For veterinarians in rural America, holidays evoke conflicting emotions. We – like normal people – enjoy spending time visiting with family and friends. We look forward to tables filled with more food than we can possibly eat and the occasion to have a cocktail or a glass of wine in the middle of what would normally be a busy afternoon at the office. Yes, holidays are marvelous – except that they encourage us to make plans. Which can be problematic for those of us in the care giving professions because we don’t always get to choose when we work. Our schedules are often dictated by the needs of our patients. And, as anyone who has ever worn a pager or been on-call can attest, formal plans pretty much guarantee that some variety of mayhem will erupt and hi-jack your agenda just as you are about to walk out the door. For the veterinarian on-call holidays can be cruel torture, bringing the possibility of celebration like normal people just within our reach only to be snatched from our grasp by a colicky horse or a vomiting dog, or, in this case, by a cow in labor.
It was Valentine’s Day 2001. Our older son, Will was three. My wife, Leigh, and I had plans to get the kiddo in bed a little early and savor a quiet, candlelit dinner at home. I scoured our favorite cookbooks and picked out the perfect recipe. It was a pasta dish from Olive Oil’s, one of our favorite little Italian restaurants in Aiken, SC. I envisioned us sipping on a glass of wine and listening to Van Morrison as the smell of tomatoes, spinach, parmesan, garlic and heavy cream simmering on the stove filled the kitchen. Then, we would enjoy a quiet dinner – just the two of us – on our wedding china before we, and our full bellies, retired to the living room to sit by the fire to finish our wine.
I had it all planned out in my head. I stopped at the grocery store to pick out a Valentine’s Day card while I was coming back from farm calls that morning. By mid-afternoon getting home on time was starting to look like a very real possibility… until the phone rang about 4:30 that afternoon. It was a cattleman from about 45 minutes away in Sparta, GA. He raised purebred Gelbvieh cattle, and he had been keeping a close eye on one of his heifers that was due to calve. He found her off by herself about 10pm the night before. Her tail was raised and she had a clear, gelatinous discharge hanging from her back end. He fully expected her to have a calf by the next morning. But, we were going on 16 hours now and she still had not calved. He asked if we could come out and check her. I glanced at the clock and sighed. We had no choice but to go. I started doing the math in my head. If I leave right now and make a bee-line for his farm I should get there around 5:15. If the calf is just positioned wrong in the uterus… I tried to estimate how long it generally took me to correct some of the more common malpresentations in cattle. Sometimes it was a pretty simple issue. Maybe the calf’s head is just turned back or maybe it’s breech… Truthfully, I always lost track of time when I was working and I had no idea how long it usually took. I knew some cases were pretty quick and some took a long time. Anyway, I thought to myself, hopefully, this one won’t take too long, and I’ll be able to get home at a reasonable time…
Since we weren’t very busy at the clinic I talked my boss into letting me take one of our assistants with me on the farm call. Having an extra set of hands, I reasoned, may save me 10 minutes or so. Without wasting anymore time we hopped in the truck and sped off down the road.
I had never been to this particular farm before, and I was impressed when we pulled up to what I reasoned must be the entrance based on our directions. It wasn’t fancy or pretentious, but everything looked very well built and maintained. A barbed wire fence skirted the ditch to our left and our right as we pulled through the gate onto the dirt drive. Rolling hills of fescue grass faded into the tree line in the distance ahead of us. And, there on the edge of the field stood a large hay barn with a catch pen on one side. The catch pen consisted of a corral made out of 6×6 posts and treated 2×6 boards spaced about 8 inches apart and at least 6 boards high. On one end of the pen a crowd gate directed the cattle into a long curved chute that ended with a new Powder River head gate. A head gate is a contraption that is designed to close on either side of the neck and keep the cow standing relatively still. Catching a wary old cow or bull in a head gate requires more skill than you would think! Plenty of cowhands have endured endless torment from their coworkers for being just a split second too late on the head gate and allowing a cow to squeeze through!
I parked the truck, climbed out and walked over to introduce myself to the farmer. He was waiting for us in his truck. The driver’s door was open and he was sitting sideways in the drivers seat. He stood up and started toward me as I approached. He was an older gentleman with a bronze, deeply lined, leathery face from a lifetime spent in the fields. He wore a straw cowboy had that had a permanent sweat stain around the base of the crown. His denim jacket and denim blue jeans were clean, but each showed the characteristic signs of clothing that was meant for work. He stood about 6 feet tall, even with a slight stoop, and he moved easily like a man who didn’t stay still very long. He was thin – built like a stalk of bahia grass – tall and slender, without the fleshy middle that most men his age cultivate in their later years, but not frail. I introduced myself and we exchanged pleasantries. I was eager to get to work so I suggested we take a look at our patient. I climbed up on the fence and peered over. She was standing on the opposite side of the corral with her tail slightly raised. She was a nice looking beef cow, good size, nice bone structure, ample body capacity, level top line, elegant head and neck with a size-able udder tucked neatly under her hindquarters. I pursed my lips together tightly when I saw that there was no portion of the calf visible at this point. That worried me because with most of the more common malpresentations at least a portion of the calf will be visible. It might only be a tail or one leg, but usually you can see something. I needed to get my arm inside her and have feel around to see what was wrong.
Between the three of us we coaxed the cow into the corral and we slipped a post in behind to keep her from backing up. We didn’t bother to catch her head because I was going to be working at the opposite end! I handed her tail to my assistant for her to hold and I quickly cleaned up her back end with scrub soap and water. I slipped on my shoulder length plastic glove and squirted some sterile lube on the back of my hand. Gently I slipped my hand and arm inside the birth canal. About a foot or so from the entrance I encountered two very large feet. The soles felt like they were pointing downward and the dewclaws were on the bottom. That meant the calf was likely coming out headfirst. I reached in almost as far as I could go and my fingertips were able to make out the features of a very large head. I stuck a finger in the calf’s mouth and felt a slight movement of the jaw and the tongue. The calf was still alive! However, the gigantic head and front legs felt too large to fit into the pelvic inlet at the same time. All my optimistic premonitions about getting this calf out easily evaporated in that instant. This calf was presenting perfectly normal, but it was just too large to fit through the interior diameter of the pelvis. That happens sometimes in cattle because the bull, and to some degree energy level in the diet during the last three months of gestation, largely determines the birth weight of the calf. When you have a size mismatch of this magnitude it means that this calf is not coming out vaginally. We were looking at a c-section. Just to convince myself, I placed OB chains around each front leg and the behind the calf’s ears like a bridle on horse. I pushed and pulled and pulled and pushed, verifying that indeed the calf’s front legs were fully extended and no, the head and legs were not going to fit into the pelvis.
I pulled off my sleeves and turned to the farmer to explain the situation. He understood and agreed to go ahead with the c-section. However, as well built as his facilities were, they were not very conducive to doing cow surgery. I preferred to do all my abdominal procedures on cows with the patient standing. Between my boss and I we did about 175 standing abdominal surgeries in cows every year. It sounds a little bizarre, but it’s the safest position for the patient. Cows have very heavy viscera and relatively small lung fields, when they lay down for long periods of time they don’t breathe well. And, because they are ruminants, they tend to regurgitate stomach contents more easily, which can cause aspiration pneumonia. Also, even as a young surgeon, I had a history of chronic lower back pain. I had my first back surgery at 19 years of age and doing surgery on a patient at working height was much easier for me! However, to do standing flank surgery on a cow, one must be able to restrain the cow and still have access to her side. The solid sides on this particular chute prevented us from getting to her side with her in the head gate. I considered our options. If we had some portable panels we could set up a temporary chute on the other side of the head gate and run her in the opposite direction, but we didn’t have any portable panels. Nor was I convinced that we would be able to confine this cow in portable panels. Beef cows are typically much more fractious to work with then their dairy cow cousins. Dairy cows are handled and moved multiple times daily during most of their life. Beef cows are usually handled once or twice a year – and then it is usually to give injections or take away their calf! This girl was already getting anxious from being separated from the others, penned up and violated. I feared if we let her out of the chute we would have our hands full getting her back in. I surveyed the corral. There were plenty of substantial posts and a water trough along the fence on one side. I decided the best thing to do would be to make a halter for her out of my catch rope and tie her up short along the fence by the water trough. To do that I would need to sedate her first, make the halter out of my catch rope, back her out of the chute and then tie up to one of those posts. I’d operated on plenty of dairy cows tied up like this, I reasoned. It should work just fine.
I gave her a dose of sedation and waited for it to take effect. When her head started drooping and drool begin to hang in long ropey strands from her chin, I knew she was ready. I secured the halter around her head and backed her down the chute. Her steps were clumsy, but we made progress. When she got out into the open area of the corral she tried to make a break for freedom, but the sedation slowed her down just enough for me to take a wrap around a post with my rope and bring her to a stop. With a little more coaxing we were able to move her closer to the post where she was anchored until she was tied with her head right up against the fence.
We quickly gathered all our supplies and surgical instruments. With water from my scrub bucket I soaped up her left flank and shaved off all the hair with a surgical razor. I prepped the bare skin three times then numbed up an area of tissue with lidocaine that was about two inches wide by fourteen inches long. During this entire time our patient had not so much as lifted a foot. She seemed oblivious to what was going on around her. I laid out my surgery instruments and suture anywhere I could find a clean dry surface. I turned my attention from cleaning and prepping the cow to cleaning and prepping my hands and arms. I was taught in vet school to use sterile sleeves and gloves over my surgically scrubbed skin, but the sleeves are loose fitting and extremely awkward. I was also taught that in surgery it is imperative to minimize the impact of the three T’s – time, trash and trauma. The gloves may have been cleaner, but for this particular procedure they increased the time and trauma factors considerably by reducing manual dexterity. Plus, as my boss explained to me once, my scrubbed skin is every bit as clean as the cow’s scrubbed skin, and we can’t avoid contact with that! So, on that brisk February afternoon I stripped down to my undershirt and scrubbed from the tips of my fingers to my shoulders.
Once scrubbed up, I opened up my surgery pack and asked for my scalpel blade. I fitted it onto my scalpel handle and created a 14” incision through the skin in the left paralumbar fossa, it separately cleanly and neatly beneath the pressure of my blade. I finished my approach into the abdomen with a combination of blunt and sharp dissection through the multiple layers of abdominal muscles and finally, the peritoneum. I returned my scalpel to the surgery pack and reached deep into the cow’s abdomen with both arms. By feel I navigated my way around until I located the calf’s hind leg through the wall of the uterus. I cupped one hand around the hock and one hand on the hoof and gently but firmly guided the uterus with its unborn payload toward my incision. With a little maneuvering I was able to bring the calf”s rear leg – still inside the uterus – just outside the opening of the incision. I asked my assistant to scrub up and help out. I showed her how to hold the uterus in place by holding onto the calf’s hock and fetlock. Up until this point our patient had not so much as lifted a foot. And, to this day, I’ll never know what triggered what happened next, but as soon as I handed off the uterus to my assistant, our patient leap sideways away from where we were standing. In a flash the uterus disappeared back into the abdomen. In it’s place out came the caudal compartment of the rumen. I rushed over and cradled the dangling blob, about the size of small beach ball, in my arms trying to keep anymore of the organ and/or it’s contents from coming out. The cow had slowed her dancing down considerably, but she was still moving back and forth. I tried my best to keep time with her rhythm as I held her stomach in my arms like a trash bag full of water. The farmer, witnessing our predicament, stepped up from where he was watching at a safe distance and put a hand on the cow’s hip to try to quiet her down.
A cow’s rumen is the largest compartment of their four-chambered stomach. It is the fermentation vat. In a large cow it can easily hold 30-40 gallons. I wanted to get what was hanging out back inside as quickly as possible! Trying to remain calm, I asked my assistant to go back to the truck and draw up another dose of sedative for our patient. She scurried off and returned a minute later with a syringe in hand. I didn’t usually rely on her to give injections to my large animal patients, but she had plenty of experience giving injections to dogs and cats. I couldn’t let go of the stomach to give it myself, so as she approached I nodded my head and asked her to give the injection in the hip muscle. I also suggested she come stand close to me and not directly behind the cow. There are a few things to always keep in mind when giving injections to cows. They have been prey animals for millions of years. Their eyes are set in the side of their head to allow them to see everything going on around them in all directions. And, despite their relaxed appearance and reputation for pastoral behavior, cows have lightning fast reflexes and amazing range of motion with their hind feet. Not only can they kick straight back, they can also lift their hind foot and kick impressively high to the side. For these reasons there are places you should and shouldn’t stand when giving a cow an injection in the hip. Unfortunately, I had the prime real estate occupied as I cradled her rumen in my arms, desperately trying to keep anymore of it from coming out. From her position beside me she reached over and poked the needle into the muscle of the cow’s hip. Instantly, as soon the needle touched her hide, the cow fired off a vicious round house kick with her left hind foot that brushed me and caught my assistant squarely in the lower quadrant of her abdomen. I heard the sickening thud as the hoof drove her back three or four steps. I saw her double over as she struggled to regain her balance. I briefly thought about the possible internal injuries she may have sustained, but my thoughts were interrupted before they could form by the cows continued rampage. Like a boxer throwing jabs at his opponent, my patient immediately fired off a second shot with her opposite hind foot aimed at the farmer standing on the other side from us. He had stepped into range earlier in order to help steady her as she danced from side to side. The glancing blow combined with his attempts to dodge the kick caused him to loose his balance and fall to the ground beside her back feet. The cow bellowed and stomped and jumped like a bucking bronco pulling against her halter rope. I could see her hind feet landing beside the farmer’s spindly legs as he scrambled to back up out of range like a crab skittering across the beach. I was certain she must have stepped on him at least once if not several times. My assistant recovered enough to run over and help the elderly farmer to his feet. I gave up on trying to hold the rumen and rushed over to help them both.
The farmer was wobbly on his feet, but we managed to walk him over to his truck. His jeans and denim jacket had large spots of mud and cow manure all over them. I asked him where it hurt, and he just grunted that he was ok. I tried not to panic as I mentally assessed the situation. I felt like we should take them both to the hospital to get them checked out, but the nearest hospital was at least 45 minutes away. I wondered if I should just euthanize the cow and focus on caring for the human casualties. However, both victims assured me they were ok. The farmer asked if we would please do what we could to save his cow and calf. My assistant was standing upright again with a perfect hoof print on the front of her jeans. She laughed that it sounded worse than it was. I didn’t really believe her.
Our bovine patient was standing rather calmly now at the end of her halter rope, looking rather inebriated still from her original sedative. At least half of her rumen was hanging out of her side by this point dangling like a stretched out water balloon just inches away from the ground. Periodically she would lift her foot and kick clumsily at the unusual structure swinging from her side making it jiggle like a huge pink udder.
I questioned the farmer about the extent of his injuries. He assured me that she had just grazed him with her feet as she was stomping around on top of him in the straw. I thought to myself how fortunate he was to have such skinny legs, they must have been a pretty elusive target for the cow! He assured me that he did not need to go to the emergency room, and he implored us to try and save his cow and calf. I left him sitting in the cab of his pickup and turned my attention back to the cow. She was standing quietly now, but I wasted no time administering the second dose of sedation. I scrubbed my hands and arms again and washed the rumen as thoroughly as possible with tap water from the hose supplying the water trough. However, so much of the rumen was hanging out now that no matter how hard I struggled, I couldn’t get it to go back into the incision. In desperation, I made a small incision in the rumen and dumped about half of the contents of the portion that was hanging out onto the ground at my feet. The footing beside the cow was already pretty poor from the mud we created with our wash water and all of our stomping around. Adding several gallons of putrid slurry from inside her rumen to the mix made the footing even more treacherous. I did a double layer closure on the rumenotomy and lavaged the visible portion of the organ with several more gallons of water. This time I was able to coax the unwieldy organ back into the incision. I breathed a brief sigh of relief. However, at that point, my heavily sedated and no doubt exhausted patient decided it was time to lie down. I cursed quietly under my breath. As she settled down into her sternal position, I leaned against her and struggled in the slick goo to gain a little traction, hoping to push her over onto her right side to avoid contaminating my incision. Miraculously, she ended up with her legs in the correct position for me to finish rolling her onto her right side by grabbing her right rear leg and pulling it under her body.
I paused to catch my breath. I noticed at this point that it was dark outside now. The farmer had trained the headlights from his truck in our direction – makeshift surgical lights. I wondered to myself how long it had been dark. I had long since given up on the possibility of getting home in time to make supper for Leigh. I sighed in resignation over the reality that our evening together that we had planned wasn’t going to happen like we envisioned. I knew she would understand, but my irregular, unpredictable schedule was difficult for us both. I also wondered to myself if my back would tolerate having to perform the rest of this surgery bent over my now prostrate patient. I scrubbed my hands and arms – again – and resumed the surgery. I felt the tension in my lower back as I bent over the incision wrestling once again with the pregnant uterus. It was a vivid and uncomfortable reminder of why I always tried to avoid having to do abdominal surgery on cows with them lying down. I chuckled as an obvious thought just occurred to me. I ALWAYS tried to avoid EVERYTHING that had gone wrong that night! The fact that my patient was lying down was a pretty minor issue in the scheme of things. I shook my head and silenced my thoughts, focusing again on manipulating the pregnant uterus.
This time as I pulled it up into the incision my patient offered no resistance. My assistant held the uterus in place my holding onto the calf’s hind leg like I showed her before. I incised and reached in and pulled out a huge bull calf! He weighed every bit of 110 pounds and looked as if he was already two weeks old! I held him head down for a second by wrapping my arms around his mid-section and letting his front end dangle. Thick, mucousy secretions drained from his nose and mouth. I handed him off to my assistant for her to finish drying him off and stimulating him to breathe. I turned my attention to the tedious task of closing the gigantic incisions I had created in the cow’s uterus and body wall. I used heavy #1 chromic gut to close the uterus with a double layer inverting pattern before rinsing it clean and replacing it in the abdomen. The muscles of the abdomen are under much greater strain than the wall of the uterus. To close them I used #3 chromic gut – practically a climbing rope in the world of absorbable suture! I laced the severed muscles together with a simple continuous pattern, then closed the skin with an equally heavy non-absorbable synthetic suture in a continuous interlocking pattern. The neat appearance of the 14” long incision gave no indication of the chaos we experienced during its creation! My back ached as I struggled to stand straight.
To this day I don’t know how long it takes me to sew up after a C-section. I just get lost in the task and tune out everything around me. I knew that we had arrived on the farm about 5:15 that night. I dried my hands and dug my watch out of my pocket. It was 9 pm. So much for a Valentine’s dinner, I thought to myself. I knew Leigh would understand, growing up on a pig farm that morphed over the years into a dairy, she knew farm emergencies were never planned or convenient. I resolved to make up our lost evening as soon as possible.
I gathered my supplied and began the process of washing and repacking all that we had used into the truck. Our bull calf was starting to make his first wobbly attempts at standing. Momma cow was worn out, but she was sitting up sternal. I worried that with the length of time we had her abdomen open and the potential contamination from the rumenotomy and c-section that she might develop peritonitis. Fortunately, cows are remarkably adept at walling off infection. Thus, they make very forgiving patients for surgery in the field! Nonetheless, I gave her high doses of antibiotics to help guard against infection and some anti-inflammatory for pain. I gave the farmer a few follow up doses to administer over the next couple days.
I finished washing and packing our supplies. We said our goodbyes and piled in the truck. I made a mental note to call and check on everybody the next day. Mentally and physically exhausted, I headed for home, stopping by the clinic just long enough to drop off my assistant.
Our little farmhouse in Greensboro, GA was set up perfectly for a large animal vet. The washer and drier were on the back porch right next to where I parked the truck. I could walk in, take off all my filthy clothes and throw them right into washing machine before entering the living quarters. That’s exactly what I did that night. It was already 10 pm and my son had been asleep since 8:30. Leigh was standing at the stove when I stepped into the kitchen. She had prepared our Valentine’s dinner by herself and it smelled amazing! I apologized for being so late and for ruining our plans. I offered her a hug, but she politely declined, wrinkling her nose at the lingering odor of manure, mud and amniotic fluid. She suggested that I head to the shower while she finished setting the table. I happily obliged, stealing a little peck on her cheek – despite her half-hearted objections – as I turned to head for the bathroom.
The Valentine’s dinner that I imagined didn’t turn out quite like I had planned, but, thanks to Leigh, it was wonderful nonetheless. As we enjoyed our meal, I filled her in on the events of the evening. I felt the tension begin to melt away as we talked. It’s amazing how a full belly and a glass of wine can alter your perspective. Mostly, I was just glad to be home with my wife on Valentine’s Day celebrating like normal people – almost!
P.S. – When I called the next day to check on our patients, the farmer was out feeding all the cows. His wife said he was a little slow to get out of bed, but otherwise just bruised. Our mama cow finally got up during the night and little bull calf was enjoying his newly found freedom outside the womb!