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



Saturday, July 25, 2015

Lily's Leg, A Novel: Chapter 4, In Which Lily's Leg Blows Up

Lily says, "Stall rest is BORING, yo!"
Blargh.

Trying really hard to get the blog caught up, but it's been hard with everything that's been happening!


Monday July 13, 2015

Dr. E came out to the barn to take out Lily's first set of sutures (pink sutures). There was a little bit of generalized swelling but she said the leg looked good. I wasn't particularly concerned; Lily was only slightly sore on it. Dr. E however, had a hard time getting the sutures out: Lily protested about their removal. One suture looked like it was just a piece of pink string hanging out of the wound but it seemed to be stuck: Dr. E was unable to remove it. She decided to leave it for Friday 7/17, when the rest of the sutures would be removed.

I was given the go-ahead to re-start Lily on bute so she would go back to being 100% comfortable on the leg. Just 1 gram once a day; Dr. E didn't think that would upset her stomach.

So we restarted the bute. And I don't remember anything else about Monday.

Eating every last bit of grain.


Tuesday July 14, 2015

I went to the barn before work and had one sore mare come out of the stall. I felt like I'd just swallowed a rock and it had dropped into my stomach. This was despite being medicated with bute. She was eating well and somehow didn't look quite as pointy as 2 days before. I removed the bandage and was concerned to discover that the swelling was worse than the day before, despite the bute and diligent antibiotic administration every 12 hours as ordered. I was in the process of flipping Lily's schedule to something like 1:00 pm and 2:30 am for the antibiotics on my work days because the barn feeding schedule wasn't ideal for a twice-a-day antibiotic regime: 8:00 am and 4:00 pm. But I still didn't think that switching the schedule should cause this amount of swelling. Her pastern was puffy whereas once it had been tight, and she had some swelling above the wound, which she had not had before. She was not stocked up on any of her other legs (something that she does tend to do when she is stalled and it is hot and humid outside); the wounded leg was the only swollen one.

I might have freaked a little.

Being a good girl. I know horses that require sedation just to be pulled out of the stall while on stall rest. Not this one.

I scrubbed the wounds, dried, and re-bandaged, mucked both stalls, gave Lily her bute and antibiotic, and brought Gracie in for the afternoon and evening. I tried calling my vet but for whatever reason they had closed early for the day. I did not leave a message.

I then went to work and worried for 12 hours while trying to save other people's animals. Let me tell you: compassion fatigue is real, and when you are already suffering from it, trying to work through it while also worried about your own animal is enough to push you to the the last limit of any emotional and psychological strength you might have left. Especially when an employee walks in the door with her dying dog and has hysterics when we could do nothing to save her pet. I had to leave the room to bawl myself. For our employee, for her dog, for the fact that she would always live thinking that she had caused her death when in fact there was nothing she could have done to prevent it. She just wouldn't believe us when we tried to explain.

When you have compassion fatigue AND one of your animals is not doing well, you are left exposed and subsequently ripped open in the face of anyone else's tragedy.

By the time 1:30 am rolled around, things had died down so I was able to leave early so I could stop by the barn to give Lily her antibiotic and check on her.


I love the way BO set the lights between the stalls and the aisle: you get clear illumination in both, especially in the stall because the horse doesn't cast a huge shadow.
She had cleaned up all of her food so I tossed her more hay and gave her another half scoop of grain (I was splitting her grain meals into several small ones, since I had absolute control over what and how much she was eating.) She took her antibiotic dose well and I checked her temperature: 100.2, which is normal for a horse. Good! There was no swelling above the bandage (on her hock) and I was not going to change the bandage again at 2:00 am, so I let it be and went home, where I slept more or less well.

For 5 hours before I had to wake up again to repeat everything all over again. As of this writing, I have not slept more than 6 hours since this whole ordeal started.


Wednesday July 15, 2015

My birthday. There were tons of well-wishes on Facebook, which was one of the few good things of the entire day. Charles was scheduled to work an overnight for the first time in forever, which meant I would not see him AT ALL for 24 hours. I was pretty upset about that.

I was even more upset when I got to the barn and Lily would not come out of the stall. She was hobbling lame. Crippled. It took a while to get her to the wash stall at the end of the short aisle, where I could see even before removing the bandage that the swelling had extended to her hock.

#$%%^^&*@#!!!!!

I removed the bandage to discover a leg swollen with cellulitis.

Fat leg. Doesn't look as bad in photos. But she had lost all of the definition of her pastern, fetlock and tendons. The leg was also hot and had pitting edema (you left an indentation if you squished her skin with a finger.) And you know, she was also crippled lame.

The original wound itself didn't look bad. She had a tiny bid of drainage from the top of the wound and she let me poke and prod it (while wearing a glove!) She was more bothered by all of the other small abrasions on the leg, including that one at the coronet band.
No definition. Note the puffy pastern too.

I took these photos and sent them to my vet, then called. Katie the receptionist answered the phone and I told her what was going on. Dr. L was taking care of an emergency, Dr. E was seeing afternoon appointments and was booked solid. I had to get into work by 2:00 pm and it was 11:30 am. There was no way either of them could make it in time for me to get to work at my scheduled hour. Dr. L might be able to make it by 2:30 pm, so I called work, explained the situation, and told them I was going to be a few hours late.

I called Charles and told him what was happening. He drove out to the barn to keep me company because he is awesome.

Silver lining: I actually DID get to spend a couple of hours with him on my bday!

She was grooming him. Just cuz.

"Can I take a selfie?"



Seriously, all animals adore him.
But she also happens to be the sweetest mare in the known universe, so there's that too.
Once I was done cleaning stalls, we put her away again (I had put a quick bandage of just cast padding and Vetrap over the wounds) and ran over to the nearby gas station to get coffee so I could stay awake while waiting for the vet.

Dr. L messaged me at 2:00 to let me know she was going to be arriving about an hour later than expected but that's okay: you can't control how long an emergency is going to take. Charles waited with me until she arrived; he had to leave to go to work himself. Dr. L took a look at the leg upon arriving at the barn and agreed that Lily had cellulitis. We talked about switching her to an injectable antibiotic (Naxcel) because it's stronger than most of the other readily available orals. She put in a call to Dr. S, the surgeon at New Bolton, to pick her brain about the situation and was told she would be called back. So we hung around and chatted.

We both had to leave; we waited for about 15 minutes but Dr. S had not yet called back. Dr. L decided to go ahead and give Lily her first Naxcel dose and we made an appointment for her to come back out the next day to reassess. She told me she would call me when she heard back from Dr. S.

I had had questions about bandaging, as I didn't feel the sheet cotton was necessary. Could I just do the Telfa, cast padding and a no-now with a standing wrap over it? Dr. L said that since the wound was not draining excessively anymore, yes. She instructed me as I re-did the wrap, with the main difference being that the no-bow was placed lower on Lily's leg so that the bottom edge was lined up with her coronet band and the standing wrap used to cinch the no-bow snugly to her pastern and fetlock. The bottom of the bandage was sealed to her hoof with Elastikon. I then placed a separate small bandage over the wound at her hock, using just a Telfa pad with SSD and Elastikon to keep it in place.

After that we were done. Lily went back into her stall, Dr. L returned to her office, and I changed clothes to go to work.

Dr. L called me about an hour later to let me know that she had spoken to Dr. S, who agreed with the use of Naxcel IM for the next 5 days. She had also recommended Dr. L do two distal limb perfusions, one on Thursday and one on Friday. We made appointments for both days.


Thursday July 16, 2015

Dr. L, Dr. E and an extern arrived at 11:00 am sharp to do Lily's local antibiotic treatment.

Distal Limb Perfusion 101

1. Lily was heavily sedated with butorphanol and Dormosedan.



2. A surgical scrub was done on her medial saphenous vein (large vein that runs up through the middle of the inside portion of the hind legs), alternating Betadine scrub with alcohol. This part can be iffy for some horses, as the dripping scrub and alcohol will tickle their leg. Lily swished her tail angrily in response but did not move.

Scrubbing the leg with Betadine scrub (red in color; that's what those reddish splatters are)
Lily did not have hives; her hair was standing on end. It's a normal side effect of Dormosedan.
3. A tourniquet is applied. Not all horses tolerate tourniquets well. If I were a horse, I would be one of those individuals. Lily, however, is not. She didn't care. You can really appreciate that medial saphenous vein both above and below the green tourniquet in this photo:


4. Vetrap is wrapped tightly over the tourniquet. Dr. L explained to her extern and Dr. E that this is the only time you will ever see her apply Vetrap tightly:




 5. A local block with lidocaine is performed, to numb the area around the vein. Another surgical scrub is done, alternating Betadine scrub and alcohol x 3. Then a strong antibiotic like amikacin is injected into the vein below the tourniquet. An artery would naturally take the antibiotic straight to the wound site but you don't want to inject an artery in a horse because they have a tendency to form huge hematomas. So instead you inject into a vein and because of the tourniquet preventing venous flow to move away from the leg, the injected antibiotic still be pulled down towards the lower leg with gravity.

Dr. L used a small gauge butterfly catheter (23 G) to inject the antibiotic while creating as little trauma as possible. The dark reddish spots on Lily's bandage are Betadine scrub.
Amikacin is injected over 2 minutes; I was in charge of timing it.

6. A pressure bandage is applied to the venipuncture site, below the tourniquet, to prevent a hematoma from forming.



7. The tourniquet is left on for 30 minutes total to allow the antibiotic to do its thing, then it is removed. The pressure bandage over the vein is left on for 24 hours. 

What is the purpose of a distal limb perfusion, aka DLP? 
There is a very limited number of antibiotics that can be safely used with horses. The stronger an antibiotic, the more expensive it is, especially at equine doses. Also, because said usable antibiotics are so limited, we are starting to see resistance to those antibiotics. DLP allows a stronger antibiotic to be used at a safer smaller and less expensive dose to aggressively attack an infection. We do not use this in small animal (cats and dogs) because there are so many more antibiotics that can be used with them. 

Cool, huh? 

Lily's leg was re-bandaged for the day, and we all returned on Friday for the next treatment. 


Friday July 17, 2015

The DLP was repeated. It was only Dr. E and Dr. L this time. Dr. L again used the smallest gauge needle possible (again, 23 G. For comparison, this is what we use in small animal for drawing blood from a cat's medial saphenous! It is a tiny gauge!) The problem this time was that they would hit the vein but a clot would form in the needle, which resulted in them having to stick multiple times, eventually with a larger 21G before they could get the amikacin into the vein. Of course Lily ended up with a huge hematoma on the inside of the leg. Nothing to be frightened of; it was just unsightly. The doctors applied a larger pressure bandage and I was left with Naxcel to get me through the weekend. They also removed all of the sutures and Lily was cleared to start hand-walking the next day Saturday. On Saturday I was also to e-mail photos to Dr. E (she was on call) and call her to decide if a third DLP should be done. 


Saturday July 18, 2015

Lily's leg looked really swollen to me, both above and below the vein pressure bandage and also around her hock. I freaked out, especially when again she was so gimpy she didn't want to leave the stall, but I was a mean person and forced her to come out for her first official hand walk. Both vets had agreed that Lily's soreness was most likely worsened from her being in the stall. 3 minutes into our walk, I had to agree: Lily was already remarkably sounder. 5 minutes into the walk, her slight head bob had disappeared entirely! We turned around and walked back to the barn for a total of 10 minutes of hand walking.

I removed the lower leg bandage and felt better once I saw that the leg beneath it looked exactly the same as the day before: still puffy, but not as bad as it had been on Wednesday. I took pictures which I e-mailed to Dr. E via phone (where would we be without smartphones, seriously?) and then called the emergency service to have them ask her to call me back.

These are the photos I sent her:

Generalized puffiness from fetlock to hock, but swelling on pastern had disappeared!
Pressure bandage over vein.
Note hock swelling when compared to the other hock.
You can really appreciate how fat this leg was. And this was an improvement from Wednesday!
Hematoma above pressure bandage
The wound itself. Goopy SSD but otherwise looking good.
Dr. E called me back within 15 minutes. She thought the leg looked good and either way, we couldn't do another DLP even if we had wanted to. She told me to apply an ice pack and some Surpass to the hematoma above the pressure bandage; she said it was excellent that Lily had walked out of her soreness. I was told to continue everything and we scheduled an appointment for Monday 7/20 for Dr. E to take another look at Lily and see if she could go on an oral antibiotic like SMZ or continue the Naxcel.

The saintliest mare of all, sporting one of Archie's bandages.

I want to make this clear, based on some posts and comments I saw on other blogs a few weeks ago because I don't want people assuming and judging me for having Lily insured: Lily is insured precisely to cover this type of event. This, what happened this month. I insured her when we moved from Florida to Maryland and had to have her hauled by a third party, as it was recommended by the hauler. It was a 1200 mile haul; she had never been trailered for such long of a distance before in her life; she was Florida bred and born, and I had no idea how she would react to it. I insured her in case something happened to her in transit and during that first year of her being insured, the insurance paid for itself tenfold (literally!) when she sustained her annular ligament injury. Since she proved to me that the insurance was worth having, she has been kept insured ever since. 

Colic surgery is not the only reason for insuring a horse. I wouldn't put any of my horses through that. A horse that has colic surgery has a 50% chance of needing it again. This is a personal decision, but that is a huge risk to me: to me, colic surgery is not worth it. That said, colic surgery is not the most catastrophic thing that can happen to your horse. If we had not had insurance for Lily, I'm not sure what we would have done given everything that has happened with her left hind during the 3 years she has been insured out of the 4 years I have owned her. Especially this time around. I pay $350 a year for her $7500 major medical & surgical coverage. It has proven yet again to be worth having. As it is, she has accrued close to $2,000 so far in emergency exams and farm calls that are not covered by her insurance. Not because we have exceeded the limit, but because farm calls and exams are not covered, period.


24 comments:

  1. I am thinking about you as you go through this. The procedures you walked through seem really cool (I'm sad she has needed them though). I really want to learn More about equine insurance.

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    1. Thank you Hillary!

      Regarding insurance, I use Broadstone's The Hartford. There are several companies out there, but from what I found Broadstone and Markel are supposed to be among the best. Markel is fabulous for high-value performance horses and will cover a lot of the high tech treatments like PRP and stem cell therapy, as well as more advanced diagnostics like MRI. Broadstone is better for the everyday kind of horse. When I called Markel to insure my $1 horse, they laughed at me. Broadstone was willing to let me establish a value for Lily based on training received and her competition record, which is her mortality value. This means that if she dies, I get that dollar amount, which in her case is $1,200. I can bump that up at renewal thanks to her continued competition record and continued training, but that also means my premium goes up. Broadstone offers major medical & surgery coverage up to $5,000, $7500, and $10,000. You choose which one you would like; with Broadstone, you can have a horse with very little mortality coverage and still request the $10,000 major medical & surgical coverage. Other insurance companies will only offer major medical & surgical coverage comparable to the dollar value of the horse.

      For Lily, I have the $7,500 MM&S coverage + $1200 mortality, and I pay around $350 a year for it. Broadstone assigned me The Hartford and I work with them directly when filing claims. My deductible is $300 per claim, and after that almost everything is covered. A claim is kept open for 4 months, so if you have something like a soft tissue injury with a long recovery, all of the diagnostics and treatments are covered for the ensuing 4 months after the claim is opened.

      Farm calls and exam fees are not covered by insurance but they cover most of the treatments. For high tech treatments and diagnostics, The Hartford covers a portion, usually from 20%-50%; you can always ask in advance. I believe for something like shockwave they cover 50%, for example.

      Once a claim is opened, The Hartford sends my vet a form to fill out regarding the diagnosis and I'm sent one to submit with my invoices. I can have The Hartford pay my veterinarian directly if I have not yet paid an invoice, but they have given me the option of just sending me the check even if I haven't paid for an invoice yet. This is a great option to have when your vet is willing to invoice you and bill you later. Otherwise, I fax them my paid invoices related to the claim and they usually send a check immediately: I have received checks from them in as little as 2-5 business days via regular USPS snail mail. Their customer service is excellent and straightforward; it's easy to get a person on the phone to talk to; you usually have a person assigned to your case so you can always speak with the same person, and they are always happy to answer questions and explain policies. They also send prompt responses via e-mail as well. I've been very happy with them. :)

      Broadstone's website is: http://www.broadstoneequine.com/
      You can request a quote and they will usually e-mail you back with the numbers within 24 hours if it's a weekday. They don't harass you nor spam you for requesting a quote, unlike some car insurance companies out there! Haha...

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  2. You summed it up, it's so emotionally draining when our animals are not well. Praying she keeps improving. Insurance is an absolute must in my book too for exactly why you stated. It's a few hundred bucks a year that can pay for itself over and over when you end up needing it. Like when your horse breaks his pastern like mine!!! Although I've seen several horses bounce back after colic surgery, so it's not a 100% no go in my book.

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    1. Pongo's ordeal with his pastern last year was epic. Insurance can make such a difference in a horse's outcome: whether we can do the treatments required to get them sound again, and it can even mean the difference between life and death. We see that in small animal too: the owners of cats and dogs that are insured are able to do so much more for their pets that can change their entire outcome.

      Thank you for the prayers Nicku! <3

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  3. I'm very happy that the whole leg blowing up thing was cellulitis (cuz you've dealt with that before) and not some internal bone infection. It was also awesome to hear how quickly it responded to antibiotics and movement. Sending lots of love!!!

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  4. You may have convinced me that insurance for major medical expenses is a good idea!:) I'm glad Lily's leg is still OK and you're hanging in there despite all the craziness!

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  5. Thanks for explaining the DLP, very cool. So glad that it helped, hang in there!

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  6. I cried reading this. All of it is so very frustrating. I cannot imagine. And when I got to the part about the employee dog at work...ugh :( :( :(

    As always, I learned from your post. DLP is something I haven't experienced, thankfully.

    As for people judging for having a horse insured... !!! I don't even have the words. There are many reasons to insure or not insure a horse, and either way, it's a very personal decision. Ugh. I know it comes with the blogging territory, but people really need to lay off on the comments sometimes...

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    1. Work just about sent me over the edge, seriously. I am desperate to get out of emergency work and that + Lily's injury + some other stuff that was going on was starting to really make me feel like a crazy person.

      And agreed. :(

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  7. I admit to not understanding half the medical terms here..I wish I did! Gotta admit this all freaks the hell out of me....all 3 of mine are too old to be insured (J is 15, and the bays are in their late twenties) and I don't have credit cards. But anyway. I'm really glad Lily is doing better and has been cleared to hand walk! I imagine that will do wonders for both of y'all's sanity!

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    1. I feel like equine insurance should raise their age limit, since so many horses nowadays live happy, healthy lives well into their late 20s-early 30s.

      There are many advantages to not having credit cards. I the main reason why I don't have a high limit card is because then the temptation to use it doesn't exist.

      Thank you! <3

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  8. Well...happy birthday! Thank you for sharing this (I learned a lot - as usual!). I hope it's smooth sailing from here on out. My horses are not insured...that's something to think about for sure.

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    1. Thank you KateRose!

      It can be tough with multiple horses. I still have to get Gracie insured! I had debated with her because she has all of these pre-existing conditions: hock arthritis, ringbone and her windpuffs. But it would still cover her if something like this happened to her.

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  9. I think Lily and Archie might have the same lead rope, too. I'm glad the wraps are proving useful. :) I bought some of them from an old IHSA buddy, who had two mares: Babe and Dancer (both OTTBs).

    Take care of yourself, too. There's no definitive "due date" for recovery and you've got to make sure that you don't burn out before the end. I'm so thankful that you've got such a willing and helpful husband.

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    1. The wraps have been a wonderful thing! Thank you so much, again, Beka! !

      Thankfully, the ordeal is over as of yesterday: after going in the stall with the run, she started going into the hospital paddock at night, and then 24/7. Yesterday she went back out in mare the field sans bandage. More stuff happened inbetween but I haven't been able to get the blog caught up. I'm typing it out in case you signed up to be notified of my response. :) We are done done DONE! FINALLY.

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  10. Oh Lily... What an ordeal... I am very grateful I had Liam insured this year as well... I don't know what I would have done if I didn't...

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  11. Wishing Lily a quick speedy recovery....and remember to take care of yourself too! Since I'm a new horse owner, I've been thinking long and hard about if I want to insure Quest and trying to making the big decisions BEFORE bad things happen e.g.; colic surgery. I have been back and forth, on the fence and haven't quite made up my mind though but seeing if there is a 50% chance of it happening again, then it's not fair to the horse to put it through surgery just to risk it happening again.

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    1. Colic surgery really is not the only reason to insure a horse, though! Insurance will partially cover stuff like joint injections, IRAP and platelet-rich plasma therapy, and they fully cover diagnostics like x-rays and ultrasound. When you have a soft tissue injury that you're rehabbing for 4 months, with monthly ultrasounds to check progress...those ultrasounds add up really fast! When Lily had her soft tissue injury 2 years ago, my vet at the time was charging $175/ultrasound. And that was just the ultrasound: sedation, the farm call and any additional meds I was prescribed were additional. The sedation and meds were also covered. For $300-$400/year, I think it's worth it to insure if you have a sport horse with no pre-existing conditions that is under 15 years of age. :) A great alternative to insurance is to have a high limit credit card and/or to set up an emergency fund for Quest that would cover more advanced diagnostics/treatments if she ever needed them.

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  12. Poor lily and poor you! Hope you were able to enjoy your bday all the same! I'm pretty far behind so hopefully when I catch up Lily will be feeling much better!

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