Ernie’s Colic Surgery, part 2
When last you, my adoring fans, heard from me, Ernie was about to get on a horse trailer headed for Equine Medical Center of Ocala (EMCO). This week, you get to hear all about surgery. All I have to say is, there are a whole lot of guts inside a horse! And now, the rest of the Ernie colic story.
Tony: OK, so you have decided to take Ernie to surgery. What are you thinking as you load him on the trailer?
Dr. L: Lots of people worry about horses going down in the trailer. I wasn’t worried about that for a few reasons: 1) I didn’t tie him, so if he went down, he wasn’t stuck with his head at a weird angle, 2) I gave him a bit of sedation right before we left to help him stay as comfortable as possible, 3) We gave him plenty of room in the horse trailer so that if he went down, he had room to get up.
What I was worried about was the hour it takes to get to EMCO, and if he was going to be painful when we got there, or if he was going to have what we call a ‘therapeutic trailer ride’, and be all better. Some people feel embarrassed when their horse is all better after a trailer ride to the clinic. DON’T!!! As veterinarians, we are very happy for you! I wasn’t that lucky.
Tony: What happens when you arrive at a referral hospital like EMCO with a colic? Do they whisk them off to surgery? Are there alcoholic beverages to calm the humans? Do they have a cat to offer up a superior opinion on the matter?
Dr. L: Well, that’s a lot of questions! The first thing they do is decide if this is a surgical colic, and how sick is Ernie. Sure, I said it’s highly likely he’s surgical, but they want to make doubly and triply sure, and I agreed! I didn’t want to put Ernie through surgery if I didn’t have to!! Ernie was placed in stocks, and many of the things I did were repeated. The ultrasound showed several more loops of unhappy small intestine, rectal palpation was still normal, and his bloodwork still looked good. That meant Dr. Adams and I had to have a serious talk about surgery.
Both of us felt it was very likely that Ernie did in fact have an epiploic foramen entrapment, surgery was almost definitely needed, but there was a small chance he didn’t need it. Given that both of us felt surgery was inevitable, and small intestine doesn’t like to be unhappy for very long, I said yes to surgery. At this point, there were no alcoholic beverages, but in hindsight, I should have started myself on anti-ulcer medication. As to the cat, not every clinic is as lucky as Springhill Equine to have an amazing cat like you, so we had to go with the human opinion only, knowing it was inferior to a quality cat scan.
Tony: Eeek, surgery… That just sounds scary!
Dr. L: It is and it isn’t. I knew Ernie had a serious problem, but wasn’t systemically sick yet. I also knew the longer I waited, the more likely he was to get sicker. More importantly, I knew that if the small intestine got worse, and he was an epiploic foramen entrapment, surgery would be much, much riskier. I also had thought about all of this before it was necessary. One thing this job has taught me is to be prepared for my horse to do something very expensive, at a bad time, that requires a quick yes or no decision from me. I know without a doubt I will do colic surgery on Ernie and Vespa. I’m pretty sure I won’t do it on the rest of them, for a wide variety of reasons. The point is, I’ve thought about it, and I’ve thought about how I’m going to pay for it.
Tony: Payment, that sounds really scary. You didn’t offer me up, right?
Dr. L: First, you are priceless, so no, I didn’t offer you. Second, there are a few options when it comes to how to pay for this sort of thing. Insurance can be a great option. You have to insure for at least a certain amount for mortality, then add on major medical and surgical. Colicare from SmartPak is also a great option. You purchase a supplement from SmartPak, and they give you up to $7500 in colic insurance. That covers the cost of an average colic surgery (this one came in at about that price). Or, you can go with what I did, which is to have a savings account with the money for an expensive injury, colic surgery, or illness tucked away somewhere hard to get to.
The point is, you need to have a plan before it happens!! Making these decisions when someone is telling you your horse needs surgery or euthanasia is extremely difficult! Write these decisions down somewhere that others can find them as well, in case you are out of town when the call needs to be made.
Tony: OK, decision made. Now surgery….How does that even work?
Dr. L: First Ernie got an IV catheter so medication and fluids could be easily given during surgery. Next, he got antibiotics prior to surgery, to help prevent infections. Then he was taken into what’s called the induction stall. This is a smallish padded stall where he was sedated heavily, then given Ketamine to fully anesthetize him. You’ll hear human anesthetists say ‘put to sleep’ in this situation. Us veterinarians don’t like that terminology so much, for obvious reasons.
Once he was completely asleep, straps were placed around his feet, and he was picked up with a hoist, and placed on a surgery table. Once there, the surgery team went to work fast to clip and scrub his belly, sew his sheath shut, and get anesthesia monitoring stuff set up.
Tony: Whoa! They sewed his sheath shut?! And what’s the other stuff?
Dr. L: Yeah, you have to sew the sheath shut to prevent urination into the surgery area. No way around that, and urine in the surgical field is generally considered less than ideal.
And the other stuff. Horse bellies are pretty dirty places, even in the best of circumstances. Add in a horse who has been down and rolling from colic pain, and they are even dirtier. This means there’s a lot of scrubbing involved to get them super clean. While the scrubbing is happening, an arterial blood pressure monitor, a heart rate monitor, and the anesthesia machine are all being hooked up to make sure Ernie stays asleep, but not too asleep, during surgery. It’s really, really important to monitor anesthesia closely. It’s one of many ways surgery is a much safer option for horses than it was 20 to 30 years ago.
Tony: And now to surgery.
Dr. L: Yep, now to surgery. Ernie got one final scrub in the surgery room, then Dr. Adams and Dr. Hicks draped him. Draping basically means he was covered in big, sterile sheets so the doctors had a sterile place to put all the guts that were about to come out of his abdomen. Once they finished that, it was the moment of truth: the incision.
You have to be careful making these incisions, since there can be gas-filled GI tract pushing up from the inside. The first thing Dr. Adams looked for after making the incision was the cecum. The cecum is the landmark you use to find all the other parts of the bowel, so it’s pretty important. Dr. Adams followed the cecum to the small intestine, and announced that Ernie did indeed have an epiploic foramen entrapment.
Here’s where the ‘curse of knowledge’ kicked in for me. I was now nervous, and would get to stay that way for 45 excruciating minutes. This type of surgery requires Dr. Adams to work the 17 feet of intestine that Ernie had trapped back into the abdomen through a very tiny hole. The risk of tearing the intestine or a blood vessel is pretty high, and it stays that way until the moment the last of the intestine is through the hole.
I also got to watch poor Dr. Adams spend 45 minutes bent over my horse’s abdomen at a horribly awkward angle, which was killing his back. It was all worth it though. At the end of that very long time, the intestine was free, and looked pretty ok. It was bruised and a little battered, but none of it was dead or even compromised, which meant none of it had to be removed. That is what getting a horse to surgery quickly does: it keeps the intestine happy!
Tony: That sounds like a long night! I know from my experience getting neutered that waking up from anesthesia can be rough. How do horses do?
Dr. L: It’s the scariest part of surgery, if that gives you any indication. Ernie was placed in a fully padded room, on a thick padded mattress. He got a little bit of sedation as he was hoisted into the room, to let the gas anesthesia from surgery wear off some more. Then the long wait began. It’s tricky, because I wanted him to get up so I could go to bed, since by now it was 1:00 a.m. and I was exhausted. However, I know that the longer they sleep, the better they stand.
There is a very real risk that horses will break a leg as they try to stand from anesthesia. That’s why they get sedation, and the very well-padded room, but it’s still a risk. Luckily, Ernie stood like a champ. He got to hang out in the recovery stall until he got his sea legs, and then he headed back to a regular hospital stall for some fluids, and the start of the long process of returning to normalcy.
Tony: How long is that process?
Dr. L: IIt takes about three months to get them back into work after surgery. Ernie stayed in the hospital for 3 days before coming home. During that time he was on antibiotics, anti-inflammatories, and had his feet in ice for 36 hours straight to prevent laminitis. Once home, he was slowly reintroduced to hay and grain. He’ll have to stay in a stall for a month, which he already thinks is stupid. Then he can start slowly returning to normal turnout.
Tony: And how’s his human handling it?
Dr. L: It’s tough to watch your horse go through surgery, but at the end of the day, Ernie’s worth it. I know we did the best we could in surgery, and afterwards, to get him back to his normal self. There’s a risk of complications, but I just have to wait and see if those become a problem. For now, it’s patience, which is really, really hard.
Many of you know that in a recent ploy to get more attention, Dr. Lacher’s horse, Ernie, decided he’d like to have colic surgery. I interviewed Dr. Lacher to get all the details about her fun evening with Ernie. Read on for this fascinating interview with one of my favorite humans!
Tony: Let’s start at the beginning. When did you find out Ernie was colicking?
Dr. L: I had just returned to the Clinic around 5pm, and was working on paperwork when Lindsey, who helps me with the horses at home, called to say Ernie was definitely colicking. He had cast himself in the stall, but managed to get himself up, but went right back down. I finished what I had to get done, then rushed home to what I figured was a gas colic.
Tony: Why did you think it was a gas colic?
Dr. L: Because, as you have noticed from your time on the front porch at the Clinic, it’s really, really hot outside. That’s why you keep making us open the door so you can come back into the air conditioning. When it’s really hot outside, horses tend to make more gas in their large colon and cecum. These areas of the intestine are huge fermentation vats. More gas means a bit of pressure, and we all know gas can be uncomfortable.
Tony: Cats don’t “get gas.” We’re too classy for that, but I digress. When did you realize it was more than that?
Dr. L: The moment our third year veterinary student, Sydney, told me his heart rate was 56. You see, heart rate is a very good indicator of severity of colic. Simple gas colic horses will often have heart rates in the mid-30’s. They might be flailing on the ground and looking incredibly painful, but they still have a low heart rate. The rest of Ernie’s exam wasn’t that exciting. He didn’t have much for gut sounds, but that can happen in these situations. He had normal gum color and hydration, his respiratory rate was a little elevated at 24 breaths per minute, and his rectal exam was pretty boring. And then he blew through my sedation in 20 minutes.
Tony: Because he got painful again so quickly, you were concerned?
Dr. L: Yes. A typical mild colic might lay down a little bit after I tube them with water and electrolytes, but they don’t thrash around and act painful. Ernie got thrash-around painful. I gave him stronger sedation while I setup my ultrasound machine, and I re-palpated him. His rectal exam was still pretty normal but I had a pretty good idea why, and it wasn’t good news.
Tony: Wait, a normal rectal exam worried you? And what does an ultrasound show you? Ernie’s a gelding, so if I understand things correctly, he can’t be pregnant.
Dr. L: HaHa! No, Ernie is not pregnant. And yes, a normal rectal exam in this situation made me think epiploic foramen entrapment. This is a very specific type of colic which cribbers are prone to. The epiploic foramen is a hole formed where some bits of the stomach, pancreas, and liver come together. Small intestine works its way through that hole and then can’t get back out. The hole is pretty far forward in the abdomen, so I can’t palpate the problem. An ultrasound lets me look inside, though. The ultrasound showed some small intestine with thick walls, and that is definitely not normal.
Tony: All of this stuff together made you decide Ernie needed surgery?
Dr. L: Yep. Any horse who gets painful quickly after repeated doses of stronger and stronger sedation is a surgical concern. Also, anything small-intestine is a big deal, and the sooner you get those to surgery, the better they do. Finally, I would definitely do surgery on Ernie if he needed it, and since it looked like we were going to need to do surgery, the sooner I got him somewhere they could do surgery, the better. Even if we ended up going down to Equine Medical Center of Ocala (EMCO), and he didn’t need surgery, all we wasted was some time and a trip, but if he did need surgery, we had him where he needed to be as soon as possible. So that’s what we did.
Next week, hear all about how colic surgery works. It’s amazing, even to a cat. Until next week, may your horses not colic!
Wow, that was some race last weekend! I had a great time hosting our annual Kentucky Derby party with our Wellness Clients here at the clinic, and sampling the delicious food from O Sole Mio. When I see the hats that you people wear to watch a horse race, it makes me even more glad I’m a cat! It looks like a lot of work to make one of those things, and then carry it around on your head. I have people that do the work
for me, so that’s really not my thing at all. Anyway, the race was very exciting, especially the saddle-bronc bucking display coming out of the gate! Thoroughbreds are certainly majestic and athletic creatures. But, as a cat who works at a vet clinic, I can’t watch Thoroughbreds without thinking about stomach ulcers. Comes with the trade, I guess!
Could my horse have stomach ulcers?
Short answer: yes. Long answer: horses of any breed or discipline, horses in and out of work, young horses, old horses, horses with a history of ulcers, and horses who have never been sick a day in their life… any horse can develop stomach ulcers. Did you know that 92% of racehorses in training have stomach ulcers? That being said, barrel racers, hunter/jumpers, reiners, eventers, harness horses, and cutting horses all have over 50% prevalence of GI ulcers as diagnosed by endoscopy. FYI, endoscopy is when a vet sticks a fiber-optic camera down your horse’s throat and into his stomach to actually look for ulcers along the stomach lining. That’s pretty cool!
But my horse isn’t stressed!
How do you know? Did you ask him? The truth is, even if your horse has the life of a pampered prince that you could only dream of, he may be stressed by his normal daily routine. Did you know that keeping a horse in a stall for half a day, and feeding only twice a day can be stressful for your horse? When I get diabetic, the docs only feed me twice a day, and trust me, that’s not the way I like it! Spending hours grooming your horse may be relaxing for you, but it likely gets on his nerves to stand still in the cross-ties for that long. Hauling your horse anywhere, even to the park for a “leisurely” trail ride, is always a stress-inducing event.
OK, so how do I know for sure if my horse has stomach ulcers?
The only way to know for sure if your horse has stomach ulcers is to have an endoscopy performed. But, I recommend simply starting with an exam by one of our awesome docs. They are highly experienced with the signs of stomach ulcers, and chances are with a thorough history and physical exam they can tell you whether your horse likely does or does not have GI ulcers. Also, they can help you navigate the confusing maze of ulcer treatments to pick the best option for you and your horse.
Boy, I think all this learning is giving me an ulcer! Time for a cat nap. Until next week!
Colics. We see a heck of a lot of them. Now a decent amount of those colics can be attributed to the fairly ridiculous design of the equine GI tract. I mean, honestly, who thought that was a good idea? However, I spent my weekend pouring through the computer to look at colics the Docs saw last year. That’s right, I spend my weekend working. What’s a cat to do when it’s far too windy for civilized folk to be outside but sleep in the sun and play on the computer?
I would like a drum roll here to acknowledge my hard work, so please play one in your head now….
Our Docs saw 318 colics last year. Of those colics, three went to surgery. That’s right, three. Four others needed surgery, but for a variety of very good reasons their owners weren’t able to take them to surgery. I did remove one very specific type of colic from those numbers, but I will explain why later. I’m going to start with the moral of story: Most colics don’t need surgery. There you go. You have the punchline. Now, let’s move on to some helpful guidelines to avoid seeing Dr. Lacher and Dr. Vurgason for… umm… ‘unscheduled opportunities’ to spend money on your horse.
Alfalfa (or peanut). I’m not talking about the bad hair day or the comic strip. I’m talking hay. Feeding coastal hay is very, very strongly associated with an emergency visit from one of my Docs after hours. Coastal hay in a round roll virtually guarantees you will see my Docs for an emergency. If you run out of round bale hay, cold weather moves in, and you put out a new round bale, make sure you throw plenty of alfalfa or peanut hay alongside. Feeding a minimum of 4-6 pounds of alfalfa or peanut hay daily will go a long way towards preventing this cause.
Be obsessive-compulsive about water. The old adage “You can lead a horse to water, but you can’t make them drink,” exists because it’s so true. If you even have a doubt about how much water your horse is drinking, get water into them. How, you ask? Watch this handy video about how to make colic soup for your horse. Besides colic soup, adding a bit of molasses to the water, or giving them a small amount of salt slurry will entice some to drink up. Each horse is different; work with your horse to figure out what works best.
Manage your horse’s environment. If your horse is in a sandy area, keeping plenty of roughage going through the system is a great way to prevent sand build-up. Psyllium is also an option here for the horse who needs fewer calories, but hay works better than anything else. For the Fall season, be aware of acorns. Acorns are like cute little field mice for cats: bite size morsels of deliciousness. Too many can lead to gas, and we all know gas can be painful. Acorns are tough to avoid, but our Docs have used muzzles and creative electrical fence configurations to help.
Finally, let me go back to that one particular colic: lipomas. Lipomas are a fatty tumor that grows in the area of the small intestine in older horses. It happens in skinny horses and fat horses alike. Lipomas are associated with age. They are not because of nutrition, bad or good, management, or any other factor you can control. These tumors are wicked. They wrap up a section of small intestine much like the bolos used by Gauchos, and strangle it until it dies. If a small amount of intestine is trapped, and the colic is caught early, surgery can be very successful. Unfortunately, many of these horses aren’t found for a few hours and by then surgery is very risky, with laminitis a very real risk about 72 hours post surgery.
Colic sucks. There’s no other way to put it. A little work on the diet and a dash of environmental management, and it will suck less. Want help with a diet plan? Contact my trusty minion Beth. She’s super smart when it comes to everything equine nutrition! And now I’m off to supervise the Clinic.