“To Cut is to Cure”

We had a 1 week surgery rotation at the university hospital. The university is a referral center with specialist surgeries being performed so we didn’t get to do much ourselves. We scrubbed into as many surgeries as possible and held tissues or passed instruments or operated the suction for the surgeon.  We worked long days; coming in early each day to check on surgery patients from the day before. We also called patients a couple days after their surgeries to check on them and see how they were doing post-op. We wrote discharge notes and surgical reports. Surgical reports are different than a normal medical history. We made sure to include all the instruments used, the type of scalpel and suture, the pattern of closures, exact dimensions of any incisions, and carefully explained each procedure. Each evening we had rounds where we talked about the surgical cases for the day and looked at the pre- and post-operative imaging (x-rays, or CT scans or MRIs).

One of my first patients this week was a beautiful dog who had a significantly sized mass removed from his soft palate (roof of his mouth). Once the surgeon took the mass out there was a very large fistula which needed to be repaired with a skin graft. I was reading some of the articles the surgeon had with him to assist the procedure. It was very complicated, and the anatomy went over my head…that’s the thing about the field of veterinary medicine & surgery… there is always so much more to learn and do and practice! He stayed in hospital for a few days and had to be stomach tubed his meals (who wants to eat when you have a skin graft in your mouth anyways?!). When we went out for walks I had to stop him from trying to pick up sticks with his mouth! Unfortunately, after a couple days one side of his skin graft had failed and he needed a repeat surgery to close the fistula in the roof of his mouth again. After freshening the edges and making another mini-graft the fistula was closed. As far as I know, this patient recovered really well after his revision surgery!

I watched a couple of other mass removal surgeries this week, they were not quite as cool as the soft palate resection + graft. One poor dog had a mass in her rectum that was very uncomfortable. Another dog was very prone to developing lumps all over her body and needed those removed!

One girl in my group watched four splenectomies or something crazy like that this week. I managed to watch one!  The university has this very cool surgical tool which makes splenectomies a lot easier; it basically cauterizes all the vessels and stops all the bleeding so the surgery is much faster and cleaner.

 

One day there was a cria (baby alpaca) that had come in for surgery. He was too big to stay in the small animal hospital so he stayed with his mum in the horse barn and then came to our small animal surgery team to have his bony sequestrum removed from his leg.  A sequestrum is basically a dead piece of bone sitting within the limb; they can be associated with infections and sometimes draining tracts will form. The CT scan of his leg was particularly impressive!

If any spays or neuters were scheduled my group members and I were meant to do them. I watched one of my friends do a spay and a couple of my other friends did castrations. I was very unlucky all week and my cases kept cancelling or no-showing on me! I didn’t get to do any surgeries this week.

 

Towards the end of the rotation I had a very complicated surgical case! The patient was in the ICU.  I completed my rotation in the ICU earlier this year. The ICU team determined that the patient had a septic abdomen. Which meant that he had a bacterial infection in his abdomen—this is really not ideal! We learned that this dog had previously been diagnosed with severe hydrocephalus and had previous brain surgery to put in a ventriculoperitoneal shunt (VP shunt). Very simply —this is a tube that goes from the brain (and tracks under the skin) to the abdomen where it drains the cerebrospinal fluid that builds up in the brain. The excess fluid cannot be in the brain and if it is drained to the abdomen it can be reabsorbed into the body there.

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Please enjoy this Google image of a puppy with hydrocephalus. His head is abnormally enlarged and domed. http://www.dogscatspets.org/hydrocephalus-in-dogs/hydrocephalus-dogs/

Unfortunately, the presence of this shunt complicated matters. We didn’t know if the bacterial infection in his abdomen had started in his brain or if it has started in his abdomen and then had tracked up to his brain. The surgery team spoke with the ICU team and then the surgery team liaised with the neurology team. Eventually we decided that it was in our patient’s best interests to complete his abdominal surgery first and then bring in the neurology team to remove his shunt. Then, if he recovered well in ICU he would require another brain surgery in a couple weeks to replace the VP shunt in his brain (this patient cannot live without the shunt). Both surgeries went really well! I helped put in the esophageal feeding tube at the end of surgery.  I’ve been trying to keep up on how this patient was doing by asking my friends who were on their ECC rotation in the ICU room.

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‘Cows Around’

If anyone caught that Corb Lund reference, thank you.

This placement was a blessing.  Last year I was trying to find placements to go to in Australia (we have to do a certain number of weeks in Australia). I was really struggling because I do not have many friends and no family in Australia. At home, it is easy for me to stay with someone I know or visit people in different areas where I might do a placement. It looked like I was going to have to spend a lot of cash to pay for transportation and accommodation to do placements in Victoria. I was chatting to some of the girls from church about this, and next thing I knew, my friend’s mum called me! She explained that her and her husband had a dairy farm in Gippsland and their vet was amazing, very busy, and took students all the time. She had already called someone and vouched for me and they had agreed to take me on as an extra student at Tarwin Vet Group.

The first day of this placement was what I had imagined real Gippsland weather to be like. It was windy and POURING rain and I started to mentally prepare myself for 3 more weeks of downpour. Our first call was to see some sick cows at a dairy. We wore our normal clothes in the truck and when we arrived at the farm we changed into our boots and rubber pants. Classic student… I didn’t realize the side panels on the vet box on the truck flipped up…so while the vet was hiding from the rain and changing in the dry area I proceeded to dance around and struggle to get my rubber pants on over my coveralls as I got progressively more soaked in the rain.  I am not meant for rain. The first cow we saw had very bloody diarrhea and very pale mucus membranes. The vet wanted to recommend an exploratory laparotomy (abdominal surgery)—in this case we didn’t think the cow would survive a surgery because of the expected amount of blood loss. We thought she had a condition called jejunal hemorrhage syndrome.  We also saw a cow with extremely bad photosensitization—so much worse than any terrible sunburn I’ve ever had, I really felt for that girl.  During my placement we had quite a few ‘sick cow calls’ which allowed me to get lots of practice doing physical exams–a few times we were able to give farmers definitive diagnoses, other times the cattle required tests to figure out what was truly going on.  I saw a lot of different cases including ill-thrift, lumpy jaw, woody tongue, coccidia scours, pneumonia, bilateral pyelonephritis, and polioencephalomalacia.

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I spent all 3 weeks on twisty roads, going up and down hills. At the tops of hills (on clear days) there was some amazing views 

We often got calls to see cows and calves with lumps on them! Our first ‘calf with lump’ call actually ended up being the most interesting.  Lumps in cattle are commonly abscesses and I couldn’t wait to lance it!  But this calf had a large, soft lump down his neck. As I palpated the lump it started getting softer and the calf would walk away and regurgitate up hairball like materials. We spent a while massaging his neck until the lump got much smaller.  We suspected that the calf was sucking hair off his pen-mates ears and ended up with a choke-like condition (more common in horses).

Lameness is another common reason a vet may be called to see a cow. We visited many lame dairy cows, and a few lame beef cattle during my placement. Depending on the vet I worked with I got to practice lifting up legs–either with pulleys (much easier) or just ropes (I need to get rid of my noodle arms). On one occasion we went to see a large Angus bull.  I learned that a lot of the vets will give a little bit of sedation to the lame beef cattle.  Sedation is given to the beef cattle because they are handled less than the dairy cattle and often more dangerous to work with, sedation can calm them down and allow us to safely complete a full lameness exam. I really liked this idea and think it is a smart option for me–especially as a new grad while I’m still developing clinical skills and figuring out my methods.  One of the best lameness cases I saw was a septic hock. I aspirated ~20ml of purulent exudate from the joint. It was very interesting to see the difference in treatment of septic hocks between the horses we saw at the referral hospital at the beginning of the year and this cow.

One of the vets that works at Tarwin is the ‘down cow guru’. One day we got an after hours call for a dairy cow with a dislocated hip. Two other students and I went with the vet to see the cow.  He showed us how to properly palpated the hip joint, the top of the femur (greater trochanter), and examine the abnormal appearance and movement of the of the leg in order to confirm that her hip had actually popped out of the  joint. He also showed me how to roll a cow over by myself (for when I’m working alone). We then put a metal bar under the cow’s leg and attached her up to a tractor to help put traction on the leg and pull it back into place —its hard to describe the procedure (but its so cool and I love it)! The sun went down as we worked and I drove back in the dark —they told me to watch out for wombats on the road…I imagine hitting a wombat is similar to hitting a boulder…

The next week we had another call for a cow with a luxated hip, I was excited because I felt like I had a better idea of what was going on and could be more involved in her treatment this time around. She ended up being a weird case–firstly, she was still walking around when we arrived on farm. We gave her enough sedation to drop a huge bull but she still wouldn’t lay down!  Then when we finally had her on the ground her knee felt swollen and we heard a loud pop when gently moving her leg. She may have had a partially luxated hip and also a knee problem.

During the last week we went to see a down cow and diagnosed her with compartment syndrome. We put hip clamps on her and used the tractor to pick her up and then completed a further exam. We tested reflexes, muscle tone, superficial, and deep pain. We diagnosed her with a radial nerve paralysis. The vet I was with then did some physiotherapy–>electrostimulation to assist her muscles in the healing process. While driving around with this vet I had some great discussions about acupuncture as a treatment for different conditions in animals.

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The machine we used for electrostimulation on the down cow

I enjoy reproductive work in cattle and horses. Unfortunately, we only had one calving call during my placement.  This was fun for me because the vet got me to stick my hand in first & diagnose the problem…. I felt 3 front legs…. and diagnosed her with twins! The vet untwisted and pulled the first one out and then left me to get the second twin out myself (which was pretty easy after she wasn’t entangled up with her sibling anymore)!  We treated quite a few cows with retained fetal membranes, did some metri-checks, and saw one cow with a mummified fetus.  Every day there was appointments booked for preg-checking. I actually quite enjoy this currently because preg-checking is something that is still quite difficult but I can see improvement in myself each time I practice. I received some great feedback from the vets on this placement about my preg-checking skills so that was encouraging!

Naturally, the call for a uterine prolapse came just after 5pm on a Friday evening. I’m sure I was much more excited about this than the vet (who probably just wanted to go home after a long week).  The cow was up and walking around when we arrived, she went down again about half way through replacing her uterus. The vet, me, and the other student had quite the time spinning her around out of the squeeze so the vet could continue…and then of course she wanted to stand up again after that!  We worked by the light of the quad and our phones until she was all put back together.  We went back to the same farm a week later to do some other work, I asked the herd manager how the cow was doing–fantastic!!

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The sun went down on us quite a few times. But I don’t mind–everyone needs more sunsets in their lives.

I also really like wounds and trauma cases. We were called to see a heifer with a torn vulva after dystocia (difficult calving) that the vet spent a while suturing back together so she could hopefully have another calf.

We did a couple of abdominal surgeries in dairy cattle during my placement. Left displaced abomasums are a relatively common problem in dairy cattle. This is a condition that is usually seen not too long after a cow has a calf, starts producing milk, and eating a really high energy diet—> part of her stomach (the abomasum) is displaced to the incorrect location in her abdomen and fills up with gas. This makes the cow feel sick and she begins to produce a lot less milk. To fix this condition you have to cut into the abdomen of the cow and deflate the abomasum before pulling it back into the correct position. It was very interesting to put my arm inside of the cow and feel the abnormal abomasum while it was full of air, and then to feel it again after we had removed the air and pulled it into a normal location. I’m concerned that I’ll get called to see a really large dairy cow with this problem and I wont be able to reach her abomasum because my arms are too short!!! One of the other surgeries we completed was an exploratory laparotomy— one of the vets had felt a large mass inside the cow’s abdomen during a rectal exam. Once we cut into her abdomen we discovered that she likely had a large abscess on her kidney!

I got to participate in an awesome new herd health management technique that Tarwin is performing—teat sealing heifers. A teat sealant is a substance put into the teats of dairy cows after they are finished milking to prevent them from getting mastitis.  The procedure is now being offered for heifers (cows who haven’t had a lactation yet) in herds who have a high percentage of mastitis in that group. I had no idea what I was in for when the vets and nurses were explaining the process to me but we donned our aprons and boots and hats and even duct taped our gloves on. They unloaded a specially made trailer and set up a whole table with ‘dirty hand wash’, ‘clean hand wash’, paper towel, and teat sealant. The farmer ran the heifers on to the trailer and then we loaded 6 or 7 of them on, cleaned the teats, put in the sealant, marked them with paint and then released them into the field. I loved how seamless the process was and would be interested in seeing results in regards to how much the mastitis rate decreased on farm.

Another day we went out and did some sedated calf de-hornings. I feel as though more and more people are moving towards this more welfare friendly option. We injected sedative into all the calves and waited until they fell asleep and then did cornual nerve blocks.  After they took effect we burnt off the horn buds,  gave each calf an anti-inflammatory/pain medication drug, and checked for supernumerary teats and removed those. This was really fun because I got to do some of the nerve blocks and removed the supernumerary teats! Also, seeing 40 sleeping calves all snoring at the same time is adorable.

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For the first week of the placement I would come back and study for my board exam (NAVLE) every night. I took one day off to write the exam in the city.  

I also really enjoy post mortem examinations–especially after my feedlot placement at the beginning of the year.  As the vet and I drove to the call we discussed reasons for sudden death of a calf a few months old. Our top differential was black leg (failure or absence of Clostridial vaccination). The calf actually died due to a failed/bad castration. We found a huge amount of hemorrhage in the lower abdomen and legs and an infection tracking up from the prepuce.

Pink eye is a common condition in cattle, especially in areas with a lot of flies because they can transmit the disease. In severe cases a 3rd eyelid flap can be performed to protect the eye and help it heal. After watching the vet do a couple of them I started helping out as well. We also injected antibiotics into the eyelids.

There was also a horse vet working at Tarwin. I spent some time shadowing him as well.  The first call we went out to was a very loved horse that had been fed bread and had choke (an obstructed esophagus). This seems like it would be a really emergent situation but its actually not that bad and horses can remain like this for a couple days while we treat them. You just have to nasogastric tube them and flush the obstruction a lot of times until it starts to break down and either goes forward into the stomach or backwards through the tube. We also went and did a gelding (male horse castration surgery) in the hot sun! No more of that pouring rain—I actually really lucked out with the weather for the rest of the week. The farmers probably wouldn’t agree, but I liked the sun.  We drove out to to a pre-purchase exam on an older horse. This was something we practiced on my equine external rotation.  We also had to put a foot cast on a couple different horses because of wounds they had.

I had an amazing time on this placement! With all the hands on practice, tutorials on abscesses, down cows, nursing strategies, calving management, and chats in the car–I learned so much! Staying at my friend’s parents’ house was also lovely; they had warm home cooked food for me each night and made me feel so at home.

Thank you to the Payettes and Tarwin Vet Group!

 

The First Cat and Dog Rotation!

I feel like there is a significant lack of cat and dog jokes around to make into a quirky title for this blog…

After my group finished our equine rotations we needed to switch our brains into ‘smallies’ mode because we had 3 weeks of Emergency and Critical Care (ECC) and Small Animal Medicine rotation ahead of us.

The Intensive Care Unit (ICU) room is located in the middle of the university hospital and all the most sick or critical patients get transferred there. Often the team is so busy they don’t leave the room and have no idea whats going on in the other departments!  We either worked day shifts or evening shifts–which were the ones I preferred.  This meant that after normal day time hours most of the other hospital departments had gone home–so if a patient needed a special procedure or diagnostic test we did it ourselves instead of transferring to another department.

Again, as a student we were meant to take a case and be “in-charge” of the treatment and monitoring of that animal while it was in hospital. If an animal presented to the hospital it was called over the loudspeaker and we went to the reception area to triage the patient and consult with the owners.

The first patient I saw ended up being the most complicated case we had all week! The cat was initially suspected to have hepatopathy (a fancy way of saying liver disease) and renal (kidney) disease. After further treatment and diagnostics we discovered both an intussusception and a gastric foreign body with bi-cavitary effusions, hypothermia, hypovolemia, and hypotension…which is a real fancy way of saying that this cat was very very sick!  Each day we had rounds where we could sit outside in the gardens and discuss emergency topics. This patient was a great patient to initiate discussions on identification of shock and management of critically ill patients.

On our next shift we had a blocked cat, which is something I had seen a lot of at my previous job! It is not an un-common problem in male cats.  My housemate went to a conference last year and listened to a lecture about sacroiliac blocks (epidurals) for cats during this procedure. We use epidurals quite commonly in cattle but less so in our small animal patients. One night we were lucky enough to have a cadaver cat to practice epidurals on as well as other emergency skills like jugular catheters, tracheotomies, thoracocentesis, and urethral catheterization.

Another evening, there must have been something in the water in Werribee because we had multiple patients present after they feasted on the laundry room products!! One dog ate everything in site—detergent, soap, wine, bleach, smashed glass, etc. One cat ate lily laundry detergent and lilies are particularity toxic to cats!!

In Australia it is quite common to see snake bite cases! The university is currently working on SnakeMap which is this cool project that collects GPS coordinates of where snake bites occur which will help veterinarians manage the cases more efficiently. We had a few patients present to us in different stages of the course of the disease. It was fun being involved in these cases and I will miss them when I practice in Canada one day.

In the true spirit of emergency we had a couple cases which were rushed directly to the ICU room.  My group stood back in awe and watched the well-oiled ECC team perform CPR on a ferret who was involved in a dog attack.  Within minutes we had experts from the anesthesia team and the exotic specialist vet at the ICU room to assist with the uncommon patient.  Another patient in the ICU needed a pericardiocentesis preformed.   This is a procedure where the vet will stick a special needle through the body wall into the sac surrounding the heart (without poking the heart) to remove fluid—often blood–which is preventing the patient from breathing and pumping blood around their body properly.  This is a really cool technique because it is both diagnostic & therapeutic. This means that by performing a pericardiocentesis we can often get a diagnosis of the disease we are dealing with and we can also TREAT that condition at the same time.

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Practicing CPR on stuffed animals during our tutorial. But with that hair-do…. I’m not sure if its CPR or headbanging 😛

My group then transitioned into the Small Animal Medicine Department for a slower paced and more detailed rotation. We had tutorials on nutrition for cats and dogs and discussed diets required for different medical conditions and how to best formulate that into a treatment management plan. We also talked about antibiotics and prudent use.  Lastly, we had a CPR tutorial where we practiced our technique on life-sized stuffed animal patients.  We had a ton of fun practicing because we searched up YouTube and played “Stayin’ Alive” on loud to help us keep on time (compressions should be done at a tempo of 120 beats/min)!

I was in charge of another critically ill patient this week that was transferred back and forth from Medicine, ECC, and Surgery. This cat initially presented with blood in his urine. However, he was very anemic as well. Over the course of the week he ended up needing at least 2 blood transfusions. At one point we were considering giving him dog blood (xenotransfusion) because we didn’t have any feline donors.  Personally, I didn’t know that you could even do that without an animal dying and was completely mind blown! The cat continued to get sicker during the week as we tried to figure out an explanation for his many problems. We performed x-rays, ultrasounds, multiple blood tests, and even an exploratory laparotomy (surgery).  This cat had a very guarded prognosis and I was amazed and delighted at the end of the week when he was pacing around the ward and meowing at me for more food in his bowl (and not through his stomach tube!).

Wednesday was cardiology day! We shadowed the specialist cardiologist that comes to the university. My group sat in on all his morning appointments to watch echocardiograms (an ultrasound of the heart) and ECGs. I had a patient that had come in earlier in the week for something unrelated and when I did my physical exam I heard an abnormally low heart rate, a few tests later and an appointment booked in with the cardiologist and we had diagnosed her with a serious heart condition requiring surgical implantation of a pacemaker.

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Sometimes you need several ECG pages to read in order to diagnose the heart condition your patient has…

And on Thursday we had extra training with the specialist oncologist. She was really lovely and spent some time helping us to better feel lymph nodes in dogs and cats. This is something that I have always struggled to find in normal patients who do not have enlarged nodes.  Several of the patients I saw this week were cancer patients in various stages of diagnosis, staging, and treatment.  I now have a better understanding of chemotherapy drugs, what to do when you think you may have found cancer in a patient, how to treat and diagnose cancer.

These 3 weeks provided tons of opportunities for reviewing multiple different diseases and we had a lovely time in the hospital!

The Mane Event

The MANE event! Get it? ha! (It’s probably too late at night to be writing for the public eye…)

After a week “off” for research my group headed back to the equine hospital for our External Equine Rotation. This rotation was meant to be like a ‘general practice horse vet’ but we actually only spent one day driving around to farms to look at horses.

On the first day of the week we used a teaching horse from the university herd and did a practice ‘Pre-Purchase Exam’ on her. This is a special type of physical exam that veterinarians can do on an animal (typically horses or breeding animals) if someone is interested in buying it. There can be a lot of legal implications surrounding these exams– disclosure of medical information, high value of animals, suspected performance status. As a veterinarian you need to know the full extent of your role in this situation. During our exam of the teaching horse we detected some lameness so we took some radiographs of her leg. I have taken many x-rays on cats and dogs but never on horses. It is very difficult to know exactly how to position the horse for x-rays and where to position the machine in order to get the best pictures. This is something I will likely need a lot more practice with if I end up seeing some horses in practice.

Horses have this weird anatomical structure called ‘guttural pouches’ inside their heads. They are a common site of infection in horses so it is important to examine them.   I got a chance to practice driving the scope again. I really like this—its the only “video game” I enjoy.

On Wednesday, my wish came true! The main event! I finally got to see a colic surgery, and not just one, but two!! The horses went into surgery right after each other. I was able to stay on the “dirty side” of the surgery (I didn’t scrub in and work on the “sterile side”) and help out with an impaction colic.  This involves getting rid of all the excessive food material in the horse’s gut that is unable to move through. This was so cool! The second colic surgery was a different kind of colic—this horse had a twist in his intestines.  Can you imagine how painful it would be if your intestines twisted up on themselves? I am so glad that I finally got to see colic surgeries before I finished my equine rotations and be involved in helping these animals recover!

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This is just before the surgeons will open the gut to remove the impacted feed material

We worked with another teaching horse from the university herd and practiced placing bandages on his limbs. I much prefer practicing on live animals instead of models or cadaver legs–it is a much more real experience and there is a lot of factors that you learn to deal with i.e: windy day, muddy feet, how to pick up a foot on a horse that doesn’t like his feet being picked up, etc.

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I know this isn’t a limb, but can we all just take a moment to appreciate how great this vet wrap is?!

We also practiced nasogastric tubing (NGT)  horses. This is a really common procedure veterinarians can do to provide a horse with fluids, medications, or decompress a stomach during colic!  It is important to make sure that you put the tube in the stomach of the horse and not the lungs! Quite often we pour fluids down the NGT and we really don’t want to be pouring fluid into the horses lungs.  The way a horse’s larynx & pharynx is placed inside it’s head means that by flexing a horse’s neck downwards while we insert the tube (through the nose) the horse will swallow the tube into the esophagus (where we want it to go!).  You can smell stomach smells from the tube (surprisingly not as bad as you would think…) and hear the stomach bubbling away (a fancy medical version of the game ‘telephone’).

Everyone looks forward to the ambulatory day of this rotation. We drove out to meet one of our wackiest professors for a day of horse vetting in the field! It was a very relaxed day, seeing and chatting about a variety of patients. None of the patients were very sick and it was a pleasant day. We preformed a Caslick procedure, a mini-neurological exam on a mini horse, did some more guttural pouch scoping, and had a lot more fun! Our lunch on this day was legendary! An extremely lovely family made us a feast and I experienced the best date scones I’ve ever eaten…

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Me and two of my group mates with our horse vet professor! There was a huge sunflower field just outside one of our appointments.

On the last day of the week we gave a presentation that we had prepared and spoke about our ambulatory cases. Our last practical class this week was on a life-size model horse. We practiced rectal palpation–it is SO important to know the anatomy of a horse (or cow) so that you know what you are feeling (because you can’t see what you are feeling). You can make a lot of diagnoses this way, so the practice was appreciated!

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My group isn’t going to leave any rotation without some great baking!

 

Thanks again to the equine team for a wonderful week! We had a blast 🙂