Browsing tag: euthanasia

As we saw in the previous part of this series, Medical colics are those which can be managed medically, usually on the yard. However, about 1 in 10 cases of colic require emergency referral to an equine hospital for surgery.

This is what most horse owners are terrified of. The general indicators that a horse has a surgical colic are:

1) Heart rate over 60 that isn’t relieved by injectable painkillers.
2) Dilated loops of small intestine on rectal exam.
3) Positive stomach reflux from the stomach tube.
4) A definite rectal diagnosis of a surgical problem.
5) “Toxic rings” – dark red or purple gums, that indicate that the horse is going into toxic shock.

Of course, it varies between horses, and the vet has to make a judgment call based on all the evidence available.

We also have to talk to the (by now usually frantic) owners about costs. Colic surgery usually costs between £4000 and £5000, but can easily be a lot more. Even if the horse is insured, it is important to check how much the insurance company will cover – there are a couple of companies out there who will only cover part of the costs of emergency surgery. If in doubt, always call your insurer’s helpline.

However, colic surgery is one of the most genuine emergency operations there is – and it can be truly life-saving.

So, what causes a surgical colic? Probably the most common are:

1) Twisted bowel. If a length of bowel twists around itself, it can cut off the circulation. At this point, the gut begins to die, and unless it can be removed by surgery, and quickly, the horse will go into toxic shock and die. This commonly happens in the small intestine or occasionally the colon, but there’s also a condition where the caecum gets turned partially inside out (an intussusception).

2) Small intestinal blockages. Horses rarely eat things that get stuck in the small intestine (although it can happen). More commonly, a really heavy worm burden can simply block up the bowel; with the bowel overfull, the blood supply starts to fail, and the gut, again, can die. I once had a patient who was a little foal with a severe colic; we removed two gallons of worms from her small intestine!

3) Strangulating Lipomas. These are really common in older horses and ponies. A small, benign, fatty tumour forms somewhere in the abdomen, causing no harm at all. However, it grows on a stalk, and eventually, the stalk gets wrapped around a length of gut, cutting off the blood supply… This results in the bowel dying, as if it had twisted. Fortunately, these are usually really simple surgical procedures; unfortunately, older horses and ponies are less likely to be insured for surgery.

There are also a number of medical conditions that can mimic those requiring surgery – particularly peritonitis and anterior (or proximal) enteritis. Horses with these conditions are often referred for possible surgery because it’s very hard for the vet in the field or on the yard to be 100% certain they’re not surgical. I think that most of us would say it makes a lot more sense to have the horse at the hospital, with a surgeon on call, to make the definitive diagnosis, rather than waste time in the stable, and risk having to then decide it needs surgery when it’s still an hour or more away in travelling time from the hospital!

So, what happens when the vet decides that a colic case isn’t suitable for medical management?

Firstly, they’ll talk to you about the options. If a horse isn’t insured, or there’s no money for treatment, it is a perfectly respectable and responsible decision to decide, sadly, to put the horse to sleep rather than prolong its suffering.

Hopefully, of course, that won’t be the case. Once you and the vet have decided that referral is the way forward, your vet will get in contact with a referral hospital. If you’re very lucky, it will be one run by your vet’s practice, but in most cases, it will be a specialist referral hospital. I must say here that not every centre with surgical facilities is able to cope with emergency colic surgery – they need not only to have the facilities (knock-down box, operating theatre, recovery box etc), but also the staff (not only a surgeon, but also enough vets and nurses to take care of your horse in the vital recovery period). Your vet will have a list of suitable referral hospitals – generally, its best to send the horse to the closest one with the shortest transport time, but your vet will be able to advise you.

Making an emergency referral is simple – but only your vet can do it. A referral hospital will not accept referrals from the horse’s owner! Once you’ve made the decision to refer, your vet will call them and speak to the veterinary team on call, who will be available 24/7/365 (when I was part of one such team, we ALWAYS seemed to get our referrals at about 10pm!). They’ll let him or her know what they want done during transport – generally, they’ll describe what painkillers they want given, and what samples they want taken (don’t be surprised if your vet gives you a couple of blood tubes to take up and give to the referral team). In addition, they’ll sometimes ask the vet to put in a stomach tube and tie it in for the journey – this is to prevent the stomach from getting over-full and bursting if there’s an obstruction in the small intestine. Don’t forget your horse’s passport – legally, they do need it even when being rushed to emergency surgery.

Your vet will generally give you directions and a contact number for the hospital, and send you on your way. Remember, they can’t normally go with you, because your horse’s colic, while devastating, is probably only one of several cases they’ll have to deal with.

If there’s a problem (e.g. your horse getting distressed) in transit, call your vet or the referral number you were given – but if at all possible don’t stop unless they tell you to! Remember, you’re on your way to the best equipped help available.

On arrival at the hospital, you can expect to be met by the veterinary and nursing team. Your horse will be rushed to an assessment area, and you’ll probably be given a lot of scary-looking paperwork to sign. Generally, this comes into 2 parts – firstly, you’re signing to give consent for whatever they need to do (and remember, a lot of drugs aren’t technically licensed for use in horses, because the manufacturers haven’t paid for an official license for that drug in horses. It doesn’t mean a drug is dangerous or experimental, it’s probably used on a daily basis by the hospital. You’ll have to sign consent to use unlicensed medication – it’s absolutely routine, and nothing to worry about). Most hospitals will also ask to see your passport – if you haven’t got it, or it isn’t signed to mark the horse as “not intended for human consumption”, legally the hospital can refuse treatment (although they rarely do).

The second set of paperwork you’ll sign is a bit more pedestrian – you’ll be signing to say that you will pay for any treatment!

While you’re contemplating the paperwork, your horse will be undergoing another examination by the veterinary team. This is to establish what’s going on, and what’s changed since your vet examined him back on the yard. They may well repeat some tests – most colic conditions are dynamic (i.e. constantly changing), and sometimes the change is more useful in working out what’s going on than a one-off test. Other tests they may wheel out include ultrasound – the powerful ultrasound systems available in a hospital environment can give the vets a lot more information about what’s going on. The vets will then make a decision about what to do – don’t be disappointed or worried if they don’t rush immediately to surgery! They may decide to try a course of medical treatment first (remember, they don’t have to rush as much as your vet does – if your horse’s situation deteriorates, they can operate at a moment’s notice).

In many cases, however, they will decide to take the horse straight to theatre. If so, you normally won’t be able to follow, so I’m going to describe what happens once you’ve been gently steered in the direction of a waiting room.

To begin with, the horse will have an intravenous catheter fitted, to allow easy access for fluids and drugs. A horse with colic is systemically weakened, so will almost invariably be given intravenous fluids during surgery. He’ll then be given a premed – this is a sedative, designed to make induction into anaesthesia gentler. It will usually contain the drug acepromazine, because the use of this before surgery has been demonstrated to reduce the risks of anaesthetics.

He’ll then be led into a knock-down box: this is a special padded room, designed to make induction of anaesthesia safer. Then he’ll be anaesthetised with an injection containing (usually) a mixture of 2 anaesthetic agents, ketamine (no, it’s not a tranquilizer, it’s an anaesthetic) and diazepam or a similar drug. Shortly after the injection, he’ll go wobbly, and then quickly lie down.

Once he’s asleep, the team will swing into action: a tube will be passed down his throat to help him breathe and he’ll be moved into the operating theatre. While this was going on, the surgeon(s) will have been scrubbing up, ready to start.

Once he’s in theatre and safely ensconced on a well cushioned table (to prevent pressure sores etc), he’ll be put onto anaesthetic gas to keep him asleep.

The surgery involves a long incision down the midline of the belly. The surgeons can then have a good look through all the intestines, to find the problem. This is the exciting, sexy bit, but it’s actually pretty simple in principle: “if in doubt, cut it out”. In other words, removing devitalized (dead) bowel, emptying out anything in the bowel that shouldn’t be there (e.g. a caecal impaction), replacing anything that’s got stuck in the wrong place (e.g. an entrapment) and untwisting anything that’s tied up. There are usually at least 2 surgeons, because one person is needed to hold loops of intestines (and they don’t stay still – sometimes they wriggle around in your arms)! Meanwhile, the anaesthetist will be carefully monitoring all sorts of parameters (heart rate, blood pressure, ECG, reflexes, breathing and blood gasses can all be monitored at many hospitals) and adjusting the anaesthetic and any other drugs to give the safest and most effective anaesthetic.

Once whatever the problem was has been found and (hopefully) sorted out, your horse will be returned to the recovery room. In many ways, this is the most dangerous part of the procedure. Horses are very prone to breaking things when they wake up, so everything is done to keep it as calm and quiet as possible. Sometimes, the veterinary team will help the horse to rise, using hoists and lifts; other times, it works out better to let him get up in his own time. In either case, he will be moved into a padded room, and left in dim light, as quietly as possible, so he wakes up slowly.

Once awake, and steady on his feet, he’ll be moved to an intensive care box; he’ll almost certainly be on a drip to keep him hydrated. At regular intervals through the next 24 hours (or longer) he’ll be checked by vets and nurses. In some cases, the guts don’t start working properly on their own, and medication may be needed to encourage motility (e.g. a lidocaine drip). Although everyone gets excited about the surgery, it is this recovery period that is in many ways the most important in getting a good long-term prognosis.

As time goes on, the vets and nurses will try and tempt the horse to eat – normally, we’ll try and get him eating fresh grass as soon as possible. As soon as he is stable enough and eating on his own, he’ll be sent home – most horses do better in their own home environment, so as soon as they no longer require advanced medical intervention, they can go home. Once home, it’s important that the discharge instructions from the hospital are followed – it can be tempting to try and speed things up, but don’t rush it! Major abdominal surgery takes time to recover from.

Colic is a worrying condition to have to deal with as an owner, especially as it often seems to come out of the blue. However, if you ever have to go through it, I hope that having read these blogs, you’ll have some idea of what’s being done, and why. Remember, our aim as vets is to help your horse and, if at all possible, send him home to you fit and well.

If you are worried your horse or pony may be suffering from colic, talk to your vet, or check the symptoms using our Interactive Equine Symptom Guide to help assess how urgent the problem may be.

Ben Fogle has written a moving piece in the Sunday Telegraph about the loss of his Black Labrador, Inca. At twelve years of age, she had lost the power in both hind legs. Ben made the right decision for Inca, but it was still terribly difficult to go through the process of euthanasia. His article is unusually frank, with Ben describing how he “burst into uncontrollable tears” on the telephone when talking to his veterinary surgeon father, Bruce, about the situation. Then later, Ben describes the actual act of euthanasia:

“I carried her from the car into the house, burying my face into her fur, and laid her on the kitchen floor. Mum, Dad and my sister were all there. “I lay on the floor, hugging Inca while Dad injected her. Her breathing became heavy. I could feel her heart pounding and the warm blood beneath her skin. I breathed the familiar scent of her fur as I nuzzled into her thick coat. I have never sobbed like that in my life. It was a primal, uncontrollable, guttural sob as I felt her heart stop beating.I lay there on the kitchen floor clutching my best friend, unable to move. Wishing, hoping it was a dream, I held her lifeless body.”

Many readers have commented on the online version of Ben’s article, with some describing how tears were streaming down their face as they read his words.

Ben’s account will come as no surprise to vets and nurses: we witness people going through the emotional trauma of losing a pet every day, or even several times in one day.  Perhaps the only surprising aspect is that the depth of grief isn’t discussed more commonly in public. It’s as if it’s only behind closed doors that it’s acceptable to express this level of grief for an animal.

The private nature of grief for pets can make it doubly difficult for some pet owners to cope with their emotional distress. They feel deeply upset, but they may feel that it’s somehow  ”not right” for them to be so distressed. To an owner, the loss is as deep – or sometimes even deeper – as if a human friend or relative has died. To society at large, the loss is still ranked as minor, with people making heartless comments like “It was only a dog”. When a human dies, a wide leeway of sympathy is given, with time off work, and sensitive understanding for many weeks. When a pet passes away, people are often expected to “get over” their loss almost immediately.

Behind the scenes, there’s wide recognition of the emotional distress caused by the loss of a pet. The Society of Companion Animal Studies runs a Pet Bereavement Support service, in conjunction with the Blue Cross. This offers support by trained counsellors for people who need someone to talk to after a pet has died, both on the phone and by email.

It’s also increasingly recognised that veterinary staff can be emotionally traumatised by the daily witnessing of deep grief: after all, there are not many jobs where, every day, you need to offer support to grown men (and woman and children) as they cry their hearts out. The suicide rate of vets is around seven times the national average, and the complex nature of pet euthanasia is thought to play a role in contributing to this. Vetlife is a website designed to provide resources to help vets and nurses cope with the stress of their daily job.

Ben’s account is sad to read, but it’s heartening that he expresses his emotions so openly. If more people like Ben spoke out so clearly and truthfully, it would make it easier for those many individuals out there who still feel that have to hide their deeply held emotions.

This week my Granny died, which was sad for us all but she was very old, had had a wonderful life and her family was with her at the end. She had been in a home for some time and was cared for very well. When she became sick and bedbound, the doctors and nurses worked together to keep her comfortable and pain free, until she slipped away in her sleep. I am lucky in that she was the first person I knew well who has died and this experience has made me understand why many people hope this is how their pets will go. However, to die in their sleep is rarely a pleasant or pain free experience for our animals.

Although, just like people, our pets are living longer and healthier lives, inevitably there comes a time when their age catches up with them and illnesses develop. Advances in veterinary care mean we can do a lot for them but eventually we won’t be able to keep up with their problems. If they were people we would put them in wheelchairs or place them in a home where their needs could be catered for, for example being assisted to the toilet or spoon fed but this isn’t practical, or in most cases fair, to a pet who won’t understand what is happening (there are many people who would argue this is no kind of life for a person either but that is a whole other debate). For a pet, when they can no longer get up and out to do their toilet or feed themselves properly, or when their illnesses or pain can no longer be controlled with medication, this is the time as owners we should objectively assess their quality of life and decide whether it is fair to let them continue. Also, just as important is your quality of life, it is hard work caring for any pet, let alone an elderly one who may be incontinent or senile.

The vast majority of pets who reach the end of their natural lives are euthanased by their vet. This is inevitably a sad experience for their owners (and us) but is far preferable than allowing them to slip away on their own. Many people hope this will happen, having probably experienced death this way with people as I recently did myself, but it is very different for animals. Bodies are designed for living and will go on doing so regardless of how painful or unpleasant it becomes for the individual. When people die in their sleep they are usually heavily medicated and cared for to ensure they are not in any pain or dehydrated but this doesn’t happen for our pets. If an animal dies this way, they have usually suffered to a large extent; likely being dehydrated, malnourished and in pain. Although from the outside they might look peaceful, they are anything but; it is simply all their exhausted body can manage.

This is why when our pets become infirm and their quality of life declines to a point where living is a struggle and not the joy it should be, by far the kindest and most humane thing we can do as owners and vets is to euthanase them in a painless and peaceful way. I often say it is the one big advantages we have over human medicine; we can stop the suffering before it becomes too great. Although it may seem daunting your vet will talk you through the procedure and make sure you are happy with the process and your decision. You will be able to stay with your pet if you want to and most vets will come to your home if your request it. Euthanasia means ‘a peaceful death’ and as a pet owner it is the final act of kindness you can bestow upon your companion.

If you are worried that your pet may be ill, talk to your vet. Try our Interactive Symptom Guide to check any symptoms they are displaying and help decide how soon you’ll need to visit your vet.

A few weeks ago I was asked by a close friend to put her dog to sleep at home. Timmy was a farm dog really, who slept in a stable, but just as much of a family member as any house-dog and much loved. I trusted Timmy’s owners’ judgement completely as to when the “right time” came to part with Timmy, and I was already familiar with his medical history.

I was glad to be able to carry out the euthanasia in the way in which his owners wanted. Timmy was in familiar surroundings, greeted me like an old friend and showed no distress at all. With his owners beside him, I clipped some hair from his front leg and injected a strong solution of anaesthetic into his vein. He went so peacefully that there were only a few tears, mixed with feelings of relief. Timmy was buried on the farm.

One of the questions people commonly ask when they first know that you are a vet is “How can you bear to put animals to sleep?” The answer is that it is still one of the most difficult parts of veterinary practice, even after many years. You become used to the technicalities of carrying out the procedure in various different circumstances, because you have to. You never become immune to the feelings of owners at this time, and never should. If you are satisfied that what you are doing is in the animals best interests and you carry it out with as little distress as possible, then you feel that you have done a necessary service.

Not everyone is fortunate enough to be able to plan exactly when, where and how their pet’s life might end, but sometimes considering some of the options in advance can be a good idea.

We would all prefer it if our dog or cat would live a happy life and then die at home in bed at an old age. Unfortunately this does not always happen, and many owners are faced with the difficult decision whether to have their pet put to sleep (euthanased) in order to prevent suffering.

Deciding when the right time has come can be difficult. No-one wants to cause unnecessary suffering by leaving it too late, but equally it would be regretted later if a hasty decision was made. Vets can advise what the likely outcome of any illness is going to be and what treatments, if any, could help. If everything has been done that should be done, then it may come down to the small things in life: does your dog still enjoy a walk, recognise members of the family, enjoy their food; does your cat show an interest in surroundings and people?

Home visits for euthanasia are often requested, and if this is your wish it would be worth talking to your veterinary practice in advance. Sometimes, however, it is easier and safer to do this at the surgery because of the availability of experienced helpers, and the availability of other drugs, if for example sedation was needed in a scared animal. The other big factor could be the time of day. In a night-time emergency, it may not be possible for the vet and nurse on duty to travel far from the surgery because of other patients.

Euthanasia in most cases is quick and painless. An injection is usually given into the vein because this will work more quickly than if given by other routes. Sometimes a sedative may be needed first, if an animal is nervous or aggressive. The decision whether to be present or not is an entirely personal one for the owner. Some people will feel they want to be present and others will prefer to leave after signing the consent form. If you are not present, your pet will be handled by gentle, caring, experienced staff on your behalf. If present, it may be better for both the owner and the animal if the holding is done by the veterinary nurse, who can raise the vein for the injection at the same time. This leaves the owner free to be where the dog or cat can see and hear them.

Most practices will use the services of a pet crematorium who will offer various different types of cremation or burial, depending on individual wishes. For example, you may wish to have your pets ashes returned so that you can keep them or scatter them in a favourite place. If you have a suitable place you may choose to bury your pet at home.

There is no right or wrong way to grieve. The bonds that exist between people and their pets are strong and the loss of a pet can cause a similar sense of loss to any other bereavement. Many people like to remember their pet with photos, by planting a tree or placing a plaque in a special place. Some practices keep a book of remembrance or a wall of photos of past and present pets. Vets and nurses also like to remember their patients.

Some practices have staff who have been specially trained in supporting clients who are going through bereavement and if you would like this help, do ask at your surgery. If not directly available within the surgery, counselling services are available including support from the national charity the Blue Cross. It can be especially important to help children talk about their loss as it may be their first experience of death. Other pets may also grieve. Some people think it helps to allow other pets to see the body of the pet who has died, and I have certainly no reason to think this is harmful or distressing to them.

Euthanasia and death are subjects that all of us would prefer not to have to consider, but sometimes things can be made a little easier for everyone by thinking ahead, so that if the worst happens, we are as prepared as possible, and left with happy memories.