Originally published in the August 2015 issue of Veterinary Practice News. Loved this article? Then subscribe today! While many general practitioners see horses somewhat regularly as part of their practice, using radiography, such as X-ray or ultrasound, isn’t that common. Veterinarians sometimes make errors or have lapses due to inexperience with equine radiology methods. Anthony Pease, DVM, MS, DACVR, associate professor, diagnostic imaging for the College of Veterinary Medicine, East Lansing, Mich., said that almost every lameness case would benefit from radiographs. “They are a non-invasive, fast way to get information about the limbs, and with digital technology, the ability to consult with specialists can be done on the farm,” he said. Meghann Lustgarten, DVM, DACVR, assistant professor, radiology at N.C. State University’s College of Veterinary Medicine, Raleigh, N.C., said the equine cases that require the most imaging are pulmonary disease, colic and lameness. “I think the most common errors made in the field regard radiographic positioning. It can be difficult to interpret studies appropriately if there is motion or obliquity,” she said. “Also, I think the interpretation environment is often suboptimal in the field. Radiographs are best interpreted in a dark and quiet environment. I have seen plenty of lesions that were much more apparent when evaluated in the proper interpretation setting.” Errors and Solutions One error Dr. Pease sees is that most people do not wear lead gloves when working with horses because they find them bulky and difficult to handle; however, he explained, the hands are the portion of your body most likely to get scatter radiation. “It is easy to wear gloves every time you are handling a cassette; however, a better investment is to purchase a film holder. This allows you to not have to hold the X-ray film and avoid the primary X-ray beam,” he said. “It requires a little more time to take the radiographs, but the safety benefit is well worth it.” Another huge mistake he sees veterinarians make is in trying to read the radiographs on the digital image unit at the farm. “The light is not good and neither is the environment (you feel rushed) and the image quality of the monitor,” he said. “The DR unit is meant to be used to determine if the positioning is correct and is not meant to be a diagnostic workstation.” The biggest tip Pease can offer someone with inexperience is to have patience and do not rush through the procedure. “Errors are always made in haste. Take your time, realize horses move and some sedation might be helpful, but having enough people available to perform the examination safely is the key,” he said. “Also, all because you cannot see radiation, wearing protect garments is imperative.” Sarah M. Puchalski, DVM, DACVR, diagnostic imaging consultant with Circle Oak Equine, Petaluma, Calif., who works with equine only, said mistakes in equine imaging happen at all levels, regardless of if someone is an equine specialist or not. “Sometimes the equipment isn’t quite right or it’s old and not working properly, and they don’t have enough experience to realize there is a problem. For example, they can be taking radiographs poorly because they aren’t positioned well,” she said. “The biggest thing is to be prepared prior to arriving at a farm. A veterinarian needs to understand the anatomy and how to make the radiograph and how to interpret the radiograph. In equine medicine, the difficulty is in localizing the anatomic site where a radiograph should be made.” The most frightening problem across all veterinarians—a problem well-understood in all medicine—is errors in misinterpretation. “The more infrequent someone is looking at a type of radiography, the more likely they are to make errors of omission particularly,” Puchalski said. “The problem there is it’s really hard to recognize an error of omission and to correct it in radiograph interpretation.” Getting Help Finding help is not always easy. Puchalski said that one of her staff members recently did an Internet search to determine how much help was out there on the topic and there were very few resources. “There are a couple of textbooks available that are good but not a lot is out there,” she said. “A good method is to reach out to specialty hospitals to get help in that regard. The onus is on the practitioner. It’s a bit of a Catch 22. They may recognize the need for more education, but it’s difficult to find.” The easiest way for a practitioner to hone his or her skills is by sending images to a radiologist or other specialist to help with the interpretation. “Generally, they will offer tips on how to take better radiographs if they have problems,” Pease said. “Also, there are wet labs and training sessions that are occasionally available. Lastly, contacting a local radiologist and perhaps arranging some time to get some practice on positioning and taking good quality radiographs is highly recommended.” Practice Makes Perfect One of the simplest ways for a vet to get better is by doing these sorts of tests regularly, but sometimes that’s not possible, and they must find other ways to improve their radiology skills. “The best way to hone their skills is through continuing education and a lot of practice,” Lustgarten said. “There are several online consultation services that, if nothing else, provide a second set of eyes to help solve the case and ensure nothing is missed.” Making Progress Puchalski said that once people get advice, it’s very easy to improve quickly. That’s why she’s very open to helping clients with radiograph readings and understanding better what they are seeing. “It only takes one or two studies to turn someone around with constructive feedback,” she said. “My observation is many schools aren’t graduating people with a huge background in it. They are just cracking the surface. They need more education is what it comes down to.” Working with horses can be difficult, and sometimes, things just don’t go smoothly. Proper sedation and patience with the patient and yourself are the best ways to improve your chance for success. Online Consultations Puchalski said the one thing she hears all the time is that people didn’t know it was possible to refer radiographs for teleradiology interpretation. “It’s interesting, because they will send off blood work or other assorted diagnostic tests, but when it comes to radiographs, they don’t think of it,” she said. One veterinarian recently asked Puchalski for advice on a patient, and she recommended taking neck images of the horse. “She told me she doesn’t interpret them well, so she is hesitant to do them. I told her to send them to me, and she didn’t think she could do that,” Puchalski said. “If you’re using digital X-rays, there are IT people who can set it up in a moment. People just don’t realize it’s available.” Pease said it’s important for general practitioners to get online consultations with boarded vets in order to become more skilled at equine imaging. “It is the best way to get another set of eyes on the images,” he said. “It is better to treat it like a consultation. The veterinarian can say what they think is wrong, and then the reader can make sure to look at that area and provide feedback on other views or techniques that could help confirm the diagnosis.”
