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."
