How to give a horse his eye medications, or, What is an SPL?

One of my patients on my Large Animal Medicine rotation had a very sick eye, for which he needed approximately 9187346 medications every few hours. Getting eye meds into a horse is not easy. Their eyelid muscles are so strong that we routinely nerve block their eyelids before doing eye exams, because otherwise it would be impossible to hold their eyes open. This is, of course, not practical for hourly medications. But they hate having things put in their eyes (who doesn’t?), and they can throw their heads up very high in addition to squeezing their eyes tightly shut. This particular horse was especially tall, as well, and could hold his head well out of my arm’s reach.

The solution in these cases is to put in a sub-palpebral lavage (SPL). “Palpebral” is the science word for “having to do with eyelids,” so an SPL enables you to lavage (wash) underneath an eyelid. This is how it works: you take a big needle, which you stick through the horse’s upper eyelid coming from the underside (the side facing the eye). You use the needle to pull a slender tube through the eyelid, so that its end is sticking just under the eyelid, and the rest of the tube runs up over the horse’s head and down its neck. You affix the far end of the tube to the horse’s mane, with an injection cap on the end. In my hospital, a popsicle stick is involved in the tube/injection cap/mane connection, to stabilize the entire apparatus.

Now when you want to give an eye drop, you can use a syringe and needle to inject it through the injection cap into the tube. You then inject air after it to push it through the long tube and into the horse’s eye. They do find this annoying, and once they learn the routine, will dance around in an attempt to not let you actually stick the needle into the injection cap on their neck. However, getting at their neck is worlds easier than getting at their eye. My patient was relatively good for the whole thing, so that I could do it without asking anyone else to hold his head. He always got a cookie after each medication administration (which added up to a lot of cookies in the end). When it was over he would immediately stick his nose agaist my shirt to get his treat. The SPL was annoying for all concerned, but so much better than the alternative.

Shelter medicine externship

I recently spent two weeks of elective time at a shelter medicine externship at a different vet school. Half the time was spent in academic pursuits on campus — going to journal club, going to talks and lectures about shelter medicine, etc. The other half was at the shelter, doing high volume spay/neuter, temperament tests, treating sick animals.

Highlights:

• Pulling worms out of a kitten’s butt (“Wow, can I?”)
• STRAY GOLDFISH. It is more amusing not to explain, but I will say that it was found in a ditch in a grocery store parking lot.
• Ratlings! Five week old foster rats came in for a visit. They had been well socialized and were extremely friendly. I badly wanted to adopt one, but suspected it would not get along with my cat.
• Seeing exactly how fast 8 week old kittens recover from spay/neuter surgery. Spay surgery is no small deal, but those girl kittens were literally climbing the walls of their cage 30 minutes later. I am sold on pediatric spay/neuter.
• Helping to set up play groups of shelter dogs and getting to watch them play together. It was lovely.

Shelter medicine is in large part population medicine, or herd health. Of course you do need to pull the occasional worm out of the rectum of a kitten, but you also need to think about how to keep animals out of the shelter in the first place, and how to keep them from getting sick once they are there. Daily rounds in my vet school’s small animal hospital are about the specifics of what diagnostics were done on an animal yesterday and what needs to be done today; daily rounds in the shelter were about why an animal hadn’t been moved to the adoption floor yet or how to deal with the placement of a feral cat. I knew that shelter medicine had a large preventative component to it but was not prepared for quite how large the component actually was. I was enthusiastic; I really like this kind of medicine.

$200 worth of oops

This Saturday I was “on duty” in the large animal hospital, meaning that I was in the hospital for about 12 hours, theoretically helping with the treatments on all the animals (mostly horses, but we have gotten a few baby alpacas, or crias), along with one of my rotation mates. I say ”theoretically” because in practice, I just worked on my actual patient, a post-colic surgery horse who was extremely time consuming. My rotation mate and the techs handled the other animals, who needed many fewer treatments.

My horse was hooked up to a bunch of bags of IV fluids. In our large animal hospital, we suspend all the fluids from a hanger on the ceiling, and they run along coiled (therefore extendable) lines into a catheter in the horse’s neck. This way the horse can walk around his stall without getting his legs tangled, although the lines will inevitably tangle among themselves if you have multiple of them, which this guy definitely does. And with horses, the amounts of fluids and medications going in are fabulous. He had two five-liter bags of fluids hung at all times, plus a one liter bag of antibiotics, and a one liter bag of painkillers. This is aside from the medications I needed to inject into his catheter periodically, plus the oral meds I had to put down the tube which runs from his nose into his stomach.

The time came to change one of the bags of fluids. One of the techs stood outside the stall and lowered the hanger with all the bags. I removed the empty bag and hung the new one (with much grunting, as it was over my head and heavy). I disconnected the line from the old bag and went to connect it to the new bag — but since the line was also still connected to the second bag of fluids, it immediately started spewing saline all over the stall. I stuck my finger over the open tube to stop the flow just as the tech yelled “It’s sterile, don’t touch it!”

Well, I did know that you shouldn’t be sticking your finger over a sterile tube opening, but I had panicked and done it anyways. I stood there looking sheepish while the techs conferred. Yes, the line would have to be replaced. A new line cost $100. We obviously could not charge the client for this. The hospital would have to eat it. (The hospital is currently not profitable, which made me feel extra guilty.) These things happen when you are learning, but it is still super embarrassing. Also, changing the line was very complicated, and therefore annoying for the tech who did it.

Later in the day I was giving my horse his IV medications, injecting them into the new line. The second medication started turning into a solid powder inside the clear tube. It was precipitating! Just like in chemistry class! Except that that is bad to put into a horse’s bloodstream. I stopped and called a tech. I should have flushed the line with saline between injections. Oops. I flushed the line again and again to get all the precipitate out, but some was just too firmly adhered to the side of the tube. So, you guessed it, we had to change the line a second time, for another $100 eaten by the hospital.

So much to learn! So many embarrassing mistakes to make! I will never make these two mistakes again, though, I am pretty sure.

That is what is known as irony

I knew I would leave something behind in the town five hours from home where I did my shelter medicine externship. It was just a question of what. The answer: my wristwatch.

I hate wearing watches, but they are essential in the hospital for taking respiration rates and pulses. My friend is bringing my watch back to me this weekend, so I figured I’d try to tough it out watchless this week on large animal medicine. How many heart rates could I have to take? One a day? I could borrow a watch for that.

This morning I received my second patient, a foal aged 20 hours. His mom (a first time mother) was not letting him nurse. If baby horses don’t get a chance to ingest colostrum while their mom is still making it, before she switches to making normal milk, they miss out on essential antibodies and can die of infection. This is not true for human babies, who get their antibodies through the placenta.

We tested the baby, and indeed his IgG level, which is indicative of the amount of antibody in his blood stream, was almost nil. The solution: give him antibiotics, and give him a plasma transfusion.

I was enthused. I had never seen a plasma transfusion! And now I was going to get to actually do one! The tech said a little dourly, “You may find it a little less exciting once you see how it works.”

This is how you do a plasma transfusion in a neonatal foal: you hook it up to IV plasma and make a vet student watch it drip in for two hours. Every five minutes, the student has to — wait for it — take a pulse and respiration rate, to make sure the baby is not getting fluid overloaded.

It turns out that my cell phone doubles as a stopwatch. Not the most convenient thing to use around large animals, though.

Do not kidnap wild animal babies!

Since spring is upon us, at least in my part of the world, I offer a public service announcement: do not kidnap wild animal babies! If you see unattended baby birds, baby bunnies, etc., please do not pick them up and bring them in to a wildlife clinic. Their parents are very likely to return to take care of them after you leave, and they will do better in the wild than in a clinic. Moving them will probably do more harm than good!

Wild Baby Rescue Center, Inc. has a nice summary of how to know when baby wildlife needs your help.

He’s a lover, not a fighter: outreach for the prevention of dog fighting

[This is the presentation I gave at a shelter staff meeting this week, as part of my shelter medicine externship.]

How can we redirect inner city kids away from using their pit bulls for dog fighting, and towards other activities? I looked into two programs that exist to reach out to youth and do exactly that. These programs focus on prevention of dog fighting, on educating kids before they decide that dog fighting is cool, rather than focusing on the punishment of dog fighters.

The first program I looked at is the End Dogfighting campaign from the Humane Society of the United States. The End Dogfighting campaign has several different arms:

• The Pit Bull Training Team provides alternative activities for youths with pit bulls (or, presumably, other breeds). Set up as a weekly class, the PBTT introduces kids to obedience and agility, and also provides some socialization for the dogs (since fighting dogs, obviously, often have poor social skills with other dogs). For students who do well and stick it out to the end, there is a Canine Good Citizen (CGC) test that they can take. If they pass, they receive a CGC title for their dog from the AKC, certifying that they have a well trained dog. Graduates of the class are encouraged to stick around and mentor new students.
• The Humane Education arm of the campaign is an 8 week curriculum for middle school students. It’s intended to be a fun set of classes, with mock game shows, videos, and hands on projects. The message of the class is that dog fighting is a crime, it’s violent, and it’s animal cruelty.
• The First Responder Outreach arm of the campaign is aimed at postal workers, utility works, and public works employees — the people who are out in the neighborhood who might encounter signs of dog fighting rings. The HSUS provides posters with information about what to look for, such as how to recognize the fighting pit where dog fights occur. The HSUS may also provide a presentation if asked.
• The Law Enforcement Outreach arm of the campaign provides a $5,000 reward for tips leading to the conviction of a dog fighter; law enforcement training classes; a database with the names of known dog fighters; grants for handling seized animals (controversial, as the HSUS recommends that such animals be immediately euthanized); and prosecutor training.

The End Dogfighting Campaign began in 2006 in Chicago. Since then it has expanded to Atlanta and Philadelphia. So far, the campaign is focused on big cities. It seems unlikely that we’re next on their list. However, the HSUS freely provides materials for download to let other groups try to implement individual arms of the campaign.

I also looked into the Lug Nuts program, which is informal weight pulling contests in cities with dog fighting problems — again, providing alternative activities for people to do with their pit bulls. In a Lug Nuts contest, children’s sleds are loaded with food until they are very heavy. Dogs (not always pit bulls, although pits are very muscular and tend to be very strong dogs) are hooked to the sleds with special harnesses. The dog that pulls the farthest wins. The food can also serve as a prize, and the prize can be doubled for animals who are spayed or neutered. As the web page for the program says, there is excitement! Machismo! Thrill! The competitive aspect of Lug Nuts may be an important way to draw people in.

Sue Sternberg started Lug Nuts in New Haven in 2002. It is associated with a Training Wheels program, which brings pet supplies and veterinary services into underserved areas, and takes the opportunity to also bring some education about positive reinforcement training to dog owners.

So who should be going into inner city communities and telling people about these programs to change how they interact with their dogs? I am pretty sure that if I tried, I’d get laughed at. The End Dogfighting campaign solved this problem with the creation of Anti-Dogfighting Advocates (ADAs), graduated students from the program. They encourage people to come in to the weekly classes, and check in on them during the week to keep their interest up. There is definitely a bootstrapping problem here. Who goes out and convinces people to go to the first classes? But the approach of keeping community members involved even after graduation is a nice one.

I like the positive approaches of these two programs. Positive reinforcement works better than punishment! I’d love to see both programs expand to more cities.

The Purebred Paradox, part four: What can be done?

(Continued from part three.)

Below are my musings on some of the talks at the recent conference, The Purebred Paradox: on the health and welfare of purebred dogs. Specifically, these talks delve deeper into ways some of the speakers thought we could move forward.

Professor Sir Patrick Bateson: “Problems of dog-breeding and what to do about them”

In his keynote address, Professor Bateson called for for “a public awareness and education campaign.” In his talk and in later discussions, the question of whom to educate was raised. Three interest groups were identified: dog owners, dog breeders, and judges of dog conformation competitions. Again and again, speakers at the conference returned with frustration to the question of how to educate dog owners. Once the bulldog has been purchased and the new puppy brought to the veterinarian for its wellness exam, it is too late. How do you educate people about healthy breeds before they bring home and bond with a new dog?

Patricia Haines, DVM: “Canine Genetics, Behavior and the role of the parent club”

Dr. Haines, a veterinarian and breeder of pointers, talked about parent breed clubs. Both the American Kennel Club (the AKC, the largest registering body of American purebred dogs) and the Kennel Club (the KC, the AKC’s British counterpart) are made up not of direct members but of member clubs, or “parent clubs.” These clubs mostly (but not entirely) represent breed specific clubs, such as the Golden Retriever Club of America.

Dr. Haines made the point that work for change would be more effective with the parent breed clubs, rather than with AKC judges. In fact, she said, many breeders joke that the judges don’t really know their breed well. It is the parent clubs which are the guardians of the breed standards, and, perhaps more importantly, the interpreters of them.

Dr. Haines’ insight highlighted, in my opinion, the usefulness of working with members of the dog breeding community. That community is a complex one which can be difficult to fully understand from the outside.
 
Gail K. Smith, VMD, PhD: “Efficacy of hip dysplasia screening: An animal welfare imperative”

Dr. Smith is the veterinary surgeon who designed the PennHip screening system for hip dysplasia. The more traditional Orthopedic Foundation for Animals screening system involves subjective judgement of a dog’s hips as poor, fair, good, or excellent. PennHip, on the other hand, provides an objectively determined “distraction index,” a numerical measurement of the amount of hip laxity (where more laxity implies worse disease). Dr. Smith explained that his PennHip system is particularly useful for genetic studies of hip dysplasia because it is a better measurement of phenotype, for use in correlation to genotype. In other words, if you want to study what genes produce hip dysplasia, an objective numerical value describing the individual animal’s anatomy is more useful than a subjective value like “fair.”

Of course, the question arises: can other characteristics be measured using numerical scales? How do you measure the flatness of a bulldog’s face? There is work to be done in this area.

Steve Zawistowski, PhD, CAAB: closing remarks
PhD behaviorist Dr. Sawistowski explicitly identified a fissure between those who breed dogs and those who identify themselves as members of animal welfare organizations. He said, “We are going to have to heal that fissure before we can heal the dogs that we all know and love.” This conference did a great job of outlining this goal and the current situation and identifying priorities to be addressed.