A hand tool gives more depth, but the fi­nal tac­tic is spray­ing med­i­cated bi­car­bon­ate soda into the tooth, which should get deeper. The cav­ity is flushed us­ing high pres­sure and treated with cal­cium hy­drox­ide, which is very al­ka­line and helps to kill bac­te­ria. The tooth is then filled with the same com­pos­ite used in hu­man fill­ings. This is an­other time-con­sum­ing process. “Be­cause the hole is so deep, we have to fill it in lay­ers so it has the best chance of set­ting prop­erly and last­ing. This needs around six lay­ers, with three min­utes or so be­tween each one to let the layer set.” In three days’ time, the horse will go home. Prog­no­sis is good, pro­vid­ing reg­u­lar six-monthly teeth checks are car­ried out.

Tough de­ci­sions

Pink’s as­sess­ment con­tin­ues. Af­ter sev­eral nerve blocks the mare, who un­der­went kiss­ing spines surgery in De­cem­ber 2017, is mov­ing bet­ter in front and be­hind, but she’s

still not com­pletely sound. Gil is faced with sev­eral sources of pain. “Horses re­act to the big­gest area of pain at that time. So first it was her front feet, then she got un­com­fort­able in her hindlegs and now that we’ve blocked those two out, she’s feel­ing it in her back.” An X-ray of Pink’s back shows that noth­ing is amiss there. It’s crunch time. “We’re at the point where we have to con­sider that she’s bi­lat­er­ally lame in front and be­hind [so lame in all four legs] and now she’s sore in her back too. She’s in pain all over. Is it time to re­tire her? It’s my job to man­age the client’s ex­pec­ta­tions around that.” Pink re­turns to her sta­ble while her owner heads home. There is a lot to con­sider, and dif­fi­cult de­ci­sions to be made.

Surgery

The clinic has two the­atres — a ‘clean’ the­atre for pro­ce­dures such as neurec­tomy and a ‘dirty’ the­atre for op­er­a­tions like colic surgery. Shortly be­fore 4pm, a horse ap­pears out­side the knock-down room to be pre­pared for laser surgery on a num­ber of sar­coids. A catheter is al­ready in place in his neck, ready to re­ceive anaes­thetic and pain re­lief. Vet staff clean out his hooves — the­atre must be dirt-free to avoid con­tam­i­na­tion — and his mouth is flushed out with wa­ter sev­eral times to re­move any loose food. This is so noth­ing can get pushed down the wind­pipe when the ven­ti­la­tion tube is in­serted — a po­ten­tially fa­tal sce­nario. All four hooves are bandaged so the horse doesn’t slip on the mats as he comes round from the anaes­thetic and starts to get up. In­side the knock-down room — a box that is fully padded, just like the com­ing-round room, so it poses as low a risk as pos­si­ble to horses go­ing un­der or com­ing round from anaes­the­sia — the horse is wedged be­tween a padded par­ti­tion and wall as the anaes­thetic takes ef­fect and he slowly slips to the floor. Vet in­tern Kris­ten in­serts a ven­ti­la­tion tube into the horse’s mouth. Se­nior part­ner Richard Stephen­son and vet Fed­er­ica Can­ta­tore at­tach the winch to all four legs and the horse is slowly hoisted into the air by an over­head ma­chine. The vets sup­port his head as he moves to the op­er­at­ing ta­ble, where he is placed ly­ing on his back so that the sar­coids are easy to ac­cess. Any op­er­a­tion is a big job and this one re­quires five the­atre staff. Once un­con­scious, time is of the essence. Be­fore mov­ing into ‘clean’ the­atre, all the sar­coids have the hair around them re­moved with clip­pers, a Henry hoover sucks away loose hair and the ar­eas are Hibis­crubed mul­ti­ple times. A clean op­er­at­ing en­vi­ron­ment is vi­tal, so ev­ery­one wears scrubs from head to toe. The horse is wheeled into the­atre, out of Your Horse mag­a­zine’s view. Now only those in the the­atre wear­ing pro­tec­tive eye­wear against the bright laser are able to watch.

Emer­gency hour

At 4.45pm an ur­gent call comes in. A col­ick­ing horse has been re­ferred to Pool House and is en route for an emer­gency op­er­a­tion. It’s all hands on deck to pre­pare ‘dirty’ the­atre for his ar­rival and those in­volved will work into the night. The sooner the horse gets onto the op­er­at­ing ta­ble, the bet­ter his chances. Out­side the hos­pi­tal ward, calls for vets to visit horses at home have come in thick and fast too. There’s a sus­pected sheath in­fec­tion, a pos­si­ble case of choke, a foal need­ing to be mi­crochipped and health checks for the Blue Cross char­ity. Two un­planned preg­nan­cies have been re­ported too — and Gi­u­lia whizzes off to scan two minia­ture don­keys. It’s fast paced, but the vets thrive on it. To­mor­row, it all starts again.

“Any op­er­a­tion is a big job and, once a horse is un­con­scious, time is of the essence”

The area is scrubbed sev­eral t imes be­fore a n erve block is put in Nerve block­ing the heels

ABOVE: A gate in­jury — the left hind­leg was slashed right down to the ten­don

LEFT: Af­ter a thor­ough clean, the in­jured legs are re­ban­daged

This pa­tient is eas­ier to han­dle when not in a con­fined space

Af­ter ex­am­in­ing the mare for pos­si­ble ar­ti­fi­cial in­sem­i­na­tion, Gi­u­lia dis­cusses op­tions with the owner

Tooth re­moval can be a tricky process

Teeth are im­pen­e­tra­ble — un­less in­fected Horses teeth are very long!

Fully prepped, the anaes­thetised horse is wheeled into the­atre for laser surgery Once asleep in the padded knock-down room, vets work quickly to get the horse onto the op­er­at­ing ta­ble

Pink’s as­sess­ment in­cludes hav­ing her back X-rayed

The horse is linked to a ven­ti­la­tion ma­chine dur­ing surgery

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