OK, hello, everyone, and welcome to this evening's Equi webinar. So before we get started, just a few housekeeping things. So my name is Zofia, and I'm from the University of Edinburgh.
So you have or have a question and answer box, so feel free to use this throughout the talk, to type in any questions that you have for the speaker, at any point, and we can then ask them at the end. Also, if you have any technical difficulties, you can also put them in the question and answer box, and we've got Lewis, as our technical backup, and he'll be able to help you hopefully resolve, any issues that you may have. There's also, just a quick questionnaire at the end, of the talk, so before you close your browser, just to give us some feedback, on the talk, it's really useful, if you guys just let us know, what you, what you think of the talk and the quality of the talks, etc.
So we can, hopefully, give you guys what you, what you want. OK, so, enough, of that. So I'm really excited to introduce Josh today as our speaker.
So Josh, graduated from the University of Edinburgh, and then spent 4 years in equine practise before moving to do a residency, in equine medicine at the University of Edinburgh, at Cambridge, sorry. He completed a PhD in virology in 1994, and was a lecturer and then a senior lecturer at the in equine medicine at Cambridge. And he then moved to the Royal Veterinary College, in London in 2005, where he's, a professor of Equine clinical studies, and his and his research interests are normally equine infectious diseases.
He's been a past president of the British Equine Veterinary Association, the, the European College of Equine Internal Medicine and of the Federation of European Equine Veterinary Associations. He was also a biosecurity advisor for the 2008 and 2012 Equestrian Olympic Games, and also the 2014 and the 2018 World Equestrian Games. But he is also a co-director with Jim Green of the British Animal Rescue and Trauma Care Association and has been the veterinary lead in the larger animal rescue initiatives in the UK from the start, representing the veterinary profession on the National Fire Chiefs Council.
So working with Jim, he's been instrumental in promoting joint training and working between the veterinary profession and the Fire and Rescue Service, including construction of national occupational standards and guidance for the UK Fire and Rescue Service, and also building and delivery of the for us and veterinary training courses. So, in Josh's own words, this will hopefully be the best webinar. Yeah.
So over to you, Josh. Sophia, thank you very much, for the introduction and, thank you very much for the invitation to give this webinar. Yes, I really hope this will be of interest to people, and it, may well be something that some of the, delegates who are listening have had some experience of.
So, hello everyone, welcome, and, thanks so much for joining me for this, webinar. As you can see from the title, I'm gonna be talking about, how we work with the emergency services at incidents involving horses. And to look at the vet's role before, during and after the rescue.
You might know this is actually a very common activity. The UK emergency services are called to around 5000 equine incidents each year, both on the road network and off the road network, and they will call for veterinary attendance at each of these. This is what the national standards and occupational guidance require.
So it's something that vets need to be ready for, and the goal of this talk is to give you an understanding of what is expected. And I do hope you'll find it, interesting. Now, just a word about barter, as, Zofiwara said, I'm a co-director of the British Animal Rescue and Trauma Care Association.
Barter, and, we're a community interest company, with, which has the purpose of representing all those who respond to incidents involving animals and to promote, the welfare and safety of people and animals who, are involved in incidents. Barter is a, a member association. We we represent our stakeholders.
And our key stakeholders are Beaver, the British Eine Vet Association, BVA, BCVA, the Cattle Vet Association, RSPCA and the National Fire Chiefs Council. And if you want to, learn more about animal rescue, the aim is for the Barter website to be a one-stop portal for information. So, do visit barterCIC.org and, there are lots of links to, information and resources that you'll, I hope find of use and of interest if you want to learn more about animal rescue and what you need to do to get ready to be an effective responder.
So, really the talk is divided into three parts, and the headline on this slide is really important, the idea of a casualty centred rescue. If you were driving home and were unlucky enough to be involved in a road traffic collision. All of those people who attend police, fire, paramedics, medics, ambulance, you, they would put you at the centre of the rescue effort.
It would be a casualty centred rescue. It's what we'd expect we'd expect them to do everything they could and be thinking about us constantly. And the reason why this is a very important but and in a way obvious point for equine rescues is that traditionally, people have tended to approach equine rescues as more of a technical rescue.
There's a large trapped object, the horse. Which needs to be removed from it's place of danger to a place of safety. And it's been approached very much from a technical rescue point of view with cranes, lifting equipment, and that sort of thing, which, although it looks very dramatic, is actually generally inappropriate.
And you'll see that the methods we've developed in the UK which have been adopted worldwide are very much low tech, simple methods because these are safer and easier for the trapped horse. So the whole approach is a casualty centred rescue, put the horse at the centre of the effort. And I've divided the talk into three parts, what we should be thinking about before, which is all about preparation and training, during the incident, which is principally about triaging chemical restraints, although we do so that's sedation and anaesthesia.
Although vets do have some of the very important roles on scene as well. And then after the immediate care of the patients on scene and thinking about transport onto either safe stables or onto hospital. So that's how I've structured the talk, and I think it gives a good framework for you to think about what you need to be doing before, during, and afterwards.
Now let's just a couple of words about your role in some more detail, . If you think about a rescue timeline from first arriving on scene to the situation being resolved and the animal being moved on by transport and then being cared at its ends cared for at its end destination. Our role would in sequence really involve these, key tasks.
Firstly, we work with the animal rescue team in tactical planning. So this is deciding how to conduct the rescue, which techniques would be appropriate. In that, image, centre screen there, you can see a shire horse that's being, manually removed from a deep bog.
Again, a good example of a simple low tech rescue in a, a beautifully well sedated horse, lots of people power there. So that plan will have been evolved by the animal rescue team and the vet in attendance to decide exactly how they can do it, what sedation protocols appropriate, and so on. We're very much responsible for delivering as safe a scene as possible and for doing everything we can to safeguard the welfare of the trapped horse.
The horse bottom, right, which is trapped in the cattle grid, that's actually a horse which survived without any serious injuries, remarkably, but clearly looking after animals' welfare. Up to the point when it's released is really, really important. So we deliver safety for the rescue team and we deliver both safety and welfare for the casualty.
Triage is really important and I'll say a few words about that. But it's clearly really important to identify the non-viable animal right at the start and to euthanize it. Euthanasia is part of the rescue kit.
The last thing we want to do is to spend a long time rescuing an animal to then discover that we've missed a proximal limb fracture or some other, injury that makes it non-viable only to then have to euthanize it at the end. And then finally, once we've got the animal out. Our more normal veterinary role of casualty management kicks in, so providing immediate care, first aid, supports, resuscitation fluids and so on, thinking about transport.
When they're making sure the animals cared for after it was being transported. So, let's get into the three sections and think about the before 1st 1st of all. So this is all about preparation and training, and let me start by saying something about keeping yourself safe and looking professional.
On the right there is the helmet that most of the UK, Fire and Rescue Service has, Fire and Rescue services have gone for for their animal rescue teams. It's also a helmet that three of the UK vet schools have gone for for their vet students and staff. You'll find details about this on the website if you'd like to, get the portal into the company to make that.
How many of you wear helmets and how many of you use helmets and carry them, I think will vary. I think generally equine vets are still not good enough at, wearing helmets, but it's brilliant to see that the culture is changing. And actually, if you think about the situation in the UK now compared to 5 years ago with horse owners.
It was, the minority of horse owners who were wearing helmets unless they were in competitions that mandated that five years ago, but now it's perfectly normal to see people wearing helmets all the time when they ride, and a lot of yards have policies on helmet use at all times. So the world has changed and we, we, we need to embrace this. The the helmet is the last resort in keeping your head safe, but if everything else fails, if all of your other measures fail, the helmet will will prevent that, life threatening injury.
So let's make sure we arrive on scene with a helmet, and if you look to the images on the left. Let's have our, equipment organised. An awful lot of us, and I'm as bad as anybody, you, you rock up with the car, a load of loose bottles, needles, syringes in the back, and you're sort of rummaging around trying to find that, injection that, that, that, that you need.
The emergency services are used to working with medics, paramedics, ambulance people who arrive with packs exactly like these with everything all ready to go, so it's professional, it's organised. And we've been working with a company called Open House to make the most of the bags that the NHS use, and they've produced a veterinary version of this so it's been you'll see it in use on all the racecourses now, and I think it's a great idea to have your kit all organised into a grab bag. So let, let's arrive with our safety equipment, helmets, high vis tabard with the words vet on it, so we're identifiable.
I'd like to see us wearing safety boots, waterproof trousers are always a good idea. Let's have our kit organised. I think looking professional arriving on scene creates, the right image.
It's also very important to be efficient. Then, in terms of what should go in that grab bag, and I think every practise should have one of these ready to go, ideally one in every car, but at least one in every practise, so that, you do have everything to hand. You probably devise your own list of things, but I think, we definitely want our safety equipment in there, basic clinical exam kit.
I think a catheterization kit very useful, not always possible to put jugular catheters in, but important to be able to do that where it's appropriate. I'll talk about a continuous infusion a bit later on, and I think this is a, a technique which, if you work in hospital practise you'll be totally familiar with. I think in first opinion practise it's not used very much, can give terrific levels of control and safety on scene.
I strongly recommend that for the longer duration rescues. Sharp's book, again, vets, I'm as bad as anyone, very naughty. We put syringes and needles in our pockets.
We put needles behind our ears in our mouths, and so on. On scene, let's use a sharp box. The fire service will very gladly provide you with a firefighter who will follow you around with his sharps box, so we don't leave things on the ground and create, needle stick injuries and risks and so on.
Remote injection pole, very useful. I'll talk about that a bit later. Sextant drugs, particularly for chemical restraintation, anaesthesia, but also antimicrobials, respiratory support, and so on, very important to carry som somulose and very important to carry ketamine.
And remember that although ketamine is now reclassified, it's perfectly acceptable to carry ketamine in a lockbox in the car, provided that lockbox is secured in some way to a structural part of the car. So a security cable around the cars, the car's seat frame, for example, is perfectly OK. And then a basic selection of things to do with wounds, including a selection of dre dressings, splints.
And I think very useful to carry a an emergency tracheostomy tube. A simple 12 or 13 mil human or small animal tube will do, even better to have the standard 20 mL equine tube in your bag. You can make up your own list, but I think it's really important to have a clear sense of what you're gonna carry and to have that ready to go.
Now, when you arrive, our instinct is to go to the casualty. We're vets, we are very patient oriented and the scene will look confusing. There will be many people there, lots of uniforms, different coloured helmets and so on, and our instinct is to plough through all the people and get to the casualty.
Don't do that. Everyone must be logged into a scene and for those people who come on the stakeholder training courses that Barta runs with BVA, B Beaver and BCI and so on. We issue you with a tag like the emergency services have.
It has your name and ID on it, and what you do on arrival is you clip your tag off your high vis vest and you hand your tag in the incident commander. They then know that you're there and they they they they they can use your tag as as a record that that you're on scene. You then collect it when you leave.
So everyone must be logged in and accounted for and your first job is to locate the person who is the instant commander. I'll show you a picture of a scene in a minute, but these people are clearly identified, and they always have a tabbo on saying instant commanders, there's no confusion. Most horse incidents will have a single incident commander.
If it's a major incident, let's say you've got a a major road incident with perhaps a multi-horse transporter that's been involved in a multi-vehicle incident, and there's maybe human casualties there as well as equine ones, there may be more than one incident commander, that this emergency services may divide the scene into different sectors, but generally there'll be a single incident commander. So report to that person. And the next point's really, really important.
In our day to day life as vets, we are the team leaders. It may only be us and the clients working out on the stable yard, but we're in charge, it's our job to keep that client safe, we make the decisions, we carry the can. On scene, we are not the team leader.
We're an integral part of the rescue team. We work with the instant commander and the animal rescue team lead, but the vet is not the actual leader of the incident, that is the instant commander's job. You're a key person, they'll be looking to you constantly for guidance and advice and nothing will happen without your say so, but it's the instant commander who's in charge.
When you meet the incident commander, they will give you a a very clear instant his history, and a safety briefs, they'll explain what's happened, what the casualty has been doing, how they found it, what they've done with it since, they arrived, and this will give you time to think about what to do. And it's worth saying that, most, in fact, almost all now of the UK regions have got a, a trained animal rescue team and the team leaders are trained. To the same high standards in animal rescue as they are for human rescue, including a working knowledge of a lot of the veterinary procedures, including things like sedation and an anaesthesia.
So they will have a professional to professional conversation with you, just like they will, they would with a medic or a paramedic. So don't be surprised. And certainly don't feel threatened if a firefighter starts talking to you about what sedation protocol you're thinking of using.
This is exactly what they're used to doing with the medics and the paramedics, and the idea is that together you formulate the tactical plan, and that's something which will take some time to, to do, and if you've been on scene, you'll know that the emergency services do spend, sufficient time planning. They don't just, jump in and do things. Which is what members of the public tend to encourage them to do.
They want to make sure they're going to act safely and in the best interests of everyone on scene, including the casualty. So let's look at what instant command looks like. This is actually a a a universal system that the emergency services use across the UK and actually most of the world to create structure and order and safety to any incidents.
Now, in this case, we're gonna look at incidents involving a horse. So here's some of the people on scene, and there is the instant commander look. In this case, this person's wearing a white helmet, they could wear any colour helmet.
The important thing is they're wearing a high vis vest, which says instant commander on it. That's the person that you report to. So let's look how the scene would be structured.
Here's our casualty, here's that horse in that cattle grid. And depending on the which fire service have responded, they will have a predetermined arrival, which means they will dispatch a a number of resources, vehicles with people on them. And that, and what they actually deploy will, vary from region to region.
Some regions will send the nearest appliance. Some regions will send, an officer in a car to assess the scene, and then the officer will decide which resources to send. This is based on the Hampshire PDA, and so in Hampshire, as in many regions, when a 999 call comes in, they will dispatch the nearest fire engine to the scene.
And these crews will have been trained to animal rescue level one. They're not trained to rescue the horse, but they're trained to contain the scene, and they will establish an outer cordon. This will mean removing members of the public and keeping them out.
They'll probably allow the owner, as long as the owner is being sensible to remain with the horse because the owner can be very calming. But they'll keep everyone else out. They may clear access, they'll cut down trees, remove fencing, they'll create access for the animal rescue team, when they arrive.
When the animal rescue, they'll also set up an equipment dump on the edge of the outer cordon, and one of the things you'll enjoy about working with emergency services they keep everything very neat and tidy. They don't leave kits strewn all over the place. The kit is kept outside the outer cordon and brought in and out as needed.
So people kits are held outside the out the outer cordon, and only people that really need to go inside the outer cordon are allowed in. When the animal rescue team arrives, they will establish an in accordon. These things are not usually established with tape, you know, they usually don't put up a fine rescue service, do not cross tape, because you don't want to have tape and things anywhere around the animal, but there'll be a a conceptually in accordon that they will then, take, take care of, and only the animal rescue team themselves go into the inner cordon.
The inner cordon is managed by 3 people, the instant commander, you as the vet, and the team lead for the animal rescue team who will either be a level 3 trained specialist or a level 2 trained team leader. And you work as a team and the 3 of you will direct operations. Very importantly, and this is something actually we can learn a lot from, and, for those of us who work in hospitals, we should do a lot more of this.
We always have somebody who is not doing the rescue, whose job is simply to stand at the edge of the inner cordon and watch what's happening, and acts as a safety observer, and at any point this person can say stop and everything stops. If everyone's involved with doing the rescue, we all become very task focused, and then we lose sight of safety. So there's always a safety officer, whose job is to watch what's going on and we'll stop proceedings if need be.
And then there'll be a number of, level 2 trained rescue operatives who will actually carry out the rescue under the supervision of the incident commander vet and the team lead, being observed by the safety officer. And then finally there'll be at least one person whose job is to ferry equipment in and out. It's all very, very structured and and this scene, this organisation would apply to any incident.
It could be a single horse, it could be 10 horses in a big transporter, and you'll see it applied to road traffic incidents involving people, fires, anything like like that. It's important to understand this because when you arrive on scene, and this is a picture of a training exercise with relatively small numbers of people in, pretty confusing. This is not a world that we're used to.
Imagine this is on a motorway at night in November and it's raining. It's dark, there's blue lights everywhere, there's, you know, 50 people there, all in different uniforms, helmets. The tard's quite an intimidating scene for us and understanding what instant command look looks like, like this.
Is very helpful. And remember, in a way, the only thing we need to remember is that the person we report to is the instant commander, and they're right in the centre look, wearing the fire instant commander Tabard is that person, so that's your sole focus when you arrive. Excuse me.
Now a word about equipment and techniques, as I mentioned, the big shift in animal rescue, large arm rescue has been away from technical rescue using cranes and things like that to low tech approaches using simple techniques and people. Nothing is fixed to the animal. Everything is done using canvas strops, so there's 3 there in the equipment dump on the left, and you can see the pony being eased out of that, lorry with a strop on the right.
Nothing is knotted, nothing's fixed to the horse, so if, so if something goes wrong, you just let go and everything falls off. And the same goes up for those rare occasions when you need to lift the horse. Everything now is done with quick release, catches, pull a pin, everything falls off.
Now, if you look at the equipment dump on the left, you'll notice there's a very important piece of equipment to the left of the image, which is a tray with some tea and biscuits. And this is genuinely important because the last thing, unless the casualty, the equine casualty is in a life threatening situation, or especially if there's a human involved, unless you're dealing with one of those two situations, there's always time to plan and to think, and rescues go much better if time is taken to plan. And also, the discipline of the cup of tea is very useful once we've given sedation.
In clinical practise, if we're honest, we're all very bad. We give our sedation, we wait about 5 seconds, and then jump in and start doing the, procedure we're doing. That is not good enough in animals which are full of adrenaline.
And, waiting and having the discipline to wait is really, really important. So it's low tech, strops, ropes, people power, not generally not using cranes, and this is given much, much better outcomes and actually much quicker rescues. I'm gonna play this video clip.
This is a, a, a training video that the Hampshire made, you'll see my colleague Jim Green his instructor. I'm sorry that the sound is gonna come across a little bit quiet, on your computers, I think. It's a short clip, but it'll show you what I mean by low tech, tech techniques.
This, shows stro positioning for a forward assist or a forward skid. And if you want to see more videos, of these techniques, then you'll find those on the, BAA website. So I'll play this.
I won't say anything whilst this is running because Jim does a commentary through it, and you may need to listen a little bit harder than you'd like just to hear what he's saying. Right. We're now gonna perform a forward skid and again firefighters will be taking control of the animal's head using the webbing head collar.
All equine tack is designed to do up on the left-hand side, and of course the way the horse is presented here, it'd be difficult to do that. So the firefighters have turned the head collar inside out, in order that the buckle will do up on the top side of the animal. Once they've gained control of the head, using the head collar, we will then place the carry sheet underneath the animal again to protect the eye and to be utilised later during the rescue as a carry sheet.
Once this is done and the head control is maintained by the firefighter, another one will put the strop guide through again through to the spine side, using the front natural hollow, and one strop will be then pulled through. Strop guide will then be given to the equipment manager and taken back to the equipment dump. And just to pause out there, you'll notice that nobody, but nobody is standing near their legs.
They're all outside the kicking zone, and they're using simple ideas like that flexible steel strop guide and shepherd's crooks like the firefighter to the left of the images using to feed these strops safely around the horse, without anyone getting into any of the hazard zones. Once retrieved by the operator on the leg side, he will then place one eye of the strop through the other eye, and that will then be drawn down against the sternum of the animal in what we call a lark's foot configuration. This is to ensure that at no time during the forwards assist or forwards skid that the stro can come off the animal by falling over the shoulders.
Once that's been taken round, the line can then be applied. And then the two people that will be carrying the animal's head will take up position prior to the. Procedure.
Again, the firefighter on the head will be giving the orders for commencing the exercise. And most rescues can be carried out using one or two strops, a similar position strop around the hind limbs around the pelvis and out between the hind limbs. Those two configurations will allow you to do most rescue.
Techniques, beautifully simple, very low tech, very safe, nothing's fixed to the horse, and it's, it gives, much simpler, much better outcomes. So that's, the, before, part of the talk finished. Let's go on to the middle bit of the talk, which is the during.
And the headlines here are really triage, and chemical restraint. So I think it's worth acknowledging that, although, for that black pony which is down, triaging that now it's been, extracted is relatively straightforward. If you've got an animal which is, buried in its neck, up to its neck in mud, actually triage is going to be very limited, but still we need to do the best we can.
We're never going to put ourselves into danger. So for example, we're not going to be climbing into the back of a wrecked trailer or lorry to triage the patients. But within the bounds of what's safe, we do need to do our best to identify the, life threatening injury.
And, wounds like the one on the left, this was a metal spar which has impaled this horse through, from in front of the shoulder. You can see where the swab is positioned and has come out, having travelled axial on the inside of the scapula and has appeared, cordless to scapula. There's a pretty difficult wounds, wounds to triage.
You can see it's a very serious wound, but it can be quite challenged to work out what's what what what's going on. Now when you. Triaging, I think however experienced you are, it's very useful to have a checklist because when you're on scene with lots of people watching you, blue lights and so on, it's a very stressful situation and pretty high pressure.
And so a mental checklist helps to, stop us, forgetting things. And these would be the common things that you are likely to encounter, it would be a very unlucky animal if you had all of these happen to it, but these are the things that you should be working through as a, a checklist. And in fact, the medics will, use these, actual physical check checklists, and will tick off.
To show that they've run through each of the items on the triage checklist to make sure they don't miss anything, but then also then provides a record which stays with the casualty and is passed on, to the receiving team in hospital. I think we would probably do well to adapt that sort of thing for our animal casualties. So the common things to think about are exhaustion and hypothermia, being large animals, horses are pretty resistant to hypothermia, but you will find hypothermic animals, particularly if they're being submerged in, in water, and you may get temperatures down into the critical zone at less than 34 degrees C.
But exhaustion is common. Myopathy and compression injury is also common, and I think we don't think enough about this in horses and humans that are trapped in mud. These are a really big deal and actually can be rapidly fatal.
Because horses are bigger, they deal with compression injury better, but I think we under recognise myopathy as a as a result of compression. In those horses which have been trapped, hypoxia circulator compromise, very, very important in animals where they've got their head in a position where the upper airways obstructed or they're on the side or particularly on their back, because of the impact of the weight of the abdominal visa on, on circulation, and on the heart and on the lungs. I think nervous system trauma, just like if you're used to doing equestrian events or racing, that exhausted collapsed horse that won't get up.
Can be difficult to sort out whether it is just exhausted or whether it's got nervous system injury, and I think like in racing and equestrianism, don't rush into making hasty decisions in those situations. Wounds. Yeah, with the, you know, if the big wounds, not gonna miss those, but also don't forget those small wounds which may be critically important because they've involved a synovial structure.
Fractures quite easy to miss, I think particularly proximal limb fractures in a horse, which is, is trapped, and from time to time, but fortunately not very often, we'll deal with burns. And I think it's quite useful to organise your thoughts, in thinking about triage, particularly if you're not particularly used to doing this, and thinking about those things which are actually important, things which are serious, versus those things which might appear dramatic, but actually not very serious at all. And you can fill in a grid like this to help you.
So if you think about . Things which look dramatic but actually aren't very serious at all, then really most wounds would fall into this bracket, not all, but, but many. Actually, a lot of cases of blood, blood loss, a bit of blood goes a long way, as we know, and the kind of things that would seriously alarm a horse owner in terms of blood loss are usually not clinically significant.
And most small burns, you know, they may look bad, but they're, usually they're not, very serious. There are things which er look dramatic and artsy, very serious clinically, some fractures and wounds had fallen into there. The more severe cases of exhaustion, myopathy, hypothermia, brain and spine trauma, and large burns would all fit into that bracket, I think.
The ones that we really want to watch out for, the ones which don't look like a big deal, but actually very serious. So definitely some fractures falling into this, if they're non-displaced. A lot of joint tendon puncture wounds, those synovial punctures, very easy to miss.
They may not look like a big deal. Body cavity punctures, both chest and abdomen, can be very easy to miss, and the animal will deteriorate very quickly once you've completed the rescue if it does have a thoracic cavity or abdominal cavity puncture. And some head trauma will belong in there.
And then finally things which er are not, don't look very dramatic actually, they're not very serious, well some wounds will go in there, milder hypothermia and exhaustion, mild myopathy and less severe hypoxesis. You can come up with your own version of this, but I think it's really useful to think about what looks bad versus what is bad, when you're on scene and and and under pressure. Now, something that I think is starting to catch on in large animals, but which historically we've been rather poor, I think, is thinking about do I need to give this animal some support before we rescue it?
What is its medical condition like? And giving IV fluids for resuscitation can have a dramatic impact on the medical state of a casualty. Now admittedly, if you take this horse that's in the bog, a bit difficult to do a full clinical exam on this, you're not gonna be able to check off all of the things in the checklist there.
So the detail, excuse me, the detailed things you might do in practise to assess cardiovascular status in reality may be very difficult, but basically if the horse is dull and depressed and you can safely give fluids, I would totally do that because it's easy to do. You only need to give about 10 litres or so. You're gonna spend, you know, 15 or so, maybe 20 minutes running those fluid fluids in.
Makes a huge difference. Hartmann's, is the appropriate choice, and, it will make a large difference. If you're given, say 10 litres of departments and the animal still looks rather dull and depressed, then, you can follow that with 2 litres of hypertonic saline.
If you like, and I've put all foods at the top of the slide because I think. In all situations, once you've completed a rescue, even if you've felt the animal looked OK, and you've decided not to give IV fluids for resuscitation, give them all some more fluids afterwards. That simple act of giving, you know, 4 or 6 litres of water plus some electrolytes makes a big difference and it's just good for casualty care.
Right, let's go on to think about, what we're gonna do with chemical restraint now, and I'm gonna start with this, important point. You will naturally focus on getting your your sedation right at the start when the crew are working around the horse and placing strops and so on. This usually takes some time and generally by the time the animal is ready to be removed, whether that's with a lift or whether it's with a skid using strops, your chemical strength will be starting to wear wear off.
These are prey animals and at the point when they sense release, that's when they will attempt to run. And it's particularly dangerous if you have done a lift, so image on the right there a horse coming out of a swimming pool. Let's say that that's very much a Hampshire problem I gather, where there's lots of horses and swimming pools that get muddled up together.
But the lift like this, the horse will hang passively in the slings. Until it's over the ground and it's about to touch down. And that's the point when it will attempt to run its its survival instincts will kick kick in.
And you, in many cases will need to give a second bolus of of sedation before the extraction happens to make sure you've got a good level of control right the way through to the point of of release. So do be ready to give additional top-ups and build that into the tactical plan. I mentioned adrenaline at the start, and you will have all experienced this.
The impact that adrenaline has on the effectiveness of alpha 2 agonists is profound. And this is because the effect of alpha 2 agonists is to reduce noradrenaline in the system of neurons throughout the brain, which is referred to as the reticular activating system. This is the network which controls how alert you are.
And alpha 2 agonists, decrease noradrenaline, which is the neurotransmitter. In other words, they make the system less active, the animal is less alert, it appears sedated. Think of it like turning down a dimmer switch on a light, light circuit.
Now stress, fear, panic, wind up causes a body wide noradrenaline release, and we get all the systemic effects. It also er triggers release of noradrenaline in the reticular activating system. So it directly antagonises alpha 2 agonists.
And so if a horse is stressed, which they will be automatically if they're trapped, even if they're unable to demonstrate that because they're stuck, they will be panicking. They are adrennalyzed and the effect of your alpha targets is greatly reduced. And that means that the standard sedative protocols that we all use in day to day practise, which mostly are effective because we're working with calm horses.
Are usually completely ineffective at rescue scenes and may actually be dangerous because the horse will appear to be a bit sedated and then when the teams start work, it will snap out and start reacting to it. And remember, sedation is only sedation. There will be some animals who are so adrenalized that no sedative protocol you use will give you satisfactory control.
And the only way that you're going to deal with that situation is to convert to general anaesthesia. This is all about being flexible, thinking a bit outside the box and being ready to switch from plan A to plan B. Now word about roots of admin, we can give our, chemical strength protocols by, IV or IM, we can give the roots to if we want to, or that's really too slower, and too unpredictable to be very satisfactory at rescues, but mostly IV or IM, and you can choose to, take staged approaches.
You can give initial dose IM and then follow that by IV. So for example, if you look at the pony, in the bottom right image that's gone over the, the partition into the jockey compartment and has crashed out through the back door, it's properly wedged, there's no access to the pony itself, but you do have access to the rump. So you could, if you wanted to start with an IM protocol, get safe control, and then, try to get access to the neck to go IV.
You could, go IM and then IV using the tail vein. And that was actually what was done in this case, very imaginative by the vet who, who attended. She got initial control to stop the pony self-destructing by giving IM sedation.
And then actually delivered a ketamine GA protocol through, through the tailbone and the pony was rescued like that. Great example of thinking outside the box and, a great way of getting that job done very safe, safely. I mentioned remote injection poles, I suspect few of us carry these, maybe we have a master jet or a cattle device, but the kind of long lightweights gas powered poles which are ideal for equine work.
Like the Dan inject pole, which is used very commonly by wildlife vets and also the Japstick device, which is a a device marketed for the equine market. They're excellent. You may not have one though, so you can improvise any old length of wood, a broomstick, with a 50 mil syringe with the end cut off taped onto that syringe, sorry, taped onto the broomstick.
And a 10 mil syringe, which is where your, dose of drugs will go. The 10 mil syringe slides perfectly and very snugly inside the cutoff barrel of the 50 mil syringe. Put a needle on the 10 mil syringe, you've then got a very simple and pretty effective injection pulse.
So you can always improvise one of these. There is genuinely no need to put yourself at risk to inject an animal. At an incident, in fact, the fire service won't let you do that, they'll expect you to be using an injection pole.
So I'm not gonna talk much more about sedation, but this just to give you a flavour of all of this, but I think you know, achieving good sedation at rescues can be a challenge because of adrenaline, so bearing that in mind, think about the horse very carefully, how wound up is it? And think about your regime, and generally we're gonna be using multimodal sedation, combinations, and do be ready to use continuous rate infusion as well. I would say at least double your dose.
And if you look at the data sheet, you'll see that the doses that you're using of your favourite alpha 2 will be right down at the bottom of the dose range. Do be ready to use, double or more than that. Do, do be ready to use, different routes, so IM and or IV do use injection poles.
But I think very importantly, don't expect too much. Sedation is just sedation, it's not general anaesthesia. The, the first arriving crew would have done everything they can to keep the horse calm.
They'll have removed noise, distractions, other animals, they'll have given it food and so on. So all of that helps, but do assess what you think the windup is and take that into account when you are, putting together your protocol. Do wait enough time, that's where the cup of tea comes in, remember, and do be prepared to re-sedate.
If you give him what he thinks would be an appropriate, cocktail, not got the effects, and you're gonna give more, well, think about giving a different alpha 2. Remember they have different alpha 2 specificities and you will get different effects in some horses if they've tried deomidine. Rather than give more, perhaps try using Romiphidine as an an alternative and do be ready to convert to general anaesthesia.
Now it's difficult to give exact guidance for each job because you're gonna have to make a clinical decision when you're there, but here is a general guide as to how to use a standard combination. Of ACP in this case, the alpha 2 is deomidine, but you could obviously use Romiphidine. I think, by the way, xylazines rather too short acting for most, in, in instances ambuorphanol.
So standard IV pro protocol meaning for a calm horse would be 2 mLs of ACP 0.5 of ditomidine and 1 of butanol all mixed together, . The same syringe, for your 500 kiloholes or the standard emperor protocol will be 2 mLs of ACP 1 mLdomidine, 2 mLsphenol.
You'll notice we've doubled the deomidine butterphenol doses, but not the ACP, and that's because unlike alpha 2s, you tend not to get a dose dependent effect with ACP and actually you just increase the unwanted cardiovascular effects of hypotension, which remember on the triage checklist is something that we want to avoid. And this is my best guidance on how to adapt from a standard dose for a relaxed horse, calm horse to a moderately stressed to extremely stressed horse. So increasing the dose of the alpha 2 and the buorphenol, but leaving the dose of ACP the same.
And you're probably not used to working up at those upper limits for the alpha 2 and buttrophenol. You can go even higher if you need to. Remember though, once you reach the maximum threshold, the ceiling effect, increasing the dose will not increase the effect, it will simply prolong the duration.
As I mentioned, and this horse in the horse box is a good example. We can use stage protocols, you can start with IM, follow with IV. Remember for going IM to allow enough time, and I think for the adrenalized animal that means 30 minutes.
So that really is time to sit back, have a cup of tea if that's available. And the tea is not a joke, it really is something that's a good discipline to step back and just wait, calm scene down, let the animal get get ready and then start. Now coming to the end now, but just, a word about extended sedative protocols.
A lot of jobs take a long time, you know, they might take 1 to 2 hours, and you could achieve control with repeat bus administration, but the problem is that the animal becomes light, and then you have to give more drug. And so you've got this fluctuating level of safety from safe to not safe, safe to to not safe. And continuous rate infusion is a much better option.
It will give you a very controlled steady plane of of sedation. And let's just run through this job, this, let's cut to the . No, sorry, to show you the protocol for adomidine CRI.
This could also be a Romiphidine CRI. Now this is a hospital protocol so this is for a 500 kg calm horse, and we're going to adjust these doses up if the horse is stressed. So ideally use a catheter, difficult to do this, consistently off off a needle.
Sedate the horse with your preferred initial bolus. Of alpha 2, give some butorphenol, while that's working, make up your infusion. All you need is a 500 mL saline bag and add.
12 mgs, that's 1.2 mL of detromiline to to to the bag. After about 5 minutes, start your infusion at about 4 drops a second.
Keep going till you've got the level of sedation you want. And then slow that down to about 1 or 2 drops per second. And you can literally keep horses going for as long as you need to with with that in the clinic we'll have horses for dental work sedated for 23 hours at a time if we need to.
And recovery will occur about 15-20 minutes after you stop. So very simple to do, you don't need any fancy kits. At all to, to do it.
And this job's a good example of how to do this. So this is a, small horse lorry. It's got a great big 17 hand warm blood in the back.
They're driving along the, dual carriageway. There's a big commotion, and they stop and they find that the horse, if I go back, has stepped over the partition. He's a huge horse, so he's been able to step over it.
He's not swinging in the breeze, he's standing on his forelimbs and hind limbs, but he is stuck. In the rear compartment of the lorry, the police have closed the lane one, but lane two is live. There's lots of road noise and there's limited access to the truck because the the entry ramp is on the side that's pulled up against the armco.
So here the guys are assessing it, deciding what to do. As you can see, you know, very limited access in the ladder there is to give access up to see what's, what's happening. You can see the vet there is inside, see the vet vet vet helmet.
This is all about planning, and I think, very sensibly they decide not to deal with this incident on the live, dual carriageway. The horse is pretty calm. So they give the horse, some IM sedation.
And then decide to move in convoy to a country park which is a little way down the road, so they can move to a quiet area and it's all about keeping it calm and and and and quiet. So here's the plan being gone through and, they, moved the horse to a country park. They've taped up the window at the back to reduce the amount of light and sun that comes in.
It's all nice and quiet, quiet here and now work can begin. The first vet attended very sensibly called for some help. There's two vets.
Attendance now, they do a brilliant job, set up a CRI, get an excellent level of control of the horse. And this was a big solid partition with some 2 steel bars in it, too thickness supply which took quite some time to dismantle. You'll see the firefighters using right shields to give hard protection to protect those people who are working down with cutting equipment from.
The horse's legs should, should it kick it, it didn't though, the vets really did do a terrific job with this. And then here's the horse out having some resuscitation fluids afterwards. Textbook rescue, all credit to the emergency services and to the vets who attended there, and very intelligent use of CRI.
And then just a word about GA, you do need to factor in plan B and C as well as Plan A. And those alternative plans should always include options for general anaesthesia. There will be some times though when you will need to go for GA at the start, and this will be all hobbled lifts.
Anything like this cattle grid dismantling where there's going to be lots of noise and stimulation and vibration, or if you're working in very confined space, it's perhaps a wrecked lorry or a trailer where it's simply not safe to have a conscious force in there. And remember, any situation where sedation fails to give you adequate control. And I think ketamine, diazamine, diazepam protocols are perfect for these kind of situations.
The only thing is that you need to have the horse well sedated first, so some of the limitations with adrenaline also apply to the effectiveness of your ketamine, diazepam, GA. If your initial alpha 2 opioid ACP combination has not given you adequate levels of sedation. In reality, you're gonna struggle to get a good quality GA, but it'll still be better than having the horse, highly adrenaized and ineffectively sedated.
So make sure everyone's ready to go, and very importantly if you're gonna do this, think ahead, work out where you're going to take the horse to to recover it. And this will need to be well away from the incident. The last thing we want is for the horse to start recovering in amongst, a a load of vehicle wreckage or to fall back into the ditch or the river again.
So think about where it's gonna recover, and then when everyone's ready to go and you've got the horse well sedated with your ACP alpha 2 opioid combination, give ketamine 15 mL per 500 kg and diazepam 6 mL per 500 kg in the same syringe. Ideally through a catheter but needle is OK, and top up every 10 minutes, top up on time not to effects and top up with a third of your initial dose. And remember that the more bus you give the less good recovery you'll get.
And I'll play this video clip, it's a short one, this is, there's no sound on this one. This is a a good example of a hobble lift, but we'll do a quick critique of it afterwards. I'll chat a little bit as we go through.
This is a horse been out for a ride, the riders in attendance. The horse had gone in a ditch. It's properly stuck.
The fire crew and, the Amrescue team and the vetter in attendants, the vet has just given a, ketamine diazepam. General anaesthesia protocol and the crew are getting ready to lift the horse out. Now this is a slightly old clip, we wouldn't recommend using leg strops quite like this.
Now there's nothing wrong with it from a welfare point of view, but we'd use slightly shorter strops, so slightly better control of the legs. They're doing a lift out with a crane, which is fine. This is a spreader bar which is appropriate, but it does not have quick release on it now, we'd have quick release pins.
Actually the the catches which are used are the same that are used for lifeboats on ships, so they'll release under load as well as under no, no, no load. So they got the horse ready. You'll see there's a lot of, brambles and thorns and such like, would have been better to have cleared those away first.
And if you watch the horse as it comes out, the head is vulnerable. They do have a head collar on, that's the one of the golden rules always have control of the head, but a a carry sheet ready or even better still a a head protector helmet would have just helped to keep this all safe. In fact, it didn't suffer any eye injuries, but .
Injuries to the eyes or any of the bony pros on the head are always a worry when you're doing this sort of thing. But this was all done under a single bolus of ketamine, so if you're organised and everyone's ready to go, you do have enough time to get the job out. You can just see that a carry sheet there for the head would have been a good idea.
But get the job done and, the horse, as is often the case, walked away from this without any serious injuries. Quick, show of this case, this is another pony in a ditch, so the fire service will talk to you about, well, what's the situation, what's the risk, what's the plan, what's the resources. Quite a few options here, and this is a good example of thinking outside the box.
So this could have been done in a variety of ways. What they actually did was to sedate the pony and then to get a, a digger in and to. Excavate the side of the bank, then do a simple skid up using the strobes, so again a load, a low .
A low tech approach to it. So, Chris gave this pony some oral fluids to help it, and here it is back in the stable again. And then to finish with, because I know I'm at time, sorry, Zofia, they do think about immediate care and transport, it's what we do day to day, it's just important to do it at the rescue ground as in everyday practise.
So just think about the state the casualty is in. If it's in poor state, do follow the usual ABCD with airway breathing, circulation, and drugs in that order. And think about whether we need to deal with wounds, if we've got fractures present, what we're going to do with those and do think about giving fluids, as I mentioned at the start.
Fractal stabilisation, you may need to do. I'm not going to run through that, but do be ready to do that and brush up on the essentials of first aid, and be, carry simple splinting equipment, including some of the proprietary things like the splint there on the left, but have a selection of sticks and splints to apply to limbs. Certainly don't show up at a job without those.
And do, do be familiar with the principles of stabilising in the four zones on the forelimb and the 3 zones on the hind limb with different splint, positions. And then finally, if, if you, if you do have a fracture case and you've chosen to rescue it and to transport it for treatment, remember that falling fractures generally travel better if you face them backwards, and hi limb fractures generally travel better facing forwards because it allows the horse to transfer its weight onto the uninjured limb when stopping. So we've got that, to summarise all of that, you're an essential part of the team.
Remember we don't, we're not in charge of the team, the incident commander is, but we're a vital part of the team, and they will look to you for guidance and help throughout. We, our aim is to deliver the casualty centred rescue, just like if you were involved in an incident yourself, and our key roles are to deliver safety and welfare. And to do this you need training.
So do have a look at, either our stakeholder websites or ours for information about training courses. Make sure you understand instant command, be confident with chemical restraints, sedation, and anaesthesia. Be confident with triage as well, do think about immediate care.
And I think most importantly, recognise that these are stressful situations. We have limited training to work in these environments. So be ready for that, be flexible, be ready to adapt from the normal and be ready to work outside your comfort zone.
So you'll be pleased to know that's all from me, thank you very much for joining me. I hope that's been interesting and I'm gonna hand back to Zofia, Zofia. Thank you very much, Josh.
That was a really brilliant talk. Oh, I loved all the images, all surprises me actually just where horses can get themselves stuck. They are incredible, aren't they?
They are really incredible, yeah. The, the, the, the pony the pony that had gone over the back, of that, in that little lorry with his, he, he'd lived in that field, belonged to that owner for 15 years. And they've been in and out of that lorry a lot and then on that particular day he decides that's the day he's going to do the unexpected.
So you're quite right, they are remarkable with their ability to do and I'm amazed actually that one on the cattle grid was OK because on the, on that picture, it almost looks as if the, the limbs have just fractured. You, you'd have been, you'd have been confident, yes, no, he was, it was actually. A critically important horse in this because he was called Flash Flash Gordon, retired, retired drum horse and and actually he was attended to by Hampshire in the days, in the very early days, and they struggled with that job, and they were, he walked away from that and went on to live a perfectly normal life, but that was one of the events that galvanised the fire service, think we've got to do a better job here.
And so he, he has a special part in all of this. Oh right, OK, yeah, no, and it, and it's brilliant. I mean, what, what, you know, what you've described, just the kind of the protocol, just breaking it down into the before, during and the after, because yeah, you know, it's such a large kind of operation, isn't it, with all the ambulance?
Well, owners are injured, say it's a RTA as well, ambulances, police, you know, firefighters, it can be quite a chaotic situation. It can almost be a comfort that maybe vets aren't the team leaders in this. It's, it's, I, I think it's a huge comfort, yes.
So, so we, we've got one quick question just regarding the, the constant rate infusion of the ditomidine. You know, as you highlighted to maybe vets in that that are don't normally work in hospitals are not normally that familiar with it. What, what could go wrong with it?
Can you over sedate the animal? Could it cause more harm than good. I, I, I, whoever asked that, thank you, I think that's a great question actually about alpha 2s in general.
We owners, and I think we sort of inherit this bit from, a lot of owners really worry about sedating their horse and your little experiences they put you under pressure to not use much to say, oh, don't give him much sedation because he reacted very badly the last time. Actually these are fantastically safe drugs. And those of us who work in vet schools have probably all experienced situations where students have made spectacular errors with working out doses.
And you know, if you overdo it, you're just gonna get a horse that's sedated to ceiling effects, but just for a long time. And my opinion is that if, and I'm, I'm not aware of situations I've certainly never experienced it, but let's say you sedated the horse and it died. I think if the horse was sufficiently medically compromised for the sedation protocol to result in its death, that essentially is a non-viable horse.
These really are are very very safe drugs. I mean, I, I, I do think it's important to think about resuscitation fluids and so on, but bottom line for me, these are safe drugs. We, generally use very small doses and doses that seem.
Alarmingly high actually are usually well within the data sheet and for CRI itself, I, I don't think there's any risk, you know, that you will, they're easy to t titrate and I think there's really no risk of doing any harm to. A horse which is viable, using a CRI. So I, it's, it's a natural thing to worry about, but personally I wouldn't.
No. OK. And how would you measure the level of sedation, say the animals stuck actually in a fog at this stage, or?
Yeah, well, that's, you know, that's just one of these jobs are just endlessly challenging because most of the things we're used to doing, we can't do, and I think that's a great example, the horse that's, you know, you've just got the head sticking out of a bog. Well, you're just gonna have to do your best really to gauge how sedated, it is, which is gonna be a bit about how, how responsive it is. And I, and I think a lot of this, I've certainly recalibrated my.
Awareness of how horses signal their alertness, because I think perhaps in clinical practise we're rather used to the, the big movements like it picks its leg up or it kicks out or whatever. But I think, I think their heads actually tell us a lot and small things like ear movement, ear position, eyelid shape, eyelid movement, all these things change and I think if the horse is showing any response. I've been very influenced just to digress slightly into, just to talk about, you know, reading horses by a lot of the work that Gemma Pearson does, and she's really helped me to understand that you need to look for the small things.
And, and I think that even though you may only have the head, I think there'll be warning signs to do with ear movement, eye movement, what the eyelids are doing. But it's judgement and often, and I think it's, you know, it's difficult sometimes, to, to, to really have access to the patient in the same way that we, we, we'd like to. Brilliant, thank you very much.
OK, so there's no further questions. So yeah, thanks again, Josh, really, really brilliant talk, one of the best. As, as, as exactly and incidentally, and if people are interested in facial expressions and dealing with horses, Gemma Pearson has actually done a webinar, so feel free to scroll back I strongly recommend that it's .
Her work is brilliant, it really is brilliant. It is inspirational. It's certainly changed the way I, I think about reading horses.
Yeah, me too, definitely. So on that note, huge thank you again, thank you all for, for joining us as well, and, enjoy the rest of your evening. Bye.
Thank you, bye. Bye.
