The Modern Equine Vet August 2019

The Modern

Equine Vet www.modernequinevet.com

Vol 9 Issue 8 2019

Shoeing Away

Navicular Syndrome Ask the Nutritionist? Sick Horses That Go Off Feed Suicide Rates High Among Veterinary Professionals Cresty Neck and Metabolic Syndrome

NEW FEATURE: ASK THE NUTRITIONIST? YOUR NUTRITION QUESTIONS ANSWERED

TABLE OF CONTENTS

COVER STORY

4 Shoeing Away

Navicular Syndrome Cover photo: Shutterstock/Alla-Berlezova

ASK THE NUTRITIONIST?

What Are the Feeding Options for a Sick Horse That Has Gone Off Feed?.................... 3 DENTISTRY

Visual Dentistry: Shining a Light on Oral Pathology............................................................ 8 COLIC

Core Abdominal Exercises Can Speed Colic Surgery Recovery...........12 THE BUSINESS OF PRACTICE

Planning to Retire? Start Transitioning Your Practice Today..............14 NEWS

Veterinarians, Other Veterinary Professionals at High Risk of Suicide.................................................................................. 7 ‘Cresty Neck’ Predicts Equine Metabolic Issues..................................13 House Passes PAST Act Against Soring.................................................13 Horse Survives After Being Impaled......................................................17 ADVERTISERS Purina Sponsored Content.........................................3 Heska..............................................................................5 AVMA | PLIT....................................................................7

American Regent Animal Health.............................9 Stokes Healthcare......................................................11 Shanks Veterinary Equipment................................12

The Modern

Equine Vet SALES: Matthew Todd • Lillie Collett EDITOR: Marie Rosenthal ART DIRECTOR: Jennifer Barlow CONTRIBUTING WRITERS: Paul Basillo • Adam Marcus COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers PERCYBO media  publishing

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LEGAL DISCLAIMER: The content in this digital issue is for general informational purposes only. PercyBo Publishing Media LLC makes no representations or warranties of any kind about the completeness, accuracy, timeliness, reliability or suitability of any of the information, including content or advertisements, contained in any of its digital content and expressly disclaims liability of any errors or omissions that may be presented within its content. PercyBo Publishing Media LLC reserves the right to alter or correct any content without any obligations. Furthermore, PercyBo disclaims any and all liability for any direct, indirect, or other damages arising from the use or misuse of the information presented in its digital content. The views expressed in its digital content are those of sources and authors and do not necessarily reflect the opinion or policy of PercyBo. The content is for veterinary professionals. ALL RIGHTS RESERVED. Reproduction in whole or in part without permission is prohibited.

SPECIAL ADVERTISING SECTION

Ask the

?

Nutritionist

DR. KELLY VINEYARD, M.S., PH.D., SENIOR EQUINE NUTRITIONIST, PURINA ANIMAL NUTRITION

Ask the Nutritionist is a new monthly column featuring questions answered

by PhD equine nutritionists and sponsored by Purina Animal Nutrition.

Have a nutrition question you want to see featured? Email the Editor. For clinics looking for specific nutritional advice, visit purinamills.com/ask-an-expert.

Shutterstock/Leonard Law

We occasionally see horses in our clinic that are sick and have gone off feed. What are some feeding options to ensure they are receiving the nutrition they need for recovery?

When a horse has little to no appetite, Traditionally, enteral preparations it’s a sign of serious illness. If the gashave been made from commercially HORSE INAPPETENT? trointestinal tract is functional and the available human liquid diets (i.e. Vital Try these highly palatable options: underlying cause of inappetence has HN and Osmolite), senior feed slurries, been addressed, it’s critical to get the or homemade recipes (i.e. the “Nayhorse eating again to help maintain lor diet”). However, liquid diets have proper gut function, deliver calories been associated with an increased risk Fresh grass Bran mash mixture and nutrients essential for healing, and of diarrhea and laminitis. Creating a prevent weight loss. low-volume, nutritionally balanced To encourage voluntary intake, first mixture that supports optimal recovoffer a variety of feeds to determine ery and proper hindgut function with Oats Leafy alfalfa hay what the horse will eat. Some highly feed slurries and homemade recipes is palatable options include: difficult. Purina® WellSolve® Well-Gel® • Fresh grass formula is a high-fiber, low-bulk enteral • Leafy alfalfa hay preparation formulated specifically for • Soaked alfalfa cubes inappetent horses. This commercially Soaked Texturized sweet alfalfa cubes feed or senior feed • Bran mash mixture available powdered formula is a con• Oats centrated source of easily digestible • Texturized sweet feed (such protein, vitamins, and minerals deas Purina® Omolene® 200 or 400) signed to be mixed with 2–3 parts water (or more as needed for desired con• Senior feed (such as Purina® Equine Senior®). sistency). Three pounds per day will deliver 100% of protein, vitamin, and Adding molasses, applesauce, or even carrot-flavored baby food on top mineral requirements when fed as directed, while also supplying digestible of the ration can also tempt them to take a bite. Note: Be sure to remove any fiber to maintain a healthy hindgut. Well-Gel® formula is not sold in stores feed the horse leaves for an extended period to avoid spoilage. Some experiand is only available to veterinarians through veterinary supply companies. mentation may be necessary to find what the horse prefers. If the horse still If long-term enteral feeding is needed (>5 days), an equine nutritionist can refuses to eat, then enteral supplementation may be warranted. provide more specific recommendations tailored to the individual patient.

ABOUT THE AUTHOR Dr. Kelly Vineyard is a Senior Nutritionist, Equine Technical Solutions, with Purina Animal Nutrition. She is responsible for providing expert technical nutrition advice and insights in a variety of areas, including new product innovation and research and veterinarian and customer technical support.

SPONSORED BY PURINA ANIMAL NUTRITION

LAMENESS

Shoeing Away

Navicular Syndrome Shutterstock/Alla-Berlezova

Years ago, “navicular disease”

typically meant that the horse’s working days were over.

But thinking has changed, and now “navicular syndrome” can refer to a variety of problems—some of which are far from career-ending, according to Vernon Dryden, DVM, CJF, of Bur Oak Veterinary and Podiatry in Lexington, Ky. There are many medical and surgical modalities available to treat and manage injuries encompassing the palmar-plantar aspect of the equine foot, but without therapeutic shoeing their effects may be short-lived or ineffective.

“There’s no magic bullet,” Dr.

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Dryden said. “There’s no one treatment or one shoe that is going to cure navicular syndrome.”

For Dr. Dryden, the trim is an important aspect of management. It is essential to trim to improve the balance of the hoof and alignment of the bony column while still improving the hoof morphology.

Diagnosis

Affected horses will typically present with lameness—often bilaterally. Most horses will show pain over the heels and frog. The hoof will typically land toe-first. After performing a palmar digital nerve

P a u l

block, the lameness may switch sides.

A note from a farrier stating that the horse resists having a shoe nailed in place may be a giveaway.

“These horses are refractory to concussion,” Dr. Dryden. “When you're nailing a shoe on, that's a lot of vibratory force going through that foot, and those horses don’t like it.”

Imaging

Radiographs are imperative for showing bony changes.

“If you’re going to evaluate the navicular bone, you have to take a full set of radiographs,” he said.

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Imaging the Possibilities

LAMENESS

“You can see certain lesions with a few radiographs, but I recommend taking all six standard views.”

A skyline view will help evaluate the flexor surface, cortex and medullary cavity, while the dorsoventral view will show the proximal and distal borders of the navicular bone. The dorsomedialpalmarolateral oblique and dorsolateral-palmaromedial oblique views will highlight the wings of the navicular bone.

The lateromedial view can help to evaluate the articular and flexor surfaces, and any soft tissue mineralization that may be present.

Finally, the horizontal dorsopalmar view can evaluate the margins of the navicular bone with normal weight bearing.

Bone scintigraphy and MRI also offer help in localizing lesions and guiding treatment plans.

Therapeutic shoeing

“The first goal of developing a shoeing protocol is to reduce the biomechanical forces on the injured structure,” he explained.

“The second is to reduce the foot to restore balance, improve existing morphology problems, and provide protection to the injured areas of the foot.”

“The first goal of developing a shoeing protocol is to reduce the biomechanical forces on the injured structure.”

Dr. Vernon Drydon A foot that is shod without enough length and support in the caudal half can cause future problems. Dr. Dryden’s personal rule is to fit the shoe all the way back to the point where an imaginary plumb line can be dropped from the heel bulb down to the end of the shoe.

For horses with navicular bone degenerative changes, the goal will be to protect the navicular bone from direct trauma, decrease the pressure exerted on the navicular bone by the tendon, and decrease concussive forces.

Unloading the frog Navicular bursitis is one of the most difficult conditions that Dr. Dryden treats. He often recommends unloading the frog in these cases, to the surprise of many. “Unloading the frog does one important thing,” he said. “It takes pressure off of the structure that’s intimately involved with the navicular bursa.”

If the frog is compressed, it pushes up into the bursa. If the bursa is inflamed, then the horse is going to feel pain. “Unloading the frog helps the horse significantly, and you’ll be able to provide ample caudal support either with a heel plate, bar shoe or onion heel.”

One technique involves taking a creaser and creating a slight onion heel shoe.

Place a leather pad and cut out a v-shape directly over the shape of the frog.

This will eliminate focal pressure in that area.

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Wedging of the heel and adding an elastomer or other impression material are two strategies to manage concussive forces and distribute the load.

“When adding a soft elastomer to a shoe, I want to make sure that the horse stands on it before the elastomer sets,” Dr. Dryden said.

“That will distribute the elastomer evenly underneath the foot. If you don’t do that, you’re going to create positive pressure and push the elastomer up into the navicular region, and the horse is going be sore.”

Composite spider or stabilizer plates are particularly effective in horses that need some reduction in concussion and protection of the navicular bone without applying too much pressure.

“Make sure that your elastomer or [other impression material] is soft,” he explained. “The more rigid it is, the less likely the horse is going to like it.”

Wedging the heel or rockering the toe may also be helpful for decreasing the force of compression on the navicular bone by the deep flexor tendon.

Medical management

“Therapy options are highly dependent on the lesion,” Dr. Dryden said. “NSAIDs such as phenylbutazone, banamine and firocoxib are used in many of these cases.”

The coffin joint is often a successful location for injection in these horses, due to the interface with navicular bone on the coffin joint side. True lesions in the navicular bursa will require an injection directly into the bursa.

Steroids, IRAP, PRP, isoxsuprine, tiludronate and injectable bisphosphonate are also a vital part of the veterinarian’s armamentarium with these cases.

Dr. Dryden spoke at the 64th Annual AAEP Convention. MeV

NEWS NOTES

High Suicide Risk Among Veterinarians Veterinarians and veterinary technicians have significantly higher rates of death by suicide than do members of the general U.S. population.

According to standardized mortality ratios (SMRs), from 2003 through 2014, 1.6 times as many male veterinarians and 2.4 times as many female veterinarians died by suicide than did members of the general population.

During that same period, 5 times as many male veterinary technicians and 2.3 times as many female technicians died by suicide than expected. Researchers from Auburn University and the CDC reviewed records from the National Violent Death Reporting System for the study.

For all 3 groups (veterinarians, veterinary technicians and veterinary assistants or animal caretakers) in the study, self-poisoning was the most common method of death, but veterinarians were more likely to die of pentobarbital poisoning than were individuals in the other groups. Most deaths did not occur at work, and it was not known where individuals obtained these substances.

Veterinarians were less likely to have a history of a suicide attempt before the fatal incident, compared with individuals in the other 2 groups. About 25% of decedents had disclosed their suicidal intent prior to their deaths, and just more than 50% had a history of mental health treatment.

It has been known for some time that the risk of suicide among veterinarians is high around the world. However, information has been lacking on the circumstances of death, including suicide methods, and about suicide among other professionals in the veterinary field.

“Every bit of light we can shine on suicide is a step in the right direction,” said John Howe, DVM, president of the AVMA. “Suicide is complex. It not only affects the veterinary profession, but is also a critically important public health crisis and the 10th leading cause of death in the United States.”

The study provides evidence that access to pentobarbital may help explain the high risk of suicide among Continued on page 11

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DENTISTRY

VISUAL DENTISTRY:

Shining a Light on Oral Pathology As the field of equine dentistry increases in

importance, there is a greater emphasis on visualizing and identifying pathology for the benefit of both the horse and the owner.

Two of the most important tools for “visual dentistry” are a mirror and an endoscope.

“These tools allow us to recognize dental disease in the early stages,” said Allison Dotzel, DVM, of Laurel Highland Veterinary Clinic in Williamsport, Penn. “They can help us facilitate placement of instruments during oral procedures, and they are useful tools for client education and for obtaining images for record keeping and referral purposes.”

An oral endoscope picture taken during an extraction of a mandibular cheek tooth.

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Photo courtesy of Dr. Allison Dotzel

The tools

The standard equine oral mirror is comprised of a rigid shaft that allows for visualization of the caudal aspect of the oral cavity. In general, the smaller the mirror diameter, the better tolerated it will be by the patient. Many commercially available mirrors will not be pre-bent; some heating and bending of the metal will be required to get the desired mirror angle.

Many different equine oral endoscope systems are commercially available, but they all typically have some common ground. They are all rigid and waterproof, and most are around 40 to 60 cm in length with a diameter between 5 and 15 mm. Lens angles will range from around 60° to 115°.

“If you’re using your endoscope to guide your procedures, then you may want to have a steeper angle, such as 90°,” Dr. Dotzel said at the 64th Annual AAEP Convention in San Francisco. “Some newer, more expensive scopes are able to be adjusted incrementally, but you can make a fixed-angle scope work for both examinations and for guidance

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DENTISTRY

during procedures.”

Endoscopes also have their own light source, and allow for the attachment of a high-resolution digital recording device.

During the exam

Whether you use a mirror or a scope, the oral examination should be performed on a well-sedated horse in a quiet environment. A full mouth speculum should be in place, and the horse’s head should be supported in a comfortable position using a dental halter or a headstand—not an assistant’s shoulder.

A systematic approach is cru-

3

QUICK TIPS

1 2 3 10

In cold weather, minimize fogging of the mirror or endoscope lens by immersing them in warm water, using anti-fogging lens sprays, or by spraying or wiping the lens or mirror with isopropyl alcohol.

When examining the vestibular aspect of the maxillary arcades, it may help to slightly loosen the speculum strap. If you have that speculum cranked wide open and the strap is tight, then you might not be able to adequately retract the cheek. If you close the mouth a little bit and loosen the strap, you may be able to get a little bit better exposure on that side of the arcade.

On examination of the lingual side of the mandibular arcade, the tongue will often get in the way. Retract that tongue with your gloved opposite hand or have an assistant retract the tongue. You can also use a long retractor to improve your visualization.

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cial. Not everyone performs examinations the same way, but if the same procedures are not followed each time then things may get missed.

“I tend to place my endoscope between the right maxillary and mandibular arcades, facing the occlusal surface of the first tooth in the arcade, which is either the wolf tooth or tooth #105 or #106,” she said. “Then I just move my endoscope caudally to visualize the occlusal surface of each tooth in the arcade. When I reach the last tooth in the arcade—typically #111—I tip my endoscope to visualize the palatal aspect of the arcade, then withdraw rostrally and look at the palatal mucosa and interdental spaces. I’ll also look for any diastema or peripheral cemental abnormalities.”

After she reaches tooth #106 again, she’ll re-orient the endoscope to look at the buccal or vestibular aspect of the arcade.

“I’ll then advance my endoscope caudally again to look at the vestibular interdental spaces in the buccal mucosa, where I’ll look for abnormalities on the cheek side of the tooth” Dr. Dotzel said. “Once I’m done with the 100 arcade I’ll repeat the same process with the 200, then rotate the scope 180° for the same systematic approach to the 300 and 400 arcades.”

Which Is Better?

“You can perform a good oral exam with either a mirror or endoscope,” Dr. Dotzel said, “But there are some benefits of the scope over the mirror.”

The main advantage is the magnification of the captured image.

An endoscopic image can be projected on a large and/or mobile screen, which can increase the ability to detect subtle oral pathology that may be missed with a mirror.

A scope can also be used to

guide placement of instruments.

“You can use your mirror to guide placement, but it’s a little bulkier and more difficult to get in there when you have things like dental extraction forceps and spreaders in the mouth at the same time,” she said. “I use my scope to help properly align and seat the blades of dental spreaders in the interdental spaces.”

Dr. Dotzel is also able to assess the quality of contact of the dental extraction forceps with the crown of the tooth, monitor surgical progress, and assess movement of the tooth on manipulation.

“I can also use it to guide placement of elevators to break down attachments of retained root tips, and to position and guide highspeed burrs when sectioning the tooth,” she added. “In addition, I use it to check for correct placement of my dental spreader blades. Dental spreaders are useful tools, but if you don't have them oriented properly it's very easy to damage adjacent teeth or the tooth you're working on. It's great to be able to check that your spreaders are in right alignment before you put pressure on them.”

Endoscopes are quite expensive, and can be cost-prohibitive for those veterinarians who work outside of a large-hospital setting.

However, with a little searching and mechanical know-how you can purchase different components separately and put together a solid system for around $2,000.

“It's incredibly useful for client education,” she explained. “I project my endoscope on an iPad, and the client can watch while I'm doing the exam. It gives them a greater appreciation for the dental pathology that's present, it gives them a greater appreciation for what we do for the horse, and it drives home our goals for equine dental care.”

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NEWS NOTES

High Suicide Risk Among Veterinarians continued from page 7 veterinarians, and stresses the importance of restricting access to lethal methods, such as poison and firearms, for individuals at risk of suicide. At the same time, there is a critical need for additional research on suicide risk factors and call for implementation of evidence-based “upstream” suicide prevention and intervention strategies, such as promoting social connectedness, identifying and supporting individuals at risk, and enhancing problemsolving and coping skills.

Methods to address the high suicide risk among veterinarians have been—and continue to be—actively explored by the AVMA and industry partners to ensure that efforts are consistent with best practices advised by suicidology experts.

“Often times, people may suspect someone is suffering but they don't know what to say, or they worry that what they say may make the situation worse,” said Jen Brandt, DVM, AVMA's director of member wellbeing and diversity. “It is my goal to have every veterinary professional complete approved suicide prevention training.

It provides guidance on what to say and ways in which you can enhance a sense of belonging and help alleviate

the sense of fear that some may have about being a burden to their friends, family or colleagues.”

As well as working closely with their partners in veterinary medicine, the AVMA is working with the American Foundation for Suicide Prevention and other suicidology experts to enhance suicide prevention, education and intervention efforts within the veterinary profession.

“We can all help prevent suicide,” Dr. Brandt said.

“The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals. For assistance, please call 1-800-273-8255 or text HOME to 741741.”

MeV

For more information: Witte TK, Spitzer EG, Edwards N, et al. Suicides and deaths of undetermined intent among veterinary professionals from 2003 through 2014. JAVMA. 2019 Sept 1 (Epub ahead of print). https://avmajournals.avma.org/doi/pdf/10.2460/javma.255.5.595 The AVMA offers resources at https://www.avma.org/ProfessionalDevelopment/ PeerAndWellness/Pages/get-help.aspx.

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COLIC

Core Abdominal Exercises Can Speed Colic Recovery

By Adam Marcus Horses that have undergone surgery to treat colic may benefit from the equine equivalent of a six-pack. That’s according to researchers in Michigan who found that a month-long regimen of core abdominal exercises significantly speeds up recovery time and improves overall performance.

The researchers, from the College of Veterinary Medicine at Michigan State University in East Lansing, studied horses that had undergone colic surgery between 2008 and 2017 and survived for at least 1 year after the procedure. All of the animals underwent 4 weeks of core abdominal reha-

bilitation exercises (CARE) during their convalescence.

The regimen involved baited, or “carrot,” stretches that target the neck and back and, in turn, helped to strengthen the abdomen.

The study group comprised 11 horses that underwent CARE and a control group of 51 animals with similar intestinal problems—such as large colon volvulus or lipoma incarcerating the small intestine—that did not undergo the rehabilitation program after colic surgery.

Horses that performed CARE, which takes about 20–30 minutes to perform, returned to work (P=0.002) or training (P=0.0002) faster than those in the control group, according to the researchers, and did not appear to experience any complications from the rehabilitation regimen.

They also were far more likely to experience an improvement in performance—as assessed by the horses’ owners—than the other animals: 81% of those in the CARE group improved their performance after surgery, versus about 8% in the control group (P<0.001), the researchers reported. “Core abdominal rehabilitation exercises were safely performed by horses after colic surgery with no reported complications and may have facilitated faster convalescence and improved performance,” they reported.

Susan J. Holcombe, VMD, MS, PhD, DACVS, DACVECC, of the Department of Large Animal Clinical Sciences at the Michigan State University College of Veterinary Medicine in East Lansing, who led the study, said she was “surprised that the horses in the CARE program actually worked at higher levels compared with precolic surgery. I was very surprised that the horse with the incisional hernia performed so well and that the hernia decreased substantially in size following the exercises,” Dr. Holcombe told Modern Equine Vet. MeV

The regimen involved stretches that target the neck and back.

For more information:

Lifting Large Animals Since 1957 www.shanksvet.com

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Holcombe SJ, Shearer TR, Valberg SJ. The effect of core abdominal muscle rehabilitation exercises on return to training and performance in horses after colic surgery. J Equine Vet Sci. 2019;75:14-18. https://www.sciencedirect.com/science/article/abs/pii/ S0737080618307457

NEWS NOTES

‘Cresty Neck’ Predicts Equine Metabolic Issues

By Adam Marcus The fattiness of a pony’s neck is an accurate predictor of how likely the animal is to have metabolic problems, Australian researchers have found.

In a new study, the researchers showed that ponies with more extreme forms of “cresty neck” were far more likely to have insulin dysregulation—a potential indicator of equine metabolic syndrome (EMS)— than animals without the disfiguration, according to the researchers.

Cresty neck describes the accumulation of fatty tissue in the neck area, and the 5-point “cresty neck score” is used to assess the extent of the condition.

Horses with little or no neck tissue have a score of 0, while animals with a bulbous neck flap that falls over dramatically to 1 side have a cresty neck score of 5.

Previous research had shown that cresty neck, also known as regional adiposity, is a factor in EMS. However, its ability to predict metabolic problems apart from more general obesity has not been clear.

Although the link has been presumed, the Australian group sought to learn if cresty neck scores were independently linked to insulin dysregulation.

Regional adiposity is a component of EMS so we know that it is associated with the syndrome.

For the study, the researchers assessed the relationship between cresty neck and insulin dysregulation in 26 ponies of varying body types, some obese, some lean. They performed glucose tolerance testing and sampled blood for various measures of metabolic health.

Animals with the highest cresty neck scores (3 or higher) were more likely to have elevated levels of insulin after eating, and were 5 times more likely than other horses to have insulin dysregulation, the researchers reported. The score was a stronger predictor of insulin dysregulation than body condition, “and this may be relevant to the diagnosis” of EMS, they stated.

“Equine vets should make themselves familiar

For more information: Fitzgerald DM, Anderson ST, Sillence MN, et al. The cresty neck score is an independent predictor of insulin dysregulation in ponies.

PLoS One. 2019 Jul 24;14(7):e0220203. doi: 10.1371/journal. pone.0220203. eCollection 2019. https://journals.plos.org/plosone/article?id=10.1371/ journal.pone.0220203

with the scoring system, and how to appropriately obtain and assign a cresty neck score,” said Melody de Laat, BVSc, PhD, MANZCVS, SFHEA, a senior lecturer in the science and engineering faculty at Queensland University of Technology, in Gardens Point, Australia, and senior author of the new study.

“They can then use this score to determine the risk of insulin dysregulation and use it to monitor their patient over time—for example their progress following dietary modification or restriction. The presence of a cresty neck should alert them to the fact that the patient likely needs further investigation for insulin dysregulation, such as dynamic tests of insulin secretion and action. It should also alert them to the fact that their patient is at higher risk of developing endocrinopathic laminitis.”

Dr. de Laat added that although the study was conducted in ponies, “it would be reasonable to assume that the association is the same in horses, but this needs to be tested.”

MeV

House Passes Anti-Soring Act The U.S. House of Representatives passed the Prevent All Soring Tactics (PAST) Act (H.R. 693). The legislation will help end the cruel and inhumane practice of horse soring, which is the deliberate infliction of pain to exaggerate a horse’s motion for the purpose of gaining an advantage in the show ring.

This bill amends the Horse Protection Act (HPA) to designate additional unlawful acts, strengthen penalties for violations, improve Department of Agriculture enforcement, and for other purposes.

Many animal rights and veterinary groups, including the AAEP and AVMA, supported the measure.

“For many years the AAEP has championed legislation to end this cruel practice, and today’s vote in the House is a victory for horses,” said Jeffrey T. Berk, VMD, 2019 AAEP president. “We now will work for passage of the Senate version of the bill.”

The PAST Act expands soring regulation and enforcement at horse shows, exhibitions, sales and auctions, including the establishment of a new system for inspecting horses for soring. In addition, the bill increases penalties for violations. Soring is pervasive in the Tennessee Walking Horse industry.

The Senate companion bill (S. 1007) introduced in April by Sens. Mike Crapo (R-Idaho) and Mark Warner (D-Va.) currently has 41 cosponsors.

MeV ModernEquineVet.com | Issue 8/2019

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THE BUSINESS OF PRACTICE

Planning to Retire?

Start Transitioning Your Practice Today

Shutterstock/bioraven

By Marie Rosenthal, MS

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The time to start transitioning the ownership of your practice is not when you are about to retire, according to Ky Mortensen, JD, MBA, of Solvang, Calif. The earlier a practice owner develops his or her exit strategy, the more successful that transition will be.

“As soon as a practice owner decides and starts acting in accordance with the decision they made, the sooner it is going to come to fruition,” he said.

The first step is deciding what type of exit strategy you want.

Do you want to sell out and retire fulltime, or gradually give up the reins and transition out over time? Do you want to sell out and stop being responsible for the business, but still come in a few days a week and see patients? You need to talk about these things with your family, as well as your associates to develop the strategy that works best for you.

“A lot of times, this is where I see

Issue 8/2019 | ModernEquineVet.com

practices struggle—they can't make up their mind, and as a result, there is no movement.” he explained.

“If you've ever been part of an associate buy-in, you probably can attest that sometimes things get put on the back burner and aren’t addressed as often as you would have hoped,” he said. “Let's face it, it's a big topic, it's typically a lot of money, and there's some emotion involved. It's a significant steppingstone for those concerned. And so the decision-making pieces are a big deal.”

Often owners may not know how much their practice will be worth when they retire, or perhaps they did not set out to create a lot of retirement wealth in the practice, and as a result, they may not be in a position to have the type of retirement they want.

“If you never really thought about how you were going to build the wealth and how to transfer the ownership, you may look around

and realize #1) you don't know how much money you need out of your practice to retire, or #2) you're not sure how much your practice is actually worth.

“And #3) you don't have an associate lined up who has the interest or the financial wherewithal to purchase the practice. So you have to think about these things earlier, and make those decisions based on what you want,” he said.

Building the culture

Profitability is important, but keep the entire picture in mind—not just how much the practice makes—but the practice culture and staff and client retention. These are vital indicators of how successful the practice is and how successful it is likely to continue to be.

“You need to have a long-term vision of where you're headed in a practice to put the best people in place. At the end of the day, anybody can buy equipment,” he said.

“It’s getting those dynamic individuals that can drive caseload and drive the culture and the morale, people

who really have that giving mindset. That is a challenging thing to do well, over an extended period.”

Recruitment has to be carried out with the end goal in mind, he added. Building the team is about taking your practice forward, and cultivating the growth of the team, mentoring them and setting clear expectations to maximize their potential.

“A successful exit strategy for an owner begins with a successful entrance strategy for an associate,” he said. “If ownership is an option, associates need to understand this and they need to know how to be evaluated both for their current performance and for future partnership opportunities.”

Here are some steps to a suc-

cessful transition.

Understand the financial picture. Nobody wants to buy a poorly managed practice. You have to have a grasp on the pressure points that impact your financial health. There's a lot that goes into business.

Get a letter of intent. A letter of intent locks down the time within which the associate or partner will evaluate the practice and make his or her decision.

Sign a confidentiality agreement. A confidentiality agreement is vital. Associates will need to see confidential financial information if they are going to buy a piece of the business. “On a given level, buying a veterinary practice is no different than buying any other business. You have to see the numbers, the cash flow, the financials. You have to understand it as a financial investment.

For a veterinarian, it is often much more than that, but the numbers

have to make sense.”

Determine the financing. Mortensen challenged practice owners to answer some predetermined questions to better position themselves and their associates for a future sale. “Is the practice going to finance the associate? Will associates be permitted to pay for the purchase over time or is it going to be a cash transaction? Are future dividends going to be used to repay the note internally? Will the associate have to go to the bank?

Will the current owners be willing to cosign for them or provide a personal guarantee? As an exiting practice owner, what are you prepared to do?

Determine the distribution.

Every associate wants to know how much of a distribution he or she might expect to receive annually.

Although it might change from year-to-year, they will want some idea of the historical payouts. Although this is highly sensitive information, to a future owner this is important—especially if they will need a bank loan to finance the transaction.

This is really essential to young associates, who are still paying off their school loans and ModernEquineVet.com | Issue 8/2019

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THE BUSINESS OF PRACTICE

starting families.

“Before we give them an additional financial burden, we want to be really careful about that and make sure they're in a good position financially to get this deal done. You don't want to complicate the whole partnership picture with a bunch of chaos financially for them,” he said.

Understand the practice value.

There are practices out there that really don’t know how their practice value will be determined when it comes time to transition.

Make sure you understand your valuation methodology and that you agree with it. Ensure that this language is included in the operating agreement. There are associations that can help recommend certified valuators, such as the

National Association of Certified Valuators and Analysts.

Build a trusting relationship. Mortensen advises practice owners and associates to understand that the transition from associate to owner is a lot more than just financial. It's about empowerment and trust and mentorship. “The financial piece is big, but it isn’t everything. You'll find that money comes and goes, but the partners are going to be there for a long time. That's the big part that you have to come to understand. Truly, the success of the transition rests on the investment you make in that piece of the equation.

Set the ground rules. “If you intend to bring on new partners, develop the requirements to be-

It Takes 2 to Tango Associates also have to think about the future, and that starts with a similar evaluation about their needs and wants. The associate has to make sure that he or she wants to be a practice owner, according to Ky Mortensen, JD, MBA. “The earlier you as an associate recognize that you would like to be an owner of a business, and that is something that you would like to see happen in your career, you should start taking those steps,” he explained.

Once that decision is made, there are a number of considerations: salary, location, type of practice, type of patients, type of clients, as well as the personalities of owner and associate, and the rest of the team.

EVALUATE YOUR FINANCIAL HEALTH. Look at your place in life. Can you afford to be a partner or owner? Are you still paying off student loans?

Are you starting a family and buying a house? Is it practical to take on the debt of a practice?

INVEST IN YOURSELF. Associates who want to become a partner need to invest in themselves. They should attend some business training and be prepared to come to the table with more than just an opinion.

“If you didn't grow up in a business and don't have a great business background, you might have to invest in some foundational level of business training, you could get an MBA, or there are online courses, industry programs—all kinds of opportunities,” he said.

“In an ownership transition, every practice needs powerful partners for powerful results,” Mr. Mortensen said.

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Issue 8/2019 | ModernEquineVet.com

come a partner. Perhaps an associate will not be considered for partnership until he or she has been with the practice for a certain number of years. Establish an expected level of production for being considered as a potential partner, and for current partners. Do they have to be on call?

Are they in charge of their own hours? What is the percentage of ownership that is available? Can they come in at 10% or 25%? Is the person getting an equal partner share right from the beginning, or is there a transition to a greater percentage of ownership over time?

Announce it. He suggested that after the decision is made to provide “buy in” opportunities, make that information public so that your associates understand the process and the expectations required of them.

“Be decisive, invest in that decision, and publicize your decision, recruit for the long term and really set expectations,” he suggested. “If you're an associate, make it known if that's something you're interested in.”

Lastly, bad things can happen to good people. “You want to look at your Operating Agreement and examine it for rules of transferability. Make sure everyone understands the agreement so that there are no surprises.

Who has the right of first refusal?

What happens if a partner gets fired, retires, or gets divorced?

Understand your organization’s response to such occurrences so that you are prepared should they arise. You want to make sure you have the insurance in place for all the things that can happen. If your current agreement does not include language to address these occurrences, or if you do not have an agreement in place, consult an attorney to have one drawn up.” MeV

Horse Survives Being Impaled on Fence Sonya Lawlis, DVM, had just put her horse Henry out to pasture at her home in Freeville, N.Y, and walked away when she heard a loud snap. In the seconds that it took her to walk about 20 feet away, Henry had somehow impaled himself on the fencing; a piece of wood stuck out of his front armpit area and disappeared somewhere in the abdomen.

Unsure how far the wood penetrated, she called Cornell’s College of Veterinary Medicine Equine Hospital for advice. Within 3 hours, veterinarians there performed emergency surgery; they spent the next 2 weeks fighting drug-resistant infections and trying to avoid crippling complications.

“We tried to gently pull the sliver and it wouldn’t budge. We knew we had to bring him to the clinic,” said Dr. Lawlis, who did her internship and residency at the theriogenology section of Cornell’s College of Veterinary Medicine and is now working in a smallanimal practice.

Elaine Claffey, DVM, DACVS, a surgeon on the Cornell Ruffian Equine Specialist team, could feel the wood piece under the skin by skimming the sternum with her hand. They sedated Henry and lifted his leg to get the wood out.

“It was really stubborn,” Dr. Lawlis said. “Whenever you remove an object that’s been impaled you worry it may have struck an artery and there will be heavy bleeding. What we didn’t know was that the stick had gone into Henry’s colon; a horrifying smell told us that as soon as they removed it.”

Animals with a punctured GI tract have a poor prognosis due to the high risk of contamination of the abdomen. “If he did make it through surgery, he’d have a really long road to recovery and could end up with complications that resulted in us putting him down anyway,” Dr. Lawlis recalled.

She considered Henry’s young age and the fact that he had a lot of potential as an eventer. Henry’s halfbrother is Theodore O’Connor, an eventing super pony who, with Olympic Eventer Karen O’Connor, was named to the eventing short list for the 2008 Olympic Games in Hong Kong. Their father is Waterford, a stallion at Cornell’s Equine Park who Dr. Lawlis rode during her time there.

“We decided we really wanted to try to save him,” she said. “The prognosis seemed better for Henry than average because the time from the accident to surgery was less than 3 hours.”

During surgery, the wound and tract into the abdo-

men were opened and cleaned. The fencing had penetrated part of the colon, so this area was quickly isolated and repaired. The tract and the abdominal cavity were both carefully closed to help seal the abdomen from the wound tract as completely as possible. After surgery, the Cornell team kept Henry in an abdominal bandage to protect the wound, as well as intensive supportive care to help prevent further complications such as peritonitis and laminitis.

Photo courtesy of Sonya Lawlis, DVM

By Cynthia McVey

After he was home, Dr. Lawlis brought him back to Cornell to have a soft, swollen spot in the abdominal closure checked. Doctors found and removed wood splinters that had worked their way to the surface and sent them for testing and found multidrug resistant organisms. The infection was treated with daily wound care and local antibiotic therapy, and Henry was fitted for a hernia belt to help his body wall heal. Fortunately, Henry once again overcame the odds and his infection resolved.

Dr. Lawlis kept Henry quiet and on stall rest until he was thoroughly healed. She sedated him once or twice a day, any time she had to do anything near the wound such as clean or change bandages.

Henry finally returned outside as spring approached. He must maintain a slow recovery pace as the damaged tissue strengthens, but he’s almost ready to start training. Dr. Lawlis plans to train Henry to do eventing like his half-brother.

“He’s an awesome horse so I’m really glad he made it,” Dr. Lawlis said.

MeV Adapted from article on https://www.vet.cornell.edu/ news. Used with permission.

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