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Not Your Usual Colic Surgery

Colic.  According to Wikipedia, “Colic in horses is defined as abdominal pain.”  Sounds simple enough and not too bad, but the word colic strikes fear in every horse owner.  It has been reported that worldwide in 2008 colic claimed over 5.1 MILLION horses or 1 horse every 10 seconds died from colic.  Yes, colic is still the single major cause of fatality among horses today.

Misha had only had one mild case in his 19 years.  But when I walked into the run-in shed, I saw Misha on the ground.  He was writhing in pain, sweating and rolling … shear panic in his eyes.  I got him up, walked up to the barn and called my vet service, Unionville Equine.  They said someone would be there in a half hour.  Thirty minutes can be an eternity when you are watching your beloved friend suffering and there isn’t much you can do.  

Finally the vet on call for emergencies, Dr. Lane arrived.  By that time however, Misha was down again and we could not get him up.  He was on the slope of a small hill and every time he rolled he worked himself further and further under a pine tree.  With the help of Dr. Lane, we managed to get him on his feet and administer IV Banamine.  She also inserted a reflux tube (without much reflux) and told us to get him to the University of Pennsylvania’s New Bolton Center right away.  She would call ahead. 

I was a wreck driving to New Bolton, but we were greeted there by several familiar faces (unfortunately, over the course of the years we have had many occasions to take advantage of the facility and get to know the dedicated people who work there).

Surgery with “Highly Unusual” Complications
The usual tests and exams were run and multiple doses of sedation delivered, but Misha was still very uncomfortable.  They were not able to definitively diagnose the problem, but felt an unusual soft tissue mass while performing the rectal exam.   I was told that we could take him in to Ultrasound, but that would take another hour or so and was asked what I wanted to do.  I asked the surgeon, Dr. Cohen, “If this was your horse, what would you do?”  She said she would take him immediately into surgery.  So, off Misha went.  I was asked about insurance, (which we didn’t have), and was told the procedure would run $8,000 to $10,000.  (as it turns out, given all of the ensuing complications, that was a huge underestimate of expenses)  But my husband and I agreed that we would do whatever he needed, as long as he did not suffer.  We are firm believers in quality of life.

Dr. Cohen told me she would call when he was out of surgery and standing, but not to worry, as that could take 3 to 3-1/2 hours.  So we drove home and waited.  And waited.  And waited.  If I had any positive feelings initially that things would be OK, they were slowly slipping away as the clock ticked.  Finally, about 5 hours later, I called the hospital and was told that he was in recovery, and that someone would call me soon.  About an hour later, I finally spoke with Dr. Cohen.  It turns out that Misha had strangulating lipomas,   benign fatty tumors that develop in the connective tissue that supports the small intestine within the abdomen. Lipomas begin as flat plaques, but over time they can elongate and develop long stalks (becoming “pedunculated lipomas”). Usually, they are harmless, but sometimes lipomas can get wrapped around (“strangulate”) the intestine, constricting it and choking off the blood supply until that portion of the gut dies. This type of colic occurs more frequently in older ponies and geldings, and is excruciatingly painful. Dr. Cohen had removed nine feet of dead bowel from my horse---but that wasn’t why the surgery took so long. The lipoma had also severed a vein, and he had bled out into his abdomen, which caused him even more pain. My poor horse required two blood transfusions to replace what he had lost. However, although “extremely unusual”, upon his recovery two catheters (one 24 “long) broke off into his veins.  These long, thin, flexible Teflon tubes---about the diameter of spaghetti---are inserted in the jugular veins during surgery so that medications and intravenous fluids can be delivered easily later on. As he struggled to rise, however, Misha snapped both---and the broken pieces were loose inside of his veins. Dr. Cohen explained that loose catheters migrate with the blood through the heart and lungs, and if they get lodged in the wrong places there, they can be immediately fatal. However, if they pass through both those organs uneventfully, they will eventually get trapped in smaller vessels, where they will be walled off by the body and, because they are sterile, generally do not cause problems. This required ultrasounds of the jugular and his heart, but they could not locate either catheter.   They placed him on a heart monitor to check for cardiac arrhythmias’ and later that evening took six x-rays of his lungs.  They thought they located one of the catheters, which they hoped would just get walled off somehow and remain there without causing any problems.  The second catheter was never located and Misha was hooked up to a Holter monitor to monitor his heart.  

Another Complication
The next morning, as soon as I was allowed, I went to visit.  He was in the CMK barn – foot wash as you enter the building, change shoes and wash hands.   Another foot wash as you enter the stall area.   Gown, boots and gloves and another foot wash before entering the stall.  Misha was pretty miserable.  The vets said they thought he looked pretty good.  I guess it depends on your perspective.  Given everything he had just been through, I was happy just to see that he was alive and standing.  After a short visit, I left and returned later that afternoon.  On my return visit, the receptionist called the nurses to accompany me back to CMK.  At first I was told they were doing a procedure and I would have to wait.  Then it was that they needed ten more minutes.  After almost two hours of waiting, they called the front desk and said that this was not a good time for me to visit.  You can imagine what was going through my mind.  At first, I didn’t know they were doing a procedure on Misha, but just thought that they were busy, as it was a Saturday on a holiday weekend.  But after waiting all that time and then having them say it wasn't a good time to visit, I knew they were working on my horse and something was wrong.  I told them I was not leaving until someone explained to me what was happening. 
Finally, I was told that while someone was inserting a nasogastric tube, a routine procedure to check for gastric reflux, Misha had developed a severe nosebleed that lasted for several hours.
            When I finally spoke to Dr. Cohen, she explained that, because Misha had lost so much blood during surgery, his clotting factors were very low. And to a very sick, stressed horse, even a minor nick to the mucosa of the nose can be a serious complication.   They had lined up a donor for another blood transfusion, but fortunately he didn’t need one.  I left, driving home in tears, not being able to even see him or say hello.  I really just wanted to let him know that I was there.

I went to visit every day, twice a day – am and pm.  Soon they let me take him for short walks and a little grazing.  I was allowed to bring him treats and some fresh grass.  He loved the fresh grass and seemed to be brighter each day.  He continued on IV fluids, antibiotics and Banamine.  The Holter monitor was finally removed, but some ventricular arrhythmias were noted and Troponin I levels were mildly elevated.  This indicated some myocardial damage, but he showed no clinical signs.  Something to be thankful for.  We will need to recheck at a later date.   Fibrinogen levels were elevated at 1040 mg/dl (normal is around 375).

 

Salmonella Scare

Almost a week later, with reams of paper for salmonella protocols and monitoring (isolation, manure disposal, handling instructions, trailer disinfecting etc, etc, etc. ), lots of medications, gowns, booties, masks, gloves and bandages, we finally came home. 

 

Home – for a visit
Misha required ‘round the clock care as he was on Chloramphenicol, a powerful antibiotic, every 8 hours, which required gloves, gown, mask and goggles for administration.  With this drug there is a risk of humans getting aplastic anemia (rare, but I had to sign a special release when we left the clinic.)  Wound dressings had to be changed twice a day.  An elastic bandage was wrapped around his middle and frequent short walks and grazing were also on the list.  Three additional salmonella tests were done and all were negative, so we were in the clear on that front.  Things were looking up.

That is until about a week had gone by.  Then a fair amount of seepage started coming from the wound site.  Initially the vets said that was good, but by Monday, I felt we were headed in the wrong direction.  The wound site was now a 2” x 2” infected hole open in to his abdomen….you could put your hand up in there!   Dr. Lane came back out that morning and took a swab from the site to identify what antibiotic would work on this infection.  Fibrinogen levels continued to be elevated.  We changed antibiotics and started on Baytril, but the Dr. Cohen and Dr. Morello, the surgeons from New Bolton thought they should come out and have a look as well.  They arrived later that day to evaluate his condition.   Trying to ease the tension, I joked to Misha that we really wanted to keep what was inside, inside and not have our insides outside.  But the tension was only going to increase.  Dr. Morello told me that she had only seen that once, where the insides actually fell out of the horse.  That certainly put the severity of the situation back on the table and painted a not so pretty picture. They took one look and decided he needed to go back to the hospital---they needed to determine whether the infection was limited to the incision itself or if it also extended into the newly repaired gut. If it did, it could spread systemically, with deadly consequences. I was also told that infections in incisions from colic surgery can be particularly difficult to treat. When the blood supply to an area has been compromised as much as Misha’s had, it is difficult for intravenous antibiotics to travel to the site where they are needed. Once again we hooked up the trailer and back to New Bolton Misha went.

Back at the Hospital
After settling Misha back into a stall at New Bolton, Dr. Morello sat me down in the lobby.  New Bolton’s former chief of medicine, Dr. Beech, and Dr. Morello told me that after discussing Misha’s case and after a phone consultation with an abdominal wound specialist, they would ultrasound the incisional defect and operate the next morning.  The prognosis was very poor.  There was little good tissue, so even if they could clear out the infection, there was not much to work with to close up his wound. Tears started to flow. I knew I would do anything to save him, even if I could never ride him again.  I agreed to the surgery, but we all agreed that we did not want him to suffer.  They would do what they could or what had to be done.

Saying Good-Bye
The next morning I went over to say goodbye to my best friend, talk to him and groom him.  I asked him to forgive me for any of the times I had lost my patience with him and having said that, he gave me a little nip.  I told him that was fine, and hope that it was his way of forgiving me. I told him how much I loved him from the day he was born and I bottle fed him, 19 years ago.   After 2 hours, I walked him to the ultrasound room where I was assured that he would get the best care possible (from the 6 doctors that were present and working on his case).  I said my goodbyes and started the drive home.

The Red Cardinal
On the way, I came upon a red cardinal sitting right in the road.  As the car got closer, he did not move.  I swerved around the bird and it still didn’t move.  I backed up, got out of the car and tried to urge it to fly off with my foot.  It moved, but not much.  I then tried to nudge it to the side of the road so that it wouldn't get run over.  It flew about 3 feet off into some brush.   I am hoping that perhaps it had just been stunned and would recover (or at least die in peace in the brush).   When I returned home I thought I would look up the symbolism of cardinals -- this bird was absolutely brilliant close up.  Here is what I found:  

Is there any symbolism in the cardinal bird appearing to you?

  “Yes, there is religious symbolism in the cardinal bird appearing to you. The cardinal bird is symbolic of faith, so it comes to remind us to "keep the faith" though circumstances might look bleak, dark and hopeless. In addition, the cardinal bird also is symbolic of the blood of Christ, as it reminds us that we as believers are covered by the blood of Jesus. “
 I wasn’t sure how to take this really, but I am hoping that it was a good omen.  At the very least, it made me reflect and thank God for the time I have spent with Misha, having him in my life, and for the support of good friends and family that have helped me through this trial.
Trying a More Conservative Approach
Misha was in good hands at New Bolton, so there was nothing more for me to do but worry.  The surgeons were concerned about ultrasounding him standing and not under anesthesia because he might eviscerate through the incision if the procedure were done with him standing without the abdominal support wrap.  After lots of consultation with many vets, the surgeons decided to do the standing ultrasound and then to determine the next course of action. The ultrasound showed that the infection was not dangerously deep, and the veterinarians thought a nonsurgical approach might be enough to get it under control. After debriding the wound, they implanted antibiotic beads directly into the incision; these would dissolve over time, releasing powerful doses of medication right where it was needed most.
Misha stayed at New Bolton another week.   He came back with IV antibiotics (oxytetracycline), fluids and associated paraphernalia, a catheter in his neck, catheter flush solution, amikacin impregnated polymethylmethacrylate beads in his incision wound site, double bandages and lots of instructions.  One bandage was the elastic belly wrap and the other a $500 abdominal pressure bandage complete with breast plate.

Fibrinogen levels were now down slightly. The surgeons showed me how to administer the IV and I took copious notes.  However, on the first night that we administered the fluids and oxytet, what was supposed to take 15 minutes, took two and a half hours with my husband standing on a ladder above Misha in the wash stall squeezing the heck out of the IV fluid bag. 

We called the surgeons and after double and triple checking everything they said that perhaps the catheter was partially blocked.  They suggested that the next morning my regular vet, Dr. Donaldson come out and that he might need to insert a new catheter. But we were determined to get the antibiotics in to him that evening, and we did. 

The next morning I took the IV set to New Bolton and reviewed the procedure with a very helpful and sympathetic nurse.  Everything seemed to be correct and in working order.  Since the flushes were going in OK, we were all a little confused over what the issue was.  I was given a pressure cuff for the fluid bag and came back home to give that a try.  When Dr. Donaldson arrived, he determined that the catheter was partially blocked, and even though the flush went in fine, the oxytet and fluid were so much thicker that they were very difficult to push through.  The next day we changed the routine to direct administration of the oxytet into the port (mixed with a little fluid) and gave up on the fluid bag.  That night the administration of the oxytet took 6 minutes (not 2-1/2 hrs)! 

Another Set-Back
One problem solved, only to be replaced by something else.  Because of the elastic bandage, Misha developed a pressure sore on his withers.  Now we had to treat that wound as well.  One on top, one on the bottom.   We began with a small surgi pad on the pressure sore, followed by a saddle pad, followed by a dense poly foam pad taped on the saddle pad. On the underside we had a large Surgipad and a folded towel, then an elastic white belly band.  Then came the thick Western saddle pad and last the abdominal pressure wrap and harness. Quite the procedure.  It is a two person job and Thank God my husband was here.  I could not have done this without him!

Misha had lived outdoors 24/7 almost all of his life and was not very happy to be in a stall.  Because of his PSSM and other neurologic issues, his hind end doesn’t function very well.  Pretty scary as he became very unstable. So we started him on Gabapentin for potential neuropathic pain.  We also switched Misha’s diet to one with less starch and more fiber. Finally we started walking him more and hoped that the drugs, change in feed and exercise (albeit very limited still) would help with his hind end problems. 

Here was our routine:
Up at 5:30. 
6:00 – 7:30 – flush catheter; take Misha for 20 minute walk; bring in my other horse and feed horses; pick out shed paddock; graze Misha and then move him into another stall; Clean/remake Misha’s stall and clean barn.
7:30  - groom, change dressing and pressure bandages and take for another short walk/grazing; wash wraps and bandages, clean my other horse’s stall
10 – administer Gabapentin, take out grazing, and pick out stall
12 – flush catheter & take out grazing, pick out stall
2 & 4 – take out grazing, pick out stall
6:00 pm – take out grazing, groom, administer Oxytet IV; change dressing & pressure bandages; take for 20 minute walk; feed dinner
8:30 pm- take out for walk/grazing, pick out stall
10:00 pm – flush catheter and administer Gabapentin, pick out stall

 

Pulling Out a Chunk of What Looked Like ‘Liver’

Later that week, Dr. Cohen and Dr. Morello came out from New Bolton again.  They were very pleased at how Misha's incision site was healing.  They also came prepared with some special adhesive and gel pad that they put on his pressure sores on his withers.   We were now able to move the bottom pressure bandage back a little to give him some relief on his topline. 

The following week, Dr. Donaldson and Dr. Acland came out again and we were having more problems with our pressure sores on our topline.  The abdominal wound looked pretty good (although still open and about an inch and a half by two inches), but seemed to be healing nicely.  The sores on the withers and spine had gotten significantly worse, despite the gel packs.  The sores looked and smelled terrible and now we are all more worried about bone infection up top than the abdominal wound. You could see the tendon covering.  CAN WE GET A BREAK HERE!!!!

Bandage Contraptions
We took off the outside pressure bandage and tried to devise some device to keep the withers and topline open (just lightly covered with a dressing bandage), yet not put any pressure up there.  We still needed to wrap the elastic belly bandage around him to cushion the abdominal site and keep things in place.  Very difficult, especially since Misha decided that he was really, really itchy and it felt good to roll in his stall, which is bedded in pine shavings.  He came out looking like chicken rolled in corn flakes.   We finally devised a contraption that started with a foam pillow rolled on 2 sides with a channel cut out of the middle and then 2 rolls of dense polyurethane foam wrapped in leg wraps on top that creates a tent over top of his withers.  This keeps things covered to some degree, but no pressure on the topline.  We also had to abandon the heavier abdominal bandage and just use the elastic belly wrap.

The catheter eventually became completely clogged and had to be removed.  Misha was put on oral Doxycycline (50tabs 2x/day) and we continued with the Gabapentin with an increased dose.  Fibrinogen was now at 603, basically the same as the previous week (596).   At this point I started to ask myself if we did the right thing having the surgery.  I still had to answer yes, because if he didn't have the complication of the abdominal wall opening up he would be out in a small paddock now, just taking it easy, but not in any discomfort.

Hope and Thanks
We are now a full year out and both the abdominal wound and the pressure sores are healed, with some irregularities and white patches on his withers and only a small soft spot in his abdominal wall.  

Misha has been a model patient -- never complaining, ever tolerant of the medications, wraps, contraptions inflicted upon him.   He is such a wonderful, kind, loving horse that we hope to have him with us for many years to come.  Thanks to all of the dedicated vets and staff at New Bolton Center and Unionville Equine Associates, friends and family who have helped us through this.  And especially thanks to my husband, Michael, for his dedication and support in Misha’s recovery.