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A surgical day in the life of an Anvil Equine Veterinary Nurse.
by Tina Chandler (Head Nurse)

"Horses' banging their doors down first thing in the morning is not an unusual noise to anyone who owns, or works with, horses. On the Anvil yard today, however, the banging is likely to continue all morning as the horse is due for surgery at 2.00 p.m. and can't have any feed or hay. Our yard is nothing if not varied, today for instance we have the surgical case, a colic case on fluid therapy (and therefore attached to a drip) which must be cross tied and a post surgery inpatient that is also cross tied, with one leg in a Robert Jones (a type of bandage which is large and bulky to maximise the pressure possible without causing pressure sores).

First thing's first and the yard must be fed, watered and hayed, with powdered treatments being added to the feeds. Next Liz, one of our vets who in addition to routine calls, does anaesthesia and deals with all inpatients, arrives on the yard with the injections for the various inpatients, needing a nurse to come and hold the horses while she gives them their jabs. Once these essential tasks are completed, the nurses can settle into the morning yard duties, much the same as any other yard, i.e. muck out, sweep yard and tidy the muck heap etc. Today, however these jobs must be done with despatch as Dr David Platt the surgeon will arrive at about 1.45, expecting to begin surgery at 2.00 and there is a great deal to do before he arrives. The yard is done by 10.30 and the attention of the nursing team is transferred to the theatre where the main part of the day's activities will be focused.

The theatre must be spotless for any surgery, no matter how simple, and while it is swept and mopped regularly, and no-one may enter without wearing either surgical boots or blue plastic boot covers (affectionately referred to as Smurfs by the nurses) it must be done even more thoroughly before a surgery. The tops, sink, and equipment must also get another going over with an antiseptic spray to prevent contamination during surgery.We go through in our minds the process of bringing a horse into surgery step by step in an attempt to prevent anything from being forgotten, starting with the horse being walked into the stocks (often easier said than done as you can probably imagine) to have it's catheter placed. The catheter is put in to the jugular vein and stitched in to make it easier for the anaesthetist to give drugs during surgery, and also to help Liz administer drugs after surgery without the patient becoming objectionable about the process - not really a concern with humans as they almost never kick or bite the doctor, but not at all amusing with horses! Before the catheter is place, the area must be thoroughly cleaned and here is one of the most repeated tasks of an Anvil nurse - scrubbing.

The catheter site must be scrubbed with Hibiscrub and hot water on cotton wool, water running down your arm and soaking your sleeve (or with limb scrubbing, blood rushing to your head and back and legs seizing up). Next Liz injects a small amount of local anaesthetic to numb the area and the scrubbing begins again - taking great care not to disperse the "bleb" of local, which identifies the numbed area (a heinous crime among nurses). Surgical spirit comes next to really kill any possible infection and then the catheter can be placed. Liz must wear sterile gloves for the procedure and so everything must be passed to her in a particular way to prevent the nurse from touching and therefore contaminating her, which requires you to grow another arm!

Once the catheter is placed and stitched, the surgical site must be clipped and scrubbed. Today's case is a splint bone amputation, and while the horse is lightly sedated so that it does not get upset by the unusual goings on, it can still make for an exciting job. The horse's tail is always bandaged up completely for two reasons, one, to keep it clean and dry as there are all sorts of liquids involved in a surgery, which have the amazing ability to become soaked up in the tail if it is not out of the way, and the second reason is once again to eliminate a further source of contamination to the surgery. A quick grooming is one last job to be done while the horse is still in the stocks and then the horse is taken out to have its shoes removed. The shoes have to be taken off so that there is less chance that the horse will injure itself while being knocked out, or "dropped down" in the knock down / recovery room which is the next stop for our patient, and where the real work begins!

The knock down room is padded all over, floor and walls and has subdued lighting so the horses naturally find this a little unusual to say the least, and the look on their faces as they discover that the floor bounces can often be quite comical. The horse is held by one of us nurses - and I must say that I often feel the atmosphere in the room, so it's not just the horses -and the first drug of the anaesthetic is administered and then once the horse is looking less than steady on it's feet the second drug. The nurse and the vet giving the drugs now sprint out- I mean quickly leave the room and leave David the surgeon with the horse to see that it has as smooth a knock down as possible, and after a series of muffled bumps and bangs which are the inevitable sound effects of an equine anaesthetic, a voice can be heard calling for every one to go back in. The most important thing now is for Liz to get the endo-tracheal tube in safely so that the horse has a good airway open and while she is doing this the nurses link the horse's feet together with the hobbles needed to attach the horse to the hoist in order to transfer it to the theatre.

Once the E.T tube is in, the hobbles are hooked on to the hoist, a feat of strength sometimes, I assure you, and the hoist is raised to pull through into the theatre. The table will already be in the correct position for the operation, i.e. either for a horse lying on it's right or on it's left or, in the case of colic surgery for instance, on it's back with all four legs in the air (a sight that takes a lot of getting used to I can tell you). Manoeuvring the table is another task that takes a lot of strength as well as a lot of patience because like the shopping trolleys we all love to hate, it has a mind of it own and will often refuse point blank to go in the direction you are politely requesting (or by the fifteenth attempt, begging) it to go in. Anyway, the horse is pulled on the hoist until it is positioned carefully above the table, Liz at it's head closely monitoring the patient's breathing and then the hoist is lowered, placing the horse on the table and the hobbles are removed. One nurse will dash about filling the cushions on the table with air from a pump, while another pulls rectal gloves over the patient's feet, once again to prevent a further source of contamination. This part of the whole surgery experience is the most frantic and is always an absolute hive of activity, but it has become such a frequently repeated sequence that it has actually become something of a smooth routine, with everyone knowing what has and has not been done, and trying very hard not to trip over each other as we rush about on our individual parts of the overall production.

Once the horse is on the table David will point out the surgical site to a nurse and then comes - you'll never guess…. more scrubbing! This is an essential job as no matter how clean the area was before, walking from the stocks to the drop down room, and the drop down itself have insured that it is not clean enough. Even the slightest bit of dirt could cause an infection in the surgical wound and this will at the very least cause the recovery to be longer than wished, so there can never be too much scrubbing! While one nurse is scrubbing the site, David will be scrubbing too, only he is scrubbing himself. There is little or no point in scrubbing the surgical site if there are possible sources of infection on the surgeon himself and for this reason, David scrubs right up past his elbows in an effort to prevent any contamination from him. One of the nurses will then pass him his sterile gown, and tie it at the back, taking very great care not to touch any other part of the sterile material or that gown must be removed and a new one opened - there is almost no crime worse in the theatre than touching anything sterile and believe me if you do it, you wish the ground would swallow you up as the now contaminated item must be replaced. Back to the nurse scrubbing the surgical site now, and she should now be …… still scrubbing! As I said before you can never scrub too much!

The next thing David needs is for his surgical gloves to be opened for him, once again without actually touching the sterile gloves inside. The other nurse should by now be on her final scrub, and giving the area a squirt with some surgical spirit and then she steps out of the way for David who will come over to begin the procedure. The most important thing for a nurse to remember at this time is that she must not only be aware of where she is and what she is doing, but also of where everyone else in the theatre is and what they are doing, particularly and definitely most importantly what David is doing as he is now sterile and must not be so much as brushed against. In fact the moment there is anything sterile exposed to the air I always feel the intense need to fold my arms behind my back so that I am not even tempted, and so that everyone else can see that I am not touching anything. As I said earlier, today's surgery is a splint bone amputation, so David covers the whole back half of the horse with sterile drapes, clipping them tightly around the leg so that there is only a small area open to the air, and that has been scrubbed.

During all this time Liz will have been establishing a good anaesthetic with the patient, ensuring that the horse is deep enough under that it will not wake up on the table but obviously she does not want the horse too deep under anaesthetic as this is bad for the horse. There are a large number of checks that Liz must keep running all through the surgery to keep track of the condition of the horse; some of which requires a watch inevitably lent by a nurse as Liz never has one! She checks continuously on breathing and blood pressure and has an E.C.G. machine to inform her of the heart rate. Also she continuously has fluids running to prevent the horse from becoming dehydrated during the procedure. It is only when Liz is happy with the anaesthetic that the surgery proper can begin.

Once the actual operation is under way, there is a lull in the nurses' mad buzz of activity. It gives us time to clear away some of the debris from the pre-surgery rush, but we have to be alert so that when David asks for something to be passed to him we are a split second behind him - you never know when it could be an urgent request. As the surgery progresses, Liz keeps a close eye on the patient's condition, while David concentrates on his end of the horse. David is usually happy to explain some of the finer points of surgery, which is always interesting, and adds to the general understanding of the horse's anatomy. Now is the time when a wise vet nurse nips in to grab a mouth full of lunch - but only if there is another nurse to cover while she is gone for five minutes. Once the splint bone is removed, David starts to need thing passing to him such as suture material, staplers, and bandage material. The bandaging is quite a work of art; David uses a particular type of bandaging for this operation called a Robert Jones bandage which maximises the amount of pressure and support which can be placed upon the leg, while minimising the chance of pressure sores. The bandage builds up layer by layer; getting fatter and fatter and making the leg look less and less like a leg at every moment. It really does seem to require an engineering degree to build but it is very secure and is essential in preventing the vulnerable leg being damaged during recovery.

Once the bandage is on, the return journey to the drop down room (now called the recovery room as that is it's current use) can begin. The gloves must be removed from the feet and the hobbles replaced, the hoist pulled through into theatre, and the hobbles clipped on and the air cushions let down. Then the hoist is raised and Liz disconnects the horse from the anaesthetic machine and everyone pushes and pulls the patient into recovery. Once there we lower the hoist and remove the hobbles while Liz quickly rolls the anaesthetic machine over to re-connect the patient so that she can continue to monitor it's breathing. Now comes the real hard work; clearing away the devastation from the battle scene! For some reason that is apparently unexplainable, vets seem to prefer to put any rubbish on the floor rather than in a bin. Of course when you're concentrating on the job at hand such considerations are minor, but they are pivotal to a nurse believe me. The rubbish must be separated into normal rubbish, clinical waste and sharps, and put into the relevant bins - not a terribly pleasant job, but one you soon get used to. The used drapes, towels, towelling swabs, and gowns must also be collected up and washed, ready to be re-sterilised and the surgical kit must be cleaned, re-packed and re-sterilised, a job which once again must be done very thoroughly as there cannot be any chance of infection being introduced through the surgical instruments.

Everything that needs sterilising is put in the autoclave, which looks pretty much like a giant pressure cooker, and is much more temperamental. It has a mind of it's own and frequently decides for no discernible reason that the seal is not correct and boils itself dry, or else it simply won't close and we have to struggle with it for ages before we convince it. After the compulsory fight with the autoclave, it's time to tackle the floor. After a colic surgery the floor is an absolute nightmare which takes forever to clean, but orthopaedic surgery is usually much cleaner, with very little blood and so the floor is not such an onerous task. The worst part of this job is attempting to remove the clipped hair from a wet floor. As a lot of you will be aware, horse hair appears to have some amazing properties; it can cling to any item of clothing, whether it has been near a horse or not, and it sticks to wet floors so well it's hard to understand why it doesn't have an advert as an industrial glue! A rule we attempt to work to in the theatre is if you can tell what colour the last horse in the theatre was, the theatre isn't clean enough. So you can imagine the frustration felt in trying to get every last hair off the floor. All the time the clean up is underway, we keep an ear out for the telltale thumps and scuffles that tell us that the patient is coming round. Usually the horse is able to get up on it's own, even with a large bandage stuck on it's leg, but occasionally human help is required, usually in the form of David, to get all four feet under the horse. After the horse has been on its feet long enough to be steady and sure of it's balance, we walk it down to a stable, propping it up on all sides like a drunk after a particularly wild night out. When the patient is alert and looking bright, we give him a small, sloppy bran mash, and later he is allowed a small, wet hay net.

Hopefully by now the theatre is once again spotless so that should there be an emergency surgery during the night, the theatre is clean enough, and then we finish the evening yard and our day is done."

Anvil Vets:

Anvil Equine Veterinary Clinic, Tuckmans Farm, Copsale, Horsham, West Sussex RH13 7DL

Tel: 01403 731 213 Fax: 01403 733992

Email anvilvets@freeuk.com


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