The Doctors Voss

I need to preface this little story. Dr. Voss was a Equine Ambulatory Veterinary at Colorado State University during my years as a student at that school, (1971 – 1975). He was an excellent instructor and veterinarian and very well liked by all the students. He went on to become Dean of that school and was held in such esteem that the new teaching hospital was named after him. This story is of a young instructor, adored by his students, and should be taken only to add to his esteem.

D. E. Larsen, DVM

When I was in Veterinary School, there were two doctors in town with the name of Voss. The older Dr. Voss was a well respected OB/GYN doctor; the younger Dr. Voss was a horse doctor.  He was in his mid 40’s and very well liked by all the students at the Veterinary School. 

  The young Dr. Voss was known to be quite a storyteller in the classroom or on farm calls.  He told stories to keep the atmosphere light, but he also used stories to drive home a point he was trying to make to the students.  

  One of his favorite classroom stories he used was to make a point about double checking yourself before administering a medication.  He always said, look at the bottle when you pick it up, look at it when you are drawing up the dose and then look at it again when you set it down.  That’s a good point, but students learn better with a story to illustrate the point.

  Dr. Voss had a story to go with that bit of instruction.  It was about a call for a horse with colic.  Doing a rectal exam on the horse, he could determine there was an obstruction at the colonic flexure.  He had administered mineral oil via a stomach tube and given a dose of pain medication.  Now he was planning to give a dose of medication to relax the contractions of the gut, allowing the mineral oil to work through the gut and loosen the obstruction.

  Dr. Voss continued the story: he grabbed the bottle of medication from the truck and drew 10cc into the syringe.  He walked over and administered the dose via the jugular vein.  When he returned to the truck to put the bottle away, he realized that it was the wrong medication.  Instead of relaxing the contractions of the gut it would cause strong contractions.  In the horse with an obstructed colon, this would most likely cause a rupture of the colon and a dead horse.  

  Realizing his mistake, he returns to talk to the owner.  “I think this horse is in a lot worse shape than I originally thought,” he says.  “I think this horse is probably going to be dead by morning. Not much more that we can do at this time.”

  The owner calls the hospital the next morning and reports that indeed the horse is dead.  Then he concludes,  “That Dr. Voss is the best veterinarian we have ever had on the farm. He predicted that death exactly.”

  The class roars at the story. The point is made and will be remembered by everyone for the next 50 years. And they didn’t have to make a single note.  It conflicted with the philosophy of honesty and transparency in treatment and medical records, but the critical point is there.  Was the story true?  Probably not, Dr. Voss was far too good of a doctor to make such an error, but nobody asked that question.

  The young Dr. Voss regularly hosted a large group of senior students at his house for poker parties.  Not a lot of money involved because most of us had very limited funds, but penny ante poker, a beer or two and good times.  On one such evening, the phone rang. 

  Dr. Voss answered the phone, “Hello, this is Dr. Voss, how can help you?”

The call gives everyone an early lesson on how the telephone was going to dominate our lives in the years to come.

  “Yes, this is Dr. Voss, what can I help you with Kathy?” he repeated into the phone.  The room was silent with all attention to the phone call.  The night crew at the veterinary hospital would take care of any emergencies, so this must be a unique client.

  After a brief silence Dr. Voss exclaims, “Oh, I see!”

A long silence this time, then another comment “Oh my!”

Then a more extended silence, “Oh, my gosh.”

Another long silence, everyone is straining to hear the call.  Dr. Voss finally speaks, “Well Kathy, I don’t know, but I can’t be of much help to you. You see, I am Dr. Voss, the horse doctor.”

 There is a brief moment of silence and then a loud ‘click’ that can be heard across the room as the Kathy slams the phone down.

  Dr. Voss hangs up his phone and beams with a broad smile, “I guess she wanted the other Dr. Voss,” he says.

  The room erupts in chaos as everyone tries to pump Dr. Voss for details.  What an evening. 

On a Thanksgiving Eve

On a Thanksgiving Eve 

D. E. Larsen,DVM

The barn was cold, but there was steam rising from the back of young heifer. A dusting of snow on her back was melting fast.  Bill and Connie Wolfenbarger had called with a heifer in labor.  They were not regular large animal clients but did visit the clinic with their small dogs.  I had been to their place several times to treat cows belonging to the Gilbert’s.

    When they discovered a tail hanging from the heifer’s vulva, they knew they had a problem. This meant the calf was in a true breech presentation and almost certainly dead. In a true breech position, the calf does not engage the cervix, and the cow doesn’t go into hard labor.  Most people will not notice a problem until the calf has been dead for a day or two.

    Tomorrow was Thanksgiving, I would miss some of the prep for the family dinner. The evening snowfall was light but continuing. Hopefully, I could make it home before the roads became a problem. Sandy’s folks were already at the house, so we didn’t have to worry about anybody traveling tomorrow.

    I tied the heifer’s tail out of the way and started to wash the her rear end. The hair on the tail came off with the slightest touch. I pulled on a plastic OB sleeve onto my left arm. With a little lube on my hand, I eased into her vulva to explore the birth canal. She strained hard when I reached the butt of the calf. No fluid was expelled with the strain. I pushed the rear of the calf with a couple of fingers. There was a spongy consistency under the skin and some crackling like I was popping air bubbles. The calf filled the entire birth canal, I could not advance my hand into the uterus, and I could not move the calf, it was wedged solidly into the birth canal.  I withdrew my hand, the sleeve was covered with hair from the calf and the odor was slightly pungent.

    “This calf has been dead for over a week,” I said as I removed the sleeve. “It is emphysematous, blown up with gas, I am not sure I am going to be able to get it out of her.”

    “What are our options?” Bill asked.  I knew their daughter was a small animal veterinarian, maybe in California. I did not know her, but I would assume they would be a little more knowledgeable than most clients.

    “Options are not many, the calf is in a breech position. That means its’ hind legs are retained and only the rump is presented. It is blown up so much that I cannot even insert my hand into the uterus. We are not going to be able to deliver this calf vaginally. I try not to do a C-Section on a dead calf, but with all the emphysema I won’t be able to do a fetotomy.  That leaves us with two viable options. Option one is a C-Section, which will be with risk and will be difficult.”

    “And the second option?” Bill asked.

    “The second option is to get your rifle and shot her now. It would not be fair to her to leave her in this situation,” I said.

    “Let’s do the C-Section,” Bill said.

    I double checked her halter to make sure she would not be choked if she went down. Then I change the tail, tying it to the right side. I placed a rope around her neck with a bowline and ran it along her side and tied it to ally fence, holding her against the fence. With her in a reasonably secure position, I clipped a wide area on her left flank, from her dorsal midline to her bottom of her flank.

   I prepped her flank with Betadine Surgical Scrub. The with 90 ccs of 2% Lidocaine, I did a large inverted ‘L’ block of her left flank. I blocked a wider area than usual because I may need to make a longer incision than is usually required. This was not going to an easy procedure. I repeated the prep after the block.

    After laying out the surgical pack and supplies, I pulled on a pair of surgical gloves, more to keep my hands clean than to pretend that this was going to be a sterile procedure.

    “We have a couple of major risks with this surgery,” I explained as I prepared to make my incision.  “The first one is that it is going be difficult to pull this uterus to the incision and second when I open the uterus, there is going to be no way to prevent the contamination of the incision and the abdomen. We are just going to have to depend on antibiotics.”

    Bill nodded, and I made a long incision down her flank, starting a few inches below her transverse processes and extending about 15 inches down her flank. The skin and subcutaneous tissues parted easily. Then I incised the muscles of the flank, they quivered as the blade divided them.  When I incised the peritoneum, the abdominal content did not sink away from the incision with a characteristic rush of air into the abdomen. The distended uterus filled the entire abdomen. There was no trouble finding it or worry about moving the rumen to externalize the uterus. The abdomen was filled with the uterus. 

    I reached into the abdomen to the tip of the uterus. Cupping my hand around the tip of the uterine horn, I pulled. The uterus did not move. I tried to rock the uterus in the abdomen. Sometimes you could swing the uterus enough to make it easier to bring it to the incision. This uterus did not budge. Again and again, I tried to bring the uterus to the incision.  I searched and found a hoof, I could not move the hoof.  

    I pulled my arm out, stretched and changed gloves. It this cold barn, but I was sweating profusely.

    “Do you think I could give you a hand?” Bill asked.

    “We might try that, if we could both get a hand under the end of the uterus, we might be able to make it move,” I replied.

    Bill stripped down to his waist and washed his hands and arms thoroughly.  I stood on the head side of the incision and ran my left hand down to the tip of the uterus. Bill on the other side of the incision inserted his right arm.  I guided his hand to the correct position.  We pulled, we pushed, we tried almost every maneuver. The uterus did not budge.

    Bill and I were almost nose to nose.  Bill had sweat on his brow and sweat dripping off the tip of his nose. He looked me square in the eye.

    “A woman couldn’t this,” he said.

    I smiled, “If you haven’t noticed, I haven’t got it done myself, yet.”

    We pulled out, and I rethought the situation.

    “I am going to try one more thing,” I explained. “I am going to open the uterus up here without externalizing it. I will then try to get a hold of the calf’s hoof and turn it up to the incision.  The risks in doing this are many. I could spill content into the abdomen, I could tear the uterus, and even with a grip on a foot, I might not be able to budge this uterus.”

    “And then, if this fails, we are going back to option two. We will get your rifle and put this girl out of her misery.”

    That said, I incised the uterus in the middle of the flank incision. With a surgical glove and an OB sleeve on, I ran by right hand down the inside of the uterus. There was a front foot, I grabbed the leg just above the hoof and pulled as hard as I could.  The uterus rolled and the hoof popped out of the incision. With my left hand, I incised the uterus over the hoof, and then I slipped an OB strap onto the hoof.  

I handed the strap to Bill. “Keep that foot from going back into the abdomen.”

    Pulling my arm out of the upper incision, I enlarged the incision over the exposed hoof. Bill was able to pull the entire front leg out of the incision.  I reached in and found the other leg. It came out quickly, and we attached it to the other end of the OB strap.

    With both front legs out, I enlarged both the flank incision and the uterine incision. Now I was able to pull the head out of the incision. Then putting things down, I helped Bill put a hard pull on the calf. It was sort like pulling a basketball through a knothole but when gas-filled abdomen of the calf finally cleared the incision both Bill and I almost fell as the rest of the calf followed with a swoosh.

    The membranes and the calf landed on the barn floor in a splat. Then the odor hit us. Bill and Connie both gagged and had to turn back to the side door.  When they opened that door, things were better, or maybe we were just adjusted.  Bill grabbed the OB strap and pulled the calf out the barn door, and I returned my attention back to closing up this mess.

    I washed and changed gloves. I put 5 grams of Tetracycline powder into the uterus and pulled the open incision to the outside. This was a long incision in the uterus, and then there was the small incision higher on the horn.  I elected to close the upper incision first, just in case the uterus would start to involute, and I would not be able to reach this incision.  I closed It with a simple continuous suture.

    The larger incision I closed with my standard Utrecht closure. After closing, I returned the uterus to the abdomen. I was concerned that there was probably a lot of leakage into the abdomen and pondered how best to deal with that event. There was no option to lavage the abdomen in the middle of this barn, so I just dumped another 5 grams of Tetracycline powder into the abdomen.

    I closed the flank incision with 4 layers. I used simple continuous in the peritoneum, interrupted mattress in the muscles and simple continuous in the subcutaneous tissues. I closed the skin with an interrupted mattress pattern.  No need to spray for flies in this weather.

    The heifer had to feel tremendous relief getting that mess out of her. She was going to need some additional antibiotics to keep her incision from falling apart. The easiest thing was to use some long-acting sulfa boluses.  I gave her 4 boluses of Albon SR. That would give her 5 days of protection.  

    I untied her tail rope and the sideline. She was as calm as could be expected.  I loosened the halter and slipped it over her head. She turned slowly and headed to the door, sniffing the floor a little as she passed.

    “She should be okay for tomorrow, but I will check with you on Friday,” I said to Bill as I was cleaning myself up.

    “She will be just fine,” Connie said.  “Our daughter will be home for a week or two.  She can check her tomorrow.  We will let you know how she is doing. You go home and rest for dinner tomorrow.”

    At least I was going to have a few days to rest up with the holiday.  I stopped at the clinic and cleaned all the equipment.  It would be a real mess if I left it for the girls on Monday.  I stripped down to the waist and washed thoroughly. The one mistake I made with the clinic was not putting in a shower. I thought I would wash here and go home for a shower.  Then probably have to start working on dinner for tomorrow. 

Friday morning, Bill called. “The heifer is doing great. Our daughter is impressed with how the incision looks. We told her the story, but I don’t think she really believed us. 

Two weeks later Bill called again to say they took the sutures out and the heifer continued to do well.

Photo by Ehoarn Desmas on Unsplash

Gus and the Manure Pile

D. E. Larsen, DVM

Manure piles were (and still are to some extent) standard fare on Oregon farms.  They were located around the barn somewhere and served multiple uses.  They came in many shapes and sizes.  Smaller places had a simple pile outside a doorway where the barn was cleaned.  Larger farms had more elaborate piles.  In my experience their edges were the easiest place to collect a can of worms for a day’s fishing.  They also were used to dispose of small animals that were casualties during the year on the farm.  They were the ultimate compost piles.

Gus was a typical barn cat.  Well past middle age when I first met him when I came to Sweet Home in 1976.  Gus was lucky to have been neutered early in his life, but still had his share of scraps defending his turf.  He was nothing special, gray tabby in color and not large, maybe 8 pounds.  He lived with his extended family on a small acreage on a hill outside of Sweet Home.  Grandma and Grandpa lived on the “farm”.  Not much of a farm, but enough for a few cows and sheep and a small barn.  The son and his family lived about a quarter mile up the road on a neighboring taxlot.  When Gus came to the clinic he came with Carol, the daughter-in-law.

Over the first few years of practice in Sweet Home Gus was approaching his golden year.  In those times I didn’t see neutered male cats over 15 years of age.  This was before the advent of the feline leukemia vaccine, and diets did not address urinary tract and heart issues.  For barns cats to reach that age was truly exceptional.

One cold winter morning Grandpa hurried into his pickup truck in the carport on the side of the barn.   It was cold and he was anxious to get the truck started.  “Thump, thump” came from under the hood.  Gus had sought the warmest spot he knew of to sleep the night before.  The warm engine block was one of his favorites.  Usually able to scramble out before the engine started, this morning it didn’t work.

Grandpa knew what the noise meant, he had seen more than one cat caught in a fan belt on cold mornings.  He was disappointed when he found Gus, he had been such a good cat.  Gus was a mess, broken leg with bone poking out, left eye hanging out of the socket, several large lacerations and bleeding from his mouth.  In Grandpa’s mind there was only one thing to do.  Picking up a hammer, he made a quick whack to the back of Gus’ head.  Disposal was easy.  Gus’ final resting place was the manure pile on the other side of the barn.

In most cases that would be the end of the story, but remember, cats have 9 lives.  Gus had already used several of his just surviving to this advanced age.  Now he would need to cash in all the others.

Carol had noticed that Gus had not been to his dish on the back porch for several days.  She mentioned his unusual absence to Grandpa.  Grandpa was quiet, knowing the she would have rushed Gus to clinic and spent a lot of money on an old cat.

The next morning, she heard a noise on the porch.  She opened the door and was aghast at the scene.  There was Gus.  Covered with manure, left eye hanging out, broken and torn.  How had he managed to make it to the door? How had he known which door was the one to provide him help? She carefully boxed Gus and headed for the clinic.  Grandpa was outside as she drove by so she stopped to show him what she had found.  Grandpa had no choice but to confess.  He said that the vet could do a better job than him, assuming that Gus would be put to sleep.  In those years, in Sweet Home, if a cat couldn’t be fixed for $100.00 it probably was not going to be fixed.  Gus would surely be well over that figure.

Carol laid Gus on the exam table and related the story.  Gus looked hopeless to me.  She wanted to know her options. Gus was a pitiful sight as he lay on the table, looking cautiously at me out of his one good eye. 

“What are your options, Gus?”  I thought to myself as I pondered the situation.

My initial thought that Grandpa had Gus’ best interest at heart, he just didn’t do the job very well.  I’m not sure that was what his owner wanted to hear.

“We have a lot problems here” I started.  “Contaminated compound fracture of the tibia, fracture of mandible, eye that needs to be removed, broken teeth and multiple lacerations that are very contaminated.  The first question we need to discuss is do we want to put him through all this over the next few weeks?”

Carol was quick to respond, “We are not going to put him to sleep, not until we don’t have any other option.  I don’t care what it costs. If we have to, Grandpa can log a few trees.  That’s the least he can do after what he did to this cat.”

I knew Grandpa.  He would log his trees for his family or for the Grandkids.  I wasn’t so sure about a cat.

Now we were on to option number 2.  Referral was out of the question. There were no specialty clinics around at that period of time.  If Gus was going to survive it was going to be by my hands only.

“We have several things to do, first we need to sedate him and get him cleaned up, get him on some fluids and antibiotics.”

“The wounds are too contaminated to close; if we clean them up and remove the grossly contaminated tissues, they will heal if he lives long enough.”

“I can probably wire the jaw and remove the broken teeth.  The eye is toast and has to go.”

“The fractured tibia is too contaminated to fix, the ends of the bones are likely dead,  The leg has to go.”

Carol finally spoke, ” I want to save the leg!”

“Can’t be done.”  I responded.

Again Carol spoke, “I want to save the leg, we can try!”

“Okay, we can try, but if it happens it will be a miracle.  And the leg will be short.  We will try.  He will have to stay a few days.  I don’t know what this will cost.”

Carol left, convinced that Gus was going be back to his old self in a few days.  Might take a little longer than that, I thought.

We sedated him with a dose of Ketamine and got him under the spray nozzle in the tub.  After cleaning the manure and dirt, it looked like things were almost doable.  We got him dried off and an IV started.  Antibiotics on board and warmed up a little, he was ready for the first of several procedures.

Putting Gus on some gas anesthesia, we started cleaning wounds.  Shaving hair from the wounds. We removed contaminated tissues and packed with Furacin Ointment (the best topical antibiotic ointment I had at the time).

I worked on the tibia next.  The ends of the bone were dry and brown with debris stuffed into the ends.  I cleaned the wound as best I could.  Calculated that I would have to removed bone from both exposed fragments.  I couldn’t make myself think this was going to be anything but a waste of time. We packed the wound with antibiotic ointment and would do the repair tomorrow.

The left eye was hanging out of the socket and did not require much to remove.  Placed a single suture around the optic stalk and removed the eye.  I could deal with closing the socket later.  

The mouth was clean compared to the rest of the cat.  Gus was missing both upper canine teeth and one lower canine tooth.  His jaw was fractured on the left side and separated at the symphysis (the mid point at the front of jaw were the mandible bones join in a non movable joint).

The symphysis was repaired by passing a 20 gauge wire around the mandibles just behind the lower canine teeth, exiting on the ventral midline where I twisted the ends to tighten the ligature, cut the ends short and buried with a single suture.  The fracture of the mandible was stabilized by wiring around two teeth on each side of the fracture.  Probably will need to do more but later.

The next morning Gus was looking pretty good and actually was ready to get out of here and back to his barn.  We gave him a few laps of gruel and continued the fluids.  We were going to tackle the leg later today.  I still felt this was a waste of time.

With Gus under anesthesia, I went to work on the exposed bone.  To my surprise, I did not have to trim too much bone before I came to bleeding bone.  The marrow cavity appeared pretty clean with the superficial debris was removed.  I repaired the fracture with a threaded intramedullary pin.  Inserted at the knee and threaded down the marrow cavity to the fracture site.  Placed the ends of the exposed bone into normal position and seated the pin into the distal fragment.  This was the common repair at that time.  We will have problems due to the contamination at the fracture site.  I cleaned up the wound as best we could and closed this wound.

Gus was ready to go home for a few days before we started the next round of repair and treatment.

Both Carol and Gus were happy to see each other.  Gus was actually stepping on the fractured leg.  Cats always make surgeons look like they know what they are doing.

Over the next few weeks, Gus became a standard visitor to the surgery room.  We would clean on his open wounds, which were granulating well.  We closed his eye socket and placed an additional wire in his jaw to improve the repair.  On each visit I was more and more cautious on how the leg was healing.  The soft tissues were looking good but I was still skeptical about the bone.  Carol was in great spirits, and I think that Grandpa was getting to come out of the doghouse once in awhile.

Finally, push comes to shove.  Time to x-ray the leg to see how the repair is going.  Gus is still quite a sight.  One eye and one lower canine tooth protruding out on the outside of his upper lip.  Larges patches with no hair, but the wounds are mostly healed.  Probably as good as they would have healed had they been sutured.  He would purr and he was bearing weight on the fractured leg.

The x-rays were better than I expected.  There was some healing but not what was needed.  We would have to try something different.

So at 6 weeks from the time of injury I removed the IM pin.   There was a pretty good fibrous union of the fracture, but no boney union.  The next try was an external fixation device, 4 small pins driven into the bone, 2 above and 2 below the fracture site and bolted to an external pin to fix the bones in position.  A tall order for a cow doctor but I got it done.

Another 4 weeks and we were done.  The leg was healed, Gus was happy, Carol was happy.  I don’t know about Grandpa.  The total dollars are lost to a clouded memory.  Anyway, it was never about the money.

The last time I saw Gus was almost a year later.  Into his golden year now, and with none of 9 lives to spare, he was truly an old cat.  He was in for routine stuff, an abscess on the side of face, (left side, he probably didn’t see the punch coming) and tapeworms.  Still defending his turf and still able to catch a mouse or two. I always wondered about his final resting place.  Was it the manure pile, again?

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