Stories from the Field
2014 HSVMA-RAVS Clinics in Guatemala

Day One

Five-time RAVS volunteer farrier, Chris Hadel
Volunteer farrier, Chris Hadel, joined HSVMA-RAVS in Guatemala for his fifth trip.  Dr. Susan Monger/HSVMA

We began coming to the Northern Jungle of Guatemala in 1997. Since that small beginning, HSVMA-RAVS has been making at least one, if not two, trips a year to this region. For the past five years the project has evolved to focusing on the training of Central American veterinarians and students, as well as a couple of veterinary students from first world countries. We have been very lucky to entice volunteer teaching veterinarians with a coveted skill set of bilingualism, 40 years’ experience in private practice, the ability to problem solve under constrained conditions, overall amicability, and effective mentorship skills. Our veterinary team this year is composed by Dr. Raul Casas-Dolz (lead veterinarian, Reid and Assoc. Loxahatchee, Fla), Dr. Sara Gomez (project manager Ometepe, Nicaragua veterinary project, previously at Essex Equine in Massachusetts), Dr. Alberto Rullan (owner of Performance Equine Veterinary services, Ocala Fla.), and Dr. Shelley Lenz (owner of Killdeer Veterinary Clinic in North Dakota). We have with us one Guatemalan veterinarian, three Honduran students, two Guatemalan students, and one American student from Colorado State University. We are also extremely lucky to entice our farrier, Chris Hadel from Western States Farrier Association in California, to join us for his fifth RAVS trip.

We entered this trip with the excitement and sadness of the changing of the guard. For the last 15 years, either Dr. Susan Monger who helped to start the project or Dr. Dave Turoff, our long-time volunteer have led this trip. As we begin to pass the torch to the next generation of leaders, which is imperative for the longevity of the project, we welcome long-time HSVMA-RAVS participant, Dr. Raul Casas as our new leader of the Guatemala project. We toast Dr. Monger and Dr. Turoff for the decade of training and grooming of Dr. Casas and countless other volunteers and the development of strong relationships in rural Guatemala which makes the transition possible. Here’s to our founders!

In general, we have never been able to get permits for our supplies and drugs to enter Guatemala. It seems to us that the government doesn’t know what to do with us or just doesn’t care. Usually it’s not a problem and we breeze through customs, but we always hold our breath until the moment they let us through. This year, things went smoothly and they only took our duct tape from our carry on luggage as we transitioned from Guatemala City to the Flores flight. The mishap is that the luggage tag from one of our boxes with supplies fell off and it did not reach its destination. Thankfully, the contact info was written on the lid so the airline contacted us and made arrangements to have the supplies sent to us. Hopefully we’ll get them before the end of the trip.

We usually try to schedule our first day in a community with a historically-light caseload to take our time with each case as we acclimate our new recruits and test new protocols. Today was perfect. We visited two communities, seeing about 50 horses in the first community, Cruzadero, where we did two castrations, two dentals, and vaccinations. The second community, the border town of Melchor de Mencos, had 12 horses with three castrations (including a 6-month mule foal, which increases its value as an adult eight-fold), two dentals, and a meeting with the commander of the local military force—a very important connection. The commander observed the team working, offered his support, and offered future personnel to help. This is a major win in a new community. It’s all about relationships and trust to ensure the success of our project.

The most interesting case was the discovery of a hermaphrodite discovered by Dr. Alberto Rullan. Dr. Rullan was teaching a proper physical exam which includes “checking under the tail”. Here we found a penis/vagina, and upon questioning the owner, we were told s/he acts like a stallion but is very usable. We explained to the owner what the physiology of the mare is and what to expect. This underscores the importance of a physical exam--often overlooked but so important to teach our developing veterinarians. Pretty exciting! View photo»

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Day Four

We are about to embark on our fourth work day in the Peten, North Guatemala. As I was considering what to blog about, I was going to comment on how so far, on our first two days, everything has gone smoothly with training the students. They are keen and even on their first castration. Even though they stumble a little with their hands, it has gone beautifully; hardly even a skin bleeder in the world of tick-borne disease. Anesthesia has gone pretty much by the book. The positive of such smooth, beautiful cases is that you get to teach the small details while the student gains palpable confidence. The negative is that they might get a false sense of security and they don’t get to experience how to deal with a complication while the experts are available.

Well, be careful what you wish for as the last two cases at a new community called El Esfuerzo, Spanish for “The Effort,” helped bring a hair-raising teaching moment to us all. The first case was a 3-month old unhandled foal that the owner asked to be castrated. One of our lead vets agreed to the procedure as our success rate has always been good with foal castrations. The procedure was done as a closed castration, and everything went well except for a minor error where the skin was mistakenly incised over a lymph node instead of a testicle. Recovery was uneventful…at first. Then, about an hour later while we were busy with other cases, the owner returned to tell us that there was something coming out of the foal. Another vet went to check it out and alerted us with just one word to gather the troops: evisceration. The four senior vets sprang into action like a well-oiled machine. Everyone wordlessly took a position as surgeon, assistant, anesthetist, and runner. The foal was anesthetized within five minutes, minimizing additional damage to the small intestine. He was maintained on double drip. We were able to put the intestine back in through the inguinal ring and closed the external ring. The other external ring was also closed at this time. The surgery took 45 minutes. The foal was given Exceed for antibiotic coverage, and we checked on the foal daily via phone and asked the owner to bring the foal back for a recheck in four days, even though the site is an hour away. It was amazing to watch a focused team work together during a crisis and have the proper preparation (an emergency bag with most supplies easily available) to make everything go as smoothly as possible. The wide-eyed students were eager to assist and try to be as useful as possible, while grasping the potential for complications for every castration they will do in the future. Ah, teachable moments.

Scrotal hernia
Scrotal hernia.  Dr. Susan Monger/HSVMA

Immediately following the evisceration, we went to approach our last case of the day: An unhandled yearling with a “funny testicle” waiting to be castrated. The rank yearling had to be sidelined so we could inject sedation and anesthesia. Sidelining is an incredibly useful, humane, and safe way to handle untouchable horses that need veterinary attention. The “funny testicle” turned out to be a scrotal hernia filled with small intestine, and the normal testicle had a five-finger size inguinal ring. Once again, the seasoned vets came together to address the situation for another long surgery on our aging knees. The scrotal hernia was carefully reduced and external ring closed. During the procedure, the yearling’s anesthesia was difficult, we were running out of proper suture, and the sun was setting. A decision was made to leave the normal testicle with the enlarged inguinal ring for when we return either later in the week or next year. The owner understood the importance of follow up on this case. The students learned about making pressing decisions for the safety of the animal and to be prepared for the unexpected.

Hopefully today, as we head out to a new community, the day will be filled with smaller teaching moments and the fine details to make cases go as smoothly as possible.

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Day Five

We are starting day five of six with heading to El Rondon, a community located close enough to the Belize border where there is military tension about where Belize ends and Guatemala begins. The Belize army has killed Guatemalan farmers growing “chate,” which is a leaf used in floral arrangements in the USA. We continue to get about 10 castrations a day and the students have become proficient in castrations, catheter placement, drug dosages, monitoring anesthesia and dropping/recovering a horse. Of course, castrations are repetitive enough that skill sets develop quickly. More difficult are the medicine and lameness education as each case is unique and diagnostics are limited. But this is where the real veterinary education opportunity lays--development of clinical thinking skills. Yesterday we had a case which combined many skill sets working together: lameness, medicine, farrier, and MacGyver.

Dead hoof capsule
Dead hoof capsule.  Dr. Susan Monger/HSVMA

A horse presented with a 4/5 front limb lameness of unknown duration. The horse had multiple lacerations on his legs and the students focused on what they could see which was a chronic, old, big, ugly laceration on the pastern. Upon lifting the foot, our farrier discovered “a wad of dead meat” hanging out of the sole and called over the veterinarians. As the farrier removed the dead hoof capsule, he realized a piece of dead bone was attached. At this point the farrier turned it over to the veterinarians. The foot was blocked and debriding began. We preformed a regional limb perfusion with gentamicin--a low cost and low tech, but incredibly effective treatment. The tourniquet was on for the regional limb perfusion, making it ideal for a bloodless sole debridement. While debriding, it was determined that the lesion encompassed 25% of the sole. Without a radiograph, we simply removed dead bone until healthy bone was felt. Upon evaluation of how to manage this large lesion, we were happy to determine the foot was still supported by the medial and dorsal-medial part of the hoof wall. Our farrier fashioned an open-toed egg bar shoe (basically a backward shoe), and the lesion was packed with metronidazole and bandaged. We are incredibly lucky to have a farrier who accompanies us on our trips and is able to create a charcoal forge in the middle of the jungle, and thus enable him to do hot shoe modifications, specifically creasing and punching nail holes for the open-toed egg bar. This trip continues to underscore the importance of the farrier-veterinarian relationship, and even the seasoned vets continue to learn from our fellow hoof professionals.

The beauty of this case was the integration of medicine, lameness evaluation, biomechanics of the foot, low cost yet effective therapeutics and interactive problem solving. To top off the coolness of the case we happened to have the military surrounding us while they got to know our intention within the community. It’s the mixture of all the above that keeps us addicted to these trips. ¡Vive Guatemala!

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