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We Are Flying Solo

May 30, 2019

What Happened To Solo (Punctuation Mark Of Choice) - The Bullet List

This post took me far longer than it should have to put together, in part because it required reliving some horrible times.  You can read here for the original post when Solo was still in hospital in 2017.  As stated there, I never could have done this without generous assistance from my mom, as well as a donation from our amazing friend, Erica, I thank you both.  We also received a care grant from the vet school since our case qualified for "high educational potential."  I would not have done this for any other horse..but it is Solo.  And he said he wasn't ready to go.    

Today I sit & watch the horses relish grass.  Solo glances over towards my chair in the shade to check in & the ripple of gratitude between us is an almost tangible pulse of energy.  "This is what we held on for, buddy," I tell him as he blows a contented snort of agreement into the breeze.


Because his 2017 case was so rare, I'm going to try & run through the executive summary of the roller coaster from hell.  As both a horse owner & a scientist, I know the value of case history & felt the acute lack of it as we tried to figure this thing out.  There is virtually nothing in peer-reviewed literature outside of one paper on ~30 horses in Europe, because there have been so few cases where it was identified, diagnosed correctly, & treatment was attempted.  Symptoms were all over the map, & if I hadn't known Solo as well as I do, I'm not sure we'd have gotten as far as we did.

Without further ado, since there is enough material to base a Master's thesis on (& one is more than enough for me), here is the bare timeline.  If nothing else, I want the information to be out there for other owners & vetsI saw Solo's file in the arms of a student...

Not a record I wanted to set
*Before proceeding, be aware there are unappetizing photos below.  Some things I did not take photos of because I never want to remember them.  But I wanted to document improvement as long as I felt we had some.  NCSU did an amazing job with pain management & my heat-intolerant horse did at least get to spend much of the summer in a climate-controlled barn, away from flies.*

Final NCSU Diagnosis:  Septic sialoadenitis with associated abscessation & draining wound.  Associated necrotic plaque within left gutteral pouch, mid-stylohyoid.  Cultured Fusobacterium, Prevotella, Klebsiella, and Enterobacter.

So It Begins

Thurs, June 15: While feeding dinner, I noticed Solo eating really really slowly, rather listlessly, & there was significant swelling developing rapidly around his throatlatch. I thought it was choke at first, but it didn’t fit; I made the first emergency call to Dr. Bob. Phone fiasco resulted in 4 tries, with me finally blurting, “PLEASE, WE NEED HELP!” (as Dr. Bob is awesome, he asked no further questions & said he was on his way).

It had been hot, I knew Solo was dehydrated, but I couldn't get anything in him. We had to tube him to deliver water, oil, & electrolytes, during which he got a bloody nose, resulting in my crossties resembling a crime scene.  No throat blockage, it looked like an allergic reaction, so he got dexamethasone, but it took about an hour (in the dark) of watching him sweat (xylazine...) & roll & generally scare the life out of me for things to begin to settle. 
The next day.  Horses have a lot of blood.  That fan never recovered.
Dr. Bob waited with me, bless him forever, leaving my farm close to midnight with instructions to give dex injections twice a day over the weekend to prevent re-occurance & call if anything changed.  We were both unsettled by the oddity of it all.

June 18:  Sunday evening feeding, Solo walked up next to me, looked sadly down at his food, then leaned into me, telling me it hurt again. Swelling reappeared, I spent most of night on phone with our clinic's other vet on call, Dr. Michelle & giving repeated shots of dex, as we thought the "reaction" had kicked back in.

He was dehydrated again after another hot day, so every hour I was holding tiny, wet, salty grain mixes under his nose, begging him to nibble on them (he gamely did). He finally took a big drink around 1 am, seeming better.  I allowed myself a few hours sleep before meeting the vet again the next day.

Emergency Hospital Admission

June 19: Dr. Michelle came out, didn't find anything apparent, we debate allergy testing pending blood panel results. Solo had been grazing & acting relatively normally, but later in the day, he stopped eating, swelling began to come back, & he wasn't drinking. By evening, the only thing clear is that we don’t understand what’s going on & he needs to go to NCSU emergency services.

He is admitted after ultrasound reveals abscess & needle aspiration brings out the stink of anaerobic bacteria.  Upper airway scope, including gutteral pouches, was clear.

Initial drainage
June 20: First abscess opened to drain through incision on back of his jaw.  Detailed oral exam revealed:
  • A hole of necrotic tissue under tongue where one salivary gland (horses have six) drains in,
  • Big ulcerations on both sides of his tongue & in mouth,
  • Severe tissue necrosis around abscess. 
IV antibiotics, daily lavages of damaged tissue, packing of wounds with antibiotic-infused gauze, & butorphenol (horse morphine) all begin.

The most difficult part of treating this is now revealed:  this area is full of vital blood vessels (carotid, jugular), nerves that supply the face & tongue, & a myriad of other structures that you can't risk nicking via cutting.  Imagine an abscess wrapped around someone's brain stem & you have an approximation of the area we were dealing with.

Gross but pain-free
June 24 (five days in hospital): Secondary abscess under tongue discovered & opened to drain through chin.
  • Has direct connection to necrotic hole under tongue, smells like a rotting corpse. 
  • Low gut motility problems developed due to opiod painkillers, hydration a struggle. 
  • Appetite is good, but eating is difficult & inefficient due to mass internal mouth carnage.

Translation:  he needed to poop more to avoid impaction, but had to eat more to make poop.  Bacterial culture/sensitivity results indicate Fusobacteria species (ubiquitous in mammalian mouths, guts, soil, the world, not a problem except when they get into places they are not supposed to be, common in human sore throats & tonsil infections) responding to the antibiotic metronidazole.

I thought we'd hit the lowest point.  We hadn't.

It Gets Much Worse

June 28 (nine days): At 1 am, our resident, Dr. Fowler calls to request permission for tracheostomy; Solo is in respiratory distress due to severe pharyngeal compression found on scope. This was a very bad call & a very bad night.  I thought we'd hit the lowest point.  We hadn't.

Prior to this, Solo's ability to eat was improving, he could go out for walks & be in the round pen. Skull radiographs on June 29.
Still the sexiest patient there

July 1 weekend: Solo spiked a high fever on Saturday morning & additional abscess pockets are found & opened (all draining from primary incision on jaw). Second round of bacteria cultures ordered.  This was even more disheartening as there had not been any systemic problems until the fever, it was all localized to his poor necrotic head.

July 3 (two weeks):  Following his afternoon treatment, I noticed Solo staring at his belly, which I'd never seen him do, & I alerted his team of potential colic.
  • Hadn't been drinking or pooping well
  • Immediately tubed, given water & Epsom salts
  • Back in stall, I then saw the ominous flank twitching & fur standing on end that is Solo's sign of a systemic allergic reaction (which I've only seen once before)
  • Sedated & walked in case it’s a pain response.
I then noticed his tongue is swollen & blueish, hanging out of his mouth while he stands head down.  I poked it & it was hard like a bar of soap.  It's late evening by now, we're all exhausted, I didn't know what to think, so I asked Dr. Fowler if sedation ever causes that.  He took one look & immediately called Dr. Prange, one of our lead surgeons, back in (who fortunately lives ten minutes away).

Bizarre mas on hyoid bone
Scope reveals
  • Total airway collapse due to swelling; if he had not already had the trach tube in, he would have suffocated.
  • Also found a mass in his left guttural pouch.  No idea where it came from or what it is, but it wasn't there in the beginning.
Dr. Prange & I had a very, very sombre conversation.  I thought we'd hit the lowest point.  We were pretty close.

Fighter

July 4:  Incredibly, unbelievably, Solo recovered after overnight solumedrol for the reaction & was chowing down on his alfalfa when I arrived.
  • Most recent culture indicated Pseudomonas (nasty, resistant anaerobe, common to infections in long-term human hospital patients). 
  • It was luckily responding to gentamicin in sensitivity tests. 
  • Solo's eating was improving, his fever finally began to subside.
The Tunnel & The Light

July 6:  Another blow; Solo was trending dull again, not wanting to chew.  We were at a loss, knew something was missing, but had another terrible conversation.  There were few, if any, options left.  This was indeed the lowest point.  And then...

As I helped support Solo's head in the treatment stocks (staff shortages & waves of emergency cases had everyone stretched thin), Dr. Prange discovered a big abscess, possibly the original, encapsulated in very thick tissue on the inside of the mandible. Opened with a burst of foul necrotic tissue, gaseous buildup, & pus, this pocket connected to the primary drain tract.  We hoped it was our missing piece & as the weekend rolled around, we finally started to see real improvement. A foley catheter was also run up Solo's nose to drain saliva pooling from the gutteral pouch (a clever invention which worked brilliantly).

You can see the nostril button anchoring the drain - & no more IV!

Setbacks & Progress

Packed & healing
July 14 (four weeks):
  • Mild colic behaviour, needed another tubing, 
  • On 15th, low albumin levels pointed to right dorsal colitis. 
  • No displacement of colon, began sucralfate & misoprostol, no more hay. 
  • Improvement of abscess issues continues with daily lavages.
  • Eating well, begins going to paddocks.
  • Injectable anitbiotics discontinued & amikacin gel on packing started. 
  • Vetericyn gel added in gauze July 16.

July 24 (six weeks): After noting some dullness the previous weekend, ultrasound revealed a final (we hoped & thankfully it was) abscess Monday morning, which opened into pharynx (which was a whole lot better than if it had erupted into gutteral pouch).
  • Nasal catheter was removed, no more buildup was occurring in the pouch. 
  • Instead of gauze packing, pair of foley catheters placed in drain tracts to hold them open. 
  • Third culture of new abscess material was ordered.
The Home Stretch

Catheters taped on
July 28: Scope revealed drain tracts healing, less unhealthy tissue (yay!). Solo was on pasture full time for most of the week & enjoying profusely, flirting with the mares, getting fat on clover.  Bacterial culture did show an extremely resistant aerobic Klebsiella, but in the absence of any clinical issues, we did not attempt treating (it would have involved even more expensive medications with questionable success).  I learned how to place catheters & flush myself for home care.

July 29 (seven weeks):  Discharge! With a big bag for daily catheter care, metronidazole, misoprostol, & follow up in a week.

We still had a ways to go.  But he was home.  And he was happy.

And he was alive.

A most wonderful sight

22 comments:

  1. Solo is a lucky, lucky boy to have you as his human minion.

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  2. Oh my goodness. Solo is so lucky to have you and your vet team. I'm so sorry you went through all that!

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    1. Everyone at the hospital was truly amazing, I owe them everything (literally & figuratively)!

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  3. My god. Horrifying and yet fascinating at the same time. I would have been taking some of his sulfracate for myself.

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    1. If I hadn't seen how much his drugs cost, I might indeed have hijacked them for myself.

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  4. i gotta be honest.... at times the only reason i could keep reading was knowing that he pulled through. dear god, what an absolute horror story :( what an incredible fighting spirit you all (including Solo!) must have had to keep pushing and trying! thanks for sharing the gory details too. obvi i hope i never ever EVER have a need for familiarity with that type of illness and treatment... but like you say, it adds to the critical collective knowledge.

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    1. The craziest part was that every day was different, but we all agreed that as long as Solo was making progress & invested in living, we would try. I was there every day except for 2 days when I had to be somewhere for work & my primary job was "Solo interpreter."

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  5. What a horrifying emotional turmoil you must have been in. Having a progbosis and proven method of treatment is one thing, but traversing the unknown must have been frightful. So happy he is enjoying his greener pasture now.

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    1. The unknown was definitely one of the biggest challenges for everyone on the team & I confess that even reviewing & posting this meant I didn't get a lot of sleep last night thanks to the reminder of the emotional chaos -- but knowing he is shiny & happy & munching grass outside my window & I'll be able to take him on a trail ride this weekend, that is worth all of it.

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  6. You both have what the Japanese call "toshi" a fighting spirit. Grateful for you both to have these quiet moments together as I'm sitting in the barn in my backyard enjoying my coffee and just sitting with a certain lil' horse, I get it...��

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    1. Give that certain lil' horse a big smooch from me!

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  7. I'm so glad he pulled through - what a rollercoaster.

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  8. Oh my gosh - that is just crazy!! I'm so glad that he fought his way back to you :)

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  9. Wow. Just wow. That case file. Amazing he pulled through and kudos to you for doing literally everything to save him. Nothing as good as watching your horses graze out your back window. Enjoy!

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    1. I would love to have a full copy of his file, but I didn't want to kill a whole 'nother forest!

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  10. I'm so glad he pulled through! I can't even begin to think of all your emotions through the whole ordeal but so glad he's still around!!! Lucky boy!

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  11. Thank you for sharing this story with us! what a nightmare that was for you, but I'm so happy to hear he pulled through. I feel silly for talking about my recent nosebleed now! Anything related to the guttural pouch is terrifying.

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    1. Nooo, don't feel silly at all! The unknown is always scary, especially with equine talent for inventing things we didn't even know were possible. We need all kinds of stories so worriers like us can know that not everything is terrible & even if it is, it CAN work out!

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