Day 11: Stem Cells and the Souk

Greetings to all! This morning started off a little differently from the others. We rendezvoused with Dr. Frappier in the courtyard a couple of minutes after 7. He thought we should see the horse/mule/donkey souk (ie, market) before we left, especially since tomorrow's patient load will certainly include at least several mules purchased at today's souk. The souk is held every Thursday morning from 7-10 am in a large vacant dirt lot, about 20 minutes from the Fondouk. Mule dealers travel from all over to buy and sell working animals. When we walked into the souk, several hundred sets of eyes turned right to us. Anna and I were the only women in the entire place since horsemanship and mule handling is very much a man's job in Morocco. Dr. Frappier told us that since we were clearly foreigners, it was okay. However, if we had been Moroccan women showing up at the souk, everyone would have assumed we were prostitutes. Thank goodness for Anna's blond hair.
We walked around the lot, looking at the different animals for sale. There was the donkey section, complete with a slipper footed donkey and a donkey with a massive intestinal hernia for sale. There was the mule section, complete with a not-so-subtle piece of cloth covering a gaping neck wound on one poor guy. There was also the horse section, split into two parts--one for the mares and youngsters and one for the stallions. The men would periodically whack their mules into a trot if someone showed any interest--every single one of them was lame. For those mules broke to ride, someone would hop on and go for a trot or canter. Interestingly, when the Moroccans ride their mules, they sit very far back on the mule's rump in order to minimize the bouncing. While his may be more comfortable for the man, this has to be very rough on the mules' back and kidneys.
Dr. Frappier knew a lot of the men there and everyone came up to him to say hello. Anna and I even recognized several men who had passed through the Fondouk in the last couple of weeks. As he always is, Dr. Frappier was invited to have mint tea with his buddies. We were offered tea as well, but, given the set up and the sanitation, we politely declined. However, we did try some bread with Moroccan olive oil--to my great chagrin, it actually tasted like olives. I'm not sure exactly why, but we were also offered large pieces of a raw red onion. Given that it was 7:30 in the morning, we passed on that too.
While Dr. Frappier was schmoozing, Anna and I joined a large group of men who were migrating towards an open area at the souk where two horses could go head to head in a gallop. We have seen a number of these "Fantasia horses" at the Fondouk--they are used in traditional Muslim holidays and festivals. The tradition involves galloping while shooting guns (always a good idea!) and the goal is to the shooting in synchrony with other riders. Most of the Fantasia horses have been gray stallions and they are decked out in elaborate tack and dressings. At the souk, there is one man who will hop on any horse (bareback!) and gallop him for a prospective buyer. It was very exciting to watch and involved a lot of hoopla and fanfare from the crowd.
Before we left, Dr. Frappier showed us the farrier section of the souk. All of the working mules, donkeys and horses are "shod" in rubber shoes made from cut up pieces of tires. The walkways in the Medina are sometimes steep and the concrete makes it very slippery. The rubber helps the mules keep their balance, especially when they're carrying a heavy or potentially uneven load. While this type of shoe may be okay in principal, the execution leaves a lot to be desired. We have seen mules come in with nails placed right into the middle of the sole. This is crippling to the mule and immediately sets up a good environment for a foot abscess or a coffin bone infection. Almost every donkey, mule and horse that has come to the Fondouk has had either completely untrimmed feet or dangerously overtrimmed feet. As we watched the farriers work today, I had the horrifying realization that the mule's feet were being trimmed to fit the shoe instead of the shoe being trimmed to fit the mule. Apparently, there have been numerous efforts made in the past to educate the local farriers and teach them how to place shoes in a more humane and productive way. Unfortunately, these programs have failed across the board since the locals want it done how it's always been done, even if it means lost days of work because the mule is too foot-sore to work. I find this notion maddening but I guess if you live in a world where progress is undermined by tradition, this is inevitable.
After our trip to the souk, we returned to the Fondouk to join the working day which was already in progress. Dr. Frappier said that Thursdays are always quiet which makes sense given that we just seen a lot of our clientele across town at the souk. Although our rectal prolapse mule went home today (with his rectum firmly planted where it belonged, I might add) unfortunately, today proved to be a day of tragedy after tragedy. We elected to euthanize another one of the neurologic donkeys, whose condition had progressed to total recumbency and rigidity. Immediately after that euthanasia, a large mule with completely fractured humerus was driven into the courtyard--he too was euthanized since there was nothing we could do for him. The small animal hospital saw more than its fair share of euthanasias today as well. 
Late morning, two men rolled in a cart carrying a mostly-dead ewe. Apparently she had been in labor about 20 days ago but never delivered any lambs. 5 days ago she stopped eating and became too weak to stand or walk. Today they decided that this was a problem. I placed a catheter in her and we bolused her some IV fluids. This was the first intravenous fluid therapy I had done since arriving in Morocco. Although we've had a few horses and mules who would have benefitted from fluids (namely "Rolex"), the only type of fluids the Fondouk has been able to get is saline in 1/2-liter bags. This is totally impractical for a horse or mule who requires 20 liters to start with. Hopefully Jeremy and Anne will be able to find some other source for fluids. We wound up doing a C-section on this ewe, too. Even though I won the "guess the number of lambs" game for the second day in a row, I didn't feel much like celebrating. She died on the operating table, which wasn't a surprise to anyone given her precarious and critical state when she arrived. After I removed 3 fetid lambs from her uterus, Houssine did a mini-necropsy to see what had killed her. He opened her rumen (the first of the four stomachs) and pulled out a large pile of plastic bags and other non-digestable plastic. 
The other interesting case of the day involved an older donkey who has been seen before for chronically failing suspensory ligaments in both front legs. Today's visit was because of a newer tendon injury. Dr. Frappier had told me that he has done a form of stem cell therapy on some of the fancier horses that have been brought to him over the past few years. In a cutting-edge technology meets third world medicine kind of way, Dr. Frappier harvests stem cells from the bone marrow in the sternum. He mixes them with saline and a bit of antibiotics and then injects them directly into the affected tendon. Apparently he has had great success with this. I thought this donkey might be a good candidate and I was excited to get the go-ahead from Dr. Frappier to try it. With Houssine's help and guidance, we made a valiant effort to retrieve the stem cells. Even Dr. Frappier himself gave it a whirl but no one could hit the bone marrow on this donkey. Who knows if he had some quirky anatomy (admittedly, Dr, Frappier hadn't done this on donkeys before) or maybe we were just a bit off our game today. Sadly, the donkey got no stem cells but some steroid injections and a bit of bute which will hopefully help a bit.
We made a final trip to the grocery store this afternoon but didn't have much to buy since we leave the Fondouk on Sunday morning for a few days of travel in Marrakech before returning home. We're a little nervous how we're going to stuff our newly acquired Moroccan presents into our bags, but we may just have to purchase some extra luggage. This should make the long trek home exciting.