Hard Lessons from RREH

Hello again from the Bluegrass! As summer winds down here, I thought I’d take a moment to talk about some of the hard lessons that we learn in equine/veterinary medicine.

Yesterday started out as a pretty routine day for surgeries with Dr. Bramlage, but right around 1:00 PM, we had an emergency that came in – an internal carotid hemorrhage in the right guttural pouch… and when I say hemorrhage, I mean pouring out! This mare was a 12 y.o. TB mare that had actually been in sometime between late April and early May with a similar presentation, and had actually had her internal carotid already ligated surgically.

Initially when she came in, she left a trail of blood from the parking lot to a pool in the work-up area and induction stall. Prior to and during surgery, she had probably lost approximately 20% of her blood volume (so roughly about 10L – horses have a lot more blood than the average human). During surgery, she had part of her volume replaced with fluids, Hetastarch, and plasma, and she was eventually matched with one of the blood donor horses for a transfusion following surgery. The surgeon on the case performed a balloon embolization to stop the bleeding from that artery – which, essentially, puts a “plug” in the vessel by inflating the end of a small, wire-like catheter with saline (almost like filling a miniature water balloon that blocks the blood flow).

The surgery was successful at stopping the hemorrhage, and the mare was placed in the recovery stall and fitted with a blood transfusion set. Two of the best recovery guys were with her the entire time, and were extremely conscientious of her condition and how she was progressing. It took a good hour and a half for her to regain enough strength and come around from anesthesia to even try to stand up with their assistance – not entirely unexpected due to how she came in and how long the surgery took (about 3 hours!). The first time, she couldn’t stand up fully, and the team allowed her to rest in lateral, a.k.a. on her side, a little bit before trying to help her up again. She was still incredibly weak from all of the fluid she lost and probably some electrolyte imbalances, etc.

Once she sat up sternal (a.k.a. on her belly), the guys and an anesthetist adjusted her hooves so that if she tried to stand again, she would be in a better position for success. Again, she tried to stand with their assistance, but, she was still too weak and collapsed from fatigue – this time, it was not a smooth fall. To everyone’s dismay, when she collapsed, she also completely fractured her right tibia (for all you basketball fans, think Kevin Ware in the NCAA tourney). Tibial fractures in horses are basically fatal because they cannot be easily repaired without major complications. And, fractures during recovery are every veterinarian’s worst nightmare.

When this happened, the interns sprung to action and were able to sedate her until her owners could be reached, and quite regrettably, she was euthanized. No one was truly to blame in this situation, nor did anyone expect for this to happen. It’s just one of the unfortunate and undesirable things about equine surgery. Mostly, I feel for the surgeon and the intern on her case – it’s devastating to complete a difficult, 3-hour-long surgery and have a positive outlook for your patient, and then have something so tragic happen that absolutely no one could control.

So, this blog is in memory of the sweet mare that we lost, though please do not let it scare you – fractures during recovery are rare if the recovery team is good at what they do, and they should never be anticipated as though it will inevitably happen. Props to our recovery guys, who watch out for the safety of all surgery patients each day, and even risk their own safety for many of our horses!