Drained

Today drained me.  Not in the usual ways, maybe, but I came home too tired to do more than sit on the couch and hug my cat.  That kind of day.

It started out with an emergency, which isn’t unusual.  Our offices open at 8:00 am, which is about the same time lots of people are looking at their horses for the first time that morning.  Or, they’ve noticed something wrong but didn’t want to incur the emergency fee that goes along with an early morning call.  So they’ve waited for the clinic to open before calling about their sick horse. 

I’m a new(ish) vet, which puts me at the bottom of the totem pole.  That usual means that I’m not scheduled for regular appointments, unless the other vets are all filled up.   This allows my day to be filled up with emergencies or add-ons as they come in.  So the early morning emergencies are usually mine. 

The presenting complaint for this emergency was confusing for the staff who took the call, but it was fairly clear to me what was going on.  This horse, an older gelding, was found down in his stall this morning with severe abrasions and lacerations around his eyes and ears.  The owner was having difficulty keeping him up, the horse kept wanting to lay back down.   There was also a large hole in the side of the horse’s stall.

The owners and our receptionist, I think, thought that there was some sort of head trauma, seizure, or other neurologic issue.  But when I hear of a combination of head abrasions and a horse wanting to lay down, I think colic.  Bad colic.  Abdominal pain so severe that simply laying down and rolling was not enough.  This horse was thrashing so hard that he put a hole in the wall, and cut up his head. 

I got there as fast as I could, and found a horse dazed and dull, stumbling and trying to fall.  His owner was at his halter, trying to lead him around.  His head looked like a boxer who just lost the fight of his life; both eyes nearly swollen shut, the hair rubbed raw from the temples, the ears red and swollen. 

It’s awful, but I can almost make the diagnosis just by looking at these horses.  Only very severe abdominal pain causes a horse to do this to himself, and it usually means something is twisted.  In an older horse, fatty (benign) tumors develop in the abdominal cavity, and can become wrapped around the intestine.  We call it a “strangulating lipoma”.  They are common, and strike without warning.  They are by far the first thing I think of in these cases.

But I’m not the type of doctor that makes assumptions, so I proceeded to spend the next 30 minutes proving my theory to myself.  A brief physical examination (you can’t do more than “brief” when the horse is trying to throw himself on the ground) revealed that his heart rate was significantly elevated.  This means pain, plus usually dehydration.  There were no gut sounds to speak of, another point for colic.   I gave him several drugs to keep him comfortable, which were minimally effective.  A rectal examination revealed dilated loops of small intestine.  Small intestine should be very hard to feel rectally – these felt like water balloons. 

So the diagnosis of colic due to a small intestinal problem was made.   But now I needed to know if this small intestinal issue was due to a strangulation.  If the intestine gets twisted, the blood supply gets cut off and the tissue begins to die.  The only way to correct this is abdominal surgery, which isn’t financially feasible for many people.   So if I can make this diagnosis on the farm, I can prevent an owner from committing to bringing their animal to a referral clinic, only to euthanize their horse later when they cannot afford surgery.  I performed a “belly tap” – essentially, I passed a blunt instrument into the abdominal space, sterilely though the skin, to sample the fluid that bathes the intestine.  Normal abdominal fluid is clear and yellow.  When a section of small intestine becomes compromised (due to a twist), the blood vessels get leaky and the fluid becomes red. 

Let me just give you a small glimpse into the intensity of equine emergency medicine, for a second.  It’s a simple thing, I suppose, to just say “sample the fluid that bathes the intestines”.  However, in health this amount of fluid is very small.  Disease processes help us out by increasing the volume.  But it is still relatively small, and tends to settle at the most depended part of the abdomen.  So, in a colicking horse who is actively trying to throw himself on the ground (or heavily sedated so that he is swaying and stumbling), I am bent underneath the horse, clipping a small section of the lowest part of the belly, and then scrubbing it, rinsing with alcohol, blocking with an injection of lidocaine, scrubbing and rinsing again… and then donning sterile gloves, making a small incision in the skin, and passing a blunt instrument through several layers of muscle into the abdominal space… and then with my third hand, collecting the fluid that runs out.  All while bent over, underneath a colicking horse.  It’s no wonder our disability insurance  is so high.

The fluid was red.  It was time to make some decisions.  The owners elected euthanasia.  I can’t blame anyone for this decision.  As I tell my clients, if I had a horse, I couldn’t afford colic surgery.  (This is, partially, why I don’t have any horses.  But that is besides the point.)

All of this, believe it or not, is actually not that out of the ordinary for me.  It sucks, and it wears on you, but it’s life, and I can take comfort in being able to end this horse’s pain swiftly.   During this entire appointment, and during the euthanasia, there was an occasional low, tolling bell.  I think it was a wind chime, but it caused just a single, low “bong” every once and while.  It seemed so appropriate, it just really struck me.   I read “For Whom The Bell Tolls” by Ernest Hemmingway when I was a senior in high school, and wrote a big paper on it.  I don’t remember much of the book, but the quote by John Donne, from which the title of the book was taken, has always stuck with me:

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.”

Sometimes this job just gets to you.  We lost another horse at the clinic today, another colic, but one that I’ve taken to surgery once before.  He had finally recovered well enough that he was putting on weight from his first surgery, and back to being ridden.  It seems he was destined for this problem. 

And we had a foal born early this morning; new life, new opportunity.  Hopefully this one has a long and colic-free life.  The cards are against the “colic free” part, unfortunately.

When did I become such a pessimist?  Sigh.  Time for bed.