Neonatal Isoerythrolysis in Foals: Signs, Treatment and Prevention

By Dr Duncan Houston

A foal with neonatal isoerythrolysis is usually born bright, active and apparently normal.

Several hours later, the same foal may become weak, stop nursing, breathe rapidly and develop pale or yellow gums. The change can be frighteningly fast because antibodies absorbed from the mare’s colostrum are destroying the foal’s red blood cells and reducing oxygen delivery throughout the body.

Early recognition matters. Mild cases may recover with close monitoring, while rapidly progressive anaemia can cause collapse, liver injury, kidney complications, brain damage and death. (UC Davis School of Veterinary Medicine)

Quick Answer

Neonatal isoerythrolysis, commonly shortened to NI, occurs when antibodies in a mare’s colostrum recognise and destroy red blood cells inherited by her foal from the sire.

Affected foals are normal at birth but commonly develop weakness, rapid breathing, a fast heart rate, anaemia and jaundice within approximately 6 to 72 hours. Any newborn foal that becomes weak or yellow after initially appearing normal needs immediate veterinary assessment. Severe cases may require an urgent red-cell transfusion. (UC Davis School of Veterinary Medicine)

Neonatal Isoerythrolysis at a Glance

Question	Practical answer
What causes NI?	Maternal antibodies absorbed from colostrum attack the foal’s red blood cells
Is the foal affected before birth?	Usually no. The antibodies do not normally cross the equine placenta
When do signs appear?	Commonly within 6 to 72 hours, but occasionally from about 5 hours to 5 days
What are the main signs?	Weakness, poor nursing, rapid breathing, rapid pulse, pale gums, jaundice and dark urine
Which foals are at greatest risk?	Foals from mares with a previous NI foal, previous blood transfusion or clinically important anti-red-cell antibodies
Can a first foal be affected?	Yes, although it is less common
Is NI more common in mule foals?	Yes. A reported incidence of approximately 10% reflects incompatibility involving donkey blood factors
How is it prevented?	Screen the mare before foaling and prevent the foal from nursing maternal colostrum when harmful antibodies are detected
What is the preferred transfusion product?	Properly washed maternal red cells or red cells from a crossmatched donor
Is there a universal donor horse?	No
Can the foal recover?	Yes, especially when recognised before severe organ complications develop

 

What Is Neonatal Isoerythrolysis?

Neonatal isoerythrolysis is an alloimmune haemolytic disease. “Alloimmune” means the immune reaction is directed against cells from another individual of the same species. “Haemolytic” means red blood cells are being destroyed.

For NI to develop, several events must occur:

1. The foal inherits a red-cell factor from the stallion that the mare does not possess.

2. The mare becomes exposed and sensitised to that foreign red-cell factor.

3. The mare produces antibodies against it.

4. Those antibodies become concentrated in her colostrum.

5. The newborn foal drinks and absorbs that colostrum.

6. The antibodies bind to the foal’s red blood cells and cause their destruction.

The foal remains protected before birth because maternal antibodies do not normally cross the equine placenta. The disease begins after the foal nurses and absorbs the antibodies through its intestine.

Blood-Type Difference Alone Is Not Enough

Mares and foals commonly have different combinations of red-cell antigens. That difference alone does not mean NI will occur.

The mare must also possess clinically important antibodies against a factor carried by the foal. Current UC Davis testing distinguishes lytic antibodies, which destroy red blood cells and can cause NI, from agglutinating antibodies that are not generally associated with clinical NI. (UC Davis School of Veterinary Medicine)

Classic NI cases often involve Aa or Qa red-cell factors, but these are not the only possibilities. UC Davis lists several factors associated with NI, including Aa, Ab, Ac, Ka, Pa, Pb, Qa, Qb, Qc and Ua. (UC Davis School of Veterinary Medicine)

How Does a Mare Become Sensitised?

A mare can develop anti-red-cell antibodies after exposure to foreign blood through:

• A previous pregnancy

• Placental leakage

• Placentitis

• A difficult foaling

• Fetomaternal bleeding around parturition

• An incompatible blood transfusion

During pregnancy or foaling, small quantities of fetal blood may enter the mare’s circulation. If the fetal red cells carry an antigen the mare lacks, her immune system may begin producing antibodies against it. The risk can increase in subsequent pregnancies involving the same red-cell factor.

Can a Mare’s First Foal Develop NI?

Yes.

The common teaching is that the first incompatible foal sensitises the mare and a later foal becomes affected. That pattern is common, but it is not absolute. UC Davis notes that a mare may occasionally produce enough antibody during a first pregnancy to cause NI in that foal, particularly when placental damage or substantial fetal blood exposure has occurred. (UC Davis School of Veterinary Medicine)

Which Foals Are Most at Risk?

Risk is greatest when:

• The mare previously produced an NI foal

• The mare previously received whole blood or another red-cell-containing transfusion

• The mare has detectable lytic anti-red-cell antibodies

• The current stallion carries the same incompatible factor implicated in a previous case

• The mare experienced placentitis, placental bleeding or difficult parturition

• A horse mare has been bred to a donkey

• The mare belongs to a population with increased recognised risk, including some Friesian lines

A mare that has produced one confirmed NI foal should be treated as high risk during every subsequent pregnancy unless appropriate testing shows otherwise. (UC Davis School of Veterinary Medicine)

Why Are Mule Foals at Greater Risk?

All donkeys possess a red-cell antigen commonly called donkey factor. Horse mares may develop antibodies against this factor after carrying a mule pregnancy.

UC Davis reports an NI incidence of approximately 10% in newborn mules, considerably higher than the reported incidence in horse foals. Mule foals may also develop immune-mediated platelet destruction alongside anaemia. (UC Davis School of Veterinary Medicine)

When Do Signs of NI Appear?

Clinical signs usually begin within 6 to 72 hours after birth. Some cases have been recognised as early as approximately five hours or as late as five days.

The timing depends on:

• How much antibody-rich colostrum the foal consumed

• How efficiently antibodies were absorbed

• The antibody concentration and activity

• How rapidly the foal’s red cells are destroyed

• Whether secondary organ complications develop

A very young foal developing signs rapidly is particularly concerning because it usually indicates substantial antibody absorption and severe haemolysis.

What Are the Signs of Neonatal Isoerythrolysis?

Early Signs

The earliest changes may include:

• Reduced nursing

• Lethargy

• Sleeping more than expected

• Weakness

• Reluctance to stand

• Rapid heart rate

• Rapid breathing

• Pale gums

• Reduced interaction with the mare

• Poor weight gain

• Repeated lying down

At this stage, jaundice may not yet be obvious. A rapidly increasing heart or respiratory rate may be the first sign that the foal is struggling to compensate for reduced oxygen-carrying capacity.

Developing Haemolysis

As red-cell destruction progresses, the foal may develop:

• Yellow gums

• Yellow sclera or conjunctiva

• Yellow skin in lightly pigmented areas

• Dark red, brown or orange urine

• Discoloured plasma

• Marked weakness

• Reduced appetite

• Dehydration

• Exercise intolerance from even brief standing or walking

Jaundice occurs because haemoglobin from destroyed red cells is broken down into bilirubin. Dark urine may occur when free haemoglobin is released directly into the circulation and filtered by the kidneys. (MSD Veterinary Manual)

Severe and Critical Signs

Advanced NI may cause:

• Inability to stand

• Severe respiratory effort

• Cardiovascular collapse

• Altered awareness

• Tremors or seizures

• Very dark urine

• Marked jaundice

• Fever or hypothermia

• Multi-organ dysfunction

• Death

Neurological signs may result from inadequate oxygen delivery or from bilirubin deposition within the brain, known as kernicterus or bilirubin encephalopathy.

How Worried Should You Be?

At Risk but Currently Normal

The foal:

• Has not yet nursed

• Was born to a mare with a positive lytic antibody screen

• Was born to a mare with a previous NI foal

• Is a mule foal from a sensitised mare

• Is bright, standing and otherwise normal

What it means: NI may still be completely preventable.

What to do: Prevent the first suckle, muzzle the foal, call the veterinarian and provide an appropriate alternative source of colostrum immediately. (UC Davis School of Veterinary Medicine)

Mild Suspected NI

The foal has:

• Mild lethargy

• Slightly pale or yellow gums

• A faster-than-expected pulse

• A faster respiratory rate

• Reduced but continuing nursing

• A relatively stable PCV

What it means: Haemolysis may be occurring, but tissue oxygenation may still be adequate.

What to do: Obtain urgent veterinary assessment, serial PCV measurements and close monitoring. Stress and unnecessary exercise should be minimised.

Severe NI

The foal has:

• Marked weakness

• Obvious jaundice

• Dark urine

• A rapidly declining PCV

• Persistent tachycardia

• Rapid or laboured breathing

• Difficulty standing

• Increasing blood lactate

What it means: Oxygen delivery and organ perfusion are becoming compromised.

What to do: Hospitalisation and a red-cell transfusion are likely to be required.

Critical NI

The foal is:

• Recumbent

• Minimally responsive

• Collapsed

• Severely breathless

• Having seizures

• Unable to nurse

• Showing evidence of liver, kidney or neurological injury

What it means: Life-threatening anaemia or secondary organ failure is present.

What to do: Immediate intensive veterinary treatment is required. (PubMed)

When Is This an Emergency?

Treat any newborn foal as an emergency when it develops:

• Weakness after initially appearing normal

• Yellow or very pale gums

• Rapid breathing at rest

• A persistently rapid heart rate

• Dark red or brown urine

• Difficulty standing

• Poor or absent nursing

• Collapse

• Seizures

• Altered awareness

• Severe jaundice

Do not wait for the foal to become recumbent before calling. Red-cell destruction may continue rapidly, and the packed cell volume can decline significantly over only a few hours.

What To Do Right Now

If the Foal Has Not Nursed

1. Prevent nursing immediately.

2. Apply a properly fitted foal muzzle.

3. Call the veterinarian.

4. Collect a pre-suckle blood sample if a jaundiced foal agglutination test or crossmatch is planned.

5. Provide safe donor colostrum or a genuine commercial colostrum replacer under veterinary guidance.

6. Milk the mare frequently and discard the antibody-rich colostrum.

7. Verify that the foal achieves adequate passive transfer.

This is the ideal time to prevent the disease rather than treat it. (UC Davis School of Veterinary Medicine)

If the Foal Has Nursed but Is Less Than 24 Hours Old

Stop further access to maternal colostrum and contact the veterinarian immediately.

The foal’s ability to absorb intact antibodies is greatest during the first six hours and declines progressively, with effective gut closure by approximately 24 hours. Continued nursing during this window can increase the antibody load.

If the Foal Is Already Two or Three Days Old and Showing Signs

Call the veterinarian immediately and focus on stabilisation, diagnosis and restoring oxygen-carrying capacity.

By this stage, intestinal antibody absorption has usually ended. Simply stopping nursing will not remove the antibodies already circulating or reverse the red-cell destruction. The foal may still need to be temporarily separated for medical management, but transfusion and supportive care are the priorities.

Keep the Foal Quiet

Avoid:

• Unnecessary walking

• Repeated attempts to make the foal stand

• Transport without veterinary planning

• Stressful restraint

• Separating the foal from the mare more than clinically necessary

Physical activity increases oxygen demand when the blood may already be unable to supply enough oxygen to the tissues.

Do Not Give Iron

NI is caused by destruction of red cells, not iron deficiency.

Haemolysis releases large quantities of iron, and repeated transfusions may add further iron exposure. Iron supplementation should not be given unless a veterinarian has identified a separate, genuine indication. Severe haemolysis may instead contribute to iron-related liver injury.

How Is NI Diagnosed?

Diagnosis combines the foal’s age and clinical pattern with evidence of haemolytic anaemia and maternal antibodies directed against the foal’s red cells.

Packed Cell Volume and Complete Blood Count

Serial packed cell volume measurements help determine:

• The severity of anaemia

• How quickly red cells are being lost

• Whether transfusion is becoming necessary

• Whether treatment has stabilised the foal

The trend is often more informative than one isolated value. A foal whose PCV falls rapidly while the heart rate, breathing and lactate worsen is more concerning than a brighter foal with a similar but stable PCV.

Bilirubin, Plasma and Urine

Blood testing may show:

• Increased bilirubin

• Anaemia

• Free haemoglobin within plasma

• Liver abnormalities

• Kidney abnormalities

• Increased lactate

The plasma may appear pink, red or yellow, while urine may become red or brown from haemoglobinuria.

Crossmatching the Mare and Foal

The mare’s serum or colostrum can be tested against the foal’s red blood cells.

Agglutination or haemolysis supports the presence of maternal antibodies that react against the foal’s cells. Current UC Davis testing focuses particularly on lytic antibodies because these are the antibodies associated with clinically important red-cell destruction. (UC Davis School of Veterinary Medicine)

Direct Coombs Test

A direct Coombs test detects antibodies or complement already attached to the foal’s circulating red blood cells.

It may support the diagnosis but should be interpreted alongside the clinical signs, blood results and mare-foal compatibility testing.

Jaundiced Foal Agglutination Test

The jaundiced foal agglutination test, or JFA test, is most useful before the foal nurses.

It mixes the mare’s colostrum with the foal’s red cells through serial dilutions. A reaction at or above approximately 1:16 in horse foals has historically been used as a reason to withhold maternal colostrum. Thresholds and procedures differ for mule foals and between laboratories.

A pre-suckle sample is important because red cells collected after nursing may already be coated with antibody and may agglutinate independently, complicating interpretation. (IVIS)

What Else Can Cause Weakness or Jaundice in a Foal?

NI is an important diagnosis, but it is not the only explanation for a weak or yellow newborn.

Differential diagnosis	Important clues
Sepsis	Fever or hypothermia, poor nursing, injected mucous membranes, diarrhoea, swollen joints or umbilical infection
Neonatal encephalopathy	Abnormal behaviour, failure to recognise the mare, wandering, seizures or loss of suckle
Internal haemorrhage	Pallor, weakness, abdominal enlargement or falling PCV without marked jaundice
Liver disease	Jaundice with abnormal liver enzymes, bile acids or congenital abnormalities
Biliary atresia or obstruction	Progressive jaundice, poor growth and laboratory evidence of cholestasis
Prematurity or dysmaturity	Weakness, silky coat, floppy ears, tendon laxity and incomplete development
Failure of passive transfer	Increased infection risk, sometimes occurring alongside another neonatal disorder
Equine herpesvirus infection	Weakness, respiratory disease, neurological signs or herd reproductive history
Toxic or infectious haemolysis	Evidence of red-cell destruction without mare-foal antibody incompatibility

Sepsis and NI can occur together. A jaundiced foal should therefore not be assumed to have a purely immune-mediated problem without evaluation for infection and organ dysfunction. (Merck Veterinary Manual)

How Is Neonatal Isoerythrolysis Treated?

Prevent Further Antibody Absorption When Relevant

Maternal colostrum should be withheld when the foal is identified as at risk before nursing or while intestinal antibody absorption remains possible.

After effective gut closure, the focus shifts from preventing absorption to supporting the foal through ongoing haemolysis.

Blood Transfusion

A red-cell transfusion is the main life-saving treatment for clinically significant anaemia.

There is no absolute PCV at which every foal must receive blood. The decision is based on:

• The foal’s clinical condition

• Rate of PCV decline

• Heart and respiratory rates

• Ability to stand and nurse

• Blood lactate

• Evidence of organ dysfunction

• Whether haemolysis is continuing

A PCV around 15% is commonly used as a practical guideline when accompanied by clinical deterioration, but it is not a substitute for assessing the whole foal.

Washed Maternal Red Cells

Properly washed maternal red cells are generally considered the preferred product for NI.

The mare’s red cells do not carry the paternal factor being attacked by her antibodies, making them compatible with the foal. However, the mare’s plasma contains the harmful antibodies and must be removed. The red cells are therefore separated and washed repeatedly before administration. (MSD Veterinary Manual)

Unwashed whole blood from the mare must not be given to an NI foal.

Crossmatched Donor Blood

When washed maternal cells cannot be prepared, blood from another donor may be used after appropriate crossmatching.

The donor’s red cells must not react with the antibodies already circulating in the foal. Current UC Davis guidance states clearly that there is no universal donor horse and recommends confirmation of compatibility whenever possible. (UC Davis School of Veterinary Medicine)

In a genuine emergency without laboratory access, a healthy young gelding with no transfusion history may be considered as a practical donor, but this is an emergency compromise rather than a truly universal match.

Monitoring During Transfusion

The veterinary team monitors:

• Temperature

• Heart rate

• Respiratory rate

• Mucous membranes

• Pulse quality

• Behaviour

• Tremors

• Hives

• Colic

• Urine colour

• Evidence of haemolysis

Transfusion reactions can include fever, allergic signs, destruction of donor cells or circulatory complications. (MSD Veterinary Manual)

Oxygen and Supportive Care

Depending on severity, treatment may also include:

• Supplemental oxygen

• Carefully planned intravenous fluids

• Glucose and nutritional support

• Temperature support

• Minimal exertion

• Monitoring for renal injury

• Monitoring for liver dysfunction

• Treatment of concurrent sepsis

• Serial PCV, bilirubin, lactate and chemistry testing

Fluids must be tailored to the individual foal. A severely anaemic foal needs adequate circulation, but excessive fluid administration may further dilute the remaining red cells without correcting oxygen-carrying capacity.

Severe Hyperbilirubinaemia

Very high bilirubin concentrations can damage the neonatal brain and cause kernicterus.

Specialist centres have used plasma exchange in selected foals with severe hyperbilirubinaemia, but this is an advanced treatment rather than routine first-line care. Liver failure, kernicterus and bacterial sepsis were the leading causes of death in one retrospective NI outcome study. (PubMed)

What Is the Prognosis?

The prognosis can be good when NI is recognised early and the foal remains neurologically normal, maintains organ function and receives appropriate support before profound anaemia develops.

The prognosis becomes more guarded with:

• Very early and rapid onset

• Rapidly falling PCV

• Persistent high lactate

• Recumbency

• Severe bilirubin elevation

• Liver failure

• Kidney injury

• Kernicterus

• Sepsis

• Multi-organ dysfunction

Retrospective studies have shown that many treated foals survive to discharge, but the outcome depends heavily on secondary complications rather than the PCV alone. (PubMed)

A foal may look substantially brighter after transfusion, but continued monitoring is essential because haemolysis, bilirubin accumulation and organ injury may continue.

How Can NI Be Prevented?

Screen the Mare Before Foaling

Current UC Davis guidance recommends testing the mare’s serum for anti-red-cell antibodies approximately one to two weeks before the expected foaling date.

The screen uses a panel of donor red cells and can also include crossmatching against the stallion or jack when his red cells are available. Blood typing may help with breeding management, but blood typing alone cannot definitively predict mare-stallion compatibility. (UC Davis School of Veterinary Medicine)

A negative result is only considered current for approximately two to three weeks. If the mare does not foal within that period, repeat testing should be discussed. (UC Davis School of Veterinary Medicine)

Which Mares Should Definitely Be Screened?

Screening is especially important for:

• Mares with a previous NI foal

• Mares with a previous whole-blood transfusion

• Mares bred to a donkey

• Mares with previous unexplained weak or jaundiced foals

• Mares with placentitis or significant placental bleeding

• Mares from recognised higher-risk lines or breeds

A previous NI case should be documented permanently in the mare’s reproductive record. (UC Davis School of Veterinary Medicine)

If Lytic Antibodies Are Detected

Prepare before foaling:

1. Have a foal muzzle available.

2. Arrange veterinary attendance or rapid access.

3. Secure safe donor colostrum or a genuine commercial replacer.

4. Prepare suitable milk feeding equipment.

5. Plan a pre-suckle JFA test or crossmatch where appropriate.

6. Plan serum IgG testing to verify passive transfer.

7. Identify a potential transfusion facility and donor.

UC Davis recommends muzzling the foal for approximately 24 to 48 hours and providing an alternative source of colostrum under veterinary supervision when clinically important lytic antibodies are detected. (UC Davis School of Veterinary Medicine)

When Can the Foal Nurse Normally?

Many foals can return to the mare after approximately 24 hours because intestinal absorption of large antibodies has effectively ended and the mare is transitioning from colostrum to ordinary milk.

Some protocols use a 24 to 48-hour period, particularly when antibody concentrations are high or milk testing remains positive. Repeating a JFA test can help confirm when the mare’s secretion is safe. The final timing should follow the veterinarian’s protocol rather than one fixed rule for every case.

Verify Passive Transfer

Preventing the foal from drinking the mare’s colostrum also removes the beneficial antibodies needed to protect against infection.

The foal must therefore receive adequate safe colostrum or replacer promptly, and serum immunoglobulin concentrations should be checked afterwards. Plasma may be required if adequate passive transfer has not been achieved.

Common NI Mistakes

Assuming a Normal Foal at Birth Cannot Have NI

Affected foals are expected to look normal before nursing because the damaging antibodies are acquired from colostrum after birth.

Waiting for Obvious Jaundice

Tachycardia, rapid breathing, poor nursing and weakness may appear before the gums become dramatically yellow.

Letting a High-Risk Foal Nurse “Just Once”

Antibody absorption is greatest during the first hours of life. Even a brief nursing period may deliver a clinically important antibody load.

Screening Too Early in Pregnancy

Antibody concentrations can change close to foaling. Current UC Davis guidance recommends screening within the final one to two weeks and repeating the test if the mare goes significantly overdue.

Relying Only on Blood Typing

Blood typing may identify potential incompatibility but does not prove that the mare currently has harmful lytic antibodies.

Using Unwashed Maternal Whole Blood

The mare’s plasma contains the antibodies responsible for the disease. Only properly separated and washed maternal red cells may be used.

Calling a Random Gelding a Universal Donor

There is no universal donor horse. Crossmatching remains the safest approach.

Giving Plasma When Red Cells Are Needed

Plasma supplies antibodies and proteins but contains very few red cells. It cannot correct life-threatening anaemia.

Giving Iron Supplements

NI is caused by haemolysis, not iron deficiency, and additional iron may be harmful.

Frequently Asked Questions

Can a First Foal Develop Neonatal Isoerythrolysis?

Yes. It is less common, but a mare may become sensitised during the first pregnancy through placental bleeding, placentitis, difficult parturition or previous blood exposure. (UC Davis School of Veterinary Medicine)

How Long Must an At-Risk Foal Be Prevented From Nursing?

Common protocols use approximately 24 to 48 hours. Intestinal antibody absorption is effectively closed by about 24 hours, but the mare’s milk or colostrum may be retested before nursing resumes.

Can the Mare Donate Blood to Her Own Foal?

Yes, but only after the plasma has been removed and the red cells have been washed repeatedly. Unwashed maternal whole blood contains the harmful antibodies and must not be given. (MSD Veterinary Manual)

Does a Positive Mare Antibody Screen Mean the Foal Will Definitely Develop NI?

No. It means clinically important antibodies may be present and preventive management is required. Whether the foal carries the target antigen can be investigated through mare-foal or mare-stallion compatibility testing. (UC Davis School of Veterinary Medicine)

Can a Foal Recover Completely?

Yes. Many foals recover when anaemia is recognised and treated before liver failure, kernicterus, sepsis or multi-organ dysfunction develops. Continued monitoring remains important after the initial transfusion. (PubMed)

Final Thoughts

Neonatal isoerythrolysis is frightening because an apparently healthy newborn can deteriorate rapidly after nursing. It is also one of the neonatal emergencies that can often be prevented with careful testing and preparation.

The most important points are:

1. NI is caused by antibodies in the mare’s colostrum attacking the foal’s red blood cells.

2. Affected foals are usually normal at birth.

3. Signs commonly develop within 6 to 72 hours.

4. Weakness, rapid breathing, pale gums, jaundice and dark urine are major warning signs.

5. A first foal can occasionally be affected.

6. Mares with a previous NI foal require careful management in future pregnancies.

7. Mare antibody screening should be performed close to foaling.

8. Blood typing alone cannot reliably predict whether NI will occur.

9. A high-risk foal must be prevented from nursing before the first suckle.

10. Safe alternative colostrum must be provided immediately.

11. After approximately 24 hours, preventing further antibody absorption becomes less important than treating the anaemia already present.

12. Transfusion decisions depend on the foal’s condition and PCV trend, not one number alone.

13. Washed maternal red cells are generally the preferred transfusion product.

14. There is no universal donor horse.

15. Liver failure, kernicterus and sepsis are the complications that concern veterinarians most.

16. Early testing and preparation can turn a potentially fatal emergency into a preventable problem.

The mistake that causes the greatest harm is waiting for a weak foal to become dramatically yellow before acting. A newborn that was bright at birth but becomes quiet, tachypnoeic or reluctant to nurse deserves immediate assessment.

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ASK A VET™ can help organise the mare’s antibody results, breeding history, foaling timeline, nursing records and changes in the foal’s gums, urine and activity while you arrange direct care with an equine veterinarian. A weak, jaundiced, breathless, recumbent or collapsing foal still requires immediate hands-on emergency treatment.