"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!!!!