Virtual Veterinary Training

Four fourth-year veterinary students huddled around a laptop in a seminar room at Cummings School’s Hospital for Large Animals on a chilly Friday morning in December. They weren’t sure why they were there. They were wrapping up a three-week rotation with Professor Melissa Mazan, V93, and had seen their share of horse problems. But there was no horse here.

Mazan breezed in with her usual authoritative air, stethoscope tossed around her neck. She had been up all night taking care of an alpaca that had just had reparative surgery for a congenital deformity of the large vessels of the heart, and she was scheduled to spend the rest of the day interviewing applicants to the veterinary school, but she still had the bandwidth to check out a few cases. She opened a laptop and pulled up VSee, a telehealth system designed to facilitate virtual communication between health providers.

Suddenly, veterinarian Gigi Kay popped up on the small screen. She was 3,500 miles away in sunny Morocco, but a good internet connection meant she came in clearly, which happens about 50 percent of the time. Kay is the director of American Fondouk, a free health clinic for working equids—donkeys, mules and horses—in Fez. Spunky and low-key, the British national has spent her entire veterinary career in developing countries serving this vulnerable population. Joining her at the table were several Muslim students in headscarves and a couple of European volunteer veterinarians.

Over the last two weeks, Kay and her team had compiled a handful of challenging cases, complete with photos and videos of the patients in question, and they were eager to discuss those cases with Mazan and Tufts professor emeritus Jay Merriam, who was also on the call. The job of the Cummings School students was to listen and learn.

American Fondouk was founded in the late 1920s by Emily Bend Bishop, a Massachusetts woman who was so disturbed by the condition of the country’s working equids while traveling in Morocco that she sought help from the MSPCA upon her return to the United States. The owners of these animals depended on them for their livelihood, but lacked access to even basic veterinary care. They would literally work their beasts to death.

Bishop hoped that founding a veterinary clinic in Morocco would alleviate some of the animals’ suffering, and nearly a century later, that wish has become a reality, improving life for two- and four-legged residents alike, even while the economic pressures remain daunting. Kay and her team see approximately 10,000 animals each year, most of them used to carry goods—tanned hides, gas bottles, construction equipment—in the narrow streets of the Fez medina. Others plow fields and pull loads. Few, according to Kay, would receive veterinary care otherwise.

“Most of our owners are critically poor, many earning between $3 and $5 per day,” she said. She added that it costs $1 a day to feed a mule, leaving little money for the drivers’ families, so many animals end up malnourished. Still, each animal is worth between $100 and $300, which means that if one dies, it “represents a financial catastrophe.”

American Fondouk’s relationship with Cummings School began five years ago, after Merriam met Kay through his own foundation, Equitarian Initiative, the equid version of Partners in Health. Merriam and his team of volunteers set up short-term on-site clinics in developing countries around the world and occasionally consulted with Mazan on American Fondouk cases. “One day it occurred to me that it was not right that I was getting all this incredible information and the students weren’t,” Mazan said. That’s what prompted her to formalize her online consulting with American Fondouk.

Virtual rounds allow Tufts students and veterinarians to witness conditions such as rabies and tetanus that they’d rarely see in the United States. Fourth-year student Heather Houser, who volunteered at American Fondouk in June 2016, described seeing a mule come in “twitchy,” with an unsteady gait. “I didn’t automatically think it was tetanus, but the vets said it was a classic case.” The team put the mule on an antitoxin, Valium and antibiotics, and five days later, it was munching away on grass.

Cummings School students also get to see the effects of malnourishment, abdominal wall ruptures, trauma left untreated and huge tumors that would have been excised long before had the animals been in the U.S. “I guess the thing with our animals is that most of the pathology is very extreme, as their access to veterinarians is so limited,” said Kay. “Diseases have been left to run out of control.”

Serving a chronically poor population with limited access to technology is difficult, even for the doctors stateside. American Fondouk lacks medications that U.S. vets take for granted, and when Kay needs them, she must obtain import licenses from the Moroccan government. Mazan and Merriam, who have volunteered in similar clinics all over the world, are very familiar with these kinds of limitations and adjust their recommendations accordingly.

They know, for example, that the clinic’s diagnostic equipment isn’t always in perfect working order, and there’s neither an MRI scanner nor a scintigraphy machine to be found. And Kay’s team does very little bacterial culturing and histopathology.

“The answers are not simply given to you on a plate or in a detailed commentary from the path lab or the radiologists,” said Mazan. Worse, she and Merriam know that sometimes, there’s nothing they can do. “There’s no legal status for animal welfare,” said Kay. “Therefore we cannot force an owner to accept euthanasia if his animal is terminally suffering.”

Mazan and her team feel strongly that exposing students to these cultural and medical challenges will make them better veterinarians. “It can be extremely difficult for students in a wealthy university in a wealthy nation to understand that a donkey with pressure sores from an ill-fitting harness cannot easily be rested long enough to heal properly without jeopardizing the well-being of the owner’s family. By understanding the exigencies of the lives of the owners of working donkeys, students are less likely to cry maltreatment and more likely to look for potential solutions without casting blame,” wrote Mazan and her team in a paper about the telemedicine program published last year in the Journal of Veterinary Medical Education.

As the sole on-site expert in Morocco, Kay values the telehealth conferences as well. “Having access to specialist opinion is very morale-boosting,” she said. And while consultation sometimes “just confirms what we are doing,” at other times it alters treatment protocols.

For example, sending X-rays and ultrasound images to the Cummings School team for further interpretation “can certainly be life-changing for our patients.” One of the most memorable cases, Kay said, was a foal with colic. Her ultrasound revealed a large intussusception—a telescoping of the bowel into itself that can cause intestinal blockage and even death of the bowel tissue.

Using Skype, the Fondouk team performed another ultrasound in real time with Mazan and a Tufts imaging specialist. After doing a literature search, the team concluded that foals can recover from this condition without surgery. They decided not to operate. “This animal went on to do well,” Kay said.

On the December day when the four fourth-year veterinary students were tuning in to American Fondouk for the first time, most of the cases did not have such a happy outcome. The first was a horse that was unsteady on its hind legs, and Kay was trying to figure out whether there was a surgical solution.

Mazan pulled up a video of the animal trying to walk. It was painful to watch the thin, scruffy horse struggle to maintain its balance. The doctors, after some discussion, concluded that the animal suffered from a neurological condition, possibly caused by equine herpes virus 1, and probably wouldn’t get better.

The second case was a donkey with a funny-acting hip—the vets could pull its leg nearly 90 degrees laterally out from its body, and when the animal walked, it dragged its toe. Merriam had seen the problem before and identified it as a ligament issue that could improve with rest. “We’d put a splint on it and keep the horse in a confined stall so that it couldn’t move around,” he said.

“Does it get better?” Kay asked him. “Well, yes,” Merriam answered. “Back to normal?” “Well, no, but better.” That’s a bleak prognosis for a working animal.

The last case in the queue—two little donkeys with huge rectal prolapses—was less disheartening. Rectal prolapse is one of those conditions that Cummings School students probably would have never seen if not for their online link to Morocco. “In the West it is very, very rare and really only known during a bad foaling,” said Kay. But in Morocco the cause is parasites, and American Fondouk sees the condition at least once a week. “We showed them this because even for us, it’s rare to see two walk in with the same owner at the same time.”

Kay used the regular treatment protocol for the patients. A week later, I asked her how the donkeys were doing, and she sent me a photo of the little guys chowing on sweet American Fondouk grass, each sporting a neat bow of surgical thread under its tail where its prolapse had been treated.

Rachel Slade is a freelance writer in Brookline, Massachusetts.