Developing a Plan for Emergency Medical Treatment

Indepth Equine Podiatry Symposium Notes Written and presented January 2009 by R.F. (Ric) Redden, DVM

If you were to be in a car accident, have a heart attack or suffer a severe injury most anywhere in America, a trained, competent EMT unit will come to your assistance within moments. Regardless of severity or type of injury, EMTs have a good plan in place, adequate training to deal with the problem and a well equipped unit. Their mission is to administer efficient emergency treatment and deliver the patient to the closest hospital for evaluation and appropriate treatment. This incredibly valuable service is state of the art for humans, but severely lacking in equine medicine. Veterinary medicine desperately needs an equine emergency medical team, well trained and equipped to deal with typical equine emergencies, whether they occur at televised sporting events, on the interstate or in the barn.

Unfortunately, the need for such a service has never been taken very seriously. Consequently even at top level events such as the Kentucky Derby, veterinarians hired to be there in case of an emergency are often not trained for emergency scenarios, are poorly equipped to physically deal with most catastrophic breakdowns and have little or no direct experience with orthopedic surgery or knowledge of potential options that may exist for horse and owner. As a result horses are often euthanized immediately, sometimes in full view of the public, without the benefit of efficient emergency medical treatment and a thorough review of available options. The goal of any emergency medical treatment should not be to make a life or death decision, but to provide emergency aid and transport the horse to a location where a thorough exam can be performed by surgeons who are experienced with catastrophic injuries and the options available to them.

Current Emergency Practices

When a horse goes down on the racetrack or other sporting event, the typical scenario unfolds like this: the track or on call vet gets to the horse's side within minutes along with an ambulance that is capable of transporting most any injury once the limb or limbs are stabilized. The life of the animal rests solely in the hands of the vet who for all practical purposes is a well respected veterinarian, but has little or no experience providing adequate emergency care. Without experience or knowledge of state of the art surgical procedures or amputation, the availability of such options would never cross the minds of those attending a fallen athlete. Oftentimes the horse is euthanized on the spot, or he may be fitted with a Kimzey splint, loaded onto the ambulance and far too often euthanized on the backside, out of sight of the public. In some cases the horse may be headed to surgery only to be euthanized en route when the ambulance team believes the situation to be hopeless, a conclusion that may be supported by other surgeons who get a description of the injury over the phone.

It is important to understand that everyone involved is doing the best they can, and making decisions they believe to be in the best interest of the horse. We simply do not have a well established plan that can be quickly executed in a timely fashion for all injuries, nor a proper training program to prepare veterinarians and other officials for these catastrophic injuries. To do a better job we must be better prepared.

Pain as a Reason for Euthanasia

The most common reason stated for immediately euthanizing an injured horse is that he is suffering inhumanely without hope of recovery. Owners have no choice but to agree with the conclusion of the professionals. But let's closely analyze this statement. The typical pain indicators used by veterinarians are heart rate and respiration. But a horse that has just run the race of his life or competed in a strenuous event will appear to be in respiratory distress as he pulls up, even when not injured. His cardiovascular system has been maxed out, and it will be several minutes at best before he can take a deep breath and not look as if he just saw a ghost. The horse with the broken leg looks essentially the same, so the usual indicators cannot be relied on. Pain is often confused with physical exertion and fear, which is caused when the horse can't find the limb to support them. This causes anxiety and even fear if he can't get away from a flailing limb.

In my experience, all catastrophic cases I have treated became quite comfortable for hours to days after being fitted with a cast that stacked the bones and allowed them to load the limb. Was it painful? Strangely enough it was not for any of my former cases. Even when the limb was completely detached they would stand on the end of the stump, dispensing the thought that they should be euthanized as quickly as possible due to inhumane suffering. Therefore, pain is apparently not a good reason to immediately euthanize a horse before a proper exam has been performed and all the options considered.

Alternative Options

Last May, the filly Eight Belles was euthanized in front of millions of television viewers within moments of her catastrophic breakdown due to one badly broken lower limb and one suspensory apparatus breakdown. Either or both had surgical options that potentially could have offered her a quality life and given her owner, trainer, caretaker and farrier a chance to repay her for her brilliant effort, speed and courage as a super race filly, but the premature decision to euthanize her precluded any options from being exercised. I'm certain the fact that she injured both limbs played a role in the quick decision to euthanize her, but was this in the best interest of the filly, owner, trainer and industry? I do think it could have been a more acceptable situation had she received state of the art EMT and been moved to a local surgical facility for a thorough exam, review of the options and consideration of short and long term goals. While it still might have been most feasible to euthanize her following this preconceived EMT protocol, at this point euthanasia would at least be justified as all options would have been reviewed, discussed with the owner and the decision made accordingly.

Orthopedic surgeons with good experience and an appetite for challenge have performed many successful repairs of some of the most horrific injuries possible. This option should always be offered to the owner and the horse. Even those that have irreversible loss of blood supply have options. While amputation and the field of prosthetics remain in the developmental stages, it is an option that has satisfied the requirements for a quality life for several horses.

Eight Belles was on her side with a man on her head when the euthanasia injection was administered. How easy would it have been to apply a Kimzey brace on the suspensory breakdown and a short leg limb cast or long leg Kimzey brace on the bone fracture? At this point it was of little concern whether she had circulation to the distal extremity or what the prognosis was following various surgical options by those well experienced with this type of injury. Regardless of what the options ultimately are, emergency medical treatment must be administered to take advantage of them. Without medical evidence that clearly defines the severity of the injury there are few if any options other than euthanasia.

Goals for Emergency Medical Treatment

The duty of EMT personnel is not to make life or death decisions but to simply offer adequate first aid. The goal at this stage is to stabilize the injury, prevent further damage, reduce the horse's anxiety and either ship him to either a surgical facility or take him back to his stall for further valuation. Euthanasia should not even be the issue at this point. This means we have to develop a new mindset that takes the focus off diagnosing and treating the horse on site and puts it on stabilizing the horse and preventing additional damage while transporting it to a facility where those decisions can be properly made. A thorough exam of the damage and consideration of the options is vital to offering sound advice to owners and is the first step to formulating an efficient plan. Well qualified surgeons with years of experience can make it happen for some of the most horrific breakdowns and injuries provided the horse arrives alive and without further unwarranted damage.

Priorities for dealing with catastrophic injuries:

• Concern for the health of riders, spectators or others that may be involved with the breakdown.

• Stabilizing the injured limb. Whatever it takes, make it happen.

• Calming the animal as best as possible.

• Providing a means of travel. We have some well equipped ambulances, but we need more.

• Protecting yourself as well as others from injury.

Immediate concerns:

• Blood loss. Adequate bandage material, tourniquets, etc. are essential to prevent excessive blood loss.

• Sedation. Sedating a horse that has just maxed out his respiration and cardiovascular system is quite difficult. Do not expect to have a super quiet horse to apply a brace or bandage to regardless of what you use.

• Stabilizing the injured limb. Explosive pastern and cannon bone fractures can be quickly stabilized with the aid of a short or full limb Kimzey splint as indicated. The splint can be a great emergency tool and is even more valuable with the addition of an elevated heel that prevents excessive loading at the most proximal contact point.

• Casting. Five inch cast material over bandage or cast padding can be applied to the horse that is non weight bearing even when he is not standing still. It takes a little experience, but works great. A throwing harness can quickly and atruamtically lay a horse down to be restrained while a cast is applied. Good horseman experience is vital when dealing with injured horses, as they can kill, cripple or maim you without even knowing it.

Potential Solutions

Racetracks could set up a training program that would prepare the gate crew to address catastrophic breakdown assistance to track veterinarians. The gate crew is always at trackside and they are very experienced horsemen who can handle a tough situation. They are also already on the payroll, which would certainly ease up the financial obligations of the track. Mock up training sessions could quickly bring the crew up to an acceptable level of efficiency, and they would certainly improve with experience. New concepts and ongoing research and development in the field of emergency medical treatment would quickly change the mindset. With time and good experience equine emergency medical treatment would be standard procedure.

Many of my clients, including animal activists, are eager and willing to support an efficient means of aiding our fallen athletes. A fund could be established for ongoing research and development in this field of service. EMT service could be a new vocation or business for those interested by the thought of providing a much needed service that doesn't currently exist. Orthopedic surgical advancements would be imminent given the chance and reason to pursue many catastrophic breakdowns.

When veterinarians are called to train wrecks or other unexpected catastrophic breakdowns it is imperative to gather as much information as possible concerning when, how and why before heading to the emergency. Having adequate support and equipment upon arrival greatly enhances our efficiency and offers optimum outcome. Facing such a task armed with formal training and experience could turn a very tragic event into a rewarding experience for all involved.

By simply changing our mindset regarding the goals of emergency medical treatment, we can drastically enhance the outcome of catastrophic injuries by offering our athletes more options, fueling new fields of research and assuring fans that the horse is our top priority.