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The Fix: Part One

44 days, 102 cold-hosings, 88 doses of bute, one Go Fund Me campaign with 87 generous donors, and a 2.5 hour trip through the Palouse hills later, Duke was unloading in the Washington State University Veterinary Teaching Hospital parking lot. He had an 11 a.m. intake appointment, an empty belly, and was scheduled for a CT scan that afternoon. 

Duke stepped out of the trailer and curiously surveyed his surroundings with the high-headed periscope posture he reserves for novel new environments. I could almost read his mind: big buildings, morning traffic, distant clip clop, horse smells, no pasture in sight. Lots of horse trailers, but no busy arena, and very few horses to be seen. Weird. But there's an embankment full of clover and grass, and the one horse in view is being lead by a woman who is letting him graze on it, so it can't be a bad place. Duke snorted and relaxed, and looked off hopefully towards the nearest green patch.

We were intercepted by two friendly students who lead us in the back door of the facility to a stall. Introductions made and intake paperwork handed off, we began reviewing his case. 13 year-old Quarter Horse gelding. Chips in the right front fetlock and right hock, the result of a traumatic automobile accident. The familiar confusion I've come to expect in my listeners appears as I'm recounting our story. The furrowed brow. The incredulous look from me to Duke and back. I've learned to keep it simple and give folks a chance to process. Without fail, there are follow up questions to make sure they haven't misunderstood.

"You say he was hit by a pickup truck, directly from behind. The truck was going 50 miles per hour?"
"Yes."
"So, he was in a horse trailer?"
"No. We were riding. You can see where the tire treads went over his withers here. He was trapped under the truck for about 75 feet, but made it out, and headed for home. The road rash is healing up really well-- this entire shoulder area and flank started with abrasions and edema, but hardened and peeled. About a third of his tail was pulled out by the root leaving big scabs on the dock of the tail, and it must still bother him-- he swishes it more than normal, but it's starting to come back in now. He had cuts and abrasions on the poll as well. I have pictures if they would be helpful?"
"He walked away from the accident?"
"Yes. Trotted away, really. By the time I found him, he was trotting across the field for home."
"That's horrible! Where were you?"
"I was in the saddle on his back. On impact I went into the windshield, over the top of the cab and landed in the truck bed."

Astonishment. And the searching gaze looking for some sort of obvious external injury.

"Are you okay?"
"I'm awfully glad to be here. We're both a little worse for wear, but we're going to make it through this."
"That's incredible! It's a miracle. You're both lucky to be alive!"
"Yes."

For a horse that had been through such a traumatic ordeal, Duke was in remarkable shape. At first we thought that aside from the road rash, bumps and bruises, he had miraculously avoided any more serious injury. He was surprisingly sound, but an odd little wound on his right front pasturn was taking forever to heal and persistent swelling in his right hock eventually demonstrated that something bigger was going on. Some X-rays with the local vet confirmed that he had a splint on the front leg, and a bone chip or fracture of the right hock joint, but because of the location, they weren't able to see it well enough to fully diagnose the issue. After consulting with Kelly Farnsworth, DVM at Washington State University Veterinary Teaching Hospital, it was clear that a CT would be needed to fully understand the situation, and surgical intervention was likely if a repair was going to be possible.

 W.S.U Veterinary Teaching Hospital

W.S.U Veterinary Teaching Hospital

For those not familiar with W.S.U.'s teaching hospital, it's one of only 28 veterinarian programs in the country, a state-of the art facility, and the go-to clinic for complex veterinary cases in our area. The admissions process is a well-oiled machine, with helpful pre-arrival instructions, intake paperwork sent before you arrive, clear payment policies, and special hotel rates for travelers. On arrival the patient is assigned to a vet school student on weekly rotation who monitors and supports the health of the animal, escalates questions and medical issues to the veterinarians, orients and shepherds the animal's guardians through the process, and is a communication lifeline. Sara, Duke's assigned student and new best friend, proved invaluable during the course of our stay. That girl is pure gold.

We were joined in Duke's stall by several undergrad students and Camila Souza, DVM, an equine surgical resident, who reviewed Duke's vitals and led the group of students through a thorough examination noting the edema in the hock, palpating carefully from head to tail, and testing range of motion. She was able to determine that the chip in the right front fetlock wasn't interfering with the movement of the joint or ligaments, had healed well, and didn't seem to be causing any pain, so was hopeful that surgery wouldn't be necessary. When flexing Duke's right hind, she noted a mobile bony protrusion that was unusual and sensitive when flexing the joint. Next we headed outside and were joined by Dr. Farnsworth for a lameness evaluation. Pleased with the attention and audience of the students, Duke trotted down the asphalt like a champ, with a limp imperceptible enough to require a couple of trips. Dr. Farnsworth smiled and shook his head. "His lameness is subtle for all he's been through. That's one lucky horse."

The next task at hand was to determine how to best get a closer look at the injury. We knew we needed to get a CT scan to be able to see the soft tissue and understand the bone injury better, but that requires full anesthesia for horses, and aside from the normal medical risks, we really didn't want to put Duke through the stress of disorientation and panic many horses have on waking more than once if we could help it. It was decided that another round of X-rays taken from different angles might yield enough new information to make a plan.

 On extension of the limb, the chip was pushed out of the joint area which probably helped prevent further damage to the cartilage and soft tissues in the joint.

On extension of the limb, the chip was pushed out of the joint area which probably helped prevent further damage to the cartilage and soft tissues in the joint.

Thankfully they did, revealing an unusual position for a bone chip on the caudal aspect of the medial trochlear ridge of the right talus. For those of you who aren't horse anatomy geeks, the hock of the horse is a complex joint made of many bones, and the ridges of the trochlea of the talus bone glide along grooves in the tibia to create the flexing movement of the joint. We still couldn't see every detail, but now knew that there was at least one large chip of the talus bone, and that it was in an area near the attachment site for the medial collateral ligaments.

At risk of over-simplifying, when dealing with bone chips, you basically have 3 options:

  1. Leave it in as it is
  2. Try to reattach it
  3. Take it out

This was a tricky situation because the position of the chip was in an unusual location deep in the joint. It was going to be harder to extract than the average superficial splint or chip fracture, but was also inside of a joint that's responsible for about 90% of the movement of the hock. Eventually the bone chip would create debris that would wear on the soft tissues around it and cause more pain, inflammation, and speed the onset of arthritis, so option one wasn't very appealing. Duke was going to have surgery.

The task Dr. Farnsworth had to wrestle with was how. The joint capsule is filled with synovial fluid, a viscous material that's responsible for reducing friction, shock absorption, and the transportation of nutrient and waste products. Anytime you breach the protective outer lining of the joint capsule, you exponentially increase risk of infection and jeopardize the integrity of the joint function. Ideally, he could reduce that risk by using Arthroscopy instead of open surgery-- a very popular minimally invasive surgical procedure done by maneuvering surgical instruments through small incisions guided with the help of a small camera.  But with a chip this big and in that position in the joint, would that be possible?

While Dr. Farnsworth was weighing the options, a critical emergency case came in requiring immediate attention, so Duke's surgery was postponed until the next day. Duke was thrilled, of course, since this meant he'd finally get breakfast, and he spent the afternoon exploring the green areas around the hospital and holding court with the friendly vet students who were stopping by at regular intervals.

 Killing time before surgery.

Killing time before surgery.

By morning, Dr. Farnsworth had a plan he felt confident about. They would put Duke under anesthesia and do the CT scan first, integrate whatever discovery they made into the plan, then proceed right away with the surgical procedure, attempting repair through arthroscopy, and only do an open surgical procedure as a last resort. There were boundaries of how long Duke could safely remain under anesthesia and on the surgical table, so efficiency was going to be important, but it was achievable. Aside from the technical strategy and normal risks associated with any operation, the other concern was how Duke would react as he was coming out of anesthesia. If his response was fearful, it was possible that he'd thrash around and cause new injuries worse than the ones he started with.

Dr. Farnsworth walked me through the facility showing me the areas Duke would be visiting that day, and explained that they're fortunate to have a therapy pool with a rising platform that helps with the post-op recovery in cases like these. Hoist apparatus attach to the ceiling throughout the facility to assist in moving the horses safely. After the surgical procedure was done, Duke's leg would be put in a cast, and while still under anesthesia, he would be lowered into the water. A sling attached to a hoist would be supporting his torso, and halter and flotation devices would be used to ensure he was positioned safely. As he woke, if he thrashed around, he would be suspended in water, so far less likely to cause new injury. Once awake and adjusted to his surroundings, they would raise the platform, Duke would slowly rise to the level of the surrounding deck, and be walked back to his stall.

Plan in place, it was time for the surgical team to scrub in. Sara promised to update me as soon as there was news, and seeing my interest during the tour, even captured a few photos (below) so I could see some of the post-op recovery process. A few anxious hours later, she called as Duke was coming out of anesthesia, and assured me all was well-- that she would come fetch me from the lobby as soon as he was more alert.

 Post-Op in the pool.

Post-Op in the pool.

 Waking Up.

Waking Up.

 Paddling

Paddling

 Headed back to the stall.

Headed back to the stall.

In the surgical debrief, I learned that the procedure had gone very well aside from a few broken surgical tools that were sacrificed trying to extract a larger chunk of bone from a tricky angle. The CT scan had been extremely helpful, and revealed four bone chips; two large, and two small. Each were removed successfully. The cartilage and surrounding soft tissues looked surprisingly healthy given the mobility of the chips, and in another great stroke of luck, only a very minor portion of the collateral ligament at the attachment site had been compromised in the injury, still clinging sadly to one of the bone chips. Duke reportedly handled his first swimming experience like a pro, calmly paddling away until he found his feet on the platform, stood while the platform raised level, then hobbled his way back to his stall escorted by the recovery team.

When I finally arrived at Duke's stall, I found a very groggy soggy horse with a flashy purple cast coming out from under sedation. Woosey and clearly struggling to understand why he couldn't bend his leg, he hobbled around a bit, testing the cast, and tried unsuccessfully to bend far enough around to launch a full investigation with his muzzle. I rubbed him down and held his sleepy head in my arms for a while, being careful to stay out of danger zones should he stumble or strike.

Riding the emotional high of finally having my boy safely through the procedure, it might have been a sentimental teary moment had Duke not heard the hay cart approaching and snapped to attention, behaving like every stoned youth I've ever witnessed trying to look sober when the authorities happen by. I burst out laughing and shook my head. That's my boy! After sedation, the concern is that the horse might be interested in food, but not be alert enough to have the coordination to chew or swallow properly and choke, or literally fall asleep in their water bucket. Duke wasn't quite sharp enough to fool the first person manning the hay cart, weaving in place and eyes at half mast, but had better luck nickering at the second cart a while later and had his dinner at long last.

 Duke desperately trying to stand at attention as the hay cart comes his way.

Duke desperately trying to stand at attention as the hay cart comes his way.

 Enjoying some of eastern Washington's finest hay.

Enjoying some of eastern Washington's finest hay.

The next week was a blur of commuting a few hours away for my own medical appointments, early morning phone calls from Sara letting me know how Duke did through the night, being walked around Pullman by my dogs Remington and Gracie who were traveling with me, hotel room pizza dinners, and hours visiting with Duke, trying to make his stall rest a little less dull. It's a shame horses aren't into Angry Birds or telenovelas-- my one brief attempt at a puppet show ended predictably with the carrot characters being promptly eaten.

Post-operative recovery included hand-walking by the students and staff, pain meds, and careful monitoring of Duke's vitals. The reduced activity of being confined to a stall makes it more challenging for the body's lymphatic system to do its job, so I did some manual lymphatic drainage to help usher the waste byproducts from his tissues, and massages to support the overworked muscles that were compensating for the bum leg. He was sore and bored, still working through the after effects of the anesthesia, and seemed really tired and out of sorts the first few days. It wasn't until the fourth night that Duke finally figured out how to maneuver with his cast to get down to sleep and caught up on his R.E.M.. He was noticeably brighter the next day, and I've never been so happy to find shavings in his tail before!

Once rested, between regular feedings, the comings and goings of other patients, and people stopping by to say hello, the steady stream of activity seemed to really help take the edge off of the monotony of stall rest for him. If you asked Duke, I think he'd probably tell you that his favorite ritual was salad time, when I'd head out to the clover patches and pick him a bowl of fresh greens. With his stall being closest to the exit, if I propped the door open for him, he could catch a fresh breeze and a glimpse of the sunshine, and I'd hear him calling after me-- maybe demanding a jailbreak, or maybe just hollering instructions-- "Get the dandelions! More clover!!"

Even so, by the end of the recovery week, even with excellent care, the charm of hospital life had worn off completely, and we eagerly loaded up and headed to our next stop in the recovery process: Paxhia Farm.

TO BE CONTINUED...

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