6:30 a.m. – 7:30 a.m.: Family Time/Morning Ritual
I like to start my morning with my two boys who are four and six years old. We get up and play a little before breakfast. We then all load into the car to head to school.
8:00 a.m. – 9:15 a.m.: Hospital Rounds
When I arrive at Palm Beach Equine Clinic, I convene with the hospital staff to discuss the hospitalized patients. There are about 15 horses currently hospitalized with us, though some of them are only here for MRI and bone scans or other outpatient procedures. During rounds, the hospital’s patient-care team of veterinarians and technicians make a plan for each patient and debate the best treatment strategies. This is an opportunity to make sure everyone is on the same page with the specific rationale for each treatment plan, and also an opportunity to quiz some of our younger veterinarians on the relevant science.
Today, I got into a good conversation with another senior clinician regarding the ideal choice of blood thinners to limit the risk of clotting in a sick patient. Although we did not totally agree, our diverging opinions provided some perspective to the young veterinarians during rounds. Honestly, even without complete consensus on any given topic, this kind of dialogue challenges us to remain abreast of the medical literature, helps us provide articulate and succinct presentations, and ultimately, promotes optimum patient care.
We also discussed modifying the treatment strategies for a six-year-old stallion who had colic surgery about 18 hours earlier. He was experiencing the all-too-common problem of “post-operative ileus” where the small intestine was not returning to normal motility as quickly as we would like. We increased the regimen of prokinetic drugs, which are IV medications that can help increase the contractions of that sluggish small intestine. We also discussed the possibility of increasing his hand-walking, which can improve his motility.
As we made our way through the barn, we talked about rechecking the current insulin levels of a 15-year-old Hanovarian mare who has been fighting founder for more than a week. If the insulin remains high, we may need to modify her treatment regime, including increasing her dose of metformin, a medication that can help modify the concentration of insulin in her bloodstream. Thankfully, it came back as normal when we checked it with the handy patient-side test called Wellness Ready.
Other notable cases included a mare who is hospitalized with us on foal-watch since her pregnancy is nearly full-term, a polo pony with a corneal ulcer (eye trauma), and an almost totally better horse that had presented to the hospital with a fever of unknown origin. After the fever had abated on its own within hours of hospitalization, he was set to remain boarded until his PCR tests confirm that he wasn’t shedding any infectious diseases and he could safely return to his home barn.
9:15 a.m. – 10:15 a.m.: Updating Clients
After hospital rounds, I spend a little bit of time returning calls and updating clients and owners on their hospitalized patients. I also document patient updates and client conversations in the medical record for each horse.
10:30 a.m. – 11:30 a.m.: Farm Call ¬– Follow-Up Gastroscopy
I arrive at a local farm along with one of our young veterinarians to do a recheck gastric scope to see how well a nine-year-old gelding has responded to 27 days of treatment for gastric ulcers. Our exam a month ago showed moderate gastric ulcers (Grade 2 out of 4 in severity) in the upper stomach (the “margo plicatus,” where the squamous stomach lining meets the portion that produces acid). There was also thickening around the pylorus, the outflow tract (“exit door”) at the bottom of the stomach. It’s good to see that the horse is acting much better, gained some weight, and has a healthier hair coat since we started treatment with Gastrogard omeprazole last month. We need to see how he has responded to a combination of medications, and hopefully, discontinue the anti-ulcer medications if possible. After a round of light sedation, we pass the endoscope into the stomach. The Grade 2/4 gastric ulcers are totally resolved, which is great news. The pyloric outflow tract is only a little bit better. Although it requires treatment twice a day, we recommend the addition of misoprostol, which is a medication that is often considered more likely to help resolve problems at the pylorus. We also discuss a plan to make sure that the horse has continuous access to grass hay and/or fresh grass in turnout. This can help prevent ulceration and, in some cases, promote healing without the necessity of additional medication. We write the prescriptions and make a plan to repeat the stomach scoping in another three to four weeks.
11:45 a.m. – 1:15 a.m.: Farm Call – Respiratory Evaluation
We continue to a second local farm to follow up on a case of suspected respiratory problems in a nine-year-old chestnut jumper mare. Earlier in the week, the mare’s regular veterinarian, who works with us at Palm Beach Equine Clinic, had been asked to evaluate her for shortness of breath and occasional coughing during and after work. The mare had been performing well, but had been a bit sluggish for the past three months. Recently, her symptoms had become much more obvious, especially after the mare finished training or competition. This raised the trainer’s concerns about asthma or possibly, Exercise-Induced Pulmonary Hemorrhage (EIPH).
Her physical exam is normal, including the “re-breathing exam”, where we ask the mare to breathe deeply by placing a medium trash bag over her nostrils. This test is the equine equivalent of when your doctor asks you to breathe deeply so they can hear your lungs. Her re-breathing is pretty normal, but it sounds like there might be a little bit of airway-narrowing in her caudo-dorsal lung fields, which is near where the back of the saddle would sit. We take a look at the lung surfaces using ultrasound, and there are no abnormalities there.
Next, in order to obtain a better understanding of what kinds of factors might be affecting her breathing, we scope her upper airways under light sedation. There are no significant abnormalities in the nasal passages, nasopharynx, larynx, guttural pouches, or the top of the windpipe. Based on this news, I recommend collecting a sample from the lower lung fields, which is called a bronchoalveolar lavage (BAL). A microscopic analysis of this sample will help us better determine if there is asthma, bleeding, or any sign of bacterial or fungal infection.
With a little bit of local anesthesia in the nasal passages, and a bit more in the windpipe and lower bronchi to minimize discomfort and coughing, we flush 240 milliliters of saline into her lungs, and aspirate it right back out. I can tell from the foaminess that we got a good sample. The good news is that while there is a little mucous, the sample is clear, so at least there hasn’t been any lung bleeding very recently. We discuss a plan to limit exposure to environmental dust and use nebulized bronchodilators and herbal medications while awaiting the results of the BAL fluid analysis. The results should be available in 24 to 48 hours.
1:14 p.m. – 2:30 p.m.: Prepare Prescriptions and Process Samples
We finalize and prepare prescriptions for the horse with stomach ulcers, including organizing the fat supplement they had requested. We also process samples from the respiratory case, and prepare to ship it out to the lab that specializes exclusively in reading BAL samples. I document the respective case details. I am almost done with these projects when one of the young veterinarians asks me to come out to the hospital barn to help assess how the stallion with post-operative ileus has responded to his prokinetic meds.
2:30 p.m. – 3:15 p.m.: Check In on the Stallion
I repeat the ultrasound exam on the stallion who, at this point, is about 24 hours post-operation for small intestinal colic surgery. The fact that our surgery team didn’t have to remove any compromised bowel bodes well for him, but we didn’t like the small intestinal distension this morning, especially so soon after his surgery. The good news is that the bowel is already moving a lot better than it was earlier in the day. Whether this represents a response to the prokinetic medications we recently started, or he is benefitting from a little more distance from the time of surgery, or both, we are happy with this improvement. We update the orders to continue with the current low dose of prokinetic drugs overnight.
3:15 p.m. – 5:30 p.m.: Finish Documenting and Reviewing Literature
I complete the documentation and records from our earlier farm calls. I also review the recent literature on a new prokinetic medication that can be given orally. Additionally, I review a recently revised consensus statement regarding Cushing’s disease. After that, I call a few clients in advance of farm calls that I will do tomorrow.
5:45 p.m. – 6:15 p.m.: Hospital Rounds
I wind down my day with evening hospital rounds to coordinate with the young veterinarians. We double-check the doctors’ orders on each patient, confirm plans and contingencies for overnight care, including feeding, medications, fluid therapy, and other treatments. We organize which member of our team will update horse owners, trainers, and also the referring veterinarians involved in every hospital case. We finish by briefly discussing the anticipated schedule of events for tomorrow’s planned procedures.
6:35 p.m.: I arrive home and enjoy dinner with my family.