"And, when you want something, the entire Universe conspires in helping you to achieve it." -The Alchemist, by Paulo Coehlo



Friday, July 17, 2015

Lily's Leg, A Novel: Chapter 1, The Return Home

This is long overdue and I'm sorry, guys. Life has been absolutely freaking insane since Lily arrived home, including an extra emergency farm call and two additional vet visits to manage some complications.

But first things first.

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On Thursday July 9th, Charles and I drove up to New Bolton at the University of Pennsylvania to pick up Lily. I had called that morning to let them know we would be there around 3:00 pm, but we ultimately arrived 30 minutes ahead of schedule. I called them at 2:00 pm to let them know we would be arriving early; they were scheduling that day's bandage change for Lily to coincide with our arrival so that they could show me how they were doing it.

The receptionist from the weekend prior was there and she remembered us, though it was another receptionist that took care of us. We were checked out and the bill was within the estimate range we had originally been given ($3-5k including the deposit of $1500). "This is amazing!" I told the receptionist, meaning it in the best way possible, and she looked at me like I had sprouted another head. I'm sure they don't hear that one a lot...The Marion DuPont equestrian hospital in Leesburg had wanted as an initial deposit what ultimately ended up being our entire bill for 7 days of hospitalization at New Bolton.

Guys, if you are in this region and your horse can be hauled the distance safely, I really recommend this hospital. Not just for the price, but for everything: the care my horse received, and the daily updates on how she was doing. I had this incredible (and annoying!) knack for calling every time Dr. S was doing Lily's bandage change. Her secretary would leave her a message and I would often get a callback within 15-30 minutes. I tried to keep phone calls short because I know how busy it is on the other end, but there was one day when I called back a second time so we could discuss treatment once Lily went home and Dr. S returned my phone call a few minutes later. I was stuttering on the phone in my attempt to make it as brief as possible and Dr. S gently said, "You have time to think; don't worry." So I stopped and was able to formulate all the questions I had, and she answered all of them.

Loved her. Really did.

I was given a paper bag with an obscene amount of antibiotics in it, as well as a printed copy of my discharge instructions for Lily's aftercare. I skimmed over them quickly to see if I woud have any questions, but it was all pretty straightforward.

A tech met us in the lobby and took us to Lily's stall, where she called Dr. S to find out about Lily's bandage change: it looked like she had a brand-new bandage already. They had indeed already changed it, but would be changing it again so I could see the process.

I realized that Lily had a little routine going on here. I initially thought she just wanted out of the stall, as she was eagerly standing next to the tech while she contacted Dr. S, but as we followed the tech and Lily to the treatment area, I noticed that Lily knew exactly where they were going.

It's hard to explain clearly, but it was strange to me to see my horse so familiar with a routine that I was not part of. Is that weird? I see her every.single.day. If two days in a row go by where I don't see her, it feels so strange. Like I'm forgetting something vital. Like how to breathe or where home is. The longest I had been without seeing her prior to this was the 5 days between her being shipped north to MD and us driving up a few days later.

She was walked into the treatment area and I was introduced to more doctors. I realized then that my horse kind of had a fan club too! I grinned because this is a common happening: Lily is a cute, dainty mare with a pretty dished face, but not particularly striking to look at like, say, Gracie with her flowing sun bleached blonde tresses and dapples. Lily's magic is when you get to know her: she is so polite, so reserved, yet so incredibly sweet that people who get to know her fall in total and absolute love with her. It takes a couple of interactions with her to see this side of her; it's not something she shows you at first sight unless she really, really likes you...like the tech that was holding her for the bandage change. :) Lily liked her a lot, and the tech rewarded her by reaching over into a bin full of small baggies and producing one. She tore it open and I saw that they were treats! Lily was familiar with what they were and was happy to eat them out of her hand.

Lily used to be a nervous wreck around vets but after her whole annular ligament ordeal + cellulitis two years ago, she became very much used to both injections and veterinarians. The mare used to spin and rear in the stall if approached with a needle in syringe...even if I was the one doing the injecting! The first time she was on injectable antibiotics, I was having to drive out to the barn in the middle of the night after work to give her her second daily dose because my BM at the time, who was a very experienced horsewoman, was unable to do it herself because Lily would flip her shit to such an extreme. Mareface has come a long, long, looooong way in more ways than one, and I was hoping that all of her previous experiences would have led to a positive outcome for her during her stay at the hospital.

It was wonderful to see that this had indeed been the case.

Dr. S showed up around then, as the other doctor was getting all of the bandage materials ready. The bandage was removed (there was one bandage up to her hock and a separate pressure bandage on her gaskin from the previous day's limb perfusion) and I won't lie: it looked a little worse than I had originally expected. The leg was still pretty swollen around the wound site. Dr. S must have seen my expression because she said, "This looks REALLY good!" And took her time explaining everything that she was seeing from her point of view compared to how the leg looked before. I felt much better then. She said Lily should be in the clear to make a full, fairly prompt recovery, as there had been absolutely no tendon involvement, no joint involvement at the fetlock, and we were a week out from the splint bone fragment removal, so she wasn't really concerned anymore about the bone becoming infected. Lily would be 2 weeks on stall rest with only hand grazing (no hand walking), with hand walking starting after her sutures were removed. The first set of sutures (pink in color) should be removed on Monday 7/13, the second set (blue in color) on Friday 7/17 or Monday 7/20; she said my vet was aware already. The worst that could happen was that Lily would get some sort of skin infection and even that would not be a major setback. She said she had spoken to Dr. L, my regular vet (Dr. E, her newer associate, was the one that referred us) and she was comfortable doing the antibiotic limb perfusion at the barn if necessary.

Correction of my previous incorrect use of terms: it's called a DLP or distal limb perfusion, not an "antibiotic infusion" as I kept erroneously calling it. There where will be a LOT more on that in the following posts, so I'm not going to go into huge detail about it now. It basically involves injecting antibiotic into a vein that communicates with the wound on a horse's lower leg so a stronger antibiotic can be administered directly to the area from the inside. I still think it's one of the coolest things I've ever heard of, and I had no idea this was a treatment for horses. It's not used in small animals...yet, at least.

Dr. S said as long as Lily stayed comfortable, she could go back to full turnout and riding after the two weeks of increasing hand walking. Best news ever, seriously, and after her much more minor ligament injury two years ago that was so much more complicated to rehab her from, this seemed easy peasy. I had high hopes that for once Lily would have an easy, smooth recovery from an injury.

I was talked through the process of re-applying the leg bandage, and I did not get pictures because I was intent on listening:

1. Scrub wound + drain site below it + scrape at coronet band and at hock with Betadine scrub
2. Apply SSD ointment to all wounds on leg
3. Apply Surpass to the swollen areas around the wounds
4. Apply nonstick Telfa pads to wounds
5. Apply thin layer of cast padding to keep all the pads in place
6. Apply a layer of sheet cotton
7. Follow with a snug layer of brown gauze
8. Finish with a layer of Vetrap
9. Place Elastikon at top and bottom of bandage to keep shavings from getting under the bandage. Elastikon is a stretchy beige tape with magikal properties: it is, I think, the only medical material that will stick securely to fur, even when wet. I think it is marketed specifically towards the veterinary field because of this. I could be wrong, but the truth is I've never been able to find it at a pharmacy. You can, however, usually find it at tack shops and farm supply stores. Note: have a roll of 4" Elastikon in your equine first aid kit! It is far superior to duct tape for securing a bandage to weird/high motion parts of your horse's anatomy.

Dr. S asked if I was comfortable with the bandage and I told her yes. It was basically a modified Robert Jones bandage, similar to what we do in small animal with cat and dogs legs. (The "regular" Robert Jones bandage uses several pounds of material to create a much bulkier bandage to stabilize more serious fractures on lower limbs.) The modified Robert Jones is used for applying light to moderate compression to a limb to both protect wounds and/or surgical sites and also to provide stability to minor fractures. (Here is a great article with photos on how it's done and how convenient that it's also by the University of Pennsylvania. ;) ) She gave me the option of buying more materials from the hospital or a farm supply store. I chose the farm supply store. I had the following day off and had the time to go hunting for everything I would need for the weekend (hint: "hunting" is the most accurate term for what would happen), as I could buy most of the materials by the case from work with my employee discount.

On the walk over I had noticed that Lily was head-bobbing a bit on her right front, like she had the day of the accident. I mentioned it to Dr. S, who palpated the leg, checked the hoof with hoof testers, and then had the technician walk her around the treatment area. "Is it a reflection of the left hind?" I asked. "I think so," Dr. S said, "She is stepping short on the hind leg as well." They had decreased her bute from 1 gram twice a day to 1 gram once a day on this day; she said I could bump her back up to twice a day since she had been perfectly sound before.

I was given all of the leftover materials from this bandage and also any extra meds from Lily's hospital supply, including a couple of bute tablets. "Here, you paid for this already. Take it with you!" And we were sent home. Dr. S said to call her if we had any questions or concerns.

The tech that had been holding Lily walked outside with us and hand-grazed Mareface while Charles and I went to hook up the trailer. It took all of 4 minutes for us to get back with the truck and trailer. The technician handed Lily's lead to me and we loaded her up. Lily seemed thrilled to be returning home.

Repeat photo but whatevs
I can't say enough good things about our experience with UPenn's New Bolton equine hospital. If things had to happen the way they did, I'm glad Lily ended up in their care. I want to note that it is not common to be able to continue to receive updates from the same doctor that admitted your animal into the hospital over the course of an entire week: they have days off during which your pet will be transferred to another doctor who will oversee his/her case while your main doctor enjoys their "weekend" (because it doesn't always fall on an actual weekend.) Lily was in the hospital for 7 days and on each day I spoke with Dr. S herself. Either the doctors have longer rotations at UPenn before a series of days off and we lucked out, or she was coming in to do the bandage changes herself, which sometimes happens but is not the most the most usual thing.

I had been dreading rush hour traffic, as we were leaving the veterinary hospital close to 4:00 pm, but as it would turn out it was not bad at all. It still took us a little over 2 hours (the drive sans traffic was exactly 2 hours) to get back to the barn, where BM had left the stall ready for Lily.

Lily was very confused at being caged instead of turned out and she stressed a bit, screaming occasionally. I stressed over the whopping dose of antibiotics she was getting...4400 mg of minocycline twice a day. 44 capsules at EACH dose!

Pro: they were capsules so I could break them open to get the powder out, mix it with molasses and water in a syringe, and syringe it to her.
Con: the powder is somehow oily (I'm sure there is a scientific explanation for that but my brain has not been working for a while and I don't care enough to go looking for the proper term) so if it falls on your clothes when mixed with water, it does not come out.

For those of you who have picky creatures like mine that won't eat their meds mixed in grain/a mash/hidden in treats (Lily will eat them in Stud Muffins up to a point; she has a limit) you can do this:

44 capsules OH.MY.GOD
Break open capsules into small Glad plastic containers. These are their smallest size. I believe they take 1/2 to 1 cup of food? I can't remember.
Each one of these is one dose.
If you have tablets instead, crush them.
Then add about 1 tbsp molasses or applesauce. (Lily hates applesauce -_- Yes she is a weirdo.)

Then add a *small* amount of water. About a tbsp also.

Put lid on container and...
Shake it like a polaroid picture!

Voila. Disgusting antibiotic mix that your horse might like a little better because it has molasses added.

Pour into a 60 ml catheter tip syringe. Using only a small amount of water and molasses means that you have a creamier liquid that sticks to your horse's tongue better and also a smaller amount of mixture to dose. Less = better! And easier to get into your horse.


For Lily's dose of antibiotics the next morning, I was able to get 5 capsules into one Stud Muffin treat at a time, for a grand total of 9 Stud Muffin minocycline sandwiches. I tossed them in her morning grain for the barn staff to give the next day, and warned BO that Lily would have a ridiculous amount of treats in her breakfast because of this.


I gave her a dose of UlcerGard and ended up giving her a titch of ace IM to keep her relaxed. I was worried about going home and leaving her alone all night, dreading that she would decide to panic in the stall and injure herself somehow. It had been two years since the last time she was confined and I really wasn't comfortable with her being completely alone without another horse in the barn. It was almost harder to leave the barn than it had been to leave the hospital after our one and only visit during Lily's stay there.

I am fortunate to have met some truly wonderful people through this blog.

"Sending an angel to help heal Lily. Hugs, Sara & Gem"
From Sara. This was a surprise that arrived right before Lily returned home.
Yup, I cried.
Guess who this is from! :D
Beka sent me Archie's standing wraps and no-bows from her own months-long saga with his left hind.
(In case you didn't notice, it is the same spot on the same leg! I think Lily wants to be Achie's twinkie.)
These have come so, so handy. Between Beka's collection and mine, Lily can have daily bandage changes for almost an entire week before I have to do horse laundry again! She also sent me a black bag to hold the bandages so that I could access them easily in our tack room or in front of Lily's stall.
Blogger love.
Many, many thanks to both of you! <3


12 comments:

  1. Distal limb perfusion was on the table for Tristan for a little while if he re-developed infection in his coffin bone. It's a really good solution to the problem of a horse's lower limbs, which don't always take enough of an oral antibiotic dose when they're in real trouble. My vet wasn't wild about doing it outside of a clinic b/c she's found it to be very painful for the horses.

    I hope the subsequent insanity is at least trending in the right direction? HORSES.

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    1. My vet had a really bad experience with her first DLP while in school because the horse she was performing it on was on xylazine and he had a rage reaction to the sedative: he literally tried to attack everyone in the treatment area. He was normally the sweetest, quietest, most laidback QH ever and my vet found the whole thing incredibly upsetting. Which I think is what makes her extra cautious about performing them now!

      She uses Dormosedan and butorphanol to sedate the horse, which both have analgesic properties as well and then numbs the area over the vein that is going to be injected with antibiotic. From what I was told, apparently the two parts of the process that horses actually object to the most are the tourniquet that needs to be applied to the leg and the sterile prep of the leg that involves lots of dripping scrub and alcohol running down the sensitive inside of the leg. The horse really doesn't feel the rest of it because the area is numbed. Lily hasn't given a hoot the 6 times it's been done on her, thankfully. The injecting an inside leg vein, either to administer an antibiotic, sedative, or draw blood, is something we do in small animal all the time, especially with cats because it is a larger vein. If they object, it's more often to the restraint than to the injection itself (as long as the person injecting is skilled at what they are doing and has a steady hand, of course!)

      If a horse is bothered by the tourniquet that would certainly be a huge problem because it has to stay on for 30 minutes after the antibiotic injection to allow for the perfusion to do its job. :/

      It's all trending in the right direction with a detour in the way.

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  2. Your experience at New Bolton sounds as close to perfect as it could be. I am so glad you had a good experience through all of this with Lily. I can attest to how much worse it is when you are fighting the vet. The distal limb perfusions really blew my mind when I learned about them. It is such a cool way to do it and I am now researching human literature to find out why we don't (at least that I have seen). Hang in there!!! You have a ton of people rooting for you two. It will all be ok :)

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    1. Oh God, yeah: if they had been like Tryon was, I would have had a massive fit. And you had to put up with that for so much longer. :( I'm just glad Gem is home now!

      The DLPs are incredible. I wonder if that would be something useful in a war zone for people with massive wounds on legs/arms? It would allow the medics to use stronger antibiotics in smaller doses.

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  3. i'm so glad she's home and happy and had such a positive experience at New Bolton! fingers crossed her recovery continues apace!

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  4. Do you by chance need ridiculously big standing bandages? I have some that I used when Houston tore open his ankle and I had to wrap from coronet to knee if they would be helpful :)

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    1. Ahhh those would have been awesome this past week but I *think* (hope!) that we're officially past the stage of needing them at the moment. Thank you so much for the offer Hillary. :D

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  5. I love the horse angel and that Beka sent you Archie's wraps! How awesome! Klein, Mochs, and Wes send their well wishes!

    I also did that with my bill for Klein's edema ordeal. I was expecting a bill at least $700 and when they told me it was $300 I said "What??? Are you sure??" and I actually asked them if I could call back in a couple days to pay because I was SURE our vet hadn't put everything in the system yet. Nope, she had. It really was only $300!

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    1. Give Klein, Mochs and Wes hugs and kisses for us!

      It is *awesome* that Klein's bill ended up being that low! It's a fantastic thing when great care ends up costing less than we originally expected. :)

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  6. Ah the blogger love is so sweet! :)

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