A CUT ABOVE (AND BELOW)

By Ken Keckler DVM

A Tale from November 2010

That Thursday morning started out just fine. A prospective intern met me at the first call, which was to be a castration: also known as “cutting a stallion”. As a general rule, geldings make much better pasture-mates  and are less dangerous (to us, other horses and themselves) than their intact (testicled) counterparts. While this is a very common surgery and should be done more often, there are always potential complications. On this day, the complication turned out to be on me.

The horse behaved himself, and things went very smoothly. Typically after a castration, I clean up my instruments (emasculators, hemostats, scalpel), put things away in the truck, and go back to recheck the surgical site for bleeding (or any other problems).  I left the barn with my stainless steel bucket in my left hand and my tray with instruments in my right.

It was cloudy, grey and a chilling misty rain was falling: another beautiful day in Cleveland, Ohio. I was about to take the direct route to my truck through a small swale with standing water, when I spied a wooden bridge. Why get my boots wet? My first step with my left foot hit the slippery, wet rounded plank.  Apparently, from the angle I approached the bridge, friction doesn’t exist and gravity’s power is multiplied, because my foot flew out from under me to my right, causing my right arm to fly up, instruments flying from the tray. As I fell, I landed on the front of my left calf and my body came crashing down on the side of my steel bucket with the outside of my left forearm catching my weight against the sharp rim. “Dag nabbit!” I said (or something like that!). Usually my cat-like reflexes can compensate for a slippery situation. This time, not so much. As I collected myself, I knew I’d hurt my left arm, and I was consciously hoping for an ugly abrasion. When I brought my hand toward my face, large droplets of blood flew, and as I looked down on my forearm, I saw a small, gaping wound. Nope, not just an abrasion. This thing’s gonna need stitches.

Pulling paper towels from my truck, I applied pressure, and went back into the barn to check the horse I had just “cut”. He was trying to eat the straw in the stall as he came out of the sedation, and was barely dripping any blood from the incision. It’s not good when the doctor is bleeding worse than his patient! (Or maybe it is?) I left preventative antibiotics for him, and showed the handler and the prospective intern my new arm decoration (it was hard to ignore as the paper towels were getting pretty saturated). “I can sew it up for you!” the potential intern said. “Ummm, thanks, but I think I’ll go to the emergency room.” I said. “Could you maybe bandage me up?” To her credit, the Telfa, brown gauze, and vetwrap she applied stayed on better than any of the other three bandages I had that day.

I called Holly at the office to tell her that I’d be running behind (understatement!). “I need to get to an emergency room.” I said. “Do you know where one is near here?”  Holly proceeded to tell me in detail specifically where four different ERs or Urgent Care centers were and which one I was closest to. Amazing. Great information. Still, I’m wondering how reckless Holly is to know every emergency room in Geauga County! She seems so careful!

After explaining what happened to the receptionist at Urgent Care, and making a couple of smart remarks about my situation, she wondered aloud “Do you think the horse set you up for this? Maybe this is karma!” Wow. If that’s so, I’m in a lot of trouble! I was shown to a room, had vitals taken by a nurse (“ Your blood pressure is borderline high. Of course here you are sitting in an emergency room with a cut. It could be that.”), and a doctor finally came in. I let him know that I can be a little light headed with my own blood.

“Does this hurt?” he said, pulling the wound around to peek under the edges for hidden damage.

“No.”

 “Can you move your fingers?”

 “Yes, see?”

 “And your wrist?”

 “Yeah. I’ve already checked all that, trust me.”

“Hmmm. I need to make a call. Be back in a few minutes.” He disappeared, leaving me holding a gauze square over my mostly stopped-bleeding forearm. It turns out that he called a hand specialist, concerned because the laceration had damaged a tendon and may have penetrated a tendon sheath. After his consultation, he decided to close the cut. Laying on my stomach with my arm against my side, face smushed into a crinkly  pillow, I listened to the doctor flush and clean the wound, felt him inject lidocaine around the margins (using a 30 guage needle- the smallest I have on the truck is a 25 guage!) and prepared to close the “tendon injury”. He used 4-0 Vicryl which is a very fine, braided, absorbable suture. I use it for eyelid lacerations. To my surprise, I could feel the vibrations as the suture was drawn through my tissue. “That’s a strange sensation.” I said. “Now I know how my patients feel.”

After getting some help from the office staff, moving a light, twisting my arm around a little, and tugging the skin margins this way and that, he said “ I’ve got some bad news. I can’t get under here far enough to close this tendon without extending the cut. I’m going to have to send you to Hillcrest to have it repaired. Worst case scenario is you’d need surgery today.” They wrapped up my arm, and I sat there, wiggling my fingers and moving my wrist, feeling very little discomfort, and feeling a little incredulous. It sure didn’t seem that bad. I hadn’t even passed out yet.

I ended up getting in to see the hand specialist in his office in Beachwood, not Hillcrest. It was a cosmetic surgery practice. I asked the assistant taking my information (she had been called in on her day off because the office was busy) if they could fix the bags under my eyes while I was there. Apparently, I have to make another appointment.

I had fallen at 9:15 AM, and the good doctor walked into my room around 1:00 PM. Graying hair and beard, with a light German-type accent, he apologized for my wait. “You were not on the schedule, you see”. I’m not complaining, because they worked me in as an emergency in a specialist’s office, but my workday was evaporating. This time I could lie on my back with my arm across my stomach, a slightly more comfortable position. Dr. Hand Specialist had a headband with a bright light (I’ve got one of those!) and glasses with “loops”, magnifiers attached to the lenses that resembled lenses from a microscope: a little better equipped than Urgent Care. With his assistant handing him instruments, he evaluated the cut. They took a few pictures of it, and I had them shoot one with my cell phone  to send to my wife.

 “I’ve got good news for you. The other doctor was being extra cautious: there is no tendon sheath damage. The muscle sheath was cut, but I am not going to close it for fear of compartment syndrome. We’ll close the skin loosely in case you have an infection.”

Looking into my arm, his assistant began to ask questions about the injury. “Is it deeper than when we remove a mole?” “Yes”, he replied. “We do not cut into the muscle to remove skin lesions.” “What are those?” she asked. “Those are the tendons for his fingers. Can you bend your wrist forward? Good. Now back?”

As I flexed and extended my wrist, the assistant said “Wow, that is so cool.”

“Can you move your fingers for me please?” I wiggled them.

“Oooo! Look at that!“ she exclaimed.

After re-blocking my skin, Dr. Hand Specialist put about five sutures in my 4.7 cm long laceration. So, after all of this, I probably could have had our potential intern sew me up! My wife said she could have closed it. I probably could have sutured it myself, but I might have passed out.

As the doctor left the room, I told the assistant “Sorry you had to come in to work today.”

“Oh no, getting to see inside your arm made the whole day worthwhile!”

Glad I could make someone’s day.

I’ve been saying that this veterinary practice is on the cutting edge…