Junior Surgery

I think it's safe to say that junior surgery is the class that everyone looks forward to the most, but fears at the same time. Nothing really gets your adrenaline going like knowing you are about to be responsible for a life and you have absolutely no idea what you're doing.

Junior surgery gets divided into two phases- cadaver and live surgeries, mostly spays and neuters. You would think it would make sense to have your cadaver surgeries before your live surgeries, to learn how to actually perform the surgery. Apparently the size of our class makes that impossible though, and I was one of 12 lucky people to have our first live surgery scheduled before having any of the cadaver surgeries. I was pretty close to a full on panic attack, and all I could do was obsessively read the lab manual and hope I understood what was going on and what to do.

For my first live surgery, I was one out of two anesthetists for the group. We performed two surgeries, a spay and a neuter. One anesthetist has the role of the main anesthetist for one surgery while the other is the recorder, writing down all of the patient's vital signs on the anesthesia record, and then for the next surgery the roles switch. I was the main anesthetist for the first surgery, a neuter of the cutest little puppy named Marty. Obviously, I was terrified of doing something wrong.

The first thing I had to do was induce Marty, which just means giving him the drugs to knock him out. The day before the surgery was scheduled I came into the hospital to prepare all my drug dosages for the mixture of Telazol, Butorphanol, and Dexmedetomidine. This is just a quick IM shot into the quadriceps (thigh muscle), but apparently it's pretty painful, because all of the dogs yelped when they got their shot. This didn't help my nerves or my confidence. But the next part was easy, just petting Marty until he got sleepy and laid down on the table.

Then I had to get the catheter in. I've never put a catheter into a small animal before, let alone a puppy. I'm used to giant horse veins, which you'd have to be blind to miss. Even after all my blood work in Africa I wasn't too confident, because even a sable's ear veins were larger than Marty's cephalic vein. It was easier getting the catheter in though than it was trying to take blood from him the day before the surgery though, because at least he wasn't squirming around. I didn't hit the vein on the first try- that would have been a miracle- but at least it only took one stick and some wiggling the needle around. I always feel bad when I have to continuously have to stab to hit the vein, especially since I hate when nurses do that to me.

After the catheter is secure I had to pick out an endotracheal tube. That was an adventure. I had absolutely no idea how to appropriately size an endotracheal tube. I grabbed like 4 different sizes and brought them all over to hold up to Marty's neck. Of course, they don't differ so much in length, but in diameter, so that didn't help too much. You want the largest diameter size you can fit without traumatizing the mucosa, and I still don't get how you know what that is. I guess just practice. I got the right size with the help of an anesthesia tech, and then I managed to slip the endotracheal tube down between the arytenoids and into the trachea. Now I was feeling a little more confident.

We finished setting up all our equipment after turning on the oxygen, and then we prepared to move from the induction room into the surgery lab. All of our animal shelter live surgeries take place in junior surgery, where our labs take place as well. We wheeled Marty in and got him hooked up to the anesthesia machine and got all of his monitors on. Now for the duration of the surgery it was my job to make sure Marty didn't wake up. I had his oxygen flowing, I had the isoflurane on, and I was constantly checking his blood pressure, pulse, and respiration. I gave him a sigh breath (manual breath) every 5 minutes or so, and if I thought he was getting a little light I would up the isoflurane. To check that he was still under and wasn't getting light, I obsessively checked his palpebral reflex and eye position. For the palpebral reflex, you tap the inner corner of the eye. In the awake dog when you do this, the dog blinks. If the dog is under anesthesia there should be do palpebral reflex. The eyes should also be pointed ventral, or looking down. So if I saw a little bit of a blink, I upped the isoflurane until I felt I could bring it back down again. My nerves went away during the surgery and I stopped worrying that I was going to kill the patient, but it did take constant attention and adjustment to keep Marty's levels good.

After the surgery was done, and I had turned off the isoflurane, it was my job to sit with Marty until he woke up. For such a little dog that had seemed to be not so deep at all during the surgery, he took a long time to wake up. He almost went past the 30 minute mark, which then would have to be marked down as a complication. But I can't complain; I got to sit there cradling him and rubbing his back, waiting for him to either cough or swallow so I could pull the endotracheal tube out. Then I carried him into recovery. I don't know how anyone goes through junior surgery, let alone the animal shelter rotation, without wanting to adopt every dog that goes through the program.

For the second surgery, a spay on a puppy named Topaz, I was the recorder. So I didn't have to place any catheters or endotracheal tubes, I just helped hold Topaz in place for them. And during the surgery, every 5 minutes I just had to record blood pressure, pulse, respiration, end tidal CO2, saturated O2%, and the flow levels for oxygen and isoflurane. And every 15 minutes I took a temperature. This was definitely much less stress than being in control of the anesthesia machine, plus I didn't have the nerves or stress that comes from not knowing what to expect or what to do. So I just stood a little off to the side, and every 5 minutes I checked all my instruments and wrote the values down. Not bad at all. Until Topaz decided to wake up halfway through the surgery and had to be given an extra shot of propofol through her catheter. That was some excitement I could have done without. But at the end of the day, both Marty and Topaz had successful surgeries and were able to go home immediately afterwards.

The next week I had two surgery labs, where I would be acting like the assistant surgeon and primary surgeon for our cadavers. On our first lab we did a spay, celiotomy, and placed a chest tube. For the second lab we did a neuter, gastrotomy and gastropexy. Celiotomy just means we explored the abdomen. For the chest tube, you have to force a tube through the thoracic wall into the thoracic cavity. It's an emergency procedure used to eliminate any excess air or fluid that's in the thoracic cavity. A gastrotomy is opening up the stomach, which is a procedure that's rarely performed, but might be done if an animal ingested a foreign body. Gastropexy is suturing the stomach to the abdominal wall. It's done mainly to prevent GDV, which is a life-threatening disease in dogs where the stomach kind of twists up on itself.

The first lab took forever, because again we had no idea what we were doing. Our first incision was not so pretty, and neither was our attempt to suture it back up. Our spay was also not the neatest job in the world, but at least it was done, and would have been a completed, successful surgery if it had been done on a live dog. It took us forever to suture up our incision, since for a spay you normally make a super small incision, but for a celiotomy you are cutting from the xiphoid to the pubis, or the entire abdomen from the rib cage to the hips. We were still trying to figure out the suture patterns, and since we were supposed to be using a simple interrupted pattern, that just naturally takes longer.

Our second lab went much smoother. Now we knew what to do, which helped a lot. Our initial incision still wasn't perfect, but it was better. At least it was through the linea alba, or the thin white line where the abdominal muscles join together, and not through muscle. The technique behind a neuter is pretty much the same as the spay, so now we knew how to use the three forceps technique and how to tie our transfixing knots and were able to move through that quicker. Plus a neuter is always just faster than a spay. The gastrotomy required a new suture pattern, the Lembert, which makes the stomach lining invert on itself to produce a better seal. But by halfway through closing that incision I really got the hang of it, so not only did it go smoothly, it looked pretty good. Same with the gastropexy; once it got going we were on a roll, and it looked good too. Our closing also went much smoother- our suture knots were much neater on the closing of the external rectus sheath. Our simple continuous pattern for the subcutaneous layer (which we couldn't even do the first lab because of our botched incision) looked consistent, and our skin closure had a little bit of puckering but overall wasn't too bad, and was still much better than our first attempt. I finally get why they make us do so much suturing and so many knots; it it so confusing at first and easy to overthink and mess up, but the more you do it the more it becomes second nature and you stop thinking and just let your hands move. By the end of the second lab I was even getting the pencil grip of the forceps down better, something which I can assure you does not come naturally.

I still don't feel like I really know how to do a spay or a neuter, but I definitely know more than I did a week ago. And I definitely know how to suture now, though the incision could still use some work. I have a little bit of a surgery break, but pretty soon my schedule is going to be nothing but surgery. I have all of mine this semester, which I think I'll appreciate next semester. For this class we have 7 surgeries as the anesthetist, and on our last one we play the role of both anesthetist and recorder for both surgeries. We have three surgeries as the assistant surgeon, and three surgeries as the primary surgeon. I'm still nervous for those. I really have to work on my aseptic technique, which we practice in our cadaver labs but it's easy to forget or ignore, since we usually mess up so much since we're still learning it. At this point I think that's actually what I'm most worried about. I think (and hope) that with three surgeries being able to watch a 4th year perform the procedure correctly I'll be able to do them myself as well. And then at least I can say I can do it and feel confident about it.

Sable, Sable Everywhere

One of the most commonly worked on animals in South Africa, at least for us, was sable. Apparently sable, which are in the antelope family, were almost extinct in South Africa, and they are now being bred back on the private game reserves. There was a huge sable sale in August, and since we were there in June, we had a lot of sable calls.

Working on the sable reminded me a lot of working on cattle here in the states, except we don't have to chase cattle around in trucks and dart them in order to work on them. But sable in South Africa are usually kept fenced off in sections of the reserves to protect them from other animals, and a lot of the same type of care goes into them. They even get ear tags like cattle do.

All in all, the sable are relatively easy to dart. They are so used to people that they really don't start running until the dart gun has been fired. And even then they don't always run far. In fact, sometimes we had to chase the rest of the herd away from the sable that was darted and went down.

When dealing with a darted sable, you always want to put pipes on their horns. Sable tend to swing their heads around a lot as they're being carried, and if you're working on them on the ground they can't hold their head up by themselves. And we had one member of our group take a pipe right in the neck, and you can bet he was grateful it wasn't the actual horn.

Once the sable have been darted and the horns taken care off, there is a pretty set routine. Each sable was given anti-parasitic (doramectin) and a vitamin complex IM, and each sable also has blood taken from their cephalic vein (on the front leg) and has hair pulled from the tail for DNA testing. Each sable also gets a shot of penicillin to help prevent infection, as the dart entry sites and other injection sites can't easily be cleaned or monitored.

Testing the DNA in the sable was of particular interest to the reserve managers, and on some sable that was all we did. We used a special dart that had a little claw on the end of it, which would stick to the sable, grab a tuft of hair, and then fall back to the ground for us to collect. The breeders are trying to breed bigger horns on the sable, so as well as DNA testing, the horns are always measured as well. And the horns are measured by not only their entire length; the tip lengths, the number of rings,  the tip to tip and the base length are all important as well.

Sable that are going to be going to sale are moved into bhomas, which are like pens without the reserve, so that the sable can get used to being fenced in more before the stress of the sale. This is not easy. Sable are heavy. In one day we moved 14 sable, and believe me, you feel that by the end of the day. And you have to watch them; one sable ninja kicked me in the back of the knee while we were driving it to the bhoma, and then one of the reserve workers had to sit on it for the rest of the ride to keep from kicking. I learned a very important lesson that day- always volunteer to hold the head of the sable. It's much better to be slobbered on than kicked. And then all you have to do is hold their head up and make sure they keep breathing.

The trickiest part is actually moving the sable into the bhomas, because sometimes it involves carrying sable down long narrow corridors. And it takes usually about 7 people to carry a sable- 3 per side and then one person holding the horns- and usually it's hard to fit everyone into the corridor and be able to move effectively. And as I said earlier, sable are heavy. But after some experimenting, I think it was easier to just carry them down rather than reverse them and hope the sable will walk down themselves, because sometimes they just don't feel like doing what you want them to do. But when you're ready to reverse them, wherever that may be, sable have very nice ear veins that are used for the reversal. And then you just remove the pipes from their horns and leave them alone. It's much easier doing all of this with them being left in the field than transporting them to a bhoma, but sometimes that's just what you have to do.

That kind of procedure is what we did the most off, but like I said, the sable are treated a lot like cattle. So we were called out to look at some for lameness and abscesses as well, which usually just involves more antibiotics or antibiotic wound spray. And for one sable with a lung infection, all we had to do was fill the dart with antibiotic instead of our regular sedatives, and that was the administration of the drug. Then all we had to do was collect the dart. We also did some pregnancy checks on our very last day. Only one sable required an actual ultrasound, and the rest were done by rectal palpation. By palpation you are able to feel a thicker uterine horn on one side. It's easiest to feel pregnancy around 4 months, which is also when an ultrasound is able to pick up a pregnancy.

The first day we worked on sable, I wasn't overly impressed. I wanted to work on the exotic wildlife, and sable really didn't seem all that exotic. By the end though, I thought they were super cute, and if they weren't endangered I would have loved to bring a sable home with me. Preferably the tame orphan.

The sable are known for having a painted face

Giving a sable a shot of penicillin in the butt

Collecting the hair and skin off of the dart for the DNA testing

A closer look at the DNA collection dart

Collecting blood from the cephalic vein

A closer look

Performing a rectal palpation for a pregnancy check

This was the sable that ninja kicked me, and had to be sat on for the ride to the bhoma

Giving the IV reversal in the ear vein

Save our Rhinos, Hunt a Poacher!

I really wanted to do a more in-depth description of the work I did with the rhinos in South Africa, because I really do feel that those two days were the most interesting. And they were the two days where I really felt that I was contributing the most to the wildlife conservation cause.

The whole idea of the rhino horn infusions is to make the ivory worthless on the black market. Of course, you can't tell that the ivory is worthless just by looking at the rhino, so the whole hope is that the procedure will spread by word of mouth, and poachers will know that rhinos on the reserves have been treated and that they'll go somewhere else. And so far, to the best of my knowledge, none of the treated rhinos have been poached, so it's hard to say whether the treatment is effective or not.

The treatment itself involves darting rhino from a helicopter (they are darted with 4 mg of etorphine, which is essentially morphine x 10,000), and once the rhino goes down holes are drilled into the horns in order to attach the hoses for the transfusion. A rhino's horn is keratin, the same material that makes up human fingernails, so they don't feel it. The infusion is a mixture of an ectoparasiticide and an indelible dye, or an indestructible dye. An ectoparasiticide is basically a medication that we would use on animals to treat and prevent fleas, ticks, and so on. The one used in this procedure is an organophosphate. Since some of the myth around rhino horn is that by ingesting it you can be cured of anything from headaches to cancer (this is an especially popular belief in Vietnam), the idea of injecting this parasiticide is that when humans ingest it, it will make them physically sick and not want to try it again in a hurry. The dye that is injected stains the ivory pink, and makes it worthless for carving. So overall, the entire procedure is designed to ruin the value of the horn by making it worthless for decoration and toxic to ingest.

There is some debate among veterinarians as to the effectiveness of this procedure, but I think that since it is still so new it will be a while before there is any data either for or against it. Some veterinarians are still in favor of dehorning, as a rhino's horn is able to regenerate itself in about 6 years. This procedure was created to try and prevent dehorning, as rhinos are such a huge part of the tourism industry in Africa. A rhino's horn is porous, and the infusion is thought to last for 4 years.

While doing the infusion, microchips are also inserted into each horn. The holes are then stuffed with putty and wrapped with duct tape. This allows the research teams to monitor the rhinos and the ivory, should the rhinos be poached. Each rhino also received an ankle tracking collar as well as an ear notch.

While doing all of these procedures, it was our drop to monitor respiration and pulse on the rhinos. We weren't able to help with the actual infusion since it is toxic. We measured the respiration by holding our hand in front of the rhino's nostril and counting breaths. The respiration on the rhino should be between 8-20 breath per minute as the widest range, but we were trying to keep it more in the 9-12 bpm range. When the respiration drops too low (we had one that dropped to around 6 breaths per minute) the rhino is given a shot of butorphanol in the ear artery to help wake it up a bit. The pulse on a rhino is actually taken on the inside of the ear. The normal pulse for a rhino is around 37, according to one of the vets in charge of the infusion procedure, but when they are under etorphine their pulse goes up to around 60, and that's where you want it. When the rhino becomes stressed, the pulse can get as high as 150. And as a fun fact, a rhino's body temp is slightly warmer than ours at 37-38 degrees C, or right around 98.6 degrees F. Because the days in Africa get so hot, even in the winter, we had to consistently pour water over the rhinos during the procedure to help keep their body temperature down.

The last part of the procedure we got to help with make have actually been the most fun- rolling the rhinos. This procedure is done with the rhino laying laterally on its side. However, we don't want the rhino laying on the same side for too long, or it can start to impair breathing and damage the lung. So halfway through each procedure we rolled the rhino onto its other side. This was quite an event that took about 7-8 people to manage. But then you get to say you flipped a rhino. And rhinos are actually quite efficient breathers, so I'm not sure how long a rhino would have to be laying on its side before damage occurred. But each rhino also got an oxygen tube as an added precaution.

When I first arrived in Africa, I was really only interested in rhinos in that they were part of the "Big 5". But after working with, I really love them. They are just such awesome animals, and there is nothing else like them on this planet. I'm really hoping that either the dehornings, this infusion procedure, or a combination of the two can help save South Africa's rhinos. Currently, about 75 rhinos are being poached in South Africa PER WEEK. Those numbers are just out of control. Our very first call out in South Africa was for a rhino poaching incident. So far about 200 rhinos have had this horn infusion, and considering we only managed to do 4 per day, that's a lot of work. The eventual goal is to do 6000-7000 out of the 20,000 rhinos still left in South Africa.

A rhino right after being darted.

Rolling a rhino onto it's other side

Checking respiration

The red line is the oxygen tube

Drilling into the horn for the infusion tubes

Attaching the infusion lines

Checking pulse on the ear veins

Our SA Worldvets group with a rhino