For the past few weeks we’ve been serializing a chapter entitled “Piaff” from the new book Equine ER: Stories from a Year in the Life of an Equine Veterinary Hospital by Leslie Guttman (Eclipse Press, 2009). Piaff, a Dutch warmblood gelding, had a devastating case of equine protozoal myeloencephalitis (EPM), an infection of a horse’s central nervous system, from which he did not survive. (See previous posts for installments.) As a final follow-up, here is a Q&A with Dr. Stephen Reed, one of the world’s experts on equine neurology and the lead veterinarian on Piaff’s case:

EQUINE ER: Was Piaff one of the most difficult EPM cases you’ve ever had?

DR. STEPHEN REED: Certainly it was one of the most challenging … the case had already been through so many excellent veterinarians prior to coming here [to Rood & Riddle Equine Hospital]. The case was also difficult in that there were periods of time when it looked like there was going to be some turnaround, and it made you think, “Oh my gosh, this is going to be OK.” But in the end, we became so distraught. No matter how hard we tried, we couldn’t make the turnaround. It reiterates again all the difficult things about EPM: the difficulty with accurate diagnosis, the difficulty with effective therapies, the understanding of how the organism hides, so there are so many aspects of the case that were in fact problematic and difficult in that regard. Couldn’t have had a better owner. She was so thoughtful and compassionate.

EQER: Is there anything Piaff’s owner could have done differently?

REED: If anything could be taken away from it, and I think even if you ask [the owner] she would say the same thing: I wish we had started aggressive treatment earlier. One of the things we know is the best likelihood and probability of saving the horse is to do really good effective treatment early on in the course of the disease.  The case did bring up some ideas for me that maybe we need to supplement medications with things that will enhance the immune system … it’s probably a reasonable adjunct to therapy. I’ve been thinking about it for a while, but Piaff made me think even more that maybe we need to be more aggressive [with the immune system] early on. Since there are less than 1% of EPM cases, yet exposure rates are high, that must mean in most instances, the horse gets exposed and the immune system clears it. So perhaps in that 1 percent, there’s something unique. The uniqueness we don’t know: Is it the organism? Is it the horse’s [individual] immune system? Is it the lack of effective treatment? What is it that is different about those horses?

EQER: What were your first thoughts when the owner said she wanted to use the human drug interferon as a last resort?

REED: She had already investigated it to her satisfaction. I had to investigate it. I contacted the person I consider one of the best veterinary immunologists around, Dr. Dave Horohov at the [University of Kentucky’s] Gluck Equine Research Center, and I ran all the ideas by Dave. And he shared with me why he thought it would not be very helpful, but he also said having stated that … he didn’t see a big downside to administering it. [See Editor’s Notes at the end of this Q&A for more on Reed’s conversation with Horohov.]

The owner’s not an intimidating person. Even though she challenged you with difficult questions, she didn’t try to push her agenda. Because of that, it made it easier to go along with her, to say, “OK, Let’s try this.”

EQER: Also, because you’re a person of medicine who deals with percentages and odds, there wasn’t a 100 percent chance that it would not work, right?

REED: That’s correct …

EQER: What’s the No. 1 thing that horse owners can do to prevent EPM?

REED: Be aware of your environment. If you see a lot of the intermediate hosts around, if you see a lot of opossums on your premises, you need to be totally aware of what those opossums are doing, to be alert to where they’re eating. Owners need to be aware of what all the intermediate hosts are [which include skunks, cats, raccoons, armadillos, and sea otters], and if they see the intermediate hosts in the area dead, they need to dispose of them because they will infect the opossums. [Editor’s Note: The opossum, a definitive host for EPM, spreads the parasite that causes the disease by eating one of the intermediate hosts and passing the infection through stool, contaminating feed and water sources.]

If they see opossums, they need to live-trap them and dispense of them elsewhere (or send them to heaven if that’s their goal). They need to keep their feed covered. And then beyond that, they need to be very aware of their horse so they can identify when their horse starts to do unusual things. Difficulty with eating, difficulty with backing, maybe some subtle nuance with the way it moves or the way it eats or the way it whinnies. If there’s something different about what it does, they need to think: “Geez, that’s not normal, we need to keep an eye on it.” Because again, we definitely know early treatment has the best success.

EQER: What’s some of the most exciting research being done on EPM right now?

REED: I think some of the most exciting work is being done by Dan Howe at the Gluck Center [See Editor’s Notes at the end of this Q&A]. He’s looking really aggressively at some new diagnostic testing. … Beyond that I would say that what’s right around the corner is more and more effort devoted toward prevention. You know, the vaccine trials that were done at Ohio State, they didn’t show success, and I believe people are going to back away from that for a while now. People didn’t give up on malaria, so I don’t think that’s a totally dead deal, but I think it’s going to take some more thought. (And I don’t know who is doing that work right now.) I think what’s coming is the development of other ways to prevent EPM, such as feeding low-dose medications on a daily basis. That’s not out there yet, but I think it’s about to start.

EQER: What would be an analogy to that?

REED: The daily dewormer.

EQER: So in terms of an EPM vaccine, what you’re saying is … ?

REED: It’s not out of the picture, but it’s not imminent.

EQER: You’ve been a vet for 33 years. Does it ever get any easier to put a horse down?

REED: Not for me. It’s very difficult to put a horse down. But you have to always remind yourself that by definition, euthanasia is humane. In this instance, it was an opportunity to do the right thing, to prevent suffering. It’s always difficult at the time, but particularly in a case like Piaff, when you see the post-mortem showing that there were irreversible lesions, you know you did the right thing. And the other thing is when you have an owner like Piaff’s, she came to that realization on her own.

EQER: What’s your best advice for someone who wants to be an equine veterinarian?

REED: Study hard. Get lots of experience. Be interested in working hard. I think it’s a great profession. I would say an awful lot of equine veterinarians, not only here, but around the nation that I know, many of them don’t consider their jobs like going to work. You just have such satisfaction doing what you do.

EQER: What specifically makes it so enjoyable for you: the work, the camaraderie, the research?

REED: Well, for me, all of those things: the opportunity to be with people you really like and trust, the opportunity to help the horses and the owners – that really means a lot to me. Even though I’ve come here [to Rood & Riddle from Ohio State], I’ve had the opportunity to stay connected to some of what I think is the best research going on. About two weeks ago, I organized a special interest group on EPM of all the internists in Central Kentucky. … some of the top researchers came and we all discussed and talked about this disease. It was like, “You know, we’re going somewhere.”

Editor's Notes:

1)  Equine ER talked to Dr. Dave Horohov who said the reason he didn't think the interferon would be effective in Piaff’s case was because what the horse needed for his illness was equine-specific interferon gamma, which was not available; only interferon alpha designed for humans was. However, Horohov said he did not think the interferon alpha would harm Piaff because studies have been done using it in horses that have shown some immune-boosting activity. Although Horohov did not think the drug would likely work in Piaff's case, he said he thought, like Reed, it was worth a try.

2) Dr. Dan Howe at the University of Kentucky's Gluck Equine Research Center said he believes the new (ELISA) test for EPM, developed in his lab (and tested and validated with the help of Dr. Martin Furr of Virginia Tech, Reed, and others), measures with much more accuracy than other EPM tests the amount of antibodies against the parasite that causes EPM, Sarcocystis neurona, in serum and cerebrospinal fluid, allowing for more accurate predictions about whether a horse has an active infection in the central nervous system. The test is still in development, but Howe said he hopes it will be commercially available fairly soon.

In her advance praise, Susan Richards, author of the New York Times best-seller “Chosen by a Horse,” calls the new book Equine ER “as thrilling and drama-filled as any of the popular hospital shows on television today.” To order, click here. Thanks for visiting this blog.

 As a follow-up, Monday will bring "Ten Questions for Piaff's Vet," a Q&A with Dr. Stephen Reed, the lead veterinarian on the case of the Dutch warmblood gelding with EPM whose journey was just chronicled in a series on this blog excerpted from the new book from Eclipse Press: Equine ER: Stories from a Year in the Life of an Equine Veterinary Hospital. (For new readers, see previous posts.) Today, we are bringing back the most-viewed Equine ER video, "It's a kick." Click HERE if you are unable to access it below. Upcoming: New videos, more excerpts. Thanks for visiting this blog.

         Dr. Stephen Reed

News flash! Coach Calipari (U.K. football coach) bumps Equine ER! Crowds revolt (OK, not really). New date and time for Joseph-Beth bookstore reading in Lexington: Friday, August 28, 7 p.m.

In the previous installment of this excerpt from the new book Equine ER, Piaff, a Dutch warmblood, was diagnosed with a devastating case of EPM that was worsening despite treatment. His owner proposed treating him with the human drug interferon as a last resort, a decision her vet supported. Below, the final installment:

The interferon was ordered Friday, but couldn’t arrive until Saturday. I found Dr. Stephen Reed, Piaff’s vet at Rood & Riddle Equine Hospital, in the admissions building Saturday morning waiting for the medication. It was supposed to be there by 10:30 a.m. and wasn’t. He was upset. “The client is looking at me expecting me to do something,” he said. “I’m really discouraged.” He went down to the barn to check on the horse. The winter’s first snow had come the night before, and the rooftops of the light brown barns were frosted; they looked like gingerbread barns. The cold was bullying.

In the barn, Piaff leaned against the wall. He looked like a war victim. The pressure sore on his right hindquarter was bigger, the skin now gray and flaking off. His right hoof was in what’s called a soft ride boot for support because of concerns about laminitis – he was leaning on his left side too much, putting little weight on the right. The pressure sore under his armpit now looked like a shark bite; occasionally he tried to lick it. He was now having respiratory problems. The night before I had read a magazine article about the rise in America’s fondness for pets. It said the French call their dogs bêtes de chagrin – beasts of sorrow, recognizing that to love a dog is eventually to mourn it. To my eyes, Piaff seemed to be turning into a horse of sorrow.

Reed needed to leave. He had promised his wife and out-of-town family that he’d spend time with them that weekend, actually since Thursday, and had barely done it. Like many veterinarians, he was in trouble with the ones he loved over his work schedule. He’d have his intern, Dr. Birthe Pegel, give the horse the medication when it came. But just as he was driving out, he got a call from the pharmacy that the interferon had arrived.

Pegel jumped in Reed’s car to stay warm after he phoned her from the parking lot, and they discussed the dosage. The small Styrofoam cooler with the orange sticker that read “SATURDAY” on the top contained 20 million units of Interferon alfa-2b, divided into two doses. Reed decided they should give Piaff a half dose Saturday and a half Sunday and see how he fared. He drove Pegel down to the barn. It had started to snow.

After preparing the medication in the small office in Piaff’s barn, Pegel went into the stall where the horse leaned against the padded wall: “Hi, Piaff. I need your neck. You like your wall, I know. Just let me give it to you.” Piaff licked his lips and put his muzzle over her shoulder as she injected the drug into his IV catheter. “That’s it,” she said.

As she left, Pegel said, “I think he’s getting weaker.” We talked briefly about whether she thought he should be euthanized. She was nonjudgmental about the owner’s desire to keep trying: “Everyone’s different about how long they hold on to their horses.”

Pegel had never given interferon to a horse, but she had worked her way through veterinary school manning a pharmaceutical hot line for human multiple sclerosis patients using the drug. Patients who called in had side effects such as fevers, chills, muscle aches, and headaches. For people who used the drug a long time, skin problems often developed near the injection sites.

Back in the office, Pegel read off the side effects from the safety material: “flu-like symptoms, skin problems … blood sugar problems …” More than fifty different potential side effects were listed. Neither Reed nor she thought the interferon would hurt Piaff at this stage, but they did not truly know what side effects might occur. Reed was more worried about the drug having no impact.

Pegel went to check on Piaff one more time before leaving. “Don’t lick your wound,” she told him.

Despite all his problems, Piaff was still bright. He hadn’t gone dead behind the eyes, as Ryan Nesemeier, the tech who was caring for him that day, put it. The contrast was as incongruous as the crimson roses still blooming outside the hospital admissions building in the middle of the falling snow.

The next day, Piaff seemed roughly the same, although one of the techs thought he might have improved a bit. But after Wednesday, he kept going downhill. He didn’t seem to be having any side effects from the interferon, but it also didn’t appear to be helping. On Friday, he stood up for eight minutes on his own without the sling and then collapsed. By now, it was the weekend before Thanksgiving. I left to see family out of state. On Monday I called from the Northwest; Piaff had been put down that night, the owner’s decision. The necropsy showed EPM was what Piaff indeed had. His spinal cord showed substantial lesions containing S. neurona, the parasite that causes EPM. A postmortem that reveals a horse had EPM will usually show the identifiable trail S. neurona leaves behind in damage to tissue, but it is actually unusual to find the organism itself.

The owner’s love for Piaff went so deep, she couldn’t find the bottom. She was struck by his character. During the entire medical experience, he never once pinned his ears back toward anyone (a sign of anger or feeling threatened), even when he woke up in Wisconsin in a sling for the first time. “He knew people wanted to help him.” She repeatedly went over the course of his illness in her head. She wondered if the colloidal silver might have undercut the effects of the earlier EPM medication, as well as if the right drugs had been given to him early on … or if something in Piaff’s immune system had made him unresponsive to them. She felt she had failed her horse. Reed didn’t know the answers, and thought probably nobody would. But he thought it was natural to question choices in a complex medical crisis. The owner said one of her biggest lessons was that “neurological illness should not be left up to an average vet. Get the horse on a trailer and take him to a specialist (no matter how far away). You don’t have time. You need a quick, definitive diagnosis. Every day you miss is a day where more damage is done.”

When I emailed with her in spring four months later she wrote of the loss, “It is still very raw. I still can't believe he is gone. I cannot really grasp that he is gone. When I stop to think about it, it is still very painful.” Her email reminded me of what a veterinarian and veterinary scholar I interviewed once told me a client said to her about losing a pet: It was like a color was missing from her life. The color of Piaff was gone, and it would be a long time before the owner stopped being aware of it.

This excerpt came from the new book Equine ER: Stories From a Year in the Life of an Equine Veterinary Hospital by Leslie Guttman, from Eclipse Press. In her advance praise for the book, Susan Richards, author of the New York Times best-seller “Chosen by a Horse,” calls Equine ER “as thrilling and drama-filled as any of the popular hospital shows on television today.” The book takes place at Rood & Riddle Equine Hospital in Lexington, Kentucky. To order, click here. Thank you for visiting this blog.

Author's note: The magazine article referred to in the above excerpt was the Sept/Oct 2007 issue of Orion, “What’s the Use of Pets” by Ginger Strand. The phrase, “It was like a color of missing from her life,” came from vet and veterinary scholar Myrna Milani in a personal interview the author had with Milani in 2008.

In the previous installment of this excerpt from the new book Equine ER, Piaff, a Dutch warmblood with a mysterious and devastating illness, was diagnosed with EPM. Now, his vet had a treatment course, and the gelding started to improve. Below, Part 4 of 5.

One of Rood & Riddle’s receptionists, Chris Pfetzer, has a son, Mark, who in 1996 at sixteen was the youngest person to climb Mount Everest. During the expedition, eight climbers died in a storm. Mark reached the highest camp, but not the top. While I was writing this book, Chris lent me her son’s book about his teenage years climbing and summiting the world’s highest peaks. One of its passages reminded me of Piaff’s case:

“Routes are not all precise. They deal with broad areas. You might aim for a particular rock face or gully, which leads you to a ridge you have to cross. You have to consider the location of camps, too, because they offer safety, protection. But no matter how well you plan a route, you never know what’s ahead of you … ”

Toward the end of the second week that Piaff was in the hospital, he was taken out of the sling for the first time. He stood on his own for twenty minutes, but then, twitching flies away with his tail, lost his balance and fell. A pressure sore was developing on his left hip and another in the accompanying axillary region (armpit), which worsened after he was hoisted back up in the sling. Two days later, he swung across the stall again via the hoist and lost his balance, although he was able to regain it on his own.

By the third week, despite treatment and padding, the pressure sores worsened, the one under his armpit draining pus. It was swollen and sensitive to touch. Piaff started leaning his left side more and more against the wall. The left front leg was still being treated regularly, but the swelling had stopped going down, and the leg had gotten stiff. The edema in his sheath increased. Piaff was getting weaker.

“I’m just so upset,” said Reed, when I caught up with him. “I can’t get that wound to heal in the axillary region … and he needs to learn to go to sleep and get some long sleeps. Horses need to sleep just like people. You can’t heal if you don’t sleep, you know?”

Although Piaff was still sunny most of the time, he started to have moments of depression – sometimes he wouldn’t nicker at the prospect of a treat or would lose interest while being petted unlike before. It seemed as if Piaff might be sliding down a mountain. Yet he didn’t want to die.

Piaff continued to decline. By the end of the third week, nobody who worked in the hospital could remember a horse ever being in a sling that long. Meanwhile, the owner had been reading about the human drug interferon and how it stimulates macrophage response in people. Macrophages are large white blood cells that have an important role in initiating immune system response (among other things). She also read that interferon activates the responsiveness of natural killer cells, another important player in the immune system.

Interferons are natural chemical messengers in the body (from a larger group of proteins called cytokines) produced by cells infected with a virus or cancer. The messengers “interfere” with the replication of a foreign pathogen, before it develops antibodies, and also stimulate the immune system. Depending on their molecular structure, most interferons are classified as alpha, beta, or gamma. The different forms have different roles. Interferon medication mimics naturally occurring interferon.

The owner had also read various veterinary studies, including one that showed mice that were genetically developed to have part of their immune system knocked out – the part containing interferon gamma – were more susceptible to parasitic and protozoal diseases, and EPM is such a disease. Interferon gamma helps regulate the immune system. She asked Reed: If the interferon level in Piaff was increased, could that possibly boost his immune system and fight EPM?

Reed was hesitant. An experiment in a mouse might not apply to a horse. He had never used interferon for EPM, and didn’t know of any case that had, and wasn’t sure what the dosage should be. Also, interferon gamma wasn’t available to him as a pharmaceutical, only a form of interferon alpha used to fight some types of leukemia, skin cancer, hepatitis B and C, and other diseases. Reed was also concerned that Piaff was starting to truly suffer. Yet he wanted to save the horse as much as the owner. This horse wants to live. He thought there was a shot that the interferon available could turn on immune-fighting cells, including those that produced interferon gamma. He said he’d try the drug for a week or so, which is about how long it would take to show any impact. But if no improvement surfaced, he thought Piaff should be euthanized. The owner was relieved the vet was willing to try.

Monday: The conclusion.

The is the fourth installment of a five-part excerpt from a chapter entitled “Piaff” from the forthcoming nonfiction book Equine ER: Stories From a Year in the Life of an Equine Veterinary Hospital by Leslie Guttman, from Eclipse Press. In her advance praise for the book, Susan Richards, author of the New York Times best-seller “Chosen by a Horse,” calls Equine ER “as thrilling and drama-filled as any of the popular hospital shows on television today.” The book takes place at Rood & Riddle Equine Hospital in Lexington, Kentucky. To order, click here. Thank you for visiting this blog.

News Flash! Author Leslie Guttman on HRTV Wednesday (7/13) at 12:10 p.m. talking about Equine ER.

In the previous installment of this excerpt from the new book Equine ER, the myelogram (a special X-ray) performed on Piaff, a Dutch warmblood gelding, showed he did not have wobbler syndrome. That meant the illness he'd had for more than a year remained a mystery. Below, Part 3.

Piaff was purchased by his current owner (who prefers to be anonymous) in The Netherlands in the fall of 2002 with the intention of using him as a dressage horse. When he first came to the United States, the horse was a nervous wreck. Everything stressed him out, from his neck being touched to the sight of the dust mop used to clean the rafters of his stall. His owner didn’t know how he was previously treated, but it didn’t appear to be well. With patience, he relaxed, becoming more trusting, less anxious.

Piaff was striking to everyone who saw him – his size, the shimmer of his coat, the lightning bolt blaze down his face. As he matured and calmed down, becoming more expressive and communicative, people were drawn even more to him. It was true animal magnetism.

Back at Rood & Riddle, after the myelogram, Piaff could not get up for seven and a half hours. The stress of the trip from Wisconsin, the anesthesia from the myelogram, and whatever disease he was suffering from had left him too weak to move. The owner came back down to Rood & Riddle. When she saw how weak he was, she thought, “OK, we’re done.” But then, some light. The cerebrospinal fluid taken at the beginning of the myelogram showed he was positive for antibodies against the parasite, Sarcocystis neurona, which causes EPM. Now, Dr. Steve Reed, Piaff’s vet at Rood & Riddle, had a treatment course.

EPM testing is thorny; no test exists that can tell, with 100 percent accuracy, if a horse has the disease. The neural tissue that S. neurona invades can’t be taken from a living horse. (The only 100 percent accurate test for EPM, as Reed and other veterinarians say, is a postmortem.) So the three major EPM tests, which all use different approaches, look for antibodies against the parasite, circulating in the blood and/or cerebrospinal fluid, as evidence of the infection.

Piaff in better days. The horse was striking to everyone who saw him.

Piaff’s last two EPM tests, done a month or so before, had indicated he did not have the disease. Both were done using blood samples. The owner thought perhaps the September tests had been inaccurate. It can happen. Or, maybe he didn’t have a measurable antibody level at the time of the previous tests, another scenario. The owner wished she had tested with cerebrospinal fluid from the start, considered by numerous veterinarians to be the best way to diagnose EPM. She hadn’t requested it because he was already being treated for EPM anyway and she was advised, correctly, that blood contamination during a spinal tap can sometimes render a false result.

In the end, whichever test (or combination of tests) is chosen is a matter of preference, for the client and the veterinarian, and has to be evaluated in combination with clinical signs and by ruling out other diseases and conditions. Reed prefers a test called the Western blot; his research contributed to its creation. (The Western blot works by detecting antibodies against different proteins from S. neurona, giving a positive or negative result rather than a level of concentration.) In Piaff’s case, for Reed, everything added up to EPM.

At Rood & Riddle, immediate EPM treatment was started for Piaff, more aggressive than before. By the next afternoon, he was back up in the sling when I came by his stall. He looked alert and happy, bouncing back, Reed thought, from the stress of the past two days and the anesthetic clearing out of his system, and benefiting from the anti-inflammatories used as part of the treatment. Piaff was not leaning against the wall for support.

The owner was tweaking the hoist at Reed’s direction. “I can’t believe he’s standing like that,” she said.

“He seems to know this (sling) will help him and we’re there for him,” said Reed. “Now, he’s relaxing into it.”

A tech took his temperature. It was normal.

EPM is the most commonly diagnosed neurological disease among North American horses. Piaff’s owner thought he might have gotten it at one of the first barns where he was boarded after being imported from Europe. Other horses there also had the infection. Horses can’t catch EPM from each other, but S. neurona might have been lurking in the feed and water.

S. neurona moves around the central nervous system, harming both the spinal cord and the brain. One of the problems with EPM is that it can be difficult to diagnose; it can look like other neurological diseases; symptoms can be mild incoordination or weakness so severe a horse can’t get up. Yet one distinctive sign is asymmetry in the presentation of symptoms. For example, gait clumsiness on only on side, or the left ear droops, but not the right.

Over the next few days, Piaff improved. In addition to the EPM medication and other treatment such as antibiotics, he was getting two medications to boost his immune system, along with Vitamin E, acting as an antioxidant. He learned how to use the hoist even more skillfully and didn’t strain his neck against the sling like some horses do. A big piece of foam was placed between his chest and the sling to help prevent pressure sores. Not every horse will stay in a sling without panicking. Some will thrash, unable to overcome their genetic desire for flight when feeling trapped. But despite being so constrained, Piaff was calm, alert, accommodating, bright, the kind of patient everybody likes to be around. His left front leg, which had been swollen when he arrived, started to improve with hydrotherapy and other treatment. Techs were with him virtually twenty-four hours, feeding him fresh grass they handpicked outside the barn, along with carrots and horse cookies called Meadow Mints his owner had left for him. Piaff was also fun; he liked to butt his caregivers gently. Almost no horse likes to be alone, and Piaff was no exception. He was becoming close to the people around him, and they to him.

But although he was improving, Piaff was not getting the deep sleep he needed standing in a sling. By Thursday of his first week at Rood & Riddle, he had not lain down to sleep since he had arrived. When his legs buckled underneath him, Reed let him stay down and sleep for two and a half hours. But he couldn’t stay down too long; he’d be vulnerable to pneumonia and other problems. The hoist was used to get him back up. The next day, he was sparky again, having had some rest. He seemed to be standing on his own, even with the sling on. In the midafternoon, Reed came to check on him. Nursing supervisor Kirsty Nolan was on watch.

“We have to establish a plan to get him out of the sling and out of the hospital,” said Reed to Nolan. “If we could just get him to start moving. I think even if he just steps around it would be good for him … to get his coordination improved, his strength improved.”

Piaff stood looking at the vet. He was starting to get a pressure sore from the sling on his right hindquarter.

“It seems like he’s holding himself up,” the vet continued. He loosened the straps of the sling a little and then had Nolan move the hoist down so Piaff could bear more weight, yet still be supported by the sling if he needed it.

“He’s so unsure of himself and lacks confidence,” said Reed.

“They learn to compensate,” Nolan said.

I asked Reed if Piaff had become psychologically dependent on the sling. “That’s personifying,” he said, “but that’s what I think. I’d like to see him walk in a circle.” He slapped Piaff on the butt lightly. Piaff stepped around tentatively and stopped. “That’s it. C’mon. C’mon. See it’s much stronger,” the vet said of the swollen left front leg.

The vet kept urging the horse to walk. Piaff reluctantly moved around in a circle.

“My goal is to have him out of the sling by the weekend,” said Reed. “The week after that, a lay-up farm. We need an endpoint for this client … I think Piaff is stronger today. If he was in an arena, I bet he’d walk without falling.”

For the third time, Reed was able to get Piaff to make a slow circle in the stall.

Earlier in the day, Danielle Thomson, an internal medicine tech, had stopped by to see how Piaff was doing. Thomson had worked briefly as a nurse in a regular hospital. After about eight months, she came back to equines. The money was better treating people, but one of the reasons she left was that it was too painful to be around people suffering at the end of their lives. Horses could be euthanized.

When Thomson was working with people, she had seen patients who were afraid to get out of bed after a serious accident such as breaking a hip. After a point, it was psychological.

“You have to make them get out of bed,” she told me. “You have to say, ‘I will be there for you. I will catch you if you fall. I won’t let you fall.’ ” After visiting Piaff, she also believed the horse might be afraid, clinging to the sling for security.

Back in his stall, Nolan did some physical therapy on his left front leg, lifting and stretching it. He was stronger than he was the day before.

Thursday: Trouble.

This is the third installment of a multi-part excerpt from a chapter entitled “Piaff” from the forthcoming nonfiction book Equine ER: Stories From a Year in the Life of an Equine Veterinary Hospital by Leslie Guttman, from Eclipse Press. In her advance praise for the book, Susan Richards, author of the New York Times best-seller “Chosen by a Horse,” calls Equine ER “as thrilling and drama-filled as any of the popular hospital shows on television today.” The book takes place at Rood & Riddle Equine Hospital in Lexington, Kentucky. To order, click here.

If you're in Lexington, Kentucky, or thereabouts, come see Equine ER author Leslie Guttman at Joseph-Beth bookstore on Saturday, August 29 at 2 p.m. She'll be reading from Equine ER and showing the video series. Come meet some of the Rood & Riddle staffers, clients, and equine vets behind the book.  If you're not in Lexington, future events will be posted on Leslie's page on booktour.com. Thanks for visiting this blog.