the Unexpected Problem #2 (ER case, part 1)

After seeing a couple of routine appointments, we started receiving back-to-back emergencies. Our emergency calls included a colic, a foot abscess, a case of cellulitis and a minor laceration. Around 9pm, right as we parked the work truck in the garage, my work phone rang. On the other end of the line, was a panick stricken owner who thought her horse had fractured its leg after getting kicked by another horse in turn-out. We regrouped, and made the short 25 minute drive to the ER.


The Presenting Complaint and (Most) Obvious Problem

When we arrived, we spotted the mare in the beam of our headlamps. She stood in the pasture, trembling, painful and unable to bear weight on her hind leg. Aside from a <1 inch long laceration through the skin located in front of her hip, there were no real significant findings on my physical exam. I could not palpate a fragment, fracture or instability in the limb. After ruling out a foot abscess, fracture of the distal phalanx, we confirmed no fracture from the stifle down. Our radiograph equipment in the field is not capable of shooting images of the hips or pelvis, and with no ultrasound, ruling out a pelvic fracture wasn’t going to be an option. Leaving her in the pasture, without water or shelter, was not an acceptable option. After giving pain meds and sedation, we inched our way slowly and steadily to the barn.

Discovering the (Less) Obvious, but Equally Serious Problem

In the barn, I turned my attention to the wound over the hip while I next steps for the painful leg. After clipping around the wound, I was both shocked and disturbed to find out the extent of the wound. What looked like a superficial, small tear in the skin, was actually a dime-sized penetrating wound. With a flashlight, I looked into the wound and probed the extent. Beyond layers of muscle, fascia, fat and connective tissue…I found myself looking through a tiny viewing window right into the mare’s abdomen. I saw the glisten of light off what I presumed to be the right dorsal colon.

Bad Gets Worse

A penetrating wound into the abdomen doesn’t carry a favorable prognosis, especially when managed in the field. The client’s financial constraints meant referral for hospitalization was not an option. Abdominocentesis (belly tap), bloodwork, ultrasound, SAA…also not within the financial realm. Dedicated to trying, and wanting to give the mare a chance, the client asked for the most aggressive approach we could take to treating in the field within set limitations.

Antibiotics, anti-inflammatories, suturing the wound and monitoring comprised the mainstay of our treatment protocol. To be honest, I was expecting these efforts to serve mainly as a comfort and reassurance that we had tried something. I’ve seen horses succumb to far less serious ailments with intensive treatments and hospitalization. We placed an IV catheter so we could start a robust course of antibiotics (kpen and gentamicin) and banamine.

Where it gets interesting

By 1am, we had discussed catheter care, administer meds, given extensive instructions on what to watch for…and when we left, the entire ride back was filled discussions on everyone’s thoughts, ideas, speculations …wondering about the source of the lameness as well as the surprising penetrating hole. The hole was clean through the side of the horse, with defined edges and minimal surrounding trauma…almost like it had been made intentionally, by someone blessed with the art of careful dissection. Without knowing the systemic status of the horse, I could hardly sleep with thoughts of the undiagnosed fracture, the possibility of punctured bowel, the chance that whatever punctured her side could be floating around in the abdomen, the imminent danger of sepsis and endotoxemia…this, combined with group speculation as to what caused the wound.

A stick?

A nail?

Fencing?

Tree branch?

What about a bullet? The client asked, explaining that the family dog had sustained a similar injury a year ago when he had been shot with a small-caliber gun (pellet gun or 22?) by a disgruntled neighbor. With so many unknowns, possible complications and serious risks associated with this emergency case… I was not optimistic about the outcome of our next visit, which I expected would in the very, very near future.

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