Inside the AAEP Convention

AAEP 2012 -- Looking Ahead

2012-12-13T16:50:00Z

As we were driving home last week from Anaheim, Calif., I laid out my writing schedule for the next month to my husband. When I got to, "And I need to write one more blog post next week to summarize the convention," he immediately said, "So, is this going to be about where you think equine medicine is heading?"

He was right. I had been fretting over how to summarize the volumes of information from the conference into one pithy post of things that I haven't already covered in this blog. I was looking back. My husband, with his eyes on the road rather than a laptop screen, was looking forward.

So, let's take a look into my crystal ball. Never mind the cracks--it's just a little fractured from years of trying to figure out prognoses for owners without all of the data. The future is cloudy ... the mists are parting ... I see a banjo ...

The 2013 Convention of the AAEP will be held in Nashville, Tenn. I have no idea what the program will contain, but I might take some guesses about what shifts we may see in equine medicine over the next few years based on some of the highlights from this year.

Nice genes, baby! The sequencing of the equine genome strikes me as one of the most exciting, eye-opening things to happen to equine medicine since the days of the chariot. (Possibly a bit of exaggeration there, but I'm not sure.) I predict (around that hairline crack to the left of the crystal) that as our knowledge of the equine genome deepens, we will better understand how certain genes respond to environmental factors, disease agents, and other genes. I predict that this understanding will allow the development of better vaccines, improved wellness screening, and earlier disease diagnoses.

Looking under the hood of that gift horse. Equine dentistry has come a long way since I was in school and, judging by the numbers I saw in some of the dentistry lectures, I predict that equine veterinarians will continue deepening their involvement in reclaiming this particular veterinary procedure from lay, unlicensed practitioners. Expect the full-mouth exam and pre-procedure radiographs to become normal parts of your horse's routine care. I suspect he will thank you.

Teamwork. Veterinarians and farriers used to be ships passing in the night, blowing our foghorns to warn the other away from our patch of the ocean. No more. As imaging techniques and biomechanical knowledge improve, veterinarians and farriers need each other more than ever. And the horse needs both. I predict that, when confronted with a lameness, or maybe even just a new horse, you will hear your veterinarian say, "I'd like to get together with your farrier to work up a plan," or your farrier say, "Can we get your vet out to have some X rays taken before I trim this guy?" with increasing frequency.

Just say ... I can't say whether we will be saying yes or no to drugs, but I suspect a bit of both. New drugs, particularly anti-inflammatories and antimicrobials, always seem to be on the horizon, and I don't see that the future will be any different there. I suspect, however, that we will see increasing levels of regulation in all of the equine performance disciplines, and that we may see changes in the use of compounded drugs and how those are regulated.

Getting social. Medical technology isn't the only thing that is changing. Our phones, computers, and that strange organism known as the Internet are changing the ways in which we interact and plan our days. This isn't going away, and I think that veterinarians, like everyone else, will begin to use these communications tools to our advantage. It's already happening. Smart phones are beginning to have apps to track human medical data; how long before that reaches the stable? Small animal hospitals have dedicated pet "portals," personalized websites for each pet that allow owners to access their animal's medical information from phone or computer. I bet that we will see equine medical communications shift in this direction as well, especially since so many of our patients travel. Is your veterinarian in your Twitter feed? Do you get updates on the latest equine health news in your area via the clinic's Facebook page? I predict that more and more practitioners will use these tools to streamline the delivery of information to horse owners throughout the busy days.

The mists are closing ... okay, my crystal ball is worn out. I guess we will all have to wait and see what the future brings. Unless the Mayans were right, but what did they know? There aren't any horses on that calendar of theirs, are there?

Home again, home again...

2012-12-07T20:30:00Z

The hotel lobby the morning following a conference has the same forlorn feeling of a house the morning after a party or a ballroom after the bride and groom have left in the limo. But, instead of a smattering of beer bottles or champagne glasses, the space is littered with the memory of stories, conversations, and debate. Even my Twitter feed has a “the party is over” feeling this morning as practitioners commiserated with the colleague stuck in an airport and others thanked each other for the lovely time.

But while most people only manage to take home a hangover or a tulle bundle of Jordan almonds from a wedding or party, those of us who attended the 2012 Annual Convention of the AAEP carry home something more lasting and requiring less ibuprofen.

Continuing education for medical professionals often errs on the side of the esoteric, with a lot of high-level research that appeals to specialists and academics but can’t really be used by the practitioner in the trenches. AAEP, on the other hand, does a great job of providing not only the latest research but also ways practitioners can use the information. Just about every presentation included comments on clinical relevance and key take-home messages. So, in that spirit, here are my top take-homes from the 2012 AAEP Convention.

A calm head and returning to the basic principles of medicine and physiology will take you a long way in an emergency.
An oral glucose tolerance test using corn syrup can be an easy and accurate means of screening horses for insulin resistance in the field.
Drug compounding from bulk ingredients is not only legally shaky but also can result in inconsistent quality, dosing, and safety.
Abuses in performance horses need to be addressed by all industry stakeholders: regulators, veterinarians, farriers, breed associations, judges, trainers, and owners. Everyone needs to step up and speak for the one stakeholder who can’t speak for himself--the horse.
Anti-ulcer medications in hospitalized foals should be used on a case-by-case rather than a cookbook basis, since they may be associated with hospital-induced diarrhea.
Formerly geographically restricted diseases expand their range as climates shift and horses and disease vectors travel. Don’t assume that a disease is impossible in your area.
“Tying-up” is a clinical description that can refer to a number of equine muscle diseases. While the causes of all of these conditions are not established, the lactic acidosis model appears to be definitively disproved.
Upper respiratory conditions can produce a chronic cough that mimics recurrent airway obstruction (RAO). Work-up for a chronic cough should include: a comprehensive exam, bronchoalveolar lavage, and endoscopy. A thorough work-up and early diagnosis/treatment may actually save money, time, and damage to the horse in the long run.
Every delay of 10 minutes after 30 minutes of labor decreases the odds of the survival of the foal.
Always, always, always perform a complete physical examination, complete oral examination, and X rays before even contemplating extracting a tooth.

I have document files full of notes and a book of the complete conference proceedings, but perhaps the most valuable thing I will take home is the same thing that returns with me from every AAEP convention--a renewed commitment to do whatever I can to support the health and welfare of the horse.

I’ll be back for one more post next week to fill in some of the gaps and to give a summary of my perceptions of the conference once I’ve had time to digest the information. Thanks for following along this week!

Internal Medicine Wrapup

2012-12-06T15:10:00Z

Sometimes in medicine, where there is so much that we don’t know, it’s pretty easy to get trapped in the familiar--stick with the drugs and dosing we know, run the tests we’ve run before, assume that if a disease hasn’t been reported in our area before we aren’t going to see it. The familiar might be a comfortable place, but it is also a deceptively dangerous place. Clinging to what we think we know or the way we’ve always done something limits us and, in the case of medical practitioners, might damage (or at least not optimally benefit) our patients.

I spent this afternoon learning about diseases I thought I knew and diseases I’ve never met. Equine piroplasmosis, a tick-borne disease, is considered an exotic disease in the U.S. I’ve never seen a case and don’t know anyone who has, so I might have been tempted to skip a talk on treatments for the condition. I’m glad, though, that I didn’t. I had no idea (well, I suppose I might have learned it for a mid-term once) that imidocarb, the standard treatment, causes severe colic signs in horses. So, of course, I didn’t know that pre-medication with another drug such as atropine or glycopyrrolate can mitigate those signs. Well, if piroplasmosis isn’t endemic to my state, will I ever need to know? Here’s the answer--once upon a time, West Nile virus was considered an exotic disease.

Never having lived even east of the Sierra Nevadas, let alone the Mississippi, I’ve never seen a case of Potomac horse fever (PHF), either. In fact, I didn’t even realize that the disease had wandered out of the mid-Atlantic. The cases presented this afternoon in a discussion of factors affecting survival of the disease hailed from Indiana and Kentucky. Just the knowledge that it isn’t confined to the Eastern Seaboard suddenly makes PHF seem a lot closer. I paid attention to the talk. Oxytetracycline. If you’re a veterinarian who's even thinking PHF, give oxytetracycline. Got it.

I’m a California girl, so there are a few bugs with whom I’m well-acquainted. Talk to veterinarians in parts of the country that are actually green year-round about Corynebacterium pseudotuberculosis (which causes pigeon fever), and you might get the same look I would give someone going on about Potomac horse fever--the look that says, “I think I learned about that--once …” I, on the other hand, used to treat three or four cases a week during the peak season. We had pigeon fever horses coming out of our ears; I would go to bed at night dreaming of plastic bags filled with pus. Having treated horses with all three reported forms of C. pseudotb infection (and some that looked like the reported forms’ alien cousins), I’ve gotten pretty cocky about my Coryne knowledge over the years. But, assuming I know it all would have been another mistake. It turns out that the test I’ve used for years to determine whether a horse has internal abscesses doesn’t work if the horse also has an external abscess. Huh. I did not know that.

Equine protozoal myeloencephalitis (EPM) is another old friend. It was the bright, shiny, new kid in town when I was in veterinary school, the diagnostic darling of every dressage barn. Now, granted, EPM hasn’t been recognized as long as pigeon fever, and the information has evolved pretty rapidly over the years, but having treated patients and written an article or two on the subject, I thought I had a reasonable handle on it. But, I didn’t know that one of the causative agents, Neospora hughesi, could be transmitted across the placenta from dam to foal, and even into a second generation.

For those of you on the other side of the country who may never have heard of pigeon fever, and those for whom EPM is a rare sighting, pay attention. As Dr. Jennifer Jeske said during her presentation, Coryne pseudotb is expanding its range. "If you're not dealing with it now, you probably will be in the future." Dr. Nicola Pusterla also showed a map demonstrating that both Sarcocystis neurona (the other causative organism of EPM) and N. hughesi EPM are becoming widespread across the United States.

With all of this in mind, I paid close attention to a presentation on an emerging disease of horses in Scandinavia called acquired equine polyneuropathy. The video and slides shown by Dr. Gittan Grondahl depicted a devastating disease characterized by an inflammatory demyelination of the long nerves of the hind limb. The horses start by losing some hind-end function and rapidly progress to knuckling over. If they go down, they usually can’t get back up and are euthanized. Will I ever see this disease? Maybe not. But I do know that it isn’t safe to assume that I know what I think I know.

Getting Social: Thoughts on Social Media in Equine Medicine

2012-12-05T20:18:00Z

My first AAEP Convention was in 2006. I flew to San Antonio alone, went to my sessions alone, spoke to exactly two colleagues whom I happened to run across at an alumni reception, went to more sessions alone, flew home alone, and then tried to pour out all of my excitement about the conference to my long-suffering, nonhorsey husband. Failing there, I did take the information back to the clinic where my colleagues, staff, technicians, and clients were properly interested. But, my convention experience remained largely locked behind my own skull.

My husband caught me checking my Twitter feed on my phone last night as we were walking through Disneyland. “I was just keeping up with my social media responsibilities,” I said, walking a little faster and shoving my phone into my purse. After he finished laughing at me, I explained that I had been replying to a tweet from a colleague with whom I’d been keeping up a sort of 21st century pen-pal friendship during the convention.

Social media can transform a solo practitioner to a member of a virtual "group practice." We all have unique experiences, and when colleagues are able to share those experiences, our patients and clients benefit.
Photos.com

This interaction took my brain back to the beginning of the convention, to the theme of communication. I began thinking about the ways that communication has shifted since my first AAEP experience six years ago. I think that the biggest shift has been in the ways that we use social media to connect, to critique, and to disseminate information.

I have colleagues who are far more adept than I in the use of social media as a veterinary medical tool. In fact, not only was the keynote speaker for the convention a communications expert, but, for what I believe may be the first time, a table topic session was devoted to social media use.

With the exception of those in large group practices or academia, most equine veterinarians spend their professional lives the way I spent my first AAEP convention, isolated from colleagues by geography and time. Spending all day in your truck doesn’t provide much opportunity to bounce ideas off of other practitioners. Social media is invaluable here; it can transform a solo practitioner to a member of a virtual "group practice." We all have unique experiences, and when colleagues are able to share those experiences, our patients and clients benefit.

It is impossible to be in two-places at once, and throughout this conference I have relied on my Twitter feed for information about the other sessions, since a number of us have been live-Tweeting throughout. By the way, if you would like a peek at snippets of the convention, and the insights of other practitioners, check out the convention hashtag on Twitter. #AAEP2012.

The double-edged sword of the internet affects veterinarians as much as it does everyone else. We can connect with colleagues faster than ever thanks to email listservs, interactive chat forums, and social media sites such as Facebook and Twitter. I have several colleagues with whom I struck up Twitter and Facebook relationships at last year’s convention. Our interactions have carried through this year, and it begins to feel as though I know what things interest them, what drives them, even non-veterinary factors that influence their lives, such as family. But, I’ve never met them in person.

That’s one of the well-known edges to the social media sword. As compelling and valuable as these connections can be, they are, in a way, unreal.

One of the other potential pitfalls is equally well-known--information dissemination. One of the great things about modern communications is the speed with which news travels. One of the terrible things about modern communications is the speed with which news travels.

In the Welfare and Public Policy forum on Saturday afternoon, Dr. Nat White presented an outline of the proposed National Equine Health Plan. A huge part of the plan developed by this task force is the development of a system of communications during disease outbreaks.

I’m sure that you’ve heard more in the last couple of years about diseases such as EHV-1 than you ever did in the past. Disease outbreaks have always been a part of the horse world, just as they are part of the entire animal kingdom. However, never before have so many known so much about an outbreak in a barn so quickly. But, with great speed comes great unreliability. It becomes challenging to sort the informational wheat from the chaff. Even veterinarians may not know in the early stages of an outbreak which of the soundbites flying at us are accurate and which are exaggerated or bogus.

I don’t have a ton of answers when it comes to navigating the social media forest. Like any forest, it is a place of enlightenment and beauty, and a place of shadows and hazards. But, the possibility of a bear behind a tree doesn’t deter us from enjoying a hike, and the possibility of getting lost in the social media forest shouldn’t deter us from reaching out--colleagues and horse owners alike. Just be careful out there, and take a compass.

A Gutsy Look at the Equine GI Tract

2012-12-05T02:58:00Z

On Christmas Eve 1995 I wasn’t thinking about cookies or presents, and my only prayer at midnight Mass was “Please let my horse live.” Over and over. Shortly before we left for church, I had given the okay to the equine surgery resident at UC Davis to take my mare to take my mare in for colic surgery. I was a senior veterinary student; I knew the risks associated with pursuing and declining surgery. But, that night, I was just another scared owner saying, “Please let my horse live.”

The GI tract of the horse, housed in that huge abdomen, sometimes seems like a giant black box where any number of things can go suddenly and mysteriously wrong. Many of those things get lumped under the label of colic, but not all of them are equal as far as outcome and expense go. The ability to peek inside that black box and to sort out the risks of each specific disease and the rewards or risks of treatment helps owners and veterinarians to make intelligent decisions regarding care.

This afternoon’s session on critical care of conditions of the gastrointestinal tract helped shed some light into that box, beginning, appropriately enough with a presentation on transabdominal ultrasound to evaluate colic cases. I wish that I had known the information presented by Dr. Michelle Henry Barton 10 years ago. Abdominal ultrasound in the horse has always felt a bit like a specialist’s game to me, but Dr. Barton presented videos in information in a way that made me say, “Hey, I see those distended loops and hairpin turns! I could do that!” She gave concrete examples of four key factors that can help distinguish between surgical and nonsurgical lesions of the small intestine: motility, distension, wall thickness, and intestinal contents. I will also now never forget that the mucosa of a horse with enteritis can look like a lasagna noodle on ultrasound. I also won’t look at my next plate of lasagna in quite the same way!

Dr. Ceri Sherlock discussed impaction of the cupula of the cecum, beginning with a pertinent reminder that cecal rupture can occur with very few preceding signs. After that scary note, however, her presentation was much more encouraging since the post-surgical prognosis for horses with cecal cupular impaction is excellent.

The outlook for neonatal foals requiring colic surgery is also sunnier than one might expect. Dr. Michelle Harris presented a retrospective study of foals hospitalized for colic, and while both the short and long-term survival for foals were not quite as good as for adult horses, the survival rates were still quite respectable, and Dr. Harris said that “owners should not be discouraged from exploratory celiotomy in neonates when indicated.”

Stent bandages, a sort of pressure bandage sutured over the incision site after a colic surgery, decrease the rate of incisional infection from about 28% to 2.7% according to a study presented by Dr. Aziz Tnibar. Dr. Tnibar hypothesized that not only does the stent decrease contamination but it may also reduce the forces of tension on the incision, optimizing the healing environment.

A big question for owners considering colic surgery is “Is it worth it?” Worth might be measured in the likelihood of the horse's survival or it might be measured by the horse’s ability to return to past performance. Two speakers addressed these considerations. Dr. Joy Tomlinson presented a paper on the return to performance and post-surgical earnings of racehorses that underwent colic surgery, and Dr. David Freeman addressed the factors that are clinically relevant to long-term survival of colic surgery.

Both of these presentations should go a long way toward helping owners make informed decisions and toward debunking some of the mythology surrounding colic surgery. Perhaps surprisingly, it turned out that the racehorses that had undergone colic surgery had neither statistically significant shortening of their racing careers when compared to the horses that had placed on either side of them in their last pre-surgery races, nor did they show a significant decrease in post-recovery racing earnings compared to the nonsurgical horses. Of course, these horses did suffer earnings loss during the layup period following surgery.

Many people shy away from colic surgery on older horses, assuming that those horses are less likely to survive the surgery. I struggled with the same dilemma in my mare who was nearly 28 years old that fateful Christmas. However, according to Dr. Freeman’s presentation, old horses do as well after colic surgery as other horses. “They didn't get to be old by not being tough!” My own experience backs that up. Goldie lived another eight years after her surgery, and her eventual euthanasia at age 36 had nothing to do with colic or her surgery. Dr. Freeman did indicate that survival rates do vary with some breeds. Drafts and Minis handle surgery the worst, while Appaloosas fare best. (My personal theory is that Appys are just hard to kill.)

To my knowledge, we don’t see a lot of equine proliferative enteropathy (EPE) due to Lawsonia intracellularis in California, or at least we didn’t in our practice, so I found the last two presentations of the session incredibly informative. Dr. Connie Gebhart presented a comparison of several serologic assays for EPE, and Dr. Allen Page presented a look at variation between years in seroconversion of horses to Lawsonia.

Several of the serology tests look very promising, although they did all seem to be more accurate in weanlings than adults. Total protein also looks quite good as a screening test, which is nice to know since it’s a quick and easy test. Pretty cheap, too.

Dr. Page’s study confirmed the seasonal spikes known for Lawsonia in Kentucky, with peaks in October-November and again in January-February. While there wasn’t any variation from year to year in samples taken from across Kentucky, decreases in the numbers of seroconversions were seen from 2010 to 2011 and from 2011 to 2012 on three farms where the disease is endemic.

And now, with the equine gastrointestinal tract in mind, it is time to go meet my family at Disneyland for dinner and some fun. I’ll be back tomorrow for the last day of AAEP 2012 with information on infectious diseases, neurology, and other fun stuff. Have a good night; I’ll say “hi” to Mickey for you!

Equine Dental Extractions: Like Pulling Teeth?

2012-12-04T21:10:00Z

It might be an understatement to say that I’ve always found extracting equine teeth to be somewhat daunting. (I won’t use the ‘It’s like pulling teeth’ cliché.) I’ll admit that whenever presented with a complaint of weight loss, I would say something along the lines of “Well, it could be lots of things other than the teeth,” and press for full physical and bloodwork with the vigor of a used car salesman--all the while chanting in my head, “Please not the teeth. Please let me find something else.”

For veterinarians with patience, skill, training, and luck with inanimate objects, equine dentistry can be tremendously rewarding. However, it also carries risk of complications or secondary injury to the horse or, as a legendary black eye on my part once bore testimony, to the practitioner. Coordination is also a useful attribute in equine dental extractions, I’ve found.

I went into this morning’s session on dental extractions highly caffeinated and expecting to learn that I had been doing it all wrong. It turns out that I didn’t need the caffeine, and that the answer was that I was doing some of it all wrong, and some of it exactly right.

Drs. Jennifer Rawlinson, Jack Easley, and Edward Earley took us through the extraction process from the initial exam and considerations, into post-operative care, and even gave us a look at our worst nightmares – when things don’t go according to the plan. Strangely, they didn’t show any slides of a veterinarian whacking herself on the cheekbone with molar forceps. That may be a rare complication.

Dr. Rawlinson’s presentation on considerations in extraction perhaps gave the best take-homes for both owner and practitioner: not every tooth with pathology is suitable for extraction, not every horse can handle extraction (at least maybe not right then), not every veterinarian is equipped to extract every tooth (see above), and not every owner can invest the money and time required not only for the procedure but for the lifetime follow-up.

It turns out that my neurotic insistence on a complete workup before extraction was the right approach. When discussing signs of dental disease, Dr. Rawlinson commented that if a horse presents for weight loss due to suspected dental disease, it’s a good idea to do a full physical exam and bloodwork first since you don't want to miss other diseases. In fact, according to Dr. Rawlinson, the most common sign of dental disease is nothing. That’s right, a large amount of dental pathology in the horse produces no obvious outward signs. So, you know that tendency to wait to have a horse’s mouth examined until something looks wrong? Yeah, don’t do that.

Dr. Rawlinson’s presentation on regional anesthesia made me realize how much harder I had made my own life by wimping out on nerve blocks and sedation techniques, and how much harder it may have been on my patients. Some of the nerve blocks she presented looked pretty intimidating, but like any medical procedure they can be learned, and they reduce the overall sedative need.

Owners may not always like the cost of X rays, but the cases presented this morning reinforced the idea that no one should go anywhere near a tooth with intent to extract without a good set of radiographs. Horse teeth not only erupt throughout their lives, but that angle of eruption changes (you don’t want to be pulling a tooth in the wrong direction), and the roots of many teeth go deep. Also, X-rays will show the badness that is hiding beneath the surface. If a tooth is fractured or there’s weird pathology at the root, the veterinarian needs to be aware before surgery. Tooth fragments left in the socket can lead to infection and recurrent draining tracts and fistulae.

Ultimately, each of the speakers made it quite clear that the decision whether to extract a tooth has just as much to do with the humans as with the horse. The veterinarian needs to be comfortable with his or her skills, diagnosis, equipment/resources, assistants, and available time. The owner needs to be comfortable with costs, understand that the procedure may not go according to plan and that other costs may arise, and that the horse will require follow-up every six months for life to keep the opposing teeth from overgrowing. With all of that in mind, the overall goal for extraction, said Dr. Rawlinson, “is to keep the horse functional and comfortable.”

Managing Field Emergencies--Back to Basics

2012-12-04T13:14:00Z

It’s probably no coincidence that several of the speakers in the afternoon session on “How to manage critical field emergencies” referenced the Winston Churchill quote-turned-Internet-meme “Keep Calm and Carry On.” Emergencies are a huge part of the ambulatory equine practitioner’s bread and butter. After all, horses are emergencies on the hoof.

Still, certain situations can make even the most seasoned veterinarian cringe. Our emergency cases are often more acute, larger, and more public than those seen by our small animal colleagues. There is no back room into which the field practitioner can take his or her patient to evaluate the patient quietly, or to stabilize the patient without a hysterical owner hovering nearby. Stabilization of equine emergencies takes place not only in front of the owner, but often the trainer, neighbor, other boarders, assorted children, and the guy who happened to drive by and wondered what all the fuss was about.

Given all of this, it is perfect that this afternoon’s session opened with a talk entitled “How to communicate with clients in an emergency setting.” Most equine practitioners are already pretty good horsemen and women, and our veterinary colleges pound a solid medical training into our heads, but unfortunately, none of that is of any use unless we can communicate with the client. And, often, we aren’t trained for that. Going back to communications basics, Dr. Amy Grice gave some excellent tips on building those skills in order to better serve our patients.

It’s easy in a crisis to forget the fundamentals or to lose track of the details. When the adrenaline runs high, everyone tends to get tunnel vision. Speaker after speaker went back to the basics on their emergency topic, and multiple speakers stressed the need for a complete history and complete physical exam, even when the problem appears obvious.

In his talk on managing non-weight-bearing lameness, Dr. Ryan Penno said, "Always perform a full and comprehensive exam even though the affected limb may be readily apparent.” He also reminded us that things are not always as they seem. In the limb, swelling may be below the site of the injury, because fluid follows gravity. However, if the injury is to the hoof the tissues above the hoof may swell as the excess fluid is forced proximally by the rigid hoof wall.

In addition to cracking up the room with her comparison of the kidney to a champagne fountain (you’ll have to trust me on that one) Dr. Emma Adam took us back to the basic sciences when evaluating and treating the dehydrated horse, pointing out that the peculiar composition of horse sweat means that excessive losses result in a metabolic state that actually produces a decreased thirst, so often the horse will fail to drink, worsening the problem.

Every horse person’s worst nightmare is the broken leg. But, Dr. Scott Palmer, who was on the team at the track that stabilized Barbaro, walked us through the basics of evaluating and stabilizing a fracture in the field. Even for someone who has seen a number of fractures in the field, it’s good to have a reminder to approach the situation as thoroughly and methodically as I would any other case.

Thorough and methodical was the name of the session. Many emergencies can be stabilized or even treated in the field, and ambulatory practitioners are at the front line of equine disasters. However, when discussing fevers of unknown origin, Dr. Amy Leibeck made one of the most important comments of the afternoon. “Referral is not an admission of failure; it is a commitment to the patient.”

It Isn't Just 'Tying Up' Any more

2012-12-03T22:33:00Z

It's had many names--from azoturia to Monday morning sickness, but, despite the disease being well-recognized for hundreds of years, the causes of the equine muscle disorder most commonly known as tying up, have been elusive. Stephanie Valberg, DVM, PhD, Dipl. ACVIM, Dipl. ACVSMR, explained the history of this disease from ancient cart horses to modern genetic testing and took the audience at the Frank J. Milne lecture at the AAEP Convention into the current understanding of equine myopathies.

This mare from the University of Minnesota Equine Center's PSSM herd is experiencing a tying-up episode with associated muscle stiffness, profuse sweating, and a reluctance to move.
Image courtesy of Dr. Stephanie Valberg

All horse people know the signs, even if we haven't seen a horse in the act of "tying up," we know to look for the muscle tremors, the shivering, the firm muscles. Nowadays, we even know to be on the lookout for more subtle signs such as reluctance to move forward, a stilted gait, or exercise intolerance. But there is still a lot of misunderstanding as to the causes and management of the conditions that result in "tying up."

Yep, conditions. As Dr. Valberg said in the conclusion of her presentation, "Tying up" is not one specific disease. It's a clinical term, like "colic" covering multiple myopathies. The understanding that multiple conditions can present in the same manner allows researchers to pursue the many factors that impact whether a horse will tie up.

Dr. Valberg began with the early history of research into equine muscle disease, noting that while the signs and even risk factors for the disease have been well-described for several centuries, names such as azoturia, black water, Monday morning disease, and others reflected a lack of ability to discover the causes of the condition.

Even when I was in college and veterinary school in the early-mid 1990s, it seemed as though we heard a different mechanism for "tying up" or "exertional rhabdomyolosis" every week. One of the more prevalent theories was that the condition was due to lactic acidosis, a build-up of lactate in the cells. It turns out that prevailing wisdom, taken for decades as gospel, was based on one 1932 study--showing once again, that we don't always know what we think we know.

Thanks to the efforts of a number of researchers including Dr. Valberg, we now know that multiple conditions can cause tying up-like signs in many breeds of horse. Some of these conditions such as polysaccharide storage myopathy (PSSM) in Quarter Horses and a number of draft breeds are genetic while others such as the highly fatal seasonal pasture myopathy affecting horses in the North American Midwest are caused by a plant toxin.

The good news is that knowing more about the causes and mechanisms of a disease helps to develop better treatment protocols. For years, rest was recommended for horses who were prone to tying up. It turns out, however, that many of these horses experience abnormalities in their muscle metabolism that are exacerbated by confinement and that improve with exercise and dietary management.

Advances in equine genomics, specifically the sequencing of the equine genome, has allowed the development of genetic testing for Type 1 PSSM and malignant hyperthermia (MH) in Quarter Horses. Development of a test for recurrent exertional rhabdomyolosis in Thoroughbreds has been slowed by the fact that the gene implicated in those horses is located on a poorly understood region of the chromosome.

However, genetic testing doesn't predict whether a horse will tie up, said Dr. Valberg, only whether it is at risk for tying up. So many factors, such as diet, exercise, fitness level, even nervousness, play into whether a horse will tie up, that a genetic test can only tell you if the likelihood of a given disorder exists.

But, even as more conditions and causes of equine muscle disease are discovered, one thing we do know, said Dr. Valberg is the answer to "Does lactic acidosis cause tying up?" The answer is a resounding no.

The Dark Side--Soring

2012-12-03T18:50:00Z

I understand that most equestrian disciplines contain a certain degree of slippery-slope-ness. When you are dealing with elite athletes, from human gymnasts to cutting horses, the balance between protecting the well-being of the athlete and maximizing the athlete’s performance is delicate to say the least. I get that. I understand complexity; I get how easy it is to nudge the balance a little too far toward performance. But there are some practices in certain performance circles that I just don’t get.

Where is the grey in doing something to a horse that has absolutely no impact on its athletics, but causes the horse pain or damage merely to fulfill an esthetic ‘norm’ that some humans have decided is desirable?

I grew up in Quarter Horse country. I heard about "tail blocks," the practice of injecting causing agents around the base of the tail in western pleasure horses in order to deaden the nerves that permit the horse to swish its tail, long before I entered vet school. And I didn’t get it then. Didn’t horses need to move their tails to get rid of flies? Why couldn’t all judges just agree that some horses are tail-wringers and leave that out of the scoring?

Yes, this view was formed when I was in my teens, and it definitely has the black-and-white mental overtones of a 14 year-old girl. I understand that tail wringing is a sign of equine displeasure, and I get that it would be considered undesirable in a show setting where the overall look is supposed to be one of calm and order. But, having seen the end-results of tail-blocks gone bad, I think the 14 year-old me had it right--some things are just wrong.

Soring involves causing foot or lower leg pain to the horse through painful shoeing techniques, caustic chemicals and/or applied around the pastern and lower legs (see yellow boxes)--all in the interests of getting the exaggerated, high-stepping movement called "the big lick."
Image courtesy of FOSH

Yesterday, I sat in on a table-topic discussion of the Horse Protection Act and the practice that drove its formation – the reprehensible practice of soring in gaited horses. Particularly endemic in the Tennessee Walking Horse industry, soring involves causing foot or lower leg pain to the horse through painful shoeing techniques, caustic chemicals and/or applied around the pastern and lower legs--all in the interests of getting the exaggerated, high-stepping movement called “the big lick.”

Soring has been illegal in the United States for more than 40 years, since the Horse Protection Act was signed. Said Dr. Rachel Cezar of the USDA, in 2012, a 9% violation rate was found at the annual Tennessee Walking Horse Celebration. That means that nearly one in every ten horses endured pain and mental torture that has been illegal for almost half a century.

Illegal. That isn’t a grey area folks. That isn’t a slippery slope. As Dr. Rick Lesser said in the session on ethics yesterday, “There is no free will within the law.”

Yesterday’s table topic focused on some of the technologies being used to inspect horses at these shows in order to curb this practice. We learned from moderator Dr. Tracy Turner that thermography can reveal patterns that indicate various forms of damage, including the possible presence of foreign substances on the leg. We also learned that even scarring isn’t as easy to find as you might think with visual examination and digital palpation as some of the trainers apply what Dr. Turner called mortician-level cosmetics to the legs in order to hide the damage.

Thermography and digital X rays can also be used to detect illegal shoes and the presence of foreign material under the pads. Samples can be analyzed to check for chemicals such as kerosene or diesel fuel. There is no legitimate reason for either of these substances to be on the leg of a show horse unless, as Dr. Turner said, “you’ve gone camping with your horse” or “you had an accident at the fuel pump with your horse.” Somehow I can’t see show horses put in either of these positions.

Ultimately, however, it doesn’t matter how much technology or how many trained personnel are thrown at the problem. Until the rewards for a behavior are lowered to the point of making the risk untenable, the behavior is unlikely to change. It’s human nature. Dr. Cezar summed it up on Saturday during the Welfare and Public Policy Forum: “It will take the industry and stakeholders working with USDA to eliminate soring.” Change has to come from within the gaited horse industry. As with abuses in any sport, we have to eliminate the incentive to cheat. That’s the only way back from the dark side.

Day 2 -- Ethics and Horses

2012-12-03T16:54:00Z

If you attend AAEP conventions there is a phrase heard over and over, year after year. It burrows into the brain with the persistence of a nursery rhyme, mantra, or Elton John lyric. "The Health and Welfare of the Horse." Whether it's stated outright or just implied, every session and every event comes back to that phrase. It makes sense, since for equine practitioners, that's really what it's all about.

The sessions I attended yesterday afternoon were less medical and more philosophical. The closest anything came to clinical medicine was the discussion of diagnostic techniques used to detect soring in gaited show horses.

Instead of diagnosing and treating diseases, with both sessions the prevailing theme was the impact of human choices on the health and welfare of the horse.

The tricky part of veterinary medicine, particularly equine practice where our patients actually earn paychecks, is that our patients do not pay their own medical bills. Veterinarians face a conflict of interest every time we roll out of bed for a work day.
Photos.com

I wonder sometimes if people realize how much time veterinarians spend in ethical wrangling--with each other and with ourselves. Sometimes I'm not even sure that we realize it. But, the tricky part of veterinary medicine, particularly equine practice where our patients actually earn paychecks, is that our patients do not pay their own medical bills. Veterinarians face a conflict of interest every time we roll out of bed for a work day.

But, of course, we don't deal with this ethical quandary in a vacuum. The first speaker in the session on "Ethics, Scope of Practice, and Racing" was Dr. Stephen Galloway talking about the regulation of veterinary medicine. Veterinarians are licensed professionals, like physicians, nurses, lawyers, and accountants. As such, we are licensed and regulated by bodies known as Boards of Veterinary Examiners (BVE). These boards regulate at the state level; there is no national regulation of veterinarians. What a lot of folks don't realize is that the BVEs exist to protect the consumer, not the profession.

The BVEs regulate the legalities of the veterinary profession. A key point made by Dr. Galloway was that legal practice defines what veterinarians can do. Ethical practice defines what veterinarians should do. He gave a trenchant example of the distinction. It may be legal (under certain circumstances) for a veterinarian to dispense sedation or to sedate a horse for a lay dentist. However, supporting medical practice by nonlicensed, non-medically trained practitioners is hardly ethical.

Yes, I know that isn't a popular point, but I happen to agree. When health care procedures are performed by individuals without medical backgrounds who have no oversight (go back to the consumer protection thing) and no, or little, medical training, the horse (and ultimately the consumer) loses.

Dr. Rick Lesser spoke on some of the more esoteric aspects of ethics and morality, but the bottom line was this: "Complex moral issues don't lend themselves to simple, clear-cut answers." From here, he made the point that the very complexity of ethics forces the examination and discussions that we need to have in order to move beyond our own biases, fears, and desires. The ethical struggle ultimately leads to moral action. "There has to be a struggle. There has to be tension. And we have to get involved in it."

Tensions in the horse world often run highest around racing and performance issues. Dr. Scott Palmer and Dr. Jeff Blea each addressed the ethical dilemmas faced in racetrack practice. Track vets have the complexity deck stacked against them. The veterinary-client-patient relationship morphs into the veterinary-owner-trainer-horse relationship, adding another level of complication. And, as Dr. Palmer said, the public perceives medications in racing as damaging, veterinarians are the purveyors of medication, ergo, the PR bullseye lands squarely on the veterinary back.

So, now what? Do equine vets roll over? Give up in the face of complex issues? Stick with what is legal and let the ethics sort themselves out? Nope.

Dr. Blea pointed out that the business model of racetrack medicine needs to change, shifting the income from goods (i.e., medications) to services since medications and medical rules still drive most of the ethical dilemmas in racetrack practice.

Dr. Palmer summed it up best: "We need to be the advocates for the horse." Good advice for all of us, from backyard to racetrack.