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When the inaugural AVS-VDS EMS Grant took me to Cornwall!

I applied to the AVS EMS Grant in December 2018 and was fortunate enough to receive the AVS EMS Grant at the AVS Congress early 2019, hosted at RVC. The focus of my application was to aim for an EMS placement with a strong Farm bias for the upcoming spring season, where I had 6 weeks of EMS available and would be an optimum time of year for this area of veterinary.

I hold a strong interest One Health, particularly through my student roles within IVSA - the International Veterinary Students’ Association - on both a global and local level. Through IVSA I met Neil Powell, a Consultant Antimicrobial Pharmacist from the Royal Cornwall Hospital Trust. Neil gave an interesting talk about the ‘Cornwall Antimicrobial Resistance Group & Cornwall Veterinary Association Dairy Antibiotic Benchmarking’ system at the first ever ‘Antibiotic Stewardship in Animal Health & Food’ conference, held in London on October 2018. The Cornwall Veterinary Association have really been working hard together to raise awareness and actively reduce the inappropriate prescriptions for antimicrobials to act on anti-microbial resistance, with benchmarking the number of prescribed antibiotics across farm veterinary practices in Cornwall. 

Cornwall was an amazing veterinary location due to the recent work, and by being very niche and collaborative together through their veterinary association. This is a strong example of prominent veterinary issues being tackled on the front-line and a strategic plan which has been implemented to make an active future difference in the profession and reduce the risk to public health.

Head & Head Vets is a mixed practice, with a farm-small animal focus, in Helston, Cornwall. The practice works closely with the Seal Sanctuary! So a true variety of animals can be seen here on a daily basis. One day, I was even drenching camels, who were surprisingly kept as pet grazing stock! To demonstrate the average day with Head & Head, here is exactly what I got up to on my first day with the practice.

A day in the life...

  • 08:30am – Arrived at practice with a member of the team who kindly allowed me to lodge with them over the course of the EMS placement. Met the team and had a tour of the practice.
  • 09:00am – Off to our first callout: 2 sick cows, one with a retained placenta and another who was off-colour.
  • 10:30am – Arrived at the second visit, TB testing Holstein Friesians and Herefords heifers and steers.
  • 11:30am – Quick cup of coffee! Amazing chocolate Easter cake courtesy of one of the Clinical Directors’ wife.
  • 12:00pm – Arrived at third farm: Pregnancy diagnosing with an ultrasound scanner and Ivermectin pour-on for Friesian heifers.
  • 2:30pm – Emergency callout to a post-calving uterine prolapse in a Hereford.
  • 4:00pm – TB testing South Devon cattle and examining tachypnoeic/tachycardic two 2-week old calves.
  • 5:30pm – Back to the practice to end the day on both farm and small animal consults, however…. Out of hours brought about an interesting twist to the evening.

A 12yo male entire Shih Tzu presented as an emergency to the out of hours team. Owners initial complaints was he had been drinking water excessively throughout the day and vomiting it back up. Also, a previously swallowed toy had been vomited back up – toy appeared entire and whole but the Shih Tzu could have swallowed something else as well. Owners reported he was lethargic and had been cocking his leg to urinate but with no urine passing. This dog had a history of bladder stones, having had bladder surgery only 2 months prior, and he had been placed onto a Royal Canin urinary diet.

Upon examination, the dog had a severely distended cranial abdomen with the stomach feeling very distended, tachycardic with HR 138 bpm, slight skin tent, MM pink, CRT < 2 secs and temp was 38.2C.

After being admitted for intravenous fluid therapy and x-rays, pre-op bloods were run, and an injection of clavulanate-potentiated amoxicillin was administered due to increased number of neutrophils. WBC count overall was within normal limits, HCT was low, Urea and ALKP slightly increased and RBC slightly low.


Figure 1. Initial x-ray

X-rays, see Figure 1, presented a much enlarged stomach and slightly distended cranial intestine and a very distended bladder.

Following this, we sedated the patient and a tube was passed into the stomach with approximately 500ml of fluid removed. No stones were visualised on x-ray however due to distension, there was high suspicion of a stone or blockage.

During ultrasound, a foreign body was not found, however this is foreign body material dependent so still could not be completely ruled-out. From ultra-sound imaging, there was a very high chance bladder rupture was imminent and/or there was a high risk the bladder wall will be prone to rupture. A urinary catheter was placed and passed quite well into the bladder. Approximately 300ml of urine was removed and the bladder appeared much smaller and evidence of stones in the bladder were viewed by ultra-sound. Stomach had returned to normal size also.

Heart rate dropped to 128bpm and the patient was not breathing well under anaesthetic, so the patient was brought back around to recovery sooner.

Anaesthetic protocol

Pre-med: Acepromazine 

Induction agent: Propofol 

Maintenance: Isoflurane using an Ayre’s T piece.

A follow-up x-ray, see Figure 2, revealed a much smaller stomach and bladder, however, still a small area of gaseous distension could be seen in the duodenum, without foreign body completely ruled out.

We phoned the owners to update them on these findings and discussed the following options:

  1. Surgery – exploratory-laparotomy to make sure no foreign body and if one is palpated then proceed to remove as well as bladder surgery, very grave prognosis. 
  2. Keep catheterising bladder when it gets blocked and send off urine sample to make sure we are on the correct urinary diet and/or try urinary dissolution. Large stone suspected so may not be possible or may not act quick enough between blockages but may also block frequently.
  3. Euthanasia

As euthanasia may have been imminent, the owners decided to collect their Shih Tzu from the practice at 11pm after he had received a few more hours of fluids. The practice provides out of hours but not an overnight hospitalisation. The owner intended to spend more time with the dog and return to the practice for frequent check-ups, but to return immediately if any deterioration was advised to bring the patient in immediately if any deterioration.


Figure 2. Follow-up x-ray: post-gastric tube and urinary catheterisation


Figure 2. Follow-up x-ray: post-gastric tube and urinary catheterisation

During fluid therapy, our next patient was a tawny owl found by the member of the public, see figure 4. We proceeded to x-ray its wing, see figure 5, which revealed a metacarpal fracture. Healing of metacarpal fractures can be tricky as there is not much soft tissue in that region, so nerves and structures are less protected and susceptible to suffer from more severe trauma. The owl had a Figure of 8 splint for its wing and was very bright throughout the week. Due to issues with territory and tauwny owls mating for life, it was important for the vet to release the owl in the same area it was found, increasing the chances of reintroduction success.


Figure 4. Owl patient


Figure 5. Owl x-ray

After a jam-packed first day, the following day the owners sadly opted to euthanise the Shih Tzu due to a combination of factors: prognosis, quality of life and financial constraints.

AVS EMS GRANTS

VDS Training are proud to be supporting the AVS EMS grants. These grants will offer financial support to veterinary students to complete an EMS placement. The applications for the 2019 grants are open and close of the 1st of December and the successful applicants will be announced at our 2020 AVS Congress at Surrey Vet School in January. There are 5 grants available each of £200 and the application form can be found here and should be emailed to: AVS.EMS.Grants@gmail.com

For more info see http://www.avsukireland.co.uk/opportunities


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