On-Call Days

Down-time and Silent Days

Making the most of it

There are on-call days when the phone is silent. This silence comes with its own secret recipe for stress…4 parts foreboding for 1 part paranioa. It can feel like the longer the silence, the more intense the impending ER storm is going to be. It took me awhile to figure out what to do, or not do, during down-time while “on-call.” After trial and error, I have developed strong on-call-but-not-on-a-call habits. When I first started taking on-call, it felt normal to be poised by the cell phone just waiting for it to ring. When an ER did ring, I could spring into action and be out the door in less than 5 minutes. But when the phone didn’t ring, a faint feeling of regret would creep in. Not only did I feel that the day was (personally) wasted, but I also felt (professionally) unfulfilled.

For me, utilizing down-time while still on-call is essential for avoiding burn-out, promoting work-life balance and reinforcing the truth that work has not become my life. When I say utilizaing, I mean being productive enough that time doesn’t feel wasted in wait for an ER than never comes. On the other hand, any project that is started has to be one that can be dropped at a moment’s notice. But on silent days…I still check my phone a minimum 5 times/hr, confirm max volume 2 times/hr and check that airplane mode is not activated once/hour.

My most recent day on call was anything but silent. Between 7:30am and 11:30pm, we had attended 7 emergencies and saw 2 add-on appointments. That’s a full day, especially during the slow season. As I drove home at 1am, I found myself running through the day’s events and eventually mulling over two emergencies in particular. It wasn’t that these two emergencies were clinically distinct, fascinating or dangerous…in fact, they are both circumstances that I would normally shrug off as inconveniences of the job. However, I think the nature of the two circumstanaces is important when gaining perspective into a day-in-the-life of a veterinarian.


The “Nevermind” Emergency

The ER call rang 15 minutes before the start of our doctors’ meeting. Susan, who was not a current client of our practice, was frantic over the phone. While in the midst of explaining what was happening with her mare, she repeatedly interrupted herself to say

“My vet’s not answering. I can’t get ahold of my vet. I don’t understand why she’s not answering.”

I can imagine how confusion, fear and panic in the moment, is exacerbated when a client’s trusted lifetime vet of 15-20 years is MIA. Tone of voice, pitch, inflection and word-choice can paint a vivid emotional picture, especially of the client feeling pain and confusion brought on by a sense of abandonment. On rare occasions, bitterness and resentment are aimed at whichever vet does respond to the call. From firsthand experience, this type of treatment from clients is hard to swallow.

“Shelving” Client Mistreatment

When it comes to professional advocacy, I think simply swallowing mistreatment from clients does the profession a disservice. In my opinion, having the issue temporarily “shelved” vs. simply swallowed, establishes a line between acceptable and unacceptable behavior. While I don’t think disrespect is something to just “put up with,” having an open discussion requires a particular environment and mindset that emergencies cannot always afford. Bottomline: In order for me to do my job, I have to focus on the reason I am there. This means “shelving” issues that are not imminent or critical.

On the otherhand, I know some vets get upset when they are called only as a “last resort.” Sometimes, clients say that.

“I am only calling you because my vet is out of town.”

“I just need a vet, any vet.”

“I wouldn’t be calling you if I had other options.”

I take these comments in context of the extremely difficult circumstance the client is in, the difficult spot this puts their vet in and the fact that I’m here to help. This thought process keeps the negative thoughts at bay. It also helps that I am an empath by nature.

8 minutes away

Returning to the ER at hand…I kept Susan focused, making sure she was in a safe situation, the mare was contained, and gave her a few minutes to call me back with their physical address. Caught up in overwhelming situations, sometimes you can’t remember how to spell your own name. In this instance, she had to find a piece of mail so she could read off her home address. According to GPS, we would arrive at Susan’s in 45 minutes. During the first half of the drive, the office relayed two other ERs to respond to. When my phone rang again, I recognized the number as Susan’s.

In my experience, when a client calls while you’re still in route, it is for one of three reasons:
– The situation has become dire, they are panicking and have lost all sense of time
– To find out where you are because it’s past your original ETA
– They are canceling the farm call for one reason or another

I answered the phone as google maps’ estimated ETA read 8 minutes.

“I actually don’t need you to come out. My vet just got here.”

This isn’t too uncommon that another vet beats you to a call, either because the client called other vets to see which would arrive fastest or because their regular vet returned their call. I will be honest, this is frustrating. I wished Susan and her horse the best.


Order of Operations

Determining Which Emergency to See First

When faced with multiple ERs, I prioritize based on severity, urgency and the potential risk to human safety. Numerous times, I’ve been less than 5 minutes from the ER when the client calls to let me know that another vet showed up. This ultimately ends up in re-routing, lost time and money, but most importantly, an unnecessary delay in rendering aid to other patients and clients. Our policy is to bill an in-route cancelation fee, but I have yet to follow through with this. With new clients that don’t have established payment methods with us, pursuing payment is nearly impossible.

I understand the panic and desperation owners feel when their horse is injured or sick. In a situation of overwhelming helplessness, the only help they can provide is getting a vet on the premises. For this reason and out of empathy for clients in these scenarios, I have not had it in me to bill them a cancelation fee. And then there are those rare occasions when the driving force behind a client’s actions are not driven by shear concern, fear and panic. There are times when a client’s motives and intentions are not upfront or even honest…


ER Disguises

Critical, urgent and not-so-urgent cases

The second emergency was located 45 minutes south, within a mile of our office. It was a choke, which resolved mostly on its own by the time we arrived. As we were finishing up this second ER, the office alerted us to another emergency. Now, the ER waiting list included a mildly painful colic, a moderately painful colic that did not improve with banamine, and a laceration that had significant, uncontrolled hemorrhage. Despite pressure wraps, the owner could not get the bleeding to stop and she feared the horse would bleed out soon. We headed straight to the laceration emergency, ready to face a chaotic, blood-soaked scene upon arrival. As we pulled up to the barn, I could hear laughter and followed the voices to a small group of people standing around a bay polo pony in the wash rack. There wasn’t a drop of blood in sight, and pony appeared healthy enough.

“I’m here for an emergency, do you know where the horse with the laceration is?”

A middle-aged woman and what I presumed was her daughter, nodded.

“This is him. This is Emo.”

For a moment, I thought I had made a grave mistake and navigated to the wrong emergency (the mild colic). I reached out for something to say, still confused and mortified that I had made this profound error. The woman turned to look at Emo, walked over to his right front cannonbone and pointed at a scrape…a two inch long superficial abrasion with only the hair missing.

“I don’t know how he did it, but he managed to lacerate his leg here.”

I thought I had gone crazy, but was much more horrified upon realizing that this scrape was the previously described uncontrollable hemorrhage. She must have read my face.

“I didn’t want to be waiting around the barn all afternoon, so I might have exaggerated a little over the phone.”

She chuckled sheepishly. The other people started to dissipate once the uncomfortable silence kicked in. On an untimely cue, my assistant came huffing down the barn aisle with arms full of wraps, suture and scrub kits, fluids, clippers and even a tourniquet tucked into the v-neck of her scrub top.


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You never know what you’ll find

Prefacing this post with a disclaimer: Graphic wound images are contained in this post.


After working with particular clients enough, you get a feel for what kind of emergencies they do and do not call about. Depending on experience, knowledge and comfort level, some may call for a tiny cut or they may only call when it appears their horse may bleed-out. And with others, you never know what you’re going to find.

One of our clients left a message on the office phone the night before. Her mare had sustained a wound to her haunches that she thought might heal well on it’s own. She described the wound as superficial, probably a kick from a pasture mate. She said the wound was not bleeding and you couldn’t see any real obvious wound. She didn’t want to pay an emergency fee because finances had been tight, so the office asked if I was willing to work her into the busy day. Fortunately, we were running early and finished up with the day’s appointments a couple hours sooner than we thought.

On arrival, the small palomino mare was in a pen. I had seen her a couple months ago for a face laceration, and before that, an episode of choke. The mare was always suspicious as we approached her with a tote of supplies. Almost an entire roll’s worth of tape had been used to secure a bandage over the right gluteal muscles. As I pulled the sheet of tape off, I saw the soaked maxi-pad that the owner immediately commented on. “I figured, what’s more absorbant than a maxi pad, right?” I removed the maxi-pad and was surprised at the severity of the wound. It was definitely a wound requiring attention, and not superficial in the least.

The wound at first glance.

An L-shaped laceration resulted in a large flap of skin. Beneath the flap of skin, was a deep gaping wound extending several inches into the underlying musculature. The owner must have read my expression because she soon asked “It’s bad, isn’t it?”

“It is big, and it is deep. But luckily, this is fairly fresh.”

After clipping some hair, the large triangular skin flap became apparent

We set about clipped the area, scrubbing the wound and exploring the extent of the damage. Meanwhile, the owner wracked her brain about what could’ve caused the wound. Most of the time we never find out what happened. It is unnerving, knowing that what sharp object inflicted the damage, still lurks in the field with the possibility of a second offense.

Determining the extent of the injury

The front half of the laceration was sutured together easily enough. Dead space was minimized with a deep layer of sutures, and the skin was re-opposed with simple interrupted. Since some dead space existed, and considering the extent of the wound, a Penrose drain was placed. The mare was started on Excede, with the plan to add SMZs due to expense. Bute and SSD were also dispensed. The owner would continue on-farm care involving flushing the wound and readjusted the drain daily. Vaseline was applied to prevent scalding of the back leg from constant drainage that was sure to ensue.

Based on the location, a simple bandage was not possible. We put in 8 stay sutures that would allow us to feed a shoelace through just like you would a tennis shoe. This shoelace method, a tie-over bandage, would secure a clean towel or pad to the wound. Unfortunately, I did not remember to take pictures of the finished work.
In 4 days, the drain will be removed. If the skin flap survives, the owner will continue to flush the wound daily and may also end up packing some of the wound with gauze. However, profound swelling and reduction of dead space, did not allow for room to pack the wound.

It has been a couple days now, and due to financial concerns, the owner could not afford for a recheck. We will be back to remove the external sutures in 10-14 days, and next time I’ll be sure to take more pictures.


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Unsolved Mystery (Part 2)

Picking up where I left off, the last entry was about an emergency case involving a non-weight bearing lameness and unexpected penetrating wound to the abdomen. Without the financial option for referral, the owner (fictitiously referred to as Karen from here on out) opted for managing the mare (fictious name of Sugar) at home. Our aggressive antibiotic required placement of an intravenous catheter, and intense training session regarding care, maintenance, problem solving and how to use a catheter. I am always nervous when it comes to client managing catheters in the field. Luckily, Karen had previous experience working under a vet in an equine surgical center.

Sugar was started on a 5 day course of intravenous antibiotics (Kpen and gentamicin) and an anti-inflammatory (flunixin). The dime-size penetrating wound was sutured closed. I expeted that the would see evidence of complications (peritonitis, compromised bowel etc) within the first 24 hours, and was pleasantly surprised when Karen informed me Sugar was holding steady. Her appetite and energy level remained consistent, as did her severe lameness on the hind leg. It wasn’t until day 3 that she threw the first fever, a staggering 104.5 F. When the fever was unresponsive to banamine, Karen took to giving alcohol baths. I was anticipating at any moment, the downward spiral would begin…but aside from transient fevers, Sugar was still holding steady at day 5.

On day 5, Karen reported the catheter wouldn’t flush and after confirming it was no longer patent, we pulled it. To continue the antibiotic coverage, Karen was given excede and her fevers had stopped. Haunting still, was the none-weight-bearing lameness that remained unchanged, and was now making me suspect a pelvic or hip injury. With her budget depleted, no additional diagnostcs or treatments were an option…and we began discussing quality of life concerns for the severe lameness. Karen painfully drew a cut-off point for Sugar’s recovery, which was a week. If her hind leg wasn’t showing improvement by the end of the week, she would have to be let go.

I didn’t hear from Karen for a week, and when an appointment popped up on my scheduled, I assumed the worst. Much to my surprise, her lameness had improved by 50%. And after another week, she was 90% sound on the left hind. Sugar never looked back after that…she recovered completely, despite the odds.

Word on the Street

And the mystery of the penetrating injury? It’s all heresay, but on my final visit to see Sugar…a neighbor just happened to swing by.

“It’s been bothering me ever since day 1. I was working in the garden, a quarter mile down the street. And you seen those big concrete pillars? Well, that day I was pulling weeds, and saw this man park his car right next to the pillars. He got out with a big black duffel bag and I remember wondering now what is he doing. At first I thought he was just working on something for the county. But he was in normal clothes, a white t-shirt and jeans. I just kept doing my gardening and it must’ve been an hour. When I looked over, he was laying on his stomach on the top of the pillar, like they always show snipers doing. And I heard my phone ring, so I went to answer it and in the middle of my phone call, there was a gunshot. My husband and I hunt, I know a gun shot when I heard one. I thought he’s poaching! I looked out to see he was still there on his stomach. So I called the police because you can’t be firing into someone’s pasture or at farm land like that. Well, I was terrified and stayed inside…I didn’t want him to know I was in there. When I heard the police knocking and answered the door, I could see over their shoulders that other cops were walking around the pillar but the guy’s car was gone. I think that guy shot the horse!”

Seeing the Signs

This story stuck with me, because a month later, at a farm in the area there had been a couple cows believed to have been shot (they didn’t die, but had wounds similar to Sugar’s. When a dog and goat were shot a months later in the neighboring town, what originally sounded like a far fetched theory…started resonate.

It’s been a couple months now, and I have yet to hear of more animal shootings…but if this really is a person targeting animals, could the target become a human? Unfortunately, the city and state police don’t consider the events related…but it also sounds like there has been little follow-up into what could be considered early indications that we have a fledging psychopath.

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.