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Proceedings of the54th Annual Convention of

the American Association ofEquine Practitioners

December 610, 2008, San Diego, CaliforniaProgram Chair : Harry W. Werner

ACKNOWLEDGMENTS

Dr. Stephen M. Reed, Educational Programs Committee ChairCarey M. Ross, Scientific Publications Coordinator

Published by the American Associationof Equine Practitioners

www.aaep.org

ISSN 00657182

American Association of Equine Practitioners, 2008


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Emergency Care at Equine Events: Endurance

Nancy S. Loving, DVM

Authors address: 2160 James Canyon Drive, Boulder, CO 80302-9306; e-mail: nsloving@ix.

netcom.com. 2008 AAEP.

1. Introduction

The sport of endurance has grown substantially inthe past 20 yrs, with enthusiastic participation oc-

curring worldwide. The standards of care havebeen elevated to meet expectations and require-ments of both the American Endurance Ride Con-ference (AERC) and the Federation EquestrianInternational (FEI), with the horses welfare fore-most in importance.

This discussion is directed toward veterinarianswho assume the responsibility of treating medicalproblems in endurance horses at competitive events.With trial and error, each practitioner devises atreatment protocol that gives the best and most ef-ficient results. Each horse presents a unique storyin its plight and therefore must be managed for itsspecific problems. There are as many ways to stirthe pot as there are cooks, with no single way tomanage a metabolic collapse. Over the years, wehave developed more tools, and more knowledge hasbecome available to bring endurance horse problemsto a successful conclusion. However, to be able tomanage the care of even a single horse, there mustbe some strategies put into place to facilitate emer-gency treatment. My intention is to share with youpractical logistics that I have learned and experi-enced over 20 yrs while treating endurance horsesaround the world, at World Championship races and

high caliber national or local backyard endurancerides.

2. Collaborative EffortsMany of the strategies discussed in this paper arebased on common sense similar to how you wouldpractice in a private clinic setting, but until oneencounters the interesting adventures of practicingmedicine along the trail, in the wilderness, andwithout many regular amenities, you will not be-lieve the breadth of convoluted possibilities thatmight occur. In addition to considering the horseand owner during a treatment situation, you alsohave to take into account a hierarchy of other re-sponsible parties, including Ride Management orthe Organizing Committee, the President of the Vet-erinary Commission (at non-FEI rides, this person is

often referred to as the Head Veterinarian), the For-eign Veterinary Delegate (at FEI events), and theoversight committee that regulates the rules of thesport, whether it be FEI or AERC. At high profileevents, there will likely be a team of veterinariansand/or a team of treatment vets, all of whom haveassigned responsibilities regarding horse welfare.Because you may be used to working by yourself oralongside a few others in daily practice, you will findthat, at an endurance event, there are teams ofpeople needing to be kept apprised of every detailconcerning the horses. Good and ample communi-

136 2008 Vol. 54 AAEP PROCEEDINGS

IN-DEPTH: EMERGENCY CARE AT EQUINE EVENTS

NOTES

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cations will help avoid a slew of problems. No mat-ter how busy you are during the course of the event,it is important to maintain active communicationsand/or to delegate this task to a reliable assistantwho is working close to you.

3. Legal Stipulations

In addition to being held responsible to other offi-cials and oversight organizations, there are statelegal statutes that dictate that a vet licensed to thatstate (or country) must be in attendance at theevent. Any further care offered by other veterinar-ians not licensed in that state usually falls under theauspices of the person actively licensed in that state(or country). It may be necessary to discuss in ad-

vance with the state veterinary board about logisticsof medical care being offered by vets unlicensed inthat state. This protects the veterinarians on thetreatment team from future litigious difficulties andalso protects those vets against license infractions.

As an example of how states may view this di-lemma, Dane Frazier, DVM (past U.S. representa-tive to the FEI Endurance Committee and pastpresident of AERC), queried the State of Missouriand summarizes the response: The State of Mis-souri does not care who vets rides for AERC inMissouri as the enforcement of club rules is not thepractice of veterinary medicine. However, to treathorses at a ride requires diagnosis as well as ther-apy, both of which are inclusive in the practice of

veterinary medicine. Therefore, a veterinarian un-licensed in that state can provide treatment only ifthey are under the direct supervision of a veteri-narian licensed in that state. Direct supervision isdefined as the licensed veterinarian being present atthe exact location of the treatment. It is particu-

larly noteworthy that an out-of-state veterinarian,not licensed in the state in which the ride is held,may not be able to provide treatment anywhere inthe course of the event unless a licensed veterinar-ian is present at the same spot as the treating vet-erinarian, not just present somewhere in the vicinityof the ride. This has relevance when horses may betreated in multiple areas or at vet checks scatteredthroughout the course of the trail and not just at asingle, central facility. In such cases, a statute con-flict may arise when veterinarians are split up toprovide sufficient coverage at various stations.

Furthermore, many states do have Good Samari-tan laws that cover treatment under emergency cir-

cumstances. However, some states do not view thevoluntary officiating at a ride (where treatment is com-monly required) as an emergency circumstance ofwhich an unlicensed veterinarian is unaware.

There are recent individual state rulings that con-sider state licensing as a requirement in the statewhere the event is to be held even for performingduties as a veterinary judge without any intent totreat. It is important for anyone involving them-selves at an endurance event, especially in a treat-ment capacity, to check with the relevant State

Board of Veterinary Medicine as to their exact re-quirements. This same detail should be addressedwhen working an endurance event in overseas coun-tries, where treatment may only be permitted underthe direct auspices of a person licensed to practice

veterinary medicine in that country. Although youmay not plan to treat horses at a ride, situations do

arise where this could become necessary to save a life;it is critical that you protect your license and ability topractice medicine into the future while also protectingyourself against any malpractice litigation.

4. Considerations in Setting up Emergency Care

It may seem obvious, but one of the most criticalsteps in offering emergency care to an endurancehorse is to have at least one practitioner on handwho is well versed in the peculiar metabolic featuresthat develop with endurance sport exercise. Differ-ent climates, terrain, and racing conditions willelicit a variety of metabolic mishaps. Experience isinvaluable in the assessment and treatment of suchsituations. Therefore, the number one issue is forthe potential endurance veterinarian to developskills based on experience in the sport. The Presi-dent of the Veterinary Commission plays an essen-tial role in outlining the details of judging criteria,as well as facilitating the working conditions for thetreatment vet or vet team. In addition, the Presi-dent of the Veterinary Commission is instrumentalin selecting the treatment personnel, and thisshould be done with consideration of the experiencelevel of the primary treatment vet. If there is to bea team of treatment veterinarians, at least one qual-ified practitioner should be present to oversee andmentor those with less experience.

There must be excellent communication and

agreement with Ride Management in advance aboutthe details of the treatment arrangements. A shortseminar and/or meeting in advance of race day canhelp get all veterinarians on the same page as totreatment technicalities and philosophies and to an-swer pertinent questions. A detailed list of cellphone numbers and contact information for all offi-cials and ride managers should be provided to every

veterinarian on the treatment and officiating teams.(In overseas venues, the Organizing Committee maybe requested to provide local cell phone equipment toforeign veterinarians to keep phone expenses to a min-imum and to encourage communications.) Mapsshould be made available to expedite travel between

veterinary check points, and every veterinarian shouldbe assigned a driver or navigator who is familiar withthe local area.

Also, it is important to recognize that at multi-national events, people come from all walks of life,and it is not just language barriers that pose achallenge; there are often cultural differences thatare enriching but may create misunderstandings.This may occur not just between veterinarians andriders and/or event officials but also among mem-bers of the Veterinary Commission. If you find

AAEP PROCEEDINGS Vol. 54 2008 137





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yourself in such a confusing situation, just remem-ber to be sensitive to others cultural differences andto keep a sense of humor.

During the course of an endurance ride, horseowners often canvas multiple veterinarians insearch of multiple professional opinions about theirhorses injury or illness. It is helpful to remind

everyone that caution should be taken for each vet-erinarian not to offer too many opinions based on acursory exam or scant information about a horse.Some comments may contradict other veterinarianscomments, causing unnecessary confusion and con-troversy. Assistants should also be cautionedagainst making any medical statements or judg-ments, and they should be advised about medicalconfidentiality regarding the horses they are helpingto treat.

5. Common Horse Emergency Conditions at

Endurance Events

Although musculoskeletal injuries may occur at anypoint along an endurance ride event, the most press-ing emergency situations generally involve meta-bolic problems. Endurance rides combine a lengthyduration, as much as 1224 h, of continuous exercisewith resultant loss of body fluids and electrolytes.Coupling this with additional demands placed onthese horses from speed, challenging terrain, andpossible adverse weather conditions, the most prev-alent metabolic concerns fall under the umbrella of acomplex known as exhausted horse syndrome, whichdevelops because of dehydration, electrolyte imbal-ances, and glycogen depletion. There are all de-grees of metabolic compromise, ranging from verymild and barely detectable to extremely serious andlife threatening. A sick horse may be affected with

myositis, synchronous diaphragmatic flutter(thumps), colic secondary to intestinal atony, andheat stress or prostration, and also has the potentialto develop laminitis.

An affected horse will show at least one or more ofthe following clinical signs as a result of fluid, elec-trolyte, and energy losses: poor heart rate recov-ery, elevated cardiac recovery index, decreasedborborgymi or total ileus, disinterest in surroundingstimuli or depression, reduced or absent appetite,lack of thirst, delayed capillary refill time and/orpale or marginated mucous membrane color, de-layed skin tenting, elevated rectal temperature, flac-cid anal sphincter tone, thumps, muscle twitching,

muscle cramps with or without associated lameness,myoglobinuria, increased digital pulses, recum-bency, or colic.

The cardiac recovery index (CRI) has become animportant criterion for evaluation of distance hors-estaken at intervals along the course, it is a mea-sure of a horses fitness and how well the horse isresponding to the exercise demand. The CRI maybe evaluated at each vet check and at the finish as ahelpful parameter to assess a horses metabolic con-dition. Once a horses heart rate has reached the

veterinary criteria of 64 beats/min (bpm) (or 60bpm), the horse is presented to the veterinarian, andthe horses resting heart rate is again taken. Thenthe horse is asked to trot away for 125 ft and back125 ft. Exactly 1 min after the horse initiated themeasured trot of 250 ft, the heart rate is againcounted, and this value is compared with the pre-

trot value. (In most cases, the trot out takes 0.5min, and the horse is allowed to stand quietly for theremainder of the minute.) The heart rate shouldreturn to the same number beats or 4 bpm less thanthe initial rate. As an example, if a horse has aresting heart rate of 64 bpm, at the minute countafter the trot out, his rate should return to 60 or 64bpm or less. If the CRI is elevated 4 bpm (68 or72 bpm or greater), this may be an indication ofsome impending metabolic problem that should becorroborated by other physical findings. It is im-portant to recognize that not all metabolic crises areaccompanied by an elevated CRI, whereas the pres-ence of an elevated cardiac index tends to be associ-ated with fatigue, dehydration, and otherindications of exhausted horse syndrome.1,2

An experienced practitioner is often able to recog-nize the more subtle signs of equine discomfort ordistress before a horse becomes overtly ill, based ona horses despondent neck and/or body posture andanxious facial expressions, such as puckering of thelips and a glazed look to the eyes. Because horsesare herd animals, a horse may tend to move along atthe pace of another horse or group of horses based onthe emotional tie to its herd, regardless of fatigueor pain or capability. This herd phenomenon andthe power of adrenalin often mask clinical signs ofimpending metabolic collapse until a horse has hada chance to stop exercise activity at the required rest

periods provided at intervals along the course.Continuous monitoring of every horse during anevent and in the hours afterward is necessary toidentify problems as early as possible.

Regardless of the specific metabolic crisis a horsemay experience, it is necessary to replenish large vol-umes of isotonic fluids and to restore electrolyte bal-ance and energy. This is accomplished with ampleintravenous fluid therapy, requiring at least 2030 l inmost cases, initially administered rapidly throughlarge-bore (12-gauge) IV catheters. For a sick horsewith audible intestinal activity, electrolyte and ener-gy-laced fluids can also be administered by nasogastrictube to bolster quick restoration of deficits.

Additional medical measures should also be takento promote intestinal motility, renal function, andneuromuscular equilibrium, to manage pain, to limitendotoxin, and to minimize the risk of laminitis.These life-saving therapies rely primarily on volumereplacement, along with energy (dextrose) supple-mentation in the IV fluids. Calcium, potassium,and magnesium IV supplementation also may im-prove intestinal activity and lessen muscle crampingfrom myositis. Dimethyl sulfoxide given IV or bynasogastric tube is helpful for its anti-inflammatory,






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anti-oxidant, renal dilatory, and diuretic properties.A horse may also need analgesic medication (non-steroidal anti-inflammatory drugs [NSAIDs] or sed-atives such as xylazine or dormosedan) andacepromazine for its vasodilatory and muscle relax-ation effects for myositis and to thwart developmentof laminitis. Anti-endotoxin medication (flunixin

meglumine and/or polymyxin B) is beneficial tolessen metabolic complications. Dantrolene maybe helpful to manage myositis, and dopamine maymaintain renal perfusion. Icing of the distal limbsand frog support can be instrumental in minimizingthe risk of laminitis provided the primary metaboliccrisis is averted. Often, timely restoration of fluid,electrolytes, and energy improves a horses overallcondition such that he will begin to take care ofhimself by eating and drinking to further restore hislosses.3

6. Triage

Much of the treatment care of an endurance horse

occurs in the field with limited facilities or sup-plies, even at world-class events. Great medicalcare can be performed out of a well-stocked veteri-nary truck, but in some cases, a horse must beshipped to a referral hospital for intensive and/orfollow-up care or surgery. Arrangements should bemade in advance with the nearest referral hospitaland surgical center to ensure that qualified veteri-narians will be available for the duration of theendurance event and also to give the referral hospi-tal staff the courtesy of advance notice of potentialcases that could arise. Depending on the caliberand nature of the endurance ride, horses are on siteat least from Friday through Sunday (or any desig-

nated 3 days) of an event, and in many cases, fordays before and after the long weekend. There maybe an event requirement that at least one qualified

veterinarian remains on site for the entire periodthat horses are stabled on site. Arrangements maybe necessary to provide meals and lodging for a

veterinarian so that the event site is not left withoutveterinary supervision at any time.

The details of the treatment/triage area(s) shouldbe arranged in advance. Practical considerationsto address include the following:

Set up triage areas that are protected frominclement weather and the elements

Have sufficient and adequate lighting, electricaloutlets, and extension cords to facilitate treat-ment at night, using generators if necessary

Design traffic flow such that a sick or injuredhorse can move directly from each vet check toa designated treatment area that is devotedsolely to treatment

The treatment area should be located out ofthe way of normal foot trafficconsider liabil-ities of a casual passerby getting involved withor interfering with care of a sick horse or of a

passerby being at risk of injury by a fractioushorse

Have consent forms available for an owner to signto authorize treatment and also a form to authorizeeuthanasia should that become necessary

Have medical record sheets available to tracktreatment specifics, monitoring of condition,

and a horses response to treatment Arrange for sufficient numbers of personnel to

enable a veterinarian to continue to treat andmonitor a horse at an out vet checka horsemay require ongoing intensive care before itcan be moved to the main treatment area, andit should not be abandoned in its medical carewhile awaiting transport nor should treatmentbe delayed

Ensure availability of adequate numbers oftransport trailers and phone contact numberswith trailer drivers and consider also that ar-rangements for a special trailer may be neces-sary for a down horse that is unable to rise

The treatment team should collaborate aboutdrugs and supplies one anticipates needing,especially at high profile events where largenumbers of horses might require treatment

Assure in advance that these medications andsupplies will be presentthere is nothingmore frustrating than to have had someoneelse arrange for medical supplies to be avail-able, especially in an overseas venue or on aweekend when many pharmacies are closed,only to find that specialized drugs or importantsupplies were not included in the preparationorder

Set up blood chemistry machines when possi-

ble and have qualified personnel available torun them and to communicate results to thetreating veterinarians

Ensure availability of ample clean water forhorses to drink, for cooling an overheatedhorse, and for necessary veterinary procedures

Ensure availability of ice to manage appropri-ate musculoskeletal problems and arrange tohave cooling fans when practical and possible

Ensure availability of ample IV fluids and ap-propriately sized, large-bore IV catheters andIV lines

Prepare for the need to hang large volumes offluids in the triage areas and in the fieldIV

poles can be constructed from electrical conduitor tree branches, 2 4s, etc. may be substituted Provide capable assistants to help veterinarians

in their tasks, and if in foreign countries, there isa need to consider qualified translators to facili-tate communication between a veterinarian anda horse owner/rider or Team Veterinarian

Consider the number of stallions that willlikely be on site (particularly in countries out-side the United States where stallions are com-monly ridden), and set up treatment areas that






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segregate stallions away from the proximity ofmares and geldings

Arrange for qualified personnel to stay with asick or convalescing horse at all times, even ifthe owner is presentthere have been situa-tions where an owner is unaware of the powerof analgesics and drugs that make a horse

seem better than it is and the owner offers thehorse grain with subsequent stomach rupture Arrange for a quiet and private location for

practitioners to collaborate on difficult casesbrainstorming and consensus of opinion maybe important in some cases for the benefit ofthe horse or because of liability issues

Additionally, the protocol followed in most compe-titions encourages veterinary evaluation of everyhorse that is disqualified from continuing in compe-tition, regardless of whether the horse has beeneliminated because of a known metabolic or suspectlameness problem or even an issue with the rider.This ensures that a horse with an impending myo-sitis, for example, is not overlooked by an assump-tion that there is only a musculoskeletal issue thatcaused the horse to be eliminated because of lame-ness. There should be provisions in place to accom-modate for enough manpower that allows time toexamine all horses that are pulled from competitionand to monitor those in question at regular inter-

vals. All horses that have received veterinary careor are in suspect medical condition should also bere-evaluated the next day and before release fromthe event or transport off the grounds.

7. Need for Treatment May Be Anywhere

Horses do not always get sick or injured in conve-

nient places or at Base Camp. An endurancecourse of 50 or 100 miles lends many opportunitiesfor a horse to suffer a metabolic collapse or injury inan area far from a vet check and easily accessedroads. It is important to coordinate in advancewith Ride Management as to how a sick or injuredhorse will be transported off trail and back to BaseCamp. If the ride is conducted along trails throughdeep wilderness, prior arrangements should be con-sidered for a Treatment Veterinarian to have horse-power access with an ATV (all terrain vehicle), four-wheel drive vehicle, or mounted on horseback.In advance, additional arrangements should be pre-pared:

Have safe trailer transport and capable driversavailable at all times to ferry a sick or injuredhorse to a designated treatment area

Have communications operable to coordinaterescue and transport of a horse from the trail tothe treatment areamany ham radio operators

view this as an exciting weekend adventure andare often available to man communications; thisbecomes essential where cell phone coverage isspotty or absent

Discuss options and make provisions of how torescue and recover a horse that cannot or willnot be movedin some cases, a horse may takea fall off trail into a position that does not allowthe horse to extricate itself without assistance4

Have an assistant available to support a Treat-ment Veterinarian called out to treat in the

fieldthis person serves as communicationsconduit, can obtain additional supplies andequipment when necessary, and is present toassist the veterinarian in providing treatment

In addition, it is important that adequate commu-nications (ham radio, cell phone, pager) are set up toalert and inform the Head Treatment Vet about allcases as they occur and as treatment progresses andthat there is a backup plan for communicationsshould transmission towers go down or equipmentbecomes inoperable. This may be in the form of adesignated person who drives between vet checksand base camp to relay information.

8. Refusal of Treatment

Sadly, there are times when a horse is in need oftreatment yet an owner refuses veterinary care.In such cases, if you are unable to convince an ownerof the necessity of treating the horse, it would bewise to have the owner/rider sign a statement thatthey have refused medical care despite your recom-mendations. It is heart wrenching not to be able tooffer treatment to a horse in need, but not all ownerswill cooperate because of financial concerns, a per-ceived stigma to having a horse treated at a ride, orbecause of denial by the owner that the horse has aproblem. A signed document, particularly one thatis also signed by a witness, is one measure you can

take to cover yourself legally should something goterribly wrong and the owner/rider later wishes toassign blame for failure to treat.

In addition, if an owner/rider refuses treatmentfor their horse, it is necessary to immediately in-

volve an official person of the event who is a repre-sentative of Ride Managementat an FEI event,this would be a Steward and/or member of theGround Jury.

9. Rider Education

At the pre-competition day ride meeting, it is impor-tant that Ride Management and/or the President ofthe Veterinary Commission advise riders in advance

as to what will be expected of them should veteri-nary treatment be rendered to their horse. Detailsof fees and expectations of reimbursement for drugsand supplies should be spelled out in advance toavoid unnecessary misunderstandings later. At lo-cal and national rides, prepare a protocol for thiscontingency and be sure to inform the owner/rider ofeach treated horse of their financial obligation, justas you would in a private practice setting. At FEIevents, often a horses national United StatesEquestrian Federation (USEF) or FEI international






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passport will be retained until the owner settles anyoutstanding bills related to emergency veterinarycare or makes payment arrangements before thehorse can be discharged from the ride site.

After the competition and before release of thehorse, the treating veterinarian can provide signifi-cant value to the horses welfare by explaining to the

owner/rider about their horses metabolic illness in-curred during the competition, how this might affectimmediate travel plans to return home, and futuretraining and competition schedules. A written andsigned medical report (preferably on letterhead sta-tionary) should be provided to the horse owner tofacilitate follow-up evaluation and care by their local

veterinarian once the horse returns home. Thisdocument should include the presumptive diagnosis,all medications and amounts given, laboratory re-sults, detailed information that tracked the horsesresponse to treatment, and recommendations for fol-low-up care. Phone contact information shouldalso accompany this report so first-hand informationcan be shared between veterinarians.

10. Care and Feeding of Ride Veterinarians

To provide the best care for the horses, it is impor-tant that veterinarians in attendance at a ride alsobe cared for. The care and feeding of all working

veterinarians is important to ensure hydration andenergy needed to work non-stop for a 24-h span ormore. Arrange with Ride Management for regulardelivery of drinks, snacks, and meals and also forchairs and areas out of the weather where one cansit for a short rest when possible. Bathroom facil-ities should be within a short reach of the areaswhere one is stationed to work, along with amplewater for use in equine medical care, cleanup of

supplies, and to refresh ones self. These creaturecomforts facilitate doing ones job and keep onesmind as sharp as possible.

11. Resources for Specifics on Treatment of the

Endurance Horse

Guidelines and detailed treatment principles andrecommendations for managing metabolic problemsin endurance horses were prepared by this authorfor the AERC veterinary handbook, VeterinaryGuidelines for Judging AERC Endurance Competi-tions (pp. 28 41).3 These can be accessed at http://www.aerc.org/upload/VetHandbook0606.pdf. Thissame website also provides appropriate forms forreporting treatment and results of necropsy findingsshould it be necessary to euthanize a horse that isnon-responsive to therapy.

For FEI events, guidelines for the use and autho-rization of veterinary treatment can be found athttp://www.fei.org/Athletes AND Horses/Documents/GuidetotheuseofMedicationForms.pdf. Specific med-ication forms must be filled out and filed with ap-propriate officials at an FEI event. The report formfor any horse receiving treatment at an FEI endur-ance event is found at http://www.fei.org/Rules/

Veterinary/Documents/Medication%20Form%201.pdf. General rules for a veterinary code of conductat FEI events can be accessed in the Endurance Rule-book at http://www.fei.org/Disciplines/Endurance/Rules/Pages/Regulations.aspx.

References

1. Veterinary guidelines for judging AERC endurance competi-tions. Available at www.aaep.org. Accessed 2008.

2. Loving NS. Go the Distance: The Complete Resource for En-durance Horses. Trafalgar Square Publishing, North Pom-fret, VT.

3. Veterinary guidelines for judging AERC endurance competitions.Available at http://www.aerc.org/upload/VetHandbook0606.pdf.

Accessed 2008.4. Madigan J. Emergency and disaster preparedness guidelines.Available at http://www.aaep.org/pdfs/Emergency.pdf. Ac-cessed 2008.



