Behind the scenes of intensive care

The scope and nature of the care offered by an equine intensive care unit is extensive. Dr SARAH GOUGH takes you behind the scenes.

Being admitted to the intensive care unit (ICU) is not a situation that any of us want our horses to be in. However, as with people, treatment in the ICU can be lifesaving.

Equine ICUs are specialised barns, stable blocks or isolation units, serviced by specially trained veterinarians and veterinary nurses who facilitate around the clock monitoring and treatment of critically ill or injured horses. While not all sick or injured horses require the level of care provided in an ICU, the lives of those whose condition may change in a matter of minutes or hours may depend upon the level of monitoring, diagnostic capabilities and medical or surgical interventions that an ICU offers.

What is intensive care?

Intensive care is specialised treatment and monitoring, tailored to the individual needs of a patient. Admission to the ICU, rather than general hospital admission, is necessary for patients requiring increased frequency of treatment and monitoring, and more specialised care. While there are many facilities that enable a patient to be hospitalised overnight, the around the clock care provided in an ICU is not always feasible due to the requirement for increased numbers of specially trained staff, the availability of specialised equipment such as fluid pumps, nebulisers, oxygen tanks and foal crates for critically ill neonates, and the huge costs associated with the provision of this level of care.

On admission to the ICU, a patient typically undergoes a range of diagnostic and laboratory tests to further evaluate the extent of injuries or degree of medical compromise, and any associated complications that may influence treatment. An individual monitoring plan is developed based on this information. This ensures that the frequency of monitoring of vital signs, blood parameters and associated factors such as blood loss or degree of pain and discomfort, is appropriate for the degree of compromise to the patient. Alongside the monitoring, the relevant treatments that may be necessary are charted with appropriate regularity.

The frequency of treatment and monitoring can range from continuous, such as for severely compromised neonatal foals requiring ventilation; through to hourly, two hourly and up to six hourly, depending on the expected dynamic nature of the patient’s condition.

A vast array of treatments may be implemented in the ICU. These range in complexity from dressing and bandage changes, through to maintenance and use of indwelling epidural catheters for continuous administration of analgesia to the hindlimbs or perineum, and even ventilation. The treatment and monitoring of patients in the ICU is performed by highly skilled and specially trained personnel under the supervision and guidance of a specially trained veterinarian.

Examples of diagnostic tools that may be used in the workup and ongoing monitoring of an ICU patient include:

• Ultrasound
• Radiography (X-ray)
• Endoscopy (‘scope’)
• Blood analysis
• Body fluid collection
• Culture and bacterial susceptibility testing
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)

Cost of ICU treatment

Unfortunately, treatment in an ICU often comes at a high cost to the owner. These costs are attributed to the overheads associated with building and staffing a veterinary facility with specially trained professionals available 24 hours a day, seven days a week; acquiring and maintaining complex medical equipment; stocking and administering medications and the associated consumables, all without the assistance of any form of government funding. Programs such as Medicare and the PBS dramatically reduce the cost of human medical treatment and hospitalisation, so much so that the average person contributes just 15% towards their medical costs. In contrast, owners are required to pay for 100% of their horse’s veterinary fees.

Medications that have a crossover between human and veterinary sectors, and more specifically equine use, are typically cheaper due to the competitive nature of human pharmaceuticals. However, medical supplies made solely for the veterinary profession do not have the same competitive advantage that drive prices down and are therefore often considerably more expensive. Due to the size of horses, the medications are often specific to large animals, which diminishes the potential for crossover and lessens the competitive advantage that can be gleaned from the human pharmaceutical industry.

Likewise, the around the clock nature of intensive care leads to a high cost in personnel wages that has to be reflected in the patient care fees. In return for the considerable cost of care and treatment, the aspect that should never be overlooked is that your horse is benefiting from the significant empathy and hard work that ICU staff put into their patients, not to mention the knowledge, many, many years of study and the experience that ICU veterinarians bring to bear.

Decision making in the ICU

As with any patient – equine or human – critical illness and injury can lead to varying degrees of recovery, and in some cases, recovery is not possible. As such, we as owners and veterinarians do sometimes need to make difficult decisions for our equine ICU patients.

The response to stabilising treatment over the initial 24-72 hours is often an important indicator of overall prognosis for recovery (of course this specific time frame depends on the initial illness or injury). However, it may take weeks or even months to determine long-term prognosis for recovery, whether that is recovery to paddock soundness, recovery to an athletic capacity below that of pre-illness/injury, or complete recovery with no restriction on athletic capacity.

During this journey it is likely that there will be ongoing diagnostic tests, whether that is in the form of follow up ultrasound, radiographs, repeat laboratory testing (blood tests, body fluid cultures), or even referral to a rehabilitation centre for ongoing treatment.

While we all want to do the very best for our equine companions, it is also important that the decisions we make are for the right reasons and are being made within the constraints of our individual circumstances. Despite the best care available and the hard work and dedication of specialist teams, we are not able to save every patient.

Unfortunately, some disease processes are irreversible or the complications that arise during treatment leave the patient irreparably compromised. I have frequently had conversations with owners who are making difficult decisions on their beloved companions (horses who are family to them), and the decision to say goodbye is often the most difficult. However, if recovery is not an option, alleviation of suffering is the kindest thing that we can do.

Owners are often uncomfortable about their decisions being influenced by cost. However, until money grows on trees it is inevitable that financial circumstances need to be considered when making decisions on costly treatments. Having open conversations with your veterinarian about your financial position should always be encouraged – in some circumstances there is a less expensive option that may not be the ‘gold standard’, but represents an appropriate middle ground. Likewise, while it can be an extremely difficult decision to make, if the cost of treatment is unachievable for an individual and a lesser treatment is not going to be effective, then euthanasia may be an appropriate option.

Thankfully, with the ongoing advancement of our medical knowledge, facilities and therapies, positive outcomes for ICU patients continue to increase. The availability of advanced imaging, blood and genetic testing, and an ever-increasing arsenal of medications has resulted in the ability to prolong the life of many more horses than even 15 years ago – and in this space, our ability to intervene with novel medical and surgical techniques to save our patients and preserve their athletic capabilities continues to improve exponentially.

Dr Sarah Gough is a European and Australian specialist in equine Internal medicine, and can be found at the Apiam Hunter Equine Centre in Scone, NSW.