Tuesday, 2/16/10 - Veterinary Tale Chapter 3 - A Man of Few Words

Sorry for no post yesterday - internet and telephone service to my valley were out for 48 hours. A transformer burned out and a new one had to be shipped in from who knows where before service could be restored.  That's the bad news - the good news is today's post is the latest chapter in Veterinary Tales.  I hope you enjoy it.   In case you missed the first two Veterinary Tales, you can find them in the blog archives from January 31st, and February 4th.  More on vaccinations and the immune system on tomorrow's Vet Tip of the Day.

Veterinary Tale Chapter 3 - A Man of Few Words
I excel in emergency situations. Throughout my life I’ve espoused the theory that there are basically two types of people. The ones who step forward toward crisis, and the ones who step back. Years ago a horse trailer pulled up in front of the large animal clinic at the University of Georgia where I was the resident on duty accepting emergencies. The driver jumped out of the truck, shouting over her shoulder as she rushed to the back of the trailer.

“It’s a really bad colic, and I think he just went down,” she said as she opened the door of the stock trailer before I could stop her.

I was standing about 6 feet away and what I saw was this woman standing there holding the door with her right hand, facing the open trailer. In the trailer, inches away from her face, was a horse in the process of throwing itself over backwards, its head and flying front feet coming directly at the woman. Without hesitation I jumped forward, shoving the gal to the side with my right arm while reaching up with my left arm and grabbing the horse’s lead rope. The rope was sailing through the air just ahead of the horse’s nose, following the trajectory caused when it snapped loose from the tie ring at the front of the trailer. As the horse’s owner went stumbling off to the right, I yanked the lead rope as hard as I could to the left, lunging in the same direction. The horse came tumbling out the back of the trailer, all 4 feet flying in the air, and hit the pavement left shoulder first. The owner was unhurt, the horse scrambled to his feet, and without pausing I headed into the clinic leading the horse to get emergency treatment started. James Bond eat your heart out.

This is the kind of thing I’m really good at – acting during a crisis. But the mass I’d discovered in my dog Sticky’s mouth was another matter all together. This was something I had time to think about, worry about, plan about – something that wasn’t going to be over and done within a short time, something that wasn’t going to go away. So I acted accordingly: I ignored it, just blocked it out, and when I did think about it, tried to convince myself that the mass was scar tissue that had formed at a tooth extraction site. I knew it had not been present 4 months ago, because Sticky had had her teeth cleaned by Dr. Mark Altman, my local small animal veterinary buddy, and a tooth had been extracted at that time. My denial continued for 5 days, and then I realized I had to face the music.

Here’s the thing. I’m a veterinarian, and while I don’t treat small animals, I am board certified by the American College of Veterinary Internal Medicine, and I’ve been practicing medicine for 22 years. I’ve seen my fair share of neoplasia (cancer) in large animal species, and I knew that the horrible thing growing in my dog’s mouth was not benign. On day 6, when Fern arrived at the office in preparation for the day’s calls, I asked for her help.

“Hey, Fern, I think we need to biopsy this thing in Sticky’s mouth,” I said, sounding all unconcerned.

“I was wondering what you were doing about it. I didn’t want to say anything, but it looks pretty bad, don’t you think?” Fern asked. Bless her heart; Fern is the soul of discretion. She’d come to work for 5 days without mentioning Sticky’s condition, even though I knew she’d been as upset by the discovery as I had. All nineteen year olds should have a fraction of her maturity and compassion.

Fern’s been one of my assistants since she was fifteen. She’s never wanted to be anything but a veterinarian, and I’ve been taking care of her horses since I met her family when Fern was eight. She announced she was ready to begin working for me when she was ten, and her mother and I struggled to dissuade her, pledging that if she was patient, she could start working at fifteen. Her intention never wavered, and for the past four years she’d been with me every summer and on weekends during the school year. We knew each other well, and worked in easy companionship most of the time. After all, I taught Fern early on my number one rule for employees: whatever goes wrong, it’s their fault. Once they get this down, the road smoothes right out.

I looked at Fern and nodded, “My small animal medicine is pretty rusty, but I do remember that oral tumors in dogs tend to be aggressive and malignant. But before we make assumptions, we need to submit a biopsy to be sure. They did pull a tooth right where the mass arises, so we cannot rule out that it is a mass of granulation tissue and not neoplastic.”

Fern gently held Sticky’s lip back while I took a scalpel blade and sliced off a small piece of the mass. My little PCD sat quietly, staring at me with absolute trust, without sedation or local anesthesia, as I performed the biopsy. She was just that kind of dog – she never made a big deal about anything. I knew the tumor would not have a nerve supply, so there would be no pain associated with the small biopsy, but most dogs would object to the restraint, especially around the mouth. But not Sticky, she didn’t move a muscle, just let Fern hold her lip back and wagged her tail slowly.

The biopsy safely stored in a submission jar filled with formalin, Sticky licked her bloody lips and jumped into the truck, ready to start the day. Fern and I looked at each other, hesitated a moment and then both burst out laughing.

“Sticky says, ‘come on you guys, let’s get going!’ “Fern said, her eyes shining with tears even as she smiled. “They just aren’t like us humans are they? No worries, just another day to live and enjoy. I don’t know, Dr. C, sometimes I’m just overwhelmed by how brave animals are.”

I climbed in and started the truck, motioning to Fern to join me. “I know, Fern, they teach us every day how to be better than ourselves, if we would just pay attention.” Sticky put her head in my lap, assuming her travel position. “Hand me a towel, will you – I’m going to have Sticky blood all over my pants for the rest of the day.”

“Here you go, Dr. C,” Fern said, handing me a blue surgical towel for my lap. “Maybe we should stop at the Frosty on the way to Roger & Barb’s and get her a soft cone – I bet that would feel good.”

“Good idea,” I agreed, “Today, whatever Sticky wants, Sticky gets.”

By the time we arrived at Roger Carlson’s cutting horse barn Sticky had lapped up her ice cream cone and was observing the world with her usual aura of ancient wisdom. Fern and I greeted Roger’s wife Barb and began preparations for the day’s procedure: castration of a two year old stallion.

Roger and Barb Carlson have been training cutting horses for over 30 years, almost as long as they’ve been married. They were high school sweet hearts, Barb the daughter of a local ranching family and Roger a Paiute Native American. They managed a training barn just over the California line, about 20 miles west of my office, in Sierra Valley. This was a picturesque area, located right at the transition elevation where desert and sage merged into aspen and pine stands peppering the steep Sierra Nevada foothills. I loved coming into this valley and had been excited about gaining the Carlson barn as an account. I inherited the work about a year previously from my friend Mark Altman when his small animal practice became so busy he no longer could provide adequate coverage to this area.

Mark was a real cowboy, a man’s man, a Deacon in the Church of the Latter Day Saints and one hell of an equine veterinarian. Guys like Roger Carlson and guys like Mark were born speaking the same language. When I first began working for the Carlson’s Roger’s wife Barb did all the talking, while Roger just watched me. I don’t think he said more than three consecutive words over the first year I came regularly to the barn. When he did finally begin talking to me, his dry humor and rare warm smile bowled me over. Roger had rich red skin, deep set dark eyes and a face etched by years riding outdoors in the high desert.

Today we were gelding one of his best young prospects. Roger brought the colt out into the center of the indoor arena and held him while I administered the first of two injections used for short term equine anesthesia. When my left hand closed around the colt’s neck to occlude the jugular vein I could feel his heart hammering through the skin against my thumb. I glanced at his eye to catch him glaring at me, his left ear cocked back and his expression saying loud and clear, “One wrong move and you are breakfast”. If only Sticky could talk to these young stallions and pass along some of her peaceful karma.

The first sedative successfully injected without incident, the colt began to relax, his head dropped, his lower lip drooped and he became wobbly. Ralph spoke to know one in particular,

“I guess this is the nicest colt I’ve ever raised.”

Silence.

“He certainly is a beauty, Roger,” I agreed. “Look at that hip, and the shoulder isn’t half bad either.” I added, thinking to myself – just lie down quietly and stay down until I’m done, you little monster.

Just as I pushed the plunger on the second syringe containing the ketamine that would cause the colt to drop, Ralph spoke again,

“You know when Dr. Mark used to do my colts he was done in no time at all.”

Silence.

“He’s quite a guy, that Dr. Mark” I mumbled, planning to wring his neck the next time I saw him.

“Why don’t you let me hold him while he goes down, Roger, “ I said, taking the lead rope into my left hand just as the youngster sank quietly to the ground with a deep groan. “How’s that for a smooth induction, oh Marvelous Mark?” I mentally complimented myself.

Fern moved in to tie up one hind leg, cover the colt’s eyes with a towel and scrub the scrotum while I gloved up and opened the emasculator and scalpel blade. I removed the first testicle and looked up to see where Sticky was. Don’t be too disgusted, but Sticky always knows when we are gelding a colt, and she is always sitting intently by the horse’s flank, waiting for her special treats. Soft ice cream cones are great, but they don’t compare to this. I spot her watchful eye and prepare to toss her the prize.

“Hold on there, doc!” Roger’s voice is actually raised a few notches, a new experience for me.

“I’m sorry Roger, I usually give these things to Sticky as a treat, but if you don’t want me too, that’s fine.”

“ I don’t care what happens to the damn things, but you move that dog up here by the colt’s head and throw ‘em forward to her – don’t you know that if you toss them over his head he’ll never look back?”

“Um, OK, no problem, come here Sticky,” I called, cursing Mark for not giving me a head’s up on this old western horseman’s tradition I’d certainly never heard before.

Sticky finished her hors d’oeuvres with relish, the colt recovered uneventfully from anesthesia, and Fern cleaned up and packed the truck while I stood with the now young gelding and Roger. More silence, but I figured I was better off saying nothing than trying to make conversation and sounding like an idiot. As I saw Fern finishing, I checked the colt’s incisions for bleeding and turned to Roger.

“Everything looks good Roger; he can go back to his stall now.”

Roger led the colt from the arena without a word and put him in his stall. I wrote up the bill and went out front to the travel trailer that served as an office to give it to Barb. We chatted as she wrote out the check and said thanks and good bye. I went out to the truck to leave. As I was pulling away from the barn Roger walked out. He spoke just loudly enough for me to hear.

“I guess Dr. Mark was right when he said you were OK.”

After a year, I was still thankful for small mercies.

Thursday, Feb 4 - The Hock and a Veterinary Tale

Vet Tip of the Day:  The Hock
Key Words: Equine tarsus, horse hock anatomy, bone spavine, degenerative joint disease

Today we will look at the hock, which is the hind limb joint that sits above the cannon/splint bones.  It corresponds anatomically to your heel.  There are 4 joints in the hock (identify them on the radiograph).  From top to bottom they are the tibotarsal joint, the proximal and distal intertarsal joints, and the tarsometatarsal joints.

The two distal intertarsal and tarsometatarsal joints are low motion joints that are very common sites for arthritic changes (degenerative joint disease or bone spavin) in all athletic horses.  This is a very common, and very treatable condition. Most horses with bone spavin continue in full work with maintenance veterinary care in the form of intra-articular injections with corticosteroids and hyaluronic acid in conjunction with a regimen of oral or injectable chondoprotectant agents such as Adequan, Legend, or oral chondroitin sulfate/glucosamine products.

The hock is a complex joint and is the site for many different problems that can cause lameness.  We will spend a few days looking at it in more depth, but since today is a Veterinary Tale day, this is the end of this Vet Tip - here's the story - hope you enjoy it.

Chapter 2 Good News Bad News

Thursday was a good news/bad news day. In the truck, my cell phone in its normal position, wedged between my head and left shoulder, in what I consider my personal “hands free” mode, I’m speeding of course, steering with my left hand while rubbing my dog Sticky behind her ears with my right hand. Sticky is in her favorite spot, curled up beside me with her shoulder pushing into my right hip and her head in my lap. This pretty much describes how I spend the majority of my life – motoring from one appointment to the next, multi-tasking on the phone, and rubbing my dog’s ears because I don’t have time to meditate. One of my two veterinary hopeful college student assistants completes our travelling circus, doing her best to keep me on track as I zoom around trying to protect the well-being of the equine population of northern Washoe County. On this particular day I was on the phone with a third year medicine resident from UC Davis who was telling me that Brandy was on her way home, fully recovered after her experience dancing with a T-post. Good news.

Sticky has been my constant companion for the past 8 years – she is much cuter than me, with better manners and a distinctly more endearing personality. She’d been in the truck when I treated Brandy, but she knew better than to get into the middle of that mess, and slept through the drama on the front seat. My clients, without exception, adore Sticky, and there is an ongoing debate among them whether or not she is part coyote. The physical resemblance is remarkable, but her disposition is so quiet, consistent and loving that it is hard to imagine she is related to those conniving rascals that lure puppies out into the desert and rip them to shreds. I tell everyone Sticky is a PCD, or Prostitute Companion Dog, descended from the gentle dogs that were friends to the girls in Julia Bouillet’s Bordello in Virginia City at the turn of the century. Some folks find this confusing, but it works for me.

I met sticky 8 years ago while responding to a call from a new client. Tanya Buckman was a cowgirl with a lame foal. Tanya was about 40 years old, 5’7”, with hair so blond, teeth so white, breasts so perky and jeans so tight if I wasn’t in Nevada I wouldn’t have believed it possible. When I first moved west these women were a real challenge to me, and I still look at them with some puzzlement and more than a little envy. They all are so beautiful, and so NICE, and SO TOUGH, they belong in movies. Every one of them wears their womanhood like a ship’s flag: the big belt buckles, the white cowgirl hats, the long stride and the high heeled Ropers. How they get their Levi’s to bunch up just so over the tops of their boots is beyond me. I’m a Yankee, I grew up in New England, I wear a string of pearls every day and my idea of risque is leaving the top button on my polo shirt open.

I’m going to digress for a minute here, but just to give you an example of what these gals are like, here’s what happened when I volunteered to draw blood for pseudorabies testing from a 4-H project pig belonging to one of my cowgirl client’s daughters. When I arrived the pig was loose in a large pen and since my generosity stopped short of chasing it around like a lunatic I asked the daughter to catch Charlotte for me. I watched her futile attempts to contain the pig until my head was about to explode then announced my impending departure if the pig wasn’t under control within 5 minutes. The daughter pulled out her cell phone and made a quick call.

The next thing I know, a bright red 1 ton Dodge diesel pickup comes screaming down the driveway from the house to the barn where we waited with the pig. The truck stops in a cloud of dust, the driver’s door flies open and Raquel Welsh in skin tight Levi’s gets out, struts over the to the pig enclosure, climbs the fence, grabs the pig by a back leg so fast I never saw her move, and hollers over her shoulder at me, “Hurry up and bleed this damn thing, I’ve got to get my nails done at three o’clock.” That was my client, the cowgirl mom, and I guarantee you that when she sashayed away from that pig pen she smelled just as fresh as a daisy.

Tanya Buckman was one of these Nevadan women, and like so many of them she was a savvy hand with horses. She had a buckskin quarter horse mare which had foaled 2 weeks previously. Everything was fine, until yesterday when the filly’s leg became swollen and it began to have trouble walking. Tanya easily cornered the wary 100 pound youngster and held her while I began my examination, questioning her as I did.

“ Has the mare ever foaled before, Tanya?” I asked as I took the foal’s temperature.

“No, this is her first, and she was real nervous about letting it suckle for the first couple of days,” she replied. “Does she have a fever?”

“Her temp’s 102.5, which is a little higher than I’d like to see. Maybe she didn’t get enough colostrum when she was born.”

Colostrum is the special milk that mares only produce for a few days after the birth of a foal. Horses are born with what is called a “naïve” immune system. They have no antibodies to protect them against infection, and must drink enough antibody rich colostrums within the first 24 hours of life or they are at high risk of developing serious infections. One of the most common ways for such infection to manifest is as a septic joint, which causes severe lameness and can be life threatening if the infection invades the bone or spreads to other organ systems.

After palpating the fluid in the foal’s fetlock joint and asking a few more questions, I was certain that the most likely cause of the lameness and fever was a bacterial infection in the joint that needed immediate attention. Tanya was clear that she wanted the foal treated there on the farm, so we began preparations to flush the joint. Needles are inserted in 2 locations, one to allow delivery of sterile fluid that lavages the joint space, the second to provide an exit route for the infected joint fluid and bacteria. This procedure is ideally performed under sterile, or aseptic, conditions. This presents a challenge in a field setting. The trick is not to make matters worse by introducing more bacteria into the joint than already are present.

The best environment Tanya could offer was a 3 sided shed with manure rich shavings covering a dirt floor. On our side was the fact that there was very little wind. In general I love the climate in northern Nevada – we enjoy over 300 sunny days a year and while winter is winter, the sun and 5,000 foot elevation usually melt snow within a few days to weeks. The climate is very dry, so the summer heat, typically 85 to the rare 100+ degree days, is very tolerable. Our one weather detractor is the wind. We have it frequently, and when it blows it is not unusual to experience gusts in excess of 45 mph. But this was a clear, quiet days, so it was unlikely we’d have chunks of windswept manure and sand landing on our sterile field.

We laid down some fresh shavings and put a clean sheet on the ground. Fern held the foal in a classic “foal grip” with one hand grapsing the base of the tail, her other arm looped under the foals neck, holding the head snuck against her chest. I sedated the foal using 50 milligrams of intravenous xylazine. Within three minutes she was a wet noodle, and we laid her down on the sheet, Tanya sitting at her head and my assistant Fern holding the affected leg in elevation. After wrapping the hoof in clean gauze and performing a sterile prep of the leg from well above the joint to hoof, I donned sterile gloves and quickly inserted the needles into the joint on either side. We were half-way through the flush procedure using a 1 litre bag of lactated ringers solution when a coyote stuck it’s head around the corner of the shed and stared at us.

“Chloe, you git!” snarled Tanya.

“My God, Tanya, is that a coyote?” I asked, trying not to lose my concentration.

“Heck no, that’s Chloe, she came from the pound in San Diego. My husband says he’s gonna divorce me if I don’t get rid of her, we’ve got so many dogs. You want her? “

“No thanks. Hey, let’s pay attention here, this foal is going to wake up soon.”

The foal responded well to a series of three joint flushes and systemic antibiotics. Her x-rays showed no evidence of invasion of the infection into the bone, and a sample of joint fluid obtained after the third lavage procedure indicated that the infection was resolving. What didn’t resolve was Chloe’s fascination with veterinary medicine, and on our last visit to see the foal the little coyote dog hopped into my truck and made it very clear that she belonged there for better or worse. I changed her name to Sticky after a few weeks because she stuck to me like a little flea, and over the years she became as much a part of my practice as my stethoscope.

Eight years later, as I’m speeding along, speaking with the UC Davis resident about Brandy and rubbing Sticky’s ears, my fingers discover a lump under Sticky’s jaw. When we arrive at our next call I take a closer look at my little dog with the piercing topaz eyes. Not only can I palpate an enlarged lymph node at the base of her neck, when I examine her oral cavity I discover a dense mass of tissue covering the floor of her mouth between her lower canines.

“Oh shit, Fern, look at this - I think Sticky has cancer,” I say quietly.

Bad news.

Thursday, 1/28/10 First Veterinary Tale

This is the first entry on my blog. I am a large animal veterinarian in Reno, Nevada. I've been here for 14 years, operating my own solo ambulatory practice. My patients are 90% horses, 8% alpacas and 2% oddities (potbellied pigs, goats, tigers!). This blog will be the initial outlet for chapters of a book I currently am writing. It's a modern day James Herriott - stories of my life as a rural veterinarian and of my life as me. I also promise to post a veterinary Tip of the Day on this blog every day - so that's the plan. Here we go. The first chapter of the book is called "All Bleeding". Today's Veterinary Tip of the Day is:
All brood mares should be vaccinated 4-6 weeks before they foal to boost antibody levels in the mare's colostrum. This is the first milk consumed by the foal and is the newborn's only source of antibodies against common diseases in the first weeks of life.

Here's the story:

“All bleeding eventually stops.” This favorite adage of an old surgery professor haunted me as I groped in Brandy’s chest, blindly searching for a primary bleeding site. The emergency call had come through on my cell phone 30 minutes ago, just as I was finishing the last farm call of a long day of farm calls. I answered at the second ring, but before I could complete my standard perky greeting , “Hello, High Desert Vet,” I was cut off by a rapid, panicky voice saying,

“Dr C? Dr C? Is that you? She’s bleeding, it’s really bad, there’s blood everywhere – I can’t stop it….”

After 18 years as a practicing large animal veterinarian, I would be a liar if I didn’t admit that these client’s cries of distress don’t send my heart racing the way they once did. I counted to three and dove in, attempting to stem the flow of words coming through the phone and get the caller’s attention.

“This is Dr. Collatos, can you hear me? Hello? Hello? You need to stop talking and breathe slowly. STOP TALKING and TAKE A BREATH. I can’t help you because I don’t know who you are or where you are.” After a few repetitions of similar phrases I finally heard silence on the other end of the line. I stopped talking and listened again.

“It’s Wendy up on Thoroughbred Circle. Brandy’s bleeding really badly, you need to hurry, and I don’t think she can stand much longer.”

The caller was a very good client who typically had a pretty cool head on her shoulders, but no matter how clearly I explained to her that Brandy had more than 10 gallons of blood in her body and could lose 2-3 GALLONS of it before there is a crisis she continued to insist that her horse was bleeding to death and I needed to HURRY UP AND GET THERE.

So I did, and she was right. I stepped down from my truck and began to walk toward Wendy where she stood holding the mare, tears streaming down her face. Then I started running. The mare had impaled herself on a metal T post, leaving a gaping wound the size of my fist right where the front leg attaches to the chest. That alone wouldn’t make me run, but Wendy was right again - there was blood everywhere, and more pumping from the wound at an alarming rate. I almost never run toward horses – it just isn’t a good idea – they tend to think you have bad intentions when you rush at them and they react accordingly which can be a dangerous thing and lead to bodily harm - but based on the amount of blood I could see on Wendy’s clothes, the mare’s leg, and the ground, I decided that running was worth the risk. I grabbed some supplies from my vet box, then kept right on running until I reached the horse. After wasting 5 minutes with futile attempts to visualize and clamp the major vessel pumping arterial blood (it turned out to be the brachial artery) I realized that this horse was going to die with both my hands in her chest if I didn’t come up with Plan B.

Plan B consisted of the very unsophisticated but effective technique of applying non-specific pressure to control the bleeding. I achieved this by packing the wound as tightly as possible with 4 rolls of brown gauze, each 12 feet long and 6” wide, and then suturing the skin closed over the gauze to put pressure on the bleeding site. I was careful to tie the end of each roll of gauze to the next roll and to keep track of how many rolls I used to ensure that whoever (hopefully not me) unpacked the wound would be able to account for all the gauze. With the skin successfully closed over the packing, I stepped back and turned to Wendy, Brandy’s owner, and gave her a warm, reassuring hug (all the while thinking Oh Man, this is a bad one).

Wendy’s face was streaked with tears and she was literally soaked in blood from her waist down. Brandy stood quietly, trembling slightly, and I silently thanked her for being so calm and cooperative as I had worked frantically on her wound. At this point I listened to her heart and lungs and completed a quick physical examination checking for other wounds and for any indication that the T-post had penetrated through her chest wall and entered her thorax. Brandy’s lungs sounded normal and although her heart rate was elevated, it was clearly audible with a regular rhythm. These were positive findings, and even better, the compression bandage appeared to be working, as there was no blood penetrating the skin edges where they were held together over the gauze.

I was feeling guilty for having doubted Wendy’s assessment of the seriousness of Brandy’s injury. The fact of the matter is that truly immediately life-threatening emergencies are fairly uncommon in equine practice. But in this case had I dawdled just a few minutes longer my patient might not have survived. Realizing this, I silently chastised myself as I prepared to discuss the next step in saving Brandy. Before I could speak, Wendy gave shaky laugh and said,

“Oh my God, Chrysann, I’ve never seen so much blood.”

“To tell you the truth, Wendy, I didn’t believe you when you told me on the phone that it was this bad and I apologize for that.” I have this somewhat irritating addiction to ruthless honesty. My friends hate me for it at times, it got me a divorce, and an attorney would tell me I was nuts to say this to a client because now if the horse died she could blame me. But there you go, I’m just that way, and I believe most of my clients appreciate this quality in me as a professional, and usually it works out in my favor.

“It’s OK, Chrysann,” Wendy smiled, “I was standing here looking at it and I didn’t believe it either. What do we do now?”

I explained to Wendy that the compression bandage should not be disturbed for 48 to 72 hours, by which time the body should have done it's amazing work in controlling bleeding and preventing its recurrence. However, if things went wrong and Brandy began to hemorrhage again when the packing was removed, I wanted her to be standing in a veterinary hospital, not Wendy’s back yard. The blood loss she had suffered already was severe enough to warrant intravenous fluid support and possibly a whole blood transfusion to ensure that she maintained adequate blood flow to all her vital organs. My recommendation was to observe her for an hour, and if her condition remained stable, transport her to UC Davis Veterinary Teaching Hospital, a 3 hour drive away, for supportive care and further evaluation.

Wendy agreed with the plan, and while we waited to be sure she was stable enough to make the trailer ride to the hospital I placed an intravenous catheter in her jugular vein and began administering IV fluids. Based on Brandy’s body weight and estimated blood loss I calculated that she needed at least 10 liters of replacement fluid. After years of bouncing numbers around in my head, the mental conversion from pounds to pints to liters was second nature, and I performed these mental gyrations while casting an eye around Wendy’s horse enclosure. Always a bigger challenge than the fluid requirement calculation was figuring out how to hang awkward, heavy 3 liter plastic bags of sterile polyionic fluids above the horse ‘s head safely and securely so that they would flow by gravity through the IV line into the jugular vein. Before moving to Nevada and setting up my solo ambulatory equine practice, I had worked as a referral internal medicine clinician in large university hospitals where there were usually 2 students, an intern and a licensed veterinary technician on hand to help out in these situations, not to mention up to date facilities with all the bells and whistles designed to expedite the treatment of large equine patients. The transition to life in rural northern Nevada veterinary practice had taxed my creativity at times, but even after all these years I continued to be amazed at what you can do in a pinch with a little imagination, a good cotton rope, and some muscle.

I identified a beam that would serve as a reasonable emergency IV pole. Scrambling up the side of a stall, I hung one leg over the 2 x 6 at the top, tossed a cotton rope with a heavy snap at one end over the beam and hooked the bags onto it while Wendy held the end of the rope tied off below me. Go figure, but during these gymnastic capers I often find myself distracted by the natural beauty of Nevada, probably in an effort to forget how far I am from those high-tech days of hospital practice. So there I am, doing a fairly admirable imitation of a Russian trapeze artist when I find myself captivated by the view of the snow-capped Peterson range that looms up behind Wendy’s house and fills the space between the barn rafters from which I dangle.

The top of the Peterson’s is 8,000 feet above sea level. Wendy’s property sits around 5,200. The high desert of Northern Nevada is sand and sage brush, mile after mile, but as you look up the Peterson’s the subtle desert hues are interrupted by rich green explosions where winter snow pack fed springs erupt from the ground. Clusters of willows and quaking aspens cling to the steep grade around the springs, and even higher perches a lonely stand of rare pine trees, many of which have been burned to skeletons by brush fires over the years. These ancient sentinels of the desert emerge from steel grey rock outcroppings close to the summit of the Peterson range right above Wendy’s home. In Nevada your eye never needs to stop, as over the summit extends the enormous intense blue sky of the West, punctuated on this day by a few cotton candy clouds indicating high winds in the upper atmosphere. All of this beauty sweeps across my vision as I finish hanging Brandy’s fluids and make my descent from the rafters. There are days when I miss my fancy hospital practice, but every time I hang from someone’s barn beam and find myself with an eyeful of the natural beauty that surrounds me here in Nevada I know that I am where I belong, with Wendy and Brandy.

Brandy remained stable and Wendy transported her to the University of California Veterinary Teaching hospital just west of Sacramento where she spent several days. She received a whole blood transfusion and underwent several uneventful bandage changes on her way to a full recovery. After seeing her safely off in the trailer, I drove home, fed the critters, gulped a glass of Chianti and bolted some leftover pizza. I then doggedly sat down at my desk and returned what felt like a hundred phone messages, confirming appointments and checking on patients I’d seen earlier that day, then organized my call book for tomorrow, thought about stocking the truck, thought about stocking the truck again, started to think about stocking the truck a third time and gave up, took a shower and went to bed.