Day 3: We're Down With the Mules

Good evening to my blog readers. Anna and I have just finished day three of work here at the American Fondouk. We've got the drill down pat and are operating smoothly in the large animal hospital. It finally stopped raining for the first time since we arrived. Right off the bat, this meant a greater flow of patients. We're happy to report that both of our rope-in-the-leg horses are doing well. The one we saw on Monday needs just another day or two of antibiotics and then we'll be able to send him on his way. Another post-op mule whose case we inherited when we arrived also looks great. His owner drove him 100 km to get him here so next time he calls to check in, we'll be able to tell him that the mule is ready to go home. Our piroplasmosis/colicky mare from yesterday was bright-eyed this morning as well.
My first case of the day was a ewe who was dragged in because her owner didn't know if she had already given birth, was about to give birth, or whether something else was going on. Half of a fetid placenta hung out of her. Through a 2-finger exam, Houssine and I were able to determine that she was in the process of aborting. Houssine was able to scoop out her fetus and membranes. I placed an intra-uterine antibiotic tablet while Houssine gave her a shot of antibiotics--then we sent her on her way. Because I was clearly running a special on small ruminants today, a ram who was off his feed was my next patient. With Houssine's guidance, we passed a surprisingly large naso-gastric tube and administered some kind of concotion for rumen health and a dewormer. He, too, was sent on his way.
Many of our other cases today were types of illnesses and problems that we see at home. One man brought in a large gray mule who was quite lame in the front end. He had an obvious carpal hygroma (fluid pocket on the knee) and the other leg was so upright that he had developed remarkable arthritis. I was all set to drain the carpal hygroma and inject some steroids into it, something I do routinely in practice at home. However, the mule's owner did not want his mule to be clipped on the knee (which is necessary for the procedure) because he hoped to sell the mule at the souk (market) tomorrow. That may sound harsh, but it's actually a very similar situation that I'm presented with at home--people don't want their horses clipped because they don't want anyone to know that their horse has a problem. This mule received a shot of bute and we bid him adieu.
We tended to a few other mules with wounds and abrasions, including one emaciated mule who comes in regularly for bute (an anti-inflammatory). One of the first things that was mentioned by the staff vets at the Fondouk was that he needed his tear ducts flushed. This is the second time in two days where flushing the tear ducts has been requested. I find this fascinating--the mule is wasting away, has minimally trimmed feet and a sore back from carrying too much weight, but the people are most bothered by the small amount of eye "crusties." We went ahead and flushed the tear ducts, but then also treated him to dental work and a hoof trim. It was a big day for Anna, partly because she was handed the powerfloat and told to "go for it."
Later in the morning, a man brought a terribly depressed mule completely caked in mud and manure. We were told he had been colicking but we didn't know for how long. While the students were trying to do a physical exam, the mule went down to the ground and we couldn't get him up. I had a debate with Houssine about the merits of his pain-killing drug of choice versus my pain-killing drug of choice. He wanted to give dipyrone, an anti-spasmodic drug that my practice doesn't even carry and I wanted to give banamine. We compromised amicably and gave both intravenously.
The needle policy here is an interesting one. Because supplies are extremely limited, needles are conserved and reused. There is no form of sterilization here but they are washed in a chlohexidine rinse between uses. A new needle is used, however, for intravenous drug administration and then that needle becomes an intramuscular needle. With this in mind, you can imagine how curious I find it that Houssine always hands me a cotton ball with alcohol on it "for sterilization" before an injection. I passed a naso-gastric tube on the mule on the ground and we gave him water and oil through the tube. The mule got up when I was done tubing him and looked mildly more comfortable. Our work was only getting started with this mule, however. At least 4 of us (including the mule's owner) went to work to clean this poor guy up a bit. I joked that we were white-washing the mule as the layers and layers of muck poured off of him. His owner talked very emphatically to me in Arabic while I was working with him--he kept pointing at the sky, pointing at me, and smiling. I couldn't help but think he was expressing some kind of gratitude. Either that or he thinks I'm a crazy American. After his rejuvenating bath, we ask his owner if we could hang onto the mule for the day and he agreed. 
      Later, when we reassessed the mule, we sedated him for a rectal exam and our findings were not encouraging. As this was a perfect teaching environment, Anna and one of the other students also got to stick their arm in the mule to learn what "abnormal" felt like. And as if that weren't exciting enough, Anna also got to pass the naso-gastric tube when we re-tubed him. She did a fantastic job and I'm sure the mule appreciated the hydration. There was a discussion of intravenous fluid therapy, but given that there are no sterile fluids in large quantity here and the pH of the distilled water isn't necessarily compatible with horse blood, instead we opted to "first, do no harm." We'll monitor the mule closely overnight, each taking turns to wake up in the middle of the night and poke our heads in stall, and hopefully a good night's rest will do him some good.
       In about 10 minutes, we're all meeting up to head out to dinner in the Medina. Last night was our first adventure outside the confines of the Fondouk. The Medina is a walled city-within-a-city and is a wild maze of narrow streets and winding alleyways. The Medina is closed to cars and trucks and the mules that we treat are the only way to get goods and merchandise into the market areas. Anna was the bravest of all at the restaurant we chose. She ate a camel burger which, interestingly, tasted very similar to our dessert. Go figure. Until tomorrow...