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TOPIC: AVMA Model Veterinary Practice Act

RE:AVMA Model Veterinary Practice Act 26 Feb 2011 22:44 #256

  • mwmyersdvm
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reillyshoe wrote:
Is money an issue or not? You seem to be giving both answers here...

All I know is that most football players who injure their knee or ankle or foot seem to have an MR exam within a day or two of the injury in human medicine, where money is not the limiting factor.

I still think the question is how to spend money wisely, and that is debated among everyone involved. Is a venogram worth the money? You seem to think so, but (as you state) not every radiologist agrees. Is an MR, or CT, or nuke scan worth it? It depends on the case, as well as the modalities available to you as well as the owner's budget.

Thank you, Pat. I believe you have my point exactly. It depends on the case and the factors surrounding it. I am interested in Travis' suggestion as I have not heard of such an entity for MRI. I am always interested in looking at any modality that will help a case. MRI has generally been cost prohibitive. I don't work for anyone with a football players salary in my practice :)

I can do three to four venograms for the price of most single MRI's. If I really need one more for a final check and the owner is reaching an impasse, I have often done a "four for the price of three" for the horse's sake.

One thought I do have is that venograms are more for repeated management of a case where an MRI is for a single shot diagnosis, so there is a big difference up front. I can get a lot of information from one venogram in most instances, but repeated ones yield far more; in a lamintic case especially. This may make them similar in overall cost, but the situations vary greatly in their use.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 22:46 #257

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reillyshoe wrote:
While I appreciate your faith in your own abilities, I would guarantee that nobody has a 100% success rate. Individual case reports, while incredibly important to the individuals involved, do not necessarily tell the whole story.

I totally agree, but these are a bit extreme. Missing a left fore lameness and thinking it is a left hind? For two years?

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 27 Feb 2011 05:24 #258

  • Travis Reed
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mwmyersdvm wrote:
Thank you, Pat. I believe you have my point exactly. It depends on the case and the factors surrounding it. I am interested in Travis' suggestion as I have not heard of such an entity for MRI. I am always interested in looking at any modality that will help a case. MRI has generally been cost prohibitive. I don't work for anyone with a football players salary in my practice :)

I can do three to four venograms for the price of most single MRI's. If I really need one more for a final check and the owner is reaching an impasse, I have often done a "four for the price of three" for the horse's sake.

One thought I do have is that venograms are more for repeated management of a case where an MRI is for a single shot diagnosis, so there is a big difference up front. I can get a lot of information from one venogram in most instances, but repeated ones yield far more; in a lamintic case especially. This may make them similar in overall cost, but the situations vary greatly in their use.

M. W. Myers, D.V.M.
.........

....www.MREQUINE.com.... they pull a 18 wheeler of sorts....clinic does have to supply the power to pull it and they plug into that power source...you also have to knock the horse down and load it on a table ...then roll table to lift gate and the load it in the trailer part that is outfitted with MR,...you also have to have a vet in the set up to keep hhorse alive.. I have seen bills from vet run in the 2k to 5k on blocks..veng..sona..radiogaphs and makeing horse lunge...when a mri finally told what the issue wasand could be treated and it was 800 to 1200...I can understand when u say the cients u work for just don't have that kind of money ..so yes I would say a mri is not for everyone...but when dealing with a horse that makes the client money or a project horse to sale money is not a issue over finding out what is deff wrong so it can be treated and get back to work......I noticed u work on a lot of founder and stuff but I just don't see much founder at all..I quess one reason is most of my work is in show and lesson barns where the horses are on a strict diet..... so I do see the point of cost when dealing with just a pasture pet that the main goal is just keep the horse comfy...
Travis Reed.....


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RE:AVMA Model Veterinary Practice Act 27 Feb 2011 16:19 #259

  • reillyshoe
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mwmyersdvm wrote:
Thank you, Pat. I believe you have my point exactly. It depends on the case and the factors surrounding it. I am interested in Travis' suggestion as I have not heard of such an entity for MRI. I am always interested in looking at any modality that will help a case. MRI has generally been cost prohibitive. I don't work for anyone with a football players salary in my practice :)

I can do three to four venograms for the price of most single MRI's. If I really need one more for a final check and the owner is reaching an impasse, I have often done a "four for the price of three" for the horse's sake.

One thought I do have is that venograms are more for repeated management of a case where an MRI is for a single shot diagnosis, so there is a big difference up front. I can get a lot of information from one venogram in most instances, but repeated ones yield far more; in a lamintic case especially. This may make them similar in overall cost, but the situations vary greatly in their use.

M. W. Myers, D.V.M.

We do not use advanced imaging techniques on every case of lameness or laminitis, and I am not suggesting that need to. Everyone has a budget, and I understand that not every horse will get nerve blocks or radiographs. Not every client will be able to afford shoes, so we work as best we can with our client's goal.

Does an MR or CT offer more info than a venogram? In my opinion, it absolutely does. The same contrast study can be viewed in 3D, and the lammelar interface can be assessed at the same time.

The question is what constitutes "ideal", and I maintain that the idea of one veterinarian with an interest in feet is not always the ideal answer.
P
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RE:AVMA Model Veterinary Practice Act 27 Feb 2011 23:11 #260

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reillyshoe wrote:
We do not use advanced imaging techniques on every case of lameness or laminitis, and I am not suggesting that need to. Everyone has a budget, and I understand that not every horse will get nerve blocks or radiographs. Not every client will be able to afford shoes, so we work as best we can with our client's goal.

Does an MR or CT offer more info than a venogram? In my opinion, it absolutely does. The same contrast study can be viewed in 3D, and the lammelar interface can be assessed at the same time.

The question is what constitutes "ideal", and I maintain that the idea of one veterinarian with an interest in feet is not always the ideal answer.

I am not discounting that you have valid points. Perhaps I am missing my own point in some of the cases i have had problems in the referral center. I would say that when the referral center is stumped to whom do they refer? There are times when the 'super team' does not have a way to compile the data to come up with a good solution. They have a myriad of diagnoses and perhaps some ideas on how to do surgery, some joints to inject, but how are they going to trim this horse's feet and shoe him if you are not the farrier? Will they have a farrier that can look at this data and make that call?

As you have suggested, I am actually not touting my excellence, but am merely pointing out that even the best of teams should keep an open mind to the possibilities that lie beyond their purview. I do feel that they become a bit too confident in their own assessments of cases and this may not be the best situation for the horse. The case from Minnesota I mentioned in the previous thread had a tragic ending at the hands of the same university. After he became sound from his trim and shoe package and progressed in his dressage work, the trainer decided she did not like the shoes. The owner complied and the horse fell immediately lame. Back to Minnesota with all of the information that had been compiled to help this horse. This amounted to a large notebook of information of everything we did, what had been done and was unsuccessful, and suggestions of how to proceed for the future. Untold hours of work had gone into this horse and the owner had been charged a total of $450 in consulting fees. The university did not even look at the history and treatment plans and cut his check ligaments and stall rested him again. He is lame to this day. I just don't want this to continue to happen.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 00:30 #261

  • Rick Talbert
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mwmyersdvm wrote:
The case from Minnesota I mentioned in the previous thread had a tragic ending at the hands of the same university. After he became sound from his trim and shoe package and progressed in his dressage work, the trainer decided she did not like the shoes. The owner complied and the horse fell immediately lame. Back to Minnesota with all of the information that had been compiled to help this horse. This amounted to a large notebook of information of everything we did, what had been done and was unsuccessful, and suggestions of how to proceed for the future. Untold hours of work had gone into this horse and the owner had been charged a total of $450 in consulting fees. The university did not even look at the history and treatment plans and cut his check ligaments and stall rested him again. He is lame to this day. I just don't want this to continue to happen.

M. W. Myers, D.V.M.

I was shoeing a horse for an owner who felt something wasn't quite right with the hind end. I watched the horse go and told her that it was inconsistent and subtle but it could be any number of issues and she needed to have it evaluated. She had 2 equine vets do a lameness workup and both told her that there was nothing wrong with the horse except the first one decided it needed its hocks injected. She still felt something wasn't right. I watched it go again and saw that the horse didn't recover its hind end normally when she tried to do a rollback. I told her that it could be neurologic, she said she was planning on taking the horse to the University of Florida, which she did. She was told that the suspensory ligaments in the hind end were "slightly thicker than normal", they decided to do some sort of surgery, spent a lot of money, and brought the horse home to be on a lengthy stall rest. The owner called about 2-3 weeks later and asked me what the symptoms were for EPM. I told her and she asked if I would come out and when I got there, I found a horse that would fall down if asked to walk in a circle, had no control over the hind end, and was pretty far gone. I agreed it was likely EPM, vet came out the next day and agreed and put the horse down. The University with all their capabilities struck out on that one.
Rick Talbert
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 02:50 #262

  • Travis Reed
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I'm sure we all have a story or two where the clinic missed something or a major issue...but I'm guessing if we all compiled our storys of a vet that played clinic in the field then I'm sure we would fill this thread to the max of wrongfull diagnosis...I showed a p3 that was half gone a bit back from a vet playing clinic in th e filed...turned a multi dollar jumper into a walk trot lesson horse...only prob not many kids wanna board a 18 hand monster hotter than a 2 dollar pistal...no way in hell does a vet with a intrest in feet have a better outcome than a clinic on a day to day basis....[HTML][/HTML]
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 05:30 #263

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I don't know that I would make an absolute statement against the individual practitioner. From a diagnostic standpoint no doubt the larger the clinic/university, the better the technology. Technology is impressive, but there is no substitute for experience. When I think of a team approach, say 4 veterinarians working together, I would compare it in my mind to 4 farriers working together. Usually, three of them are along for the ride and one is driving the bus. A large equine hospital may be ideal for high end cases, but the individual veterinarian is on the front line dealing with the practical realities of the average horse and owner. So being, talk of MRI's and bringing in top level specialists in every category is utopian. They (vets) are often in a similar situation as we are (as farriers), and that is you must do the best you can with what you have to work with. If you have a capable vet and farrier in an area that can work together great, if not then either or, has to do the best they can. There is not always another practical option for an owner. The larger the facility does not mean the higher the quality of care, it may just mean they have a higher bank loan. The one making the decisions is what it really all boils down to. I don't care if the one making the decisions is a DVM, a CJF, or the head illustrious potentate at whatever hospital or university. Someone has to be the bus driver. An individual has the advantage of thinking independently and applying what may be just the right application for a particular case but the same ideas may not have passed the approval of a group. There is often no need for Dr Dewey to say to Dr Cheatum "I think the horse is foundering do you concur?" "I concur but lets see what Dr Howe says, Dr Howe do you concur?" "Yes, I concur, lets form a task force and committee to analyze this hoof every possible way and we will meet back up at o' 3 hundred and decide what sort of application we shall instruct the farrier to apply." "Yes Dr and shall we get the hoof mapping specialist to be on site to show him where to put the breakover?" "Good idea super vet tech, we will also need someone who specializes in running a grinder, and a forging specialist, as our man is more of a nail driving expert." .....Just call a spade a spade and do the best job you can, know your limitations and request that someone more qualified do something if that is a feasible and practical option. A human being is capable of chewing gum and walking at the same time, and I can't see the logic in thinking that every lameness has to have 20 people working on it.
Rick Talbert
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 14:47 #264

  • Travis Reed
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I can agree with most of that Rick.....but I think we all are talking about 2 diff markets... I think horses fall under about 4 markets...1st that of horses that are used to hold down the pasture to keep it from bloweing away and will never see a vet and a farrier 2x a year.....2nd being they will give the horse wormer and shots and a farrier will be used when a big trail ride is comming up...3rd reg hoof care all shots and basic vet care up to date and if the horse needs help a vet will be called out and if horse needs more they will send it to the clinic but with a tight budget...4th horse type no limits just give the horse what it needs...... so diff markets will dictate what care the horse gets and we deff do not need to send every horse to the clinic and the house to house vet does fill the market in area of voids.........but I also think the bigger clinic are there do to reputation and being able to help horses and not so much of a big bank loan...bottom line is if you don't help or fix horses at a large clinic you will go out of business...USA and our free market place is great at weeding out the lazy and uninformed......................with that said I think we have sliped of topic and now are comparing clinics to farm to farm vets...and my opinon on that is not all vets are the same some are better than others..its up to the horse owner to seek out the best.....what I see that Dr Myers is looking to do is start a program with vets and farriers working on foot lamness in the field and I feel as if he thinks the MRI is not that usefull of a tool....he rather do blocks and other method and I'm of the thoughts use the tools before us and all the tools....I think the surface is only been scratched with what use can been done with MRI ....I'm just a po dunk country shoer from alabama and even I was aware of a MRI that travels in a effort to make th ings more more cost effective for the vets and horse owner and I would think a vet on the cutting edge of things would also know this and apply it to his/her practice.......... ..........I also think there will be 2 sides of the story of the deal Doc was pointing out where he had the horse sound and the trainer said pull the shoes..... the thing about our business is we are in a pformance based field as in the horse must do the job its intended to do and do that job well and win.....who's not to say the package Doc had on the horse allowed the horse to do its job...my guess is the horse had lost its movement...I just can not figure and trainers said pull the shoes and owner agree if the horse was moveing good....if the horse has no chance to win then what good is it to a owner that shows so why not try everything one can to try get horse back to its best then after all has failed then its time to retire the horse...its crazy talk to think if a horse was doing its job as it should to say let's pull the shoes..there is another side to that story.....I'm not saying a clinic or mri is a 100% but I'm of the thoughts of if you have a horse give the horse the best chance it can at a good life..........
Travis Reed.....


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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 15:03 #265

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Travis,

Your input is great! But very difficult to read, which means that part of it's instructional value is lost. May I suggest you try regular sentence/paragraph structure? Just a thought....

Baron Tayler
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 20:24 #266

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We all have our successes and failures, I am sure nobody is perfect in that regard.

The original point (in my opinion) is that we are better off utilizing people who are specifically trained in specific areas of study, and this includes farriery. Shoeing horses each day makes me better than if I only worked at this occasionally. I think I am better than if I was required to devote time and effort to study other professions.
P
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 20:32 #267

  • Rick Talbert
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I agree that we are all probably talking about the different levels of owners as you described Travis. But, the upper eschelon owners are going to be already taking their horses to places like Rood and Riddle and super clinics with all the bells and whistles and experts, so I don't think this sort of owner is in question as to whether or not their horse can be diagnosed and treated properly by a vet or vet farrier combo.
I dont know that I agree entirely with the idea that a very nice equine clinic got that way by providing outstanding service in a free market economy. There is one not too far from my house that is very big and nice and to look at it your perception would be that the vets were excellent. Perception goes a long way. And they may well be excellent in other aspects of equine medicine (maybe that is what keeps some equine facilities going but as it pertains to the topic of hoof related lameness they are quite poor in my opinion), bring a horse there with a lameness and your not necessarily going to get your moneys worth. Pretty much everything leaves with a NB shoe, a 4 point trim, an aluminum wedge shoe, or a size too small aluminum egg bar. All are often poorly applied. There are numerous stories and complaints that I hear regularly and I get to see many of the misdiagnosed horses when the owner gets a second opinion from the vets I work with or when I have a client who learns the hard way. I think the place is all hat and no cattle, with a small bag of gimmick shoes and a little guesswork based on a shallow understanding of the hoof. I don't know the vets there very well and I am sure their intentions are good, but I have witnessed some silly stuff, and yet they have one of the nicest facilities in the state. But if the idea of a free market and owners dictating quality is valid, and I think it is in most cases. Then whats the beef with an individual vet having a go at making a living with an expressed interest in horse's feet. If the quality of the services rendered are not up to snuff then that takes care of that eh? But we also must remember that an owner does not know right from wrong, good from bad, and half of them could be duped easily, so I don't know that the free market influences quality of care concerning a horse's hooves in the same way that it will put a hamburger joint out of business for making nasty burgers. The area also matters. In a rural or small town area word gets around and poor service puts you out of business. In a larger area there are always new horse owners and you have to be very negligent to entirely ruin your business.
As for the story about the shoeing job being nixed by the trainer, and the history not being taken into account on the referral, I can easily believe it. First seldom is the proper respect given to the previous guy. Some individuals think that they are the only ones that can have a good idea, others think that it would improve their standing with the owner if they can top the previous idea and do something better. Seldom when a horse goes to a clinic is it going to leave with the same application it walked up with. Right wrong or indifferent, an owner brings the horse to someone or somewhere looking for answers. If they were content with what they had they would not be there. So, even if it is for no other reason than a placebo effect for the owner shoeing applications are altered or at least fine tuned, something is changed and the owner is made to feel like something unique and potentially better has just occured. I have seen good shoeing jobs that an owner may be questioning some aspect of, and that expressed doubt is siezed on and capitalized with emphatic agreement that something else MUST be done. Its sometimes easier to change the shoeing than to change the mind of the owner.
Maybe you know something of Dr Meyer's intentions that I do not know, or maybe we take away a different meaning from reading his posts. I take long breaks from this site sometimes so maybe I just don't know whats up, but I think he seems to be doing what I think more vets should do. He is on here looking for ideas and cooperation from farriers and everyone seems to be hard on him. I don't get it.
Rick Talbert
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 20:43 #268

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Wouldn't it be good if treatment was improving at the same pace as the diagnostic technology.
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RE:AVMA Model Veterinary Practice Act 28 Feb 2011 21:35 #269

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Cyber Farrier wrote:
Travis,

Your input is great! But very difficult to read, which means that part of it's instructional value is lost. May I suggest you try regular sentence/paragraph structure? Just a thought....

Baron Tayler

Your right and when using the phone I will try to keep responce down to one liners....like awfull..or good job....I'm sure it does not reflect well for the whole farrier industry when doing run on sentence and miss spell words....
Travis Reed.....


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RE:AVMA Model Veterinary Practice Act 01 Mar 2011 00:14 #270

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Travis Reed wrote:
I just can not figure and trainers said pull the shoes and owner agree if the horse was moveing good....if the horse has no chance to win then what good is it to a owner that shows so why not try everything one can to try get horse back to its best then after all has failed then its time to retire the horse...its crazy talk to think if a horse was doing its job as it should to say let's pull the shoes..there is another side to that story.....I'm not saying a clinic or mri is a 100% but I'm of the thoughts of if you have a horse give the horse the best chance it can at a good life..........

Most dressage trainers do not like pads, especially five degrees worth of them that had to be applied by a semi retired Saddlebred farrier we were lucky enough to find in the area. Four other farriers simply refused to shoe the horse in the manner suggested and had no other suggestions as to how they would do it that could work. I have a hard time getting past a dressage trainer with a well balanced hoof as they want to see an elongated toe. They are still of the opinion that this is needed to "get the horse under himself". BTW, this horse was sent to a university and given the benefit of nuclear scintigraphy, multiple veterinary exams from even a top specialist in feet and they didn't get a diagnosis because they looked at the wrong leg. MRI is not needed when a simple exam of a video revealed which leg was lame and I convinced a veterinarian to do one nerve block which localized the area of lameness and a few plain raidographs and we were on the road to recovery. All of the available technology didn't work when it was misapplied. A good history and clinical exam cannot be replaced by an MRI.

The thought that a group of specialists working in concert is a good theory, but in practice can be a disaster. Can you imagine four farriers with each one having a special skill and then trying to get them to agree on how to handle a case. Does that clarify the picture? I have some experience of this type of medicine in the human field and after two years of foot dragging and errors, my wife is finally able to walk on her leg she fractured two years ago. The string of 'oops', misdiagnoses and over treatment with antibiotics she endured is absolutely a travestry.

MRI is a wonderful tool, but you will have to do the clinical exam first to find the area that is lame unless you can spend several thousand dollars to do multiple MRI's on an entire limb. Doing this can also uncover many small lesions that will not be causing any problem and may just be developmental anomalies or old injuries but simply looking at them doesn't tell you if they are actively causing a problem.

M. W. Myers, D.V.M.
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