Strategies for Improving Vet-Client-Farrier Relations
When a horse has a foot problem that involves both the farrier and the veterinarian, the owner, and possibly a trainer and/or an insurance agent, communications can get more than complicated. They can snarl into a convoluted tangle of terminology and "he said, she said" that leaves everyone unhappy, including the horse.
At the Bluegrass Laminitis Symposium, held Jan. 25-28 in Louisville, Ky., Amy Rucker, DVM, of Midwest Equine in Columbia, Mo., discussed ways to improve communications between the various members of the team caring for a horse.
"How do we communicate? We exchange ideas," she began. "It isn't me talking and you having to listen to it all. The veterinarian, client, farrier, and trainer (if applicable) all need to be together to discuss the plan of action for this horse. There needs to be clear communication about all aspects of a case, including the following:
- "Introduction/history of the case.
- "Examination: Summary of findings, proposed diagnostic tests, estimated cost of diagnosis, and owner permission for all of these.
- "Results of diagnostic tests (such as radiographs and venograms).
- "Summary of findings and discussion of possible treatment plans. Owner goals should be established and short- and long-range plans and costs should be discussed.
- "Agreement on how the horse will be treated.
- "Case progression with treatment.
- "Recording of plans and expectations, barring any and all unforeseen setbacks (the last is very important, she noted).
"Here's how I explain to an owner what I want to do (with a laminitic horse): I want to support that foot by loading the relatively healthy areas and reduce forces on the diseased laminae and crushed sole corium," she said. "I want to do this to prevent further damage to unstable tissue."
To explain her goals relative to this horse's feet, she will also show the owner her measurements of the feet (on the radiograph, or X ray) and show how she wants those measurements to improve (more on measuring feet coming up next).
The Common Language of Numbers
"Veterinarians and farriers often have different ideas, backgrounds, and vocabularies," she said. "But we have to communicate, and I think our language is going to be numbers. What numbers do we have (measurements of various foot parameters)? What numbers are we looking for? What numbers determine success, and which ones mean failure? I really think numbers are what are going to unify the vet and farrier."
She went on to describe the following foot measurements she uses to communicate with farriers, owners, and other veterinarians:
- Coronary band-extensor process distance: (CE, measured in millimeters): Vertical measurement from the level of the proximal (upper) aspect of the coronary band to the proximal aspect of the coffin bone's extensor process.
- Horn-lamellar zone (HL, mm): Thickness of the dorsal (front) hoof wall when measuring perpendicular to the dorsal face of the coffin bone.
- Sole depth (SD, mm): Measurement from the bottom tip of the coffin bone to the distal (outer) sole; often expressed as "mm sole + mm cup": to distinguish the actual thickness of the sole (gray on a radiograph or X ray) plus the distance to the X ray block (black on X ray; the air-filled cup of the foot).
- Digital breakover (DB, mm): Measurement from the most dorsal aspect of the toe of the hoof capsule to the level of the tip of the coffin bone.
- Palmar angle (PA, degrees): Measurement of the palmar angle the wings of the coffin bone make with the ground.
"This is how we need to communicate about the horse while treating him," she advised. "Record what's going on and set goals and expectations. For example, I might say that if this horse hasn't grown 3 mm of sole in a certain period of time, we're going to do another venogram (a radiograph or X ray of the foot taken with contrast media injected into the blood vessels to visualize any compromise) to see how his blood flow is doing, etc. We need benchmarks, and the owner has to have something to refer to because most of this is very foreign to them. They need to understand things to feel like part of the team."
Coming Up With the Numbers
One key to understanding and communicating about a foot case is radiographs, and those radiographs have to be taken with a particular technique to reveal details about the soft tissues of the foot, said Rucker. She commented that the focus of foot radiography generally taught in veterinary school--focusing on the coronary band area to evaluate the coffin joint--is not suitable for measuring most foot parameters. Instead, the focus of the beam should be at or very near the bottom of the coffin bone. This is easily recognized when you radiograph a foot with a shoe on and you see two branches of the shoe rather than one (meaning the foot is being seen from a low or high angle and is not a pure lateral view).
She recommended that anyone who wants to read about proper foot radiographic technique log into www.ivis.org and see the 2003 Proceedings of the American Association of Equine Practitioners Convention, "Clinical and Radiographic Examination of the Equine Foot" on page 169. (This paper can also be found without images at www.TheHorse.com/ViewArticle.aspx?ID=1457.)
Working From the Numbers
"Once you have your radiograph, you can trace it, Xerox it, do measurements, get a protractor to measure the angles, write prescriptions, and phone someone to talk about the numbers," Rucker said. "We can draw what we have, what we could do, and what happened with what we did. We can show people how different shoes will affect that same foot. And this tells you if your plans will work--if it doesn't fly on paper, it definitely won't work with the horse."
She noted several considerations in sharing numbers with others via various means of communication as follows.
- When you print and/or fax images, they often are reduced in size; make sure you write down measurements so you're on the same page as the recipient.
- When taking foot photographs, get down on the ground and get good light.
- If you email images, don't send them too big because you can't see it all at once on the screen. Make sure they're less than 100 K (kilobytes) in size.
- To make images smaller, edit them in Photoshop or another image editing program, or set the camera on a lower-detail setting.
- Send no more than five attachments per e-mail (too many images can make the e-mail big enough that it bounces back to you).
- Name and date each attachment. Don't leave file names as just a number as this makes it very hard to find what you want later.
- You can send radiographs around by photographing them. If you take photos of radiographs, make sure the camera's flash is off. Again, write down the measurements.
- If you computer only has dialup Internet access, go to an Internet cafè and pay to use a high-speed modem when sending or receiving images.
Getting on the Same Page
"Many times there is a lack of understanding on the owner's part as to the severity of the laminitic case," Rucker commented. "If you accept a case in your practice, then you also take the responsibility of communicating with that client. Communicate directly with the client--don't rely on friends/trainers/barn managers to relay the information. Ask if the horse is insured. Discuss short- and long-term goals, write them down, and realize that they may change by the day or month. Call the owner back to see how the horse is doing. And remember that 'fixed' to you might mean 'alive,' while to the client 'fixed' might mean 'horse will suddenly develop the ability to jump an eight-foot fence combo and win the next Olympics," she said with a laugh. "Get on the same page."
Regarding communication between veterinarians and farriers, she remarked that lunch was an amazing communication tool. "You'll discuss cases and ideas, send each other business, and learn what is going on with your horses. Develop friendships, go out riding, go out to lunch, whatever. We can't work together when we don't get along."
About the Author
Christy West has a BS in Equine Science from the University of Kentucky, and an MS in Agricultural Journalism from the University of Wisconsin-Madison.
POLL: Rehabbing the Injured Horse