Don’t Be Too Smug

D. E. Larsen, DVM

I pushed the winch out to the end of the track and jumped up on the truck’s bed. I secured a chain around the hocks of the dead horse. With the shackle secure, I connected the hook on the winch cable to the chain and lifted the horse up and pushed it into the necropsy room.

This was the summer of my sophomore year in vet school. I was lucky enough to land this job as a necropsy technician in the Colorado State Veterinary Hospital. Up to this point, it was proving to be a tremendous learning experience.

There was a joke in the profession that had a punch line something like; a veterinarian can eat his mistakes. I was never good at remembering jokes. This summer, I got to see the mistakes and the pathology associated with the profession.

I positioned the dead horse in the middle of the necropsy room and lowered it to the floor. I unhooked the winch and removed the shackles, before rolling the winch to the side, out of the way for now.

Dr. Norrdin was on duty as the necropsy pathologist this week. I enjoyed working for him because I got to do most of the necropsy, and he was always challenging my knowledge, usually in a game-like manner.

“Okay, let’s look this guy over closely, read the notes and then come up with a possible diagnosis before we start the necropsy,” Dr. Norrdin said. “You have to be prepared to defend your suspected diagnosis. Then we will find out who was closest to the actual diagnosis.”

This was a young horse, less than four years old. Found dead in the paddock this morning. He was never observed to be sick, ever. Looking over him, there was hardly a mark on him. The only thing evident was his front teeth were punched through his upper lip and protruding out of that lip.

Dr. Norrdin quizzed the resident first, the junior technician next, and finally came to me.

“What is your diagnosis, Larsen?” He asked.

“Cardiac Tamponade,” I said.

“Cardiac Tamponade!” Dr. Norrdin remarked. “How in the world do you arrive at that diagnosis from looking at a young, healthy horse?”

“A young, healthy, dead horse,” I corrected. “This young heathy horse, who has never been sick a day in his life, was dead when he hit the ground. His death was sudden. We know that, not because he was unexpectedly found dead in the morning, but because his front teeth are punch through his upper lip. He hit the ground nose first. Who has seen a horse, standing in a paddock, fall nose first? This had to be a sudden cardiac event.”

“But Cardiac Tamponade,” Dr. Norrdin said, “I have not seen a Cardiac Tamponade in the horse. You know the saying, when you are in a barn and hear hoofbeats, you look for a horse, not a zebra.”

“And, the proof is in the pudding,” I said as I stuck my knife into the dead horse’s ventral midline on his chest.

“If I am correct, we will know in a minute or two,” I said as I sliced open the skin from the end of his sternum to his jaw’s angle.

With the junior technician lifting up the right front leg, I severed all the muscle attachment to the ribs, and we reflected the front leg over the horses back to expose most of the ribs. Then I severed the lower cartilage attachments of the ribs to the sternum. The other technician, standing at the horse’s back, pull up several ribs as I cut the intercostal muscles. 

There is was, the pericardium, that sack around the heart, distended with blood. I was vindicated, my diagnosis was spot on. Cardiac Tamponade occurs when the pericardium fills with fluid, usually blood. That constricts the hear’s function. If it is a slow accumulation, it can be recognized and corrected. If it is sudden, it results in sudden death.

“I’ll be damn,” Dr. Norrdin said. “Now, let’s find out just what happened to allow Larsen to win the game.”

“Verminous arteritis,” I said.

“Now you are really sticking your neck out,” Dr. Norrdin said. “But this time, I think you are probably correct.”

We opened the pericardium and drained a surprising amount of blood. The heart was small in appearance because it had not been able to fill with blood. And there it was, a hole in the aorta, right where it came out of the heart. This hole, the size of a match stick, would have filled the pericardium with blood in seconds. A very sudden death would have resulted.

“You guys pull the heart and lungs with the aorta attached,” Dr. Norrdin said. “Try to keep the aorta intact all the way down to the mesenteric artery.”

In the horse, one of the critical intestinal parasites, a large strongyle, Strongylus vulgaris, has a larval stage that causes severe damage and inflammation to the mesenteric artery, the main artery to the gut. This is one of the leading causes of colic in the horse.

We opened the aorta from the heart to the mesenteric artery. There were lesions the entire length of the aorta. The root of the mesenteric artery was swollen and heavily involved with verminous arteritis. This is the standard location of those lesions. The fact that lesions were also located along the entire length of the aorta was an indication of a massive infestation with this dangerous parasite.

“If this horse did not die from this cardiac tamponade, he would have died from severe colic before long,” Dr. Norrdin said. “This is as extensive of an arteritis as I have ever seen.”

“Do you think the rupture of the aorta was caused by the parasite?” I asked.

“Oh, most definitely! This owner needs to get his horses on a rigorous parasite control program, or he will be losing a lot of horses,” Dr. Norrdin said. 

“And Larsen, don’t be too smug,” Dr. Norrdin said. “You will never see another case like this in your life. These once in a lifetime cases, just happen, early in your career and later in mine, but only once. Had this been on a test, all of your answers would have been marked wrong. You just had a lucky guess here today.”

Of course, Dr. Norrdin was correct. I never saw another case like this. I never read of another case like this. But having seen the damage from uncontrolled parasitic infections, it is much easier to make strong recommendations to horse owners about their parasite control programs.

Photo Credit: Photo by Pixabay from Pexels

Back to Her Old Self

D. E. Larsen, DVM

“I know you don’t believe me, Doctor,” Althea said. “But she is just not herself.”

Penny was a yellow lab cross, maybe more reddish than yellow, and smaller than most labs. Her toenails were long, causing her to be unsteady as she thrashed about on the exam table. Penny was one of those dangerous, friendly dogs. If you got too close, she would lick you to death.

Althea was a slender middle-aged lady who noticed our clinic while she was doing laundry next door. At one time in her life, she had been a medical technician. Now she worked nights at the hospital, transcribing records.

“I am finding it hard to think she is sick,” I said. “I don’t see too many sick dogs dance around on the exam table like this. Let’s draw some blood, and I will give her an antibiotic injection. We won’t have the blood results until morning. You can take her home, and I will give you a call when I get the results.”

“I feel a lot better with you running some blood on her,” Althea said. “And I am sure she will be more comfortable at home.”

“We can set up an appointment to recheck Penny in the morning about 9:00. We should have the blood results by then.”

Collecting a couple of tubes of blood from Penny was somewhat difficult. She was bouncing so much it was almost impossible to restrain her enough to get the needle in a vein. The blood collection was followed by an injection of Ampicillin. Then I lifted Penny down to the floor. She was instantly dragging Althea toward the outside door,

“I will get the appointment written down,” I said to a struggling Althea who was having trouble bringing Penny to a stop at the front desk. “We will see you both in the morning.”

I scanned the values quickly when Judy handed me the results of the blood work the next morning.

The white blood cell count jumped out at me, 29,000 white blood cells. There are not too many things that will cause that high of a number in the dog. But Penny was an older, intact female. A pyometra, a pus-filled uterus, was high on the list of possibilities.

“I think you should clear the schedule for the morning,” I said to Judy. “I am betting that we are going to have to schedule surgery for Penny.”

Right at 9:00, Althea came through the door with Penny. Penny was still bouncing around on the end of her leash.

“I know she still looks fine to you,” Althea said. “But she is even slower this morning. And I noticed a little vaginal discharge this morning.”

“Well, her blood results got my attention this morning,” I said. “Her white blood cell count was 29,000. In an older, intact female dog with vaginal discharge, the diagnosis is a pyometra, pus-filled uterus, until I prove otherwise. We can easily confirm that diagnosis with an x-ray.”

“I am on somewhat of a budget here,” Althea said. “What are the treatment options, and can we do those without the x-rays?”

“There are no options, the treatment is surgery,” I said. “We have to get that uterus out of there before we get into all sorts of complications. Surgery is diagnostic also. If we are correct, we save the cost of the x-rays. If it is something else, then we are back to square one. But doing an ovariohysterectomy while we are there would be to Penny’s benefit.”  

“I think with my funds, we should just go right to surgery,” Althea said. “You can call it an exploratory.”

“That sounds good to me,” I said. “I am pretty confident of the diagnosis, especially with the vaginal discharge this morning. We will give her a bottle of fluids before surgery and continue the fluids during surgery. It would be a good idea to keep her overnight, but we can make that decision this afternoon.”

With that, we got started getting Penny ready for surgery. Althea was right, she was slower this morning. As we worked through the preoperative exam, I noticed that the vaginal discharge was increasing. She was dripping a foul-smelling vaginal discharge onto the exam table.

We got an intravenous catheter into her cephalic vein on a front leg and started a bottle of Ringer Lactate. I added a dose of IV antibiotics to the fluids, and we made Penny comfortable in a kennel while we set up the surgery room. I wanted to get the whole bottle of fluids into her before we started surgery.

With the catheter and the fluids already set up, anesthesia was easily induced. A good dose of Pentathol, and then with an endotracheal tube, we hooked her up to the Metaphane gas machine. When we got her on her back, it was evident that her abdomen was full, and the uterine discharge was really going now. 

Often a pyometra will start with a closed cervix. The pus that develops due to chronic overstimulation of the uterine lining from estrogen just accumulates in the uterus. The uterus can reach a large size, at least as large as a full-term pregnancy, if not larger. When the cervix opens, a lot of the pus is discharged, and the dog may feel better for a time.

When we had Penny’s belly prepped for surgery and a second bottle of fluids started at a slow drip, I pulled on a pair of gloves and opened the surgery pack. In the mid-1970s, I wore a surgical mask, but I did not gown for surgery.

I started with a small midline incision. As soon as I could see the size of the uterus, I extended the incision to about six inches. Then very gently, I eased the right uterine horn out of the abdomen and laid it out on the surgery drape. Then I did the same with the left uterine horn. 

This was one large uterus. In school, during my junior year in my surgery rotation, I had assisted with the ovariohysterectomy of a very pregnant Saint Bernard. With a third trimester pregnancy, that uterus was large. This uterus, on a much smaller dog, was just about that size. 

I clamped the ovarian vessels, ligated them with 2-0 Dexon, used scissors to severe the broad ligament from the uterus along each uterine horn. There were a couple of larger vessels in the broad ligament that needed ligation. Then I clamped the uterine body at the level of the cervix and ligated the middle uterine vessels. I separated the uterus between two clamps, and with great care, not wanting to rupture the uterus at this point, I transferred the entire uterus to a disposal bucket. I took a deep breath with that container of pus safely disposed of in the bucket.

Now it was simple, I oversewed the uterine stump and returned it to the abdomen. Then just to make sure there was no contamination from the uterus, I changed gloves, surgery pack, and drape. Then I closed the abdomen in a standard three-layer closure.

With the slow recovery from Metaphane, I turned off the gas when I started to close the abdomen. By the time I finished closing, and we got Penny cleaned up, and back to the kennel, she was just beginning to wake up, and I was able to pull the endotracheal tube.

Wow, just wow. Penny wakes up, and she is back to her old self. It is always amazing when you remove a bucket of pus from a dog’s abdomen.  Then give her some antibiotics and a couple of bottles of fluids. With Penny, she was bouncing off the walls of the kennel.

We pulled the catheter and checked her over. Everything was in order, and the incision looked good.

“You need to give Althea a call,” I said to Judy. “I think we can send Penny home anytime this afternoon. She will surely be quieter at home than she is here. We will check her back in a day or two, depending on Althea’s schedule, to make sure things are going along okay.”

Althea was pleased, Penny was jumping all over herself when Althea showed up. I was happy to see Penny pull Althea out the door.

The recheck was quick, Penny was almost uncontrollable. I mainly wanted to check the incision. It was fine.

“I told you the first time you saw her,” Althea said. “Now, you can see that I was comparing her to her regular activity level.”

Photo Credit: Photo by 42 North from Pexels

Who Pays Who

D. E. Larsen, DVM

Johnnie was waiting at the old barn when I pulled off the road. I stopped in front of the barn.

“I have her in the far side of the barn,” Johnnie said with some excitement in his voice. He rested with his elbows on the hood of my truck.

“Is this her first calf?” I asked.

“Yes, and she is sort of a little thing,” Johnnie said. “I have been watching her pretty close, and she has been pushing for a couple of hours. I don’t see anything.”

“Let’s go get a look at her,” I said as I gathered things from my truck. “Will I need a rope?”

“You probably will, she is just loose in the old milking side of the barn,” Johnnie said.

Johnnie was sort of a fixture around Sweet Home. He was probably as old as the barn. Not a large man, but he had a hidden strength and endurance. His gray hair, mostly uncombed, framed his wrinkled face that carried a constant smile. A little chuckle punctuated his conversations. Johnnie came from another generation. He was not a man to ask for help often, and when he did, he would be right there to help the helper.

I had attended a continuing education conference at Colorado State some months before this call. I was talking to an older veterinarian there, telling him about this vet I knew who didn’t carry a rope. 

“Hell, if I didn’t have a rope, I would starve to death,” the old vet said.

That was my thought as I returned to the truck to retrieve my rope.

We entered the barn through the exit door to the milking side. The heifer scrambled to her feet as soon as we entered. She was still pushing as she walked to the far corner and laid back down. I walked up to her, threw the rope over her head, and she did not budge. I fashioned a halter with a loop over her nose and tied her to the stanchions corner. 

I turned around to get my stuff and almost bumped into Johnnie. He was standing there with my bucket of water and calf puller in hand.

“Aw, thanks,” I said. “But you probably want to stand back a little in case she starts dancing around on the end of that rope.”

“I’ll be right here if you need any help,” Johnnie said.

I washed the heifer up and tied her tail out of the way. She was really pushing now, and I could see a foot and the nose of the calf. 

“It looks like it is coming now,” Johnnie said.

I reached in and explored the calf’s position. There was only one front leg was in the birth canal. I plunged my arm in up to my shoulder, and the heifer strains hard, I vocalize.

“What’s the matter?” Johnnie asked as he is standing where a kick by the heifer will knock him right off his feet.

“There is one leg back,” I said. “I don’t have room to reach it. So I am going to put a strap on this leg, return it to the uterus, so I will have room to reach the other leg. Once I get it up, I will be able to pull this leg back into position with this strap.”

That sounded easy when I explained it. This was not something I did every day. I could only remember one other time I had to use this technique. 

It worked like a charm. Pushing the leg back into the uterus gave me ample room to reach deep into the other side, and grabbed the other leg by the cannon bone. I pulled it up the brim of the pelvis and popped the foot into the birth canal. Then with a little pull on the strap attached to the first leg, I had the calf in normal position.

Now came the easy part. I just had to hook up the calf jack and pull the calf out. It should be no problem.

Johnnie was already pulling the parts of the calf jack out of the carrying case. At first, I thought I would just ask him to busy himself elsewhere. But I decided just to use this as a teaching moment. The instruction should keep him occupied.

I started grabbing the parts from Johnnie and explaining how everything went together. He listened with genuine interest. It only took a couple of minutes, and everything was put together.

“Now we just have to position the butt plate below the calf, hook the straps onto the jack, and crank him out of there,” I explained.

Johnnie took that as instruction as to what he was to do. 

Here we are, the heifer is straining, Johnnie and I are struggling to see who gets to put the calf jack in position, and I am sure I am not going to get through this without this old man getting injured.

“Okay, I am all hooked up, and I am going to start pulling this calf,” I said. “When I do this, I am going to pull the end of the bar down toward her feet. So you want to stand over there, behind her back. You might want to sort of hold her steady while I start this pull.”

That worked for a few seconds. When the calf’s head and shoulders cleared her vulva, Johnnie was right there to start clearing mucus from its nose and mouth. Then as I pulled down on the bar to help the hips clear the pelvis, Johnnie was coming around behind me. 

Finally, the calf popped out. 

“Look at that little fella shake his head,” Johnnie chuckled as he helped me pull him away from momma. The heifer jumped up and swung around on the end of the rope, almost knocking Johnnie over.

“I’m okay,” he said as I grabbed him by the arm to steady him. 

With the heifer on her feet, I pulled the calf over under her nose and untied the rope. Then I stuffed everything into the bucket and disassembled the calf jack. 

As we waited a few minutes to make sure the calf was going to be okay, I glanced around the barn. 

“Did you milk cows here?” I asked Johnnie. 

“Oh yes, I milked cows, but that was years ago,” He said.

I looked at some of the old tools hanging on nails along the side of the stall. An old jar of some kind of medicine caught my eye. It was stuck in the corner of a brace that was holding the upper floor. I reached up and picked it up. There was a label on it, probably readable years ago but not now.

“What is this stuff?” I asked Johnnie.

“I don’t rightly know,” he said. “But it is good stuff. I had this growth on my leg, and the doctor wanted to cut it off. The growth, not my leg. I was out here in the barn cleaning things up one day, and I noticed that jar, sorta just like you noticed it. Anyway, I thought, what the heck. I started putting that stuff on my leg, every day for week or so. And to my surprise, that growth just fell off. The old doctor just shook his head.”

“That is quite a story, Johnnie,” I said. “Maybe we should find out what is in this stuff.”

“Naw, we will just leave it right where it was, I might need it again someday,” Johnnie said as he carefully replaced the jar to its resting place.

I was planning to make a couple of trips back to the truck with all my stuff, but Johnnie was right there to drag the pieces of the calf jack along behind me, almost tripping as he made his way out of the barn.

“That calf is going to be fine,” I said. “I would just leave them in there until later this afternoon, make sure the calf is up and nursing.”

“Okay, Doc, I will stop by the office and pay you in a couple of days,” Johnnie said.

“I don’t know, maybe I am the one who should be doing the paying, for all your help this morning.”

Johnnie just snickered and waved his arm as he headed back to the barn to check the calf.

Photo credits: Miner Ranch

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