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Experienced Nursing Care Key to Healing, Handling

By: Louisa Shepard Date: Oct 8, 2015
New Bolton Center Equine intubationConstant care by experienced, skilled, attentive veterinary technicians can make the all the difference in how well an animal heals, especially in the most critical cases.

Turning a very sick foal regularly around the clock to prevent bedsores. Lifting a 1,200-pound horse into a sling as it recovers from botulism. Monitoring vital signs, drawing blood samples, administering multiple medications.

And in the case of a talented off-the-track Thoroughbred gelding named Reese, tube feeding every four hours to provide nutrition and hydration, because he couldn’t swallow on his own.

“The nurses are critical in these cases,” said Dr. Amy Johnson, Assistant Professor of Large Animal Neurology and Internal Medicine. “They work with our students to accomplish the task of tube feeding multiple times a day for weeks to keep the horse alive until he can regain his ability to swallow.”

All 22 vet techs, referred to as nurses at New Bolton Center, are certified, which means they have earned a clinical certification and have consistently met a set of national standards.

New Bolton Center Nursing team

Under the supervision of Jamie DeFazio and Jaime Miller, most of the nurses provide general technical care, but New Bolton Center also has a separate operating room team specialized in surgical nursing, including anesthesia. Meet our nurses.

 New Bolton Center OR Nursing Team

In addition, the 10 patient care technicians are experienced in handling large animals, keeping patients and their human caregivers safe. Meet our patient care technicians.

“Just like with human nurses, we are on the forefront of patient care,” said DeFazio, supervisor of the evening and midnight nursing staff.

Nursing tasks are many and varied: conduct general physicals, insert and replace intravenous catheters, administer and monitor medications and fluids, take blood samples, insert nasogastric tubes, manage bandages, and continually assess general well-being.

“We are a dedicated staff,” said DeFazio, who has been with New Bolton Center for 15 years. “A lot of times, nurses and PCTs will stay beyond their shifts to see through a procedure because they really care and they are dedicated not only to their jobs, but also to their patients.

“It’s very demanding work, physically and emotionally,” she continued. “But what keeps us going is that we are making a difference in the lives of our patients.”

Taking Care of Reese

Nurses work 24/7 at New Bolton Center. Reese came in on Christmas Eve.

Reese, equine patient at New Bolton

“He couldn’t eat,” said owner Lynne Pennypacker. “Every sip of water he took, every time he swallowed, water was coming out of his nose. We couldn’t figure out what was going on.”

Referred to New Bolton Center, Reese was examined by Dr. Rose Nolen-Walston of Internal Medicine. Using an endoscope, she identified a dark spot, a fungus, in the right guttural pouch, over a nerve that controls the ability to swallow. Pennypacker went home with an oral anti-fungal medication, with a goal of getting through the holidays.

Reese made it to New Year’s Day, but then Pennypacker rushed him to New Bolton Center’s Emergency Service. “He was getting worse and worse, losing weight. Every time he swallowed hay he would stick his neck out and back up in the stall,” she said. “His ability to swallow was more and more compromised."

The nursing staff inserted a nasogastric tube to feed him a thick slurry of nutritional supplement, Purina Wellsolve® Well Gel™.

“They rigged up a series of smaller and smaller hoses to get the Well Gel into him, assuring me that if they were able to feed him six times a day, we would meet his very basic needs,” Pennypacker said.

Passing a nasogastric tube correctly is essential, said Miller, supervisor of the day shift nursing staff.

“It is a highly technical skill: you have to make sure you know you are in the esophagus and stomach, rather than the trachea,” said Miller, who has been at New Bolton for 18 years. “Tubing into the lungs can be life-threatening.”

Nurses intubate a horse at New Bolton

The nurses are trained to use a quality check system: to make sure his stomach was not overly full, to make sure he was passing manure, and to confirm he was not showing signs of colic.

“We always check for reflux,” said Eileen Rule, who has worked as a New Bolton Center nurse for 31 years. “It is most difficult to tube a horse like Reese, who is having trouble swallowing. It takes patience. We don’t want to be too forceful."

Pennypacker visited every day she could, driving in from the Pottstown area.

“The nurses were phenomenal,” she said. “There was always someone to meet me at the stall, and to ask if I needed anything. They encouraged me to spend time with him and groom him. There were a couple of days when I couldn’t make it down, and they would walk him at least 20 minutes every day.”

Mycosis of the Guttural Pouch

Reese actually was lucky, Johnson said, because usually with this condition, the fungus attaches to the internal carotid artery in the guttural pouch (an air-filled structure within the horse's head that arises from the eustachian tube on each side). In its typical form, the fungus can erode into the wall of the artery, resulting in massive nosebleeds, which can lead to death.

In Reese’s case, the fungus was not on the artery, but was instead on the tissue of the wall of the guttural pouch right over a nerve that affects the ability to eat, drink, and swallow.

Dr. Eric Parente, Surgery Professor, surgically removed the fungal plaque and opened up the area to increase the airflow with the goal of making the guttural pouch less hospital for fungus. Reese was put on antifungal drugs.

Then it was up to New Bolton Center’s intensive care nursing team to keep him fed and hydrated until he could swallow again.

“The nurses are so well trained,” Johnson said. “They will immediately recognize complication and take care of it themselves or bring it to my attention.”

Experience is Critical in Critical Care

That recognition often comes with experience, observing patient after patient on a day-to-day basis, said Christopher Rizzo, who has been a nurse at New Bolton Center for nine years.Christopher Rizzo, LVT, VTS-EVN

“I pick up on things like weight shifting, or flank watching,” Rizzo said. “As a nurse, you also have to be able to know the difference between pawing because the horse is upset, versus pawing and circling because he is uncomfortable and colicky.”

Every patient is checked by a nurse regularly around the clock. “With a patient as critical as Reese, we would check on him at least every two hours, noting his comfort, appetite, general attitude, urination, and manure production,” DeFazio said, noting that four times a day, the nurses conduct a complete physical.

“We not only give the medication, but we know why we are giving the medication, so we can be alert for any problems,” she said.

The nurses are constantly instructing others, including Penn Vet’s third- and fourth-year students, as well as students from the veterinary technician program at Harcum College.

Jen Macomber, a nurse at New Bolton Center for 18 years, leads the teaching partnership with Harcum College to provide hands-on experience to students in the two-year veterinary technician certification program. “I like sharing my techniques with other people and seeing them succeed,” she said. “I enjoy when they have that ‘aha’ moment when it clicks.”

Rule assists Macomber and the other nurses in teaching. In fact, she taught DeFazio, who fell in love with New Bolton Center and nursing during a summer camp in 1992.

The Front Line: PCTs

Patient care technicians handle the animals and restrain them when doing procedures. They are vital to managing challenging procedures like passing the nasogastric tube or performing an endoscopic exam like in Reese’s case.

“They are really knowledgeable about animal behavior, especially restraint,” said Dr. Louise Southwood, Associate Professor of Emergency and Critical Care, a surgeon who specializes in colic. “We couldn’t do our jobs without them. They keep the horse safe, the client safe, and us safe when we are trying to evaluate and treat the patient.”

 New Bolton Center Patient Care Tech

The PCTs are on the front line, the first to greet an owner and take a patient for admission, and the last to see them at discharge.

Going Home, With Instructions

Sometimes nurses have to educate the clients, too. In Reese’s case, Pennypacker had to learn how to manage the nasogastric tube and monitor his vital signs.

Working in shifts with her barn manager, Justine Howell of Whysper Wynd Farm, Pennypacker kept Reese going for 12 days until he could finally swallow on his own. “He just started being able to eat better, and he kind of came back to us,” she said.

But full recovery took more than a year and a half, which is typical for this condition. Now seven years old, Reese has returned for rechecks and examinations several times, but now he is sound, Pennypacker said, and ready to work. “His system took such a hit,” she said. “But now his sparkle is back.”

Knowing a patient made it home and recovered is one of the great payoffs of veterinary nursing, DeFazio said. “Nothing compares to having those moments with an animal people really care about, and knowing your care made a difference.”