Thursday, 1/28/10 First Veterinary Tale

This is the first entry on my blog. I am a large animal veterinarian in Reno, Nevada. I've been here for 14 years, operating my own solo ambulatory practice. My patients are 90% horses, 8% alpacas and 2% oddities (potbellied pigs, goats, tigers!). This blog will be the initial outlet for chapters of a book I currently am writing. It's a modern day James Herriott - stories of my life as a rural veterinarian and of my life as me. I also promise to post a veterinary Tip of the Day on this blog every day - so that's the plan. Here we go. The first chapter of the book is called "All Bleeding". Today's Veterinary Tip of the Day is:
All brood mares should be vaccinated 4-6 weeks before they foal to boost antibody levels in the mare's colostrum. This is the first milk consumed by the foal and is the newborn's only source of antibodies against common diseases in the first weeks of life.

Here's the story:

“All bleeding eventually stops.” This favorite adage of an old surgery professor haunted me as I groped in Brandy’s chest, blindly searching for a primary bleeding site. The emergency call had come through on my cell phone 30 minutes ago, just as I was finishing the last farm call of a long day of farm calls. I answered at the second ring, but before I could complete my standard perky greeting , “Hello, High Desert Vet,” I was cut off by a rapid, panicky voice saying,

“Dr C? Dr C? Is that you? She’s bleeding, it’s really bad, there’s blood everywhere – I can’t stop it….”

After 18 years as a practicing large animal veterinarian, I would be a liar if I didn’t admit that these client’s cries of distress don’t send my heart racing the way they once did. I counted to three and dove in, attempting to stem the flow of words coming through the phone and get the caller’s attention.

“This is Dr. Collatos, can you hear me? Hello? Hello? You need to stop talking and breathe slowly. STOP TALKING and TAKE A BREATH. I can’t help you because I don’t know who you are or where you are.” After a few repetitions of similar phrases I finally heard silence on the other end of the line. I stopped talking and listened again.

“It’s Wendy up on Thoroughbred Circle. Brandy’s bleeding really badly, you need to hurry, and I don’t think she can stand much longer.”

The caller was a very good client who typically had a pretty cool head on her shoulders, but no matter how clearly I explained to her that Brandy had more than 10 gallons of blood in her body and could lose 2-3 GALLONS of it before there is a crisis she continued to insist that her horse was bleeding to death and I needed to HURRY UP AND GET THERE.

So I did, and she was right. I stepped down from my truck and began to walk toward Wendy where she stood holding the mare, tears streaming down her face. Then I started running. The mare had impaled herself on a metal T post, leaving a gaping wound the size of my fist right where the front leg attaches to the chest. That alone wouldn’t make me run, but Wendy was right again - there was blood everywhere, and more pumping from the wound at an alarming rate. I almost never run toward horses – it just isn’t a good idea – they tend to think you have bad intentions when you rush at them and they react accordingly which can be a dangerous thing and lead to bodily harm - but based on the amount of blood I could see on Wendy’s clothes, the mare’s leg, and the ground, I decided that running was worth the risk. I grabbed some supplies from my vet box, then kept right on running until I reached the horse. After wasting 5 minutes with futile attempts to visualize and clamp the major vessel pumping arterial blood (it turned out to be the brachial artery) I realized that this horse was going to die with both my hands in her chest if I didn’t come up with Plan B.

Plan B consisted of the very unsophisticated but effective technique of applying non-specific pressure to control the bleeding. I achieved this by packing the wound as tightly as possible with 4 rolls of brown gauze, each 12 feet long and 6” wide, and then suturing the skin closed over the gauze to put pressure on the bleeding site. I was careful to tie the end of each roll of gauze to the next roll and to keep track of how many rolls I used to ensure that whoever (hopefully not me) unpacked the wound would be able to account for all the gauze. With the skin successfully closed over the packing, I stepped back and turned to Wendy, Brandy’s owner, and gave her a warm, reassuring hug (all the while thinking Oh Man, this is a bad one).

Wendy’s face was streaked with tears and she was literally soaked in blood from her waist down. Brandy stood quietly, trembling slightly, and I silently thanked her for being so calm and cooperative as I had worked frantically on her wound. At this point I listened to her heart and lungs and completed a quick physical examination checking for other wounds and for any indication that the T-post had penetrated through her chest wall and entered her thorax. Brandy’s lungs sounded normal and although her heart rate was elevated, it was clearly audible with a regular rhythm. These were positive findings, and even better, the compression bandage appeared to be working, as there was no blood penetrating the skin edges where they were held together over the gauze.

I was feeling guilty for having doubted Wendy’s assessment of the seriousness of Brandy’s injury. The fact of the matter is that truly immediately life-threatening emergencies are fairly uncommon in equine practice. But in this case had I dawdled just a few minutes longer my patient might not have survived. Realizing this, I silently chastised myself as I prepared to discuss the next step in saving Brandy. Before I could speak, Wendy gave shaky laugh and said,

“Oh my God, Chrysann, I’ve never seen so much blood.”

“To tell you the truth, Wendy, I didn’t believe you when you told me on the phone that it was this bad and I apologize for that.” I have this somewhat irritating addiction to ruthless honesty. My friends hate me for it at times, it got me a divorce, and an attorney would tell me I was nuts to say this to a client because now if the horse died she could blame me. But there you go, I’m just that way, and I believe most of my clients appreciate this quality in me as a professional, and usually it works out in my favor.

“It’s OK, Chrysann,” Wendy smiled, “I was standing here looking at it and I didn’t believe it either. What do we do now?”

I explained to Wendy that the compression bandage should not be disturbed for 48 to 72 hours, by which time the body should have done it's amazing work in controlling bleeding and preventing its recurrence. However, if things went wrong and Brandy began to hemorrhage again when the packing was removed, I wanted her to be standing in a veterinary hospital, not Wendy’s back yard. The blood loss she had suffered already was severe enough to warrant intravenous fluid support and possibly a whole blood transfusion to ensure that she maintained adequate blood flow to all her vital organs. My recommendation was to observe her for an hour, and if her condition remained stable, transport her to UC Davis Veterinary Teaching Hospital, a 3 hour drive away, for supportive care and further evaluation.

Wendy agreed with the plan, and while we waited to be sure she was stable enough to make the trailer ride to the hospital I placed an intravenous catheter in her jugular vein and began administering IV fluids. Based on Brandy’s body weight and estimated blood loss I calculated that she needed at least 10 liters of replacement fluid. After years of bouncing numbers around in my head, the mental conversion from pounds to pints to liters was second nature, and I performed these mental gyrations while casting an eye around Wendy’s horse enclosure. Always a bigger challenge than the fluid requirement calculation was figuring out how to hang awkward, heavy 3 liter plastic bags of sterile polyionic fluids above the horse ‘s head safely and securely so that they would flow by gravity through the IV line into the jugular vein. Before moving to Nevada and setting up my solo ambulatory equine practice, I had worked as a referral internal medicine clinician in large university hospitals where there were usually 2 students, an intern and a licensed veterinary technician on hand to help out in these situations, not to mention up to date facilities with all the bells and whistles designed to expedite the treatment of large equine patients. The transition to life in rural northern Nevada veterinary practice had taxed my creativity at times, but even after all these years I continued to be amazed at what you can do in a pinch with a little imagination, a good cotton rope, and some muscle.

I identified a beam that would serve as a reasonable emergency IV pole. Scrambling up the side of a stall, I hung one leg over the 2 x 6 at the top, tossed a cotton rope with a heavy snap at one end over the beam and hooked the bags onto it while Wendy held the end of the rope tied off below me. Go figure, but during these gymnastic capers I often find myself distracted by the natural beauty of Nevada, probably in an effort to forget how far I am from those high-tech days of hospital practice. So there I am, doing a fairly admirable imitation of a Russian trapeze artist when I find myself captivated by the view of the snow-capped Peterson range that looms up behind Wendy’s house and fills the space between the barn rafters from which I dangle.

The top of the Peterson’s is 8,000 feet above sea level. Wendy’s property sits around 5,200. The high desert of Northern Nevada is sand and sage brush, mile after mile, but as you look up the Peterson’s the subtle desert hues are interrupted by rich green explosions where winter snow pack fed springs erupt from the ground. Clusters of willows and quaking aspens cling to the steep grade around the springs, and even higher perches a lonely stand of rare pine trees, many of which have been burned to skeletons by brush fires over the years. These ancient sentinels of the desert emerge from steel grey rock outcroppings close to the summit of the Peterson range right above Wendy’s home. In Nevada your eye never needs to stop, as over the summit extends the enormous intense blue sky of the West, punctuated on this day by a few cotton candy clouds indicating high winds in the upper atmosphere. All of this beauty sweeps across my vision as I finish hanging Brandy’s fluids and make my descent from the rafters. There are days when I miss my fancy hospital practice, but every time I hang from someone’s barn beam and find myself with an eyeful of the natural beauty that surrounds me here in Nevada I know that I am where I belong, with Wendy and Brandy.

Brandy remained stable and Wendy transported her to the University of California Veterinary Teaching hospital just west of Sacramento where she spent several days. She received a whole blood transfusion and underwent several uneventful bandage changes on her way to a full recovery. After seeing her safely off in the trailer, I drove home, fed the critters, gulped a glass of Chianti and bolted some leftover pizza. I then doggedly sat down at my desk and returned what felt like a hundred phone messages, confirming appointments and checking on patients I’d seen earlier that day, then organized my call book for tomorrow, thought about stocking the truck, thought about stocking the truck again, started to think about stocking the truck a third time and gave up, took a shower and went to bed.