Double the Fun

Yesterday, I performed two Cesarean sections (C-Sections). These were two cows that were pregnant with valuable embryos. There were 2 other cows also carrying embryos from the same mating that had already calved. Unfortunately for the cows carrying the first two embryos, these calves tended to be quite large and it was very traumatic for the cows and the calves, resulting in injury to the cow and death upon birth of the calf.  Knowing there were still two more cows yet to calve, we decided that maybe it would be best to perform C-sections on the cows rather than potentially losing the next two cows and/or calves. These cows were due within days, so we knew the calves would be large enough and developed enough to survive.

The only "pre-surgical" preparation that was needed was to give the cows each a dose of Dexamethasone about 24 hours prior to surgery. This is a steroid that is commonly used to induce cows that are beyond their due date. It is necessary to give the steroid even when performing a planned C-section because the lungs are the very last thing to be fully developed and functional at the time of birth. The injection of Dexamethasone to the cow, causes the production of the last components of the calf's fully functional lungs so that when the umbilical cord of the calf breaks, the calf is able to take a breath and take in oxygen via the lungs.

As with every surgery, the cow is sedated, clipped, sterile scrubbed and blocked (numbed) with Lidocaine. Luckily I had enough help with these two C-sections, we were able to have a photographer. So this is a post of pictures! I'll explain what we are doing where needed. Both surgeries went very smoothly and there were two happy, BIG, healthy girls born!

Opening the skin and muscle layers of the cow.

Moving the uterus from the right hand side of the cow to the incision.

Opening the uterus while my assistant holds the uterus at the incision.

Getting the head and legs of the calf out of the uterus.

Two other helpers pulling the calf up and out of the uterus.

Trying to get the large hips of the calf out without tearing the uterus.

The hole the calf just came out of.

The empty uterus before being sewn up.

Suturing the first layer of the uterus.

Suturing the second layer of the uterus. The uterus is closed in 2 layers to prevent leakage.

Washing, washing and washing the uterus.

More washing of the uterus. Need to get all "extra" stuff off to prevent scarring of the uterus and infection.

The uterus back in it's rightful place.

Closing the muscle layers of the cow.

Closing the skin of the cow.

Put back together!

Both cows were very good patients and stood very well during the entire procedure. Because the body was not yet prepared to have the baby, the placenta was still very strongly attached to the uterus, and I was not able to remove it. Both cows were started on antibiotics to prevent them from getting sick from the surgery or from the retained placenta. They will be checked again at their routine herd check on Friday to be sure they are on the right path to healing.  The calves were given 1 gallon of colostrum within 5 minutes of being born, an oral vaccination to prevent colonization of pathogenic E. Coli, and the umbilicus was dipped with 7% tincture iodine to prevent infection entering the body from the open umbilical stump. Both calves were already trying to stand up before I even had their mom sewn up!!!  C-sections are a bit harder on the cow than a natural birth, and require a longer recovery time. However, in this situation, based on the size of the calves, these C-sections were the right decision for both the cow and the calf!

The new addition to the farm!!!

The "Big Picture"

In vet school there is always at least one class that you just don’t seem to comprehend, no matter how hard you study, or talk through it with classmates or stare at the pages of the textbook.  For me, one of those classes (there were actually a couple for me…) was pathology. Pathology is by definition the “condition and processes of disease.” 

We started learning pathology 2^nd year  of vet school at the cellular level and spent A LOT of time (6-8 hrs/wk) looking through a microscope.  It didn’t matter how much time I spent looking at slides or reading descriptions, it just didn’t make sense to me. I’m a “big picture” person. And looking at individual cells under 100 x magnifications was NOT big picture. I hated the class and thought I was going to DREAD my pathology rotation my senior year.

It wasn’t until that senior year rotation, where I spent 6 weeks on the necropsy (a.k.a. autopsy) floor, did the “big picture” finally make sense.  I’m not sure how many animals I actually necropsied, but examining the dead animal as a whole and then dissecting down to a microscopic level actually helped me figure out all the stuff I was SUPPOSE to learn 2^nd year…. By the end of the 6 weeks, I actually liked necropsies and trying to figure out why the animal died.

In general practice, I have performed multiple necropsies, but not nearly as many as I did during my pathology rotation at school.  Unfortunately, many producers don’t want to spend the money to figure out why the animal died, especially if it’s just one animal every now and then.  I will say that producers are MUCH more willing to spend the money when there are multiple deaths and there is obviously a serious disease wreaking havoc on the system.

 

I was at a regular herd check the other day when I saw a dead cow lying outside one of the pens.  As I always do, I asked the herdsman what the cow’s history was and if they knew why she died. In this case, the herdsman said they really didn’t know. She was a “low cow” which is a cow that is probably at one of the least stressful time periods of her life, other than a dry cow.  The night crew had said they found her pushed by the alley scraper to the edge of the pit where the manure dumps into.  Even if she slipped and fell, getting pushed by the alley scraper is not nearly enough to kill a cow.  So, I asked if they would like me to perform a necropsy on her.  They agreed that would be a good idea since there really was no other apparent reason for her death.

I’ve talked a bit about how we perform necropsies in at least one other post.  So as a quick review, we want the animal lying down on her left side so the right side is facing up. This is because the rumen takes up the entire left side of the abdomen and if the cow were laying on her right side, we would open the cow up and only see rumen.  We would then have to try to move the very large, very heavy, 2^nd stomach compartment out of the way to see the rest of the abdominal contents. 

Cows eye socket with white conjunctiva

Once the cow is lying on the correct side, I like to take an overall assessment of the animal to see if there are any obvious exterior signs the animal has. In this case the cow did not have any apparent scrapes, bruising, broken bones or discharge coming out of any orifice. I then noticed her eyes.  As you can see in the picture, the area around the actual eyeball is VERY white. So, before I even cut her open to evaluate the inside, I knew this cow had severe blood loss and cause of death was most likely due from exsanguination. I just had to find where such an event occurred. 

Findings when opening the abdominal cavity

When I opened her up, I found what is pictured.  The intestines all looked fine, but the blood obviously pooled in the cranial (front) part of the abdominal cavity. At first I thought this was a cow that suffered from a right displaced abomasum. When severe enough and twisted, a RDA can cut off all circulation to the intestines, essentially making them die off and turn black.  After a bit more investigation, I found the abomasum, and it was normal. This was NOT an RDA. 

 

I was then concerned that the cow may have suffered from hardware disease and the blood loss was from a punctured vessel caused by a wire or nail or some sharp metal object. Based on other findings such as perfectly normal lungs, heart and liver,  and lack of finding any sharp metal object, this was also ruled out.  When I cut into the blood mass, I thought I would be cutting directly into the stomach.  To my surprise, I cut into a giant blood clot and that was it. There was no feed material or fecal material coming out at me.  It was pure blood.  Dissecting further I realized that ALL of the blood was in the omentum, and all the stomach compartments and intestines were completely normal in appearance.

Blood Clot

Blood clot

The omentum is the “sling” that holds all of the abdominal contents in place.  It is a vital organ in that it will wall off any leakage from the intestines or infection, provides immune function and stores fat.  In this cow, I was able to dissect away enough blood in the omentum to follow the clot back up to the liver.  In the picture you can see the size of the vessel at the end of my thumb. It is not as large as the mammary veins are, however this is still a significantly sized vessel.

The vessel seen at the end of my thumb

Unfortunately there was too much blood for me to truly find whether there was an aneurysm or hole in the vessel. I did dissect through various parts of the liver to see if there were any liver abscesses that might have caused bacterial migration through the vessel and essentially erode the vessel so that it leaked.  The liver looked completely normal and healthy.

This is a diagram of the mesentery of a dog. Although a cow's is a little different, you can still appreciate how intricate and important the mesentery is and how many vessels could potentially have problems!

My diagnosis based on my gross findings or the “big picture” findings, was that the cow had a mesenteric artery or vein tear and bled out into the omentum. I don’t believe it was anything the farmer or herdsman was going to prevent and it wasn’t anything that would affect the rest of the animals in the group.  The omentum did its job and walled off the emergency, but unfortunately it was unable to stop the bleeding before the cow bled to death.  I may not know the exact microscopic pathology and the owner did not want to spend money to send in samples, but sometimes all we really need to see is the big picture.  In this case the “big picture” cause of death was from exsanguination.

The Changing Face of D.V.M.

I went to one of my old high school football play-off games a couple weeks ago.  As we were sitting on the bleachers wrapped in blankets, with our winter coats and gloves on, my grandmother turns to me and says; “You are really slacking on the blog posts these days aren’t ya????.” Touche Gram, Touche. 

Well here is my defense…  We are well into fall and winter is right around the corner. This time of year is always a bit slower for multiple reasons. The weather is much cooler. Cows LOVE when it doesn’t get above 50 degrees.  The farmers have harvested all the crops and they are properly stored and “cooking” in the bunker silos.  The food supply for the cows is much more consistent, which in turn results in a more consistent life for cows, and therefore they are happy and healthy.  I’m not cutting multiple DA’s a week and the cows having calves for whatever reason, seem to have an easier go of it.

This "slow" time of year also seems to bring about multiple opportunities for different drug companies, veterinary organizations and veterinary clinics to host a continuing education meeting.  I recently attended one at the Sagamore Resort in Lake George, NY.  It was sponsored by Zoetis Animal Health, a popular drug company formerly known as Pfizer.  Whenever drug companies offer to put you up, it’s always worth taking the opportunity. Lake George is a gorgeous part of the region as it is, but this was the view from my top floor hotel room, and a view of my marble lined tub.  Drug companies don’t usually skimp on accommodations.  And I can guarantee you that this is not a place I would have paid for on my own… yeah, I’m part Dutch and cheap, when it comes to certain things.

The title of my post this week is “The Changing Face of D.V.M.”  It’s a bit of a play on words, because everyone with a D.V.M. degree is very aware that the environment of the job is changing.  The cost of a veterinary degree is skyrocketing and starting salaries rarely keep pace. Those of us in Dairy Veterinary Medicine (D.V.M.) seem to be feeling the changes a little closer to home.  

When I started writing this blog almost a year ago, it was because my friends and family would hear some of the crazy stories I had, and say “you need to write a book.”  Well, my position hasn’t changed, and I have no interest in writing a book.  I never read the James Herriot series and I know that may surprise you.  It was my life growing up on a farm that sparked my interest in veterinary medicine, not heroic stories of a country vet.  Now, as I go through my days and think about what I’m going to write about in my next blog, I do struggle to find the cool or crazy stories of cases I’ve seen or dealt with.  As a profession we don’t run from farm to farm seeing 20 individual sick cows a day.  The dairy industry has changed and changed quite dramatically from the times of the early James Herriot novels.

 Even in the small animal world, veterinarians focus on preventative medicine; vaccinations, good nutrition, exercise, regular checkups and blood work to PREVENT diseases from creeping up.  It is very similar in the Food Animal world.  Now, as I’m sitting in this conference in Lake George, words like “PREDICTIVE Medicine” and “Consulting” are being tossed around in common dialogue. We have reached a point in this profession where I’m not a James Herriot and never will be. We have blood tests that can detect pregnancy (what has previously and continues to be most dairy veterinarians bread and butter), lay people doing surgeries, and having the knowledge to diagnose and treat sick cows, and the list goes on.  As a profession, we now have the technology that we can use to predict those animals that area going to get sick, or that population of animals that is at an increased risk of having issues and are not running around to treat these animals after they become sick.

  

Our conferences focus on designing and evaluating ventilation systems for calf barns, developing new services so clients see the value in a “need” for veterinarians and their knowledge, dealing with new rules and regulations from the FDA when it comes to antibiotics, and evaluating and implementing new reproductive programs to get cows pregnant on a farm, just to name a few.   It’s pretty rare that I’ve been to a conference in the last several years that tells me how to specifically deal with a specific disease one dairy cow has.  

So, yeah, I’ve been slacking on the blog posts lately because I’ve already talked about the most common diseases I deal with as a dairy veterinarian. It’s not that I haven’t been working, it’s just I’ve been spending time in the “preventative” realm of my job; monitoring, evaluating and consulting.  Although I do see the occasional weird case, it’s not like I have crazy, weird cases every day.  It’s even pushing it to find a weird one in a month! For most veterinarians, we prefer NOT to see lots of sick cows. It means we, my clients and I, are actually doing a good job at the PREVENTATIVE portion of my job!

"An apple a day....."

Fall in the Northeast is probably my favorite time of year. The red, orange, yellow and gold colors are abundant and make the scenery even more beautiful than it already is. Dunkin Donuts has pumpkin donuts, pumpkin coffee and pumpkin muffins and the fresh apple cider can’t be beat!!! Along with the fresh cider is an abundance of fresh apples to make pies, apple crisp, applesauce… and the list of my favorites goes on.

We’ve all heard the saying “an apple a day keeps the doctor away.”  As much as I love apples, cows tend to love apples too.  Unfortunately, when cows try to eat apples, it’s more of a request for a visit from the doctor than it is to keep her away….. 

I’ve had two calls in the last week from clients that thought their cow was not eating or drinking, was coughing and acting “off.”  The most recent call was much more emergent in the fact that the farmer brought the cow in from pasture and she was extremely bloated. The owner thought he felt something hard in the cow’s throat, but wasn’t really sure if it was real.  When I arrived I found #100 lying down, very uncomfortable, with an extremely distended abdomen, cold ears and obviously in distress. 

Severe Rumen Bloat

As I’ve discussed before, when a cow bloats, it causes severe pressure on their diaphragm and lungs and prevents them from breathing easily and efficiently.  As you can see from the picture, she was severely distended, so my first order of business was to relieve the bloat and allow her to actually be able to catch a breath.  In order to relieve her bloat, I placed a red trocar in the rumen as I have also discussed in a previous post. Once the bloat was relieved, and she was able to take a breath, I was able to examine the rest of her.  As I was looking at #100 I was asking the farmer if he had any apple trees in the pasture.  His response was “yeah a pile of them.” 

The obstruction visible in the shaved area

Feeling the cow’s neck, I was able to palpate a large baseball size lump, about half way down her neck.   I was pretty positive she tried to eat an apple and she ended up swallowing it whole and was now choking on it.  Because cows do not have upper incisors, they can’t just bite into part of an apple. Usually they end up putting the entire apple in their mouth and then try to bite it with their molars. If the apple is hard it may not break and can shoot directly down their throat, or the cow will just try to swallow the apple whole.  It’s great if they can actually get the apple to their stomach without any trouble, but if the apple is bigger than the esophagus, it can cause some major issues.

The first call I had with this issue, was a small beef cow, which must have eaten a smaller apple. By the time I arrived, she had passed the apple on her own and had started to nibble on hay and drink some water.  She was started on some anti-inflammatory medicine to help with the soreness and any trauma the apple caused on its way down.  She was in a much better way than #100.

The approach that I take when I am faced with an animal choking is to first sedate the animal.  When an animal is choking, much like a human, they begin to panic and all their muscles, including the esophagus, will tense. With sedation, we hope that the animal will relax enough that we may be able to massage the obstruction down the esophagus, or when we pass a tube down the esophagus, we will be able to move the obstruction with the tube.

  

Once #100 was sedated, I took a firm tube and tried to move the apple down the esophagus. It wouldn’t budge.  Because the esophagus is a smooth muscle, and kind of an important muscle to have, it’s crucial not to be too forceful when trying to remove an obstruction, causing more damage. When the apple wouldn’t move with the gentle pressure of a tube, I went to my next plan- pumping water down her throat to try and “flush” the apple down, rather than adding more force.  As I was pumping the water in, she was spitting it right back up as fast as I was pumping it. After trying to pump 3-4 gallons of water down her, I decided it was a futile effort.  Now I’m not sure what I’m going to do… The poor cow was still coughing and trying to burp to get the apple up, and what I was doing was not working. 

Another view of the obstruction

 

I thought about pumping mineral oil down her throat, to "slide" the apple down, but because she was spitting up the water so forcefully, I was afraid she would do the same with the oil and possibly aspirate on the oil.  It’s pretty much a death sentence if she ended up aspirating oil.  And, even if we were able to move the apple down the esophagus further, because of the size of it, there was still a chance that the apple would lodge where the esophagus meets the stomach or somewhere in the esophagus where it passes through the chest cavity.  I didn’t see many good outcomes with this idea.

So, in my gut, I figured we were headed for surgery, but I wanted to bounce ideas off of another vet first, so I called another vet in the practice.   She was wondering if there was any way I would be able to put something down her throat to mash the apple up into smaller pieces so it would pass.  My concern was the trauma to the esophagus in trying to pass something  that would do the "mashing," and then what happens if we lose that down the throat too??????  She also suggested I try to reach down and grab it as someone pushes it back up to me.  Well I do have long arms, but they aren’t that long… And I kind of need them to do my job, so I wasn’t real keen on putting an arm down a cows mouth and have her, as a  natural reaction, bite down on it…..

So, now I’m back to surgery as my option.  Any other choke I have dealt with, cow or horse, I have been able to relieve the obstruction with all the aforementioned ideas, which means I have never actually done a surgery on a choke case.  Well one of the great things about veterinary medicine is that you learn to improvise, and you do so under duress.  I know how to do surgery, I mostly remember my anatomy- well at least the important things in the neck region; like the jugular vein, carotid artery,  and some pretty major nerves, so I’ve got it covered…..  Ha!

  

I tied the cows head up in the air so that I was working directly under her. After I clipped and washed the area, I blocked it with lidocaine and started my exploration.  Being careful not to cut through any major things, I took a great deal of time NOT using a scalpel, but rather using my fingers and scissors to dissect through the tissue.  Once I reached the esophagus, I was able to cut over the top of the apple and see that it indeed was an apple; a yellow-green one at that!

 

Now for my vet friends reading this, I know you aren’t supposed to cut directly over the obstruction, but based on location, I didn’t want to sway too far in either direction. So I went with it.

  

After a fair amount of work, using scissors and my fingers, I was able to get the apple removed from the esophagus. I could tell that #100 was feeling much better the minute I removed the apple because as she coughed, I had a face full of saliva and rumen juice spew out at me through my opened esophagus.  I sutured her closed and could tell that it was truly closed when I no longer had saliva coughed in my face.  I then sutured the muscle layers closed and then partially closed her skin, leaving a space for any drainage that may occur.  I was concerned about infection because it wasn’t a truly sterile procedure and I am not 100% sure I removed all apple chunks or rumen fluid that may have come through the opened esophagus when she coughed.

The culprit in pieces.

   

She was placed on an anti-inflammatory medicine and antibiotics. When I called to check on her the next day, the farmer said she had started to pick at some food but wasn’t eating with vim and vigor quite yet.  I can only imagine how sore her throat must be with having the apple stuck in there for who knows how long, and then me trying to get the apple to move with tubes, and finally the surgery. 

 I still worry about aspiration pneumonia, infection in the incision, as well as the esophagus forming a stricture at the point of my incision and suturing.  I am very fortunate in the fact that cows have an amazing ability to heal and surprise me every day with that ability.   This was certainly a new one for me.  I never did mention that #100 was due to have a baby in less than a month.  After all this, I really hope she will be able to have her baby and go on living a happy life AWAY from the apple trees!!!!

Finally! A Prolapse with Pictures!

I was on call this past weekend and had quite an array of calls. The first was for a left DA; pretty routine procedure that went well. The second call was for a weak goat that, after performing a fecal, was found to be loaded with intestinal parasites (worms). He was treated with electrolytes, dewormed and sent home. Hopefully he had not lost so many nutrients and blood from the worms that he is able to recover after a couple rounds of dewormer.  The next call was for a cow that had calved earlier that day and suffered from a uterine prolapse.  The final call of the weekend was a calving. 

I know I’ve discussed other emergency calls where I’ve had to attend to a prolapse, but never had any pictures to show you what it really is. When I arrived at this farm, the cow was out in the pasture and I had to have them run back to the barn to get water, so I had some time to actually take a picture!  

Uterine prolapses are one of the few TRUE, emergency- drop- everything -and – come calls that we get in dairy practice. This condition usually occurs in older cows that have already had one or two calves. It can happen in first time mothers, but is not quite as common.  Normally prolapses will occur within the first 24 hours after a cow has had a calf. If she has made it through the first 24 hours without any trouble, it is pretty rare that she will prolapse at that point.

For those that have never seen a uterine prolapse, it is when the entire uterus, which I remind you just had an 80+ pound calf inside it, completely inverts and falls outside of the vagina. It is the uterus, inside out, outside the cow. Sometimes the bladder will also come out with it, and in really bad cases, there may be some loops of intestines that also have prolapsed. 

 In the picture you can see these large “lumps” on the uterus.  These lumps are called the “caruncles” and are the attachment points of the placenta (cotyledons) for the calf.   The best analogy I can come up with for a uterine prolapse, is a pair of pants that you have taken off, and instead of grabbing the ankle and pulling, you start at the waist and completely turn them inside out. 

Prolapsed uterus

There is no definitive “cause” of a uterine prolapse; however there are certain conditions that predispose cows to prolapse.  A difficult calving where the cow strains a great deal, continues to strain and/or has a very large calf, will predispose a cow to having the uterus prolapse, as well as when the cow is hypocalcemic (low blood calcium). Calcium plays a role in smooth muscle contractions in the body. The uterus is considered a “smooth muscle” organ, so when the cow is low on calcium in her blood, the uterus is not contracting down like it should, after the cow has calved.  

Some of the biggest concerns we have about cows with a uterine prolapse is shock due to blood loss, traumatic damage to the uterus as it is outside the cows’ body, and entrapment of the intestines in the inside-out uterus, causing an entirely different issue.  The uterus is suspended in the cow from two ligaments that attach to the side if the body. Inside each of these ligaments is a major vein and artery.  As the uterus is prolapsing, turning inside out, headed out of the vagina, it stretches these ligaments and therefore the veins and arteries inside them.  The concern is when they have been stretched to the point that they have ripped and as tension is released on these vessels, the cow starts bleeding internally and can easily bleed to death in a short time.

So how do we take care of this 50+ pound organ that is supposed to be inside the cow that is now outside??? Well, first and foremost we give the cow an epidural, or spinal, to prevent her from feeling the procedure and also to prevent her from continuing to push and strain against us as we try to replace the uterus.  The cow can be standing while we fix her, or can be laying down with both back legs extended directly behind her. We then wash the uterus being sure to remove as much bedding, mud, debris, etc. from the uterus as possible.  

Now back to the pant analogy.  We can fix the pants by going from the waistband, back down the leg, grab the cuff and pull it back up through. Well in a cow, we can’t jump inside the cow, and reach from the inside to the tip of the uterus and pull it back through. Instead, we have to start gently pushing the uterus back in, starting close to the vulva and working it back inside. It would be like starting with the cuff of the pants and pushing it back through to the waistband.

As we are pushing the uterus back, we have to be sure not to rip off any caruncles, or push our fingers through the sensitive and damaged uterine tissue.   If a tear does occur, then we can suture the hole and continue on. It’s just better if we avoid making a hole in the first place. 

Replacing the uterus is quite a workout, if I do say so, but I can replace a nice “easy” prolapse in about 20 minutes.  I have also worked on them for over an hour  only to have the cow push it back out just as I have it almost all the way in.  The longer the uterus is prolapsed, the more edema the uterus will get, it can dry out and become less pliable and can be severely injured from other cows or herself.  When a cow does have a uterine prolapse, we recommend the farmer keep her quiet, keep other cows away from her, and try to keep the uterus as clean and moist as possible until we can get there. 

After the uterus has been pushed back inside the body, we have to make sure it is completely everted so it doesn’t re-prolapse. We then give the cow an injection to help with the smooth muscle contraction and shrinking the uterus back down so it can’t come back out.   Finally we give the cow some calcium in the jugular vein and start her on antibiotics in case we didn’t get every little spec of dirt off the uterus before we replaced it. 

Some practitioners will place a “buhner stitch” in the cow’s vulva after replacing the uterus.  It is a stitch that essentially closes the vulva up and allows only enough room for her to urinate. As a practice we have decided to do this, but it really is more of a placebo effect for the farmer.  If the uterus was replaced properly, and the cow was given the appropriate medication to start the uterus shrinking back down, there is no need for this stitch.  If the uterus was not replaced correctly and the cow continues to strain, or the medications were not given to start the uterus shrinking back down, she can re-prolapse and this stitch will do nothing to stop it.  For the cows that do have a buhner stitch placed, it is removed about 4-5 days later.  The picture shows the stitch placed after I replaced the uterus on this cow. 

Buhner Stitch Placed

This cow stood during the entire procedure and walked to another part of the pasture and started eating when we were done.  I think she will be fine and should breed back in a few months with no issues.