Two days later I got a call from Ms. Farmer. “I’m afraid I’ve been a bad momma,” she said.
“Oh, I doubt that. What happened?”
“Well, Megan got out the back door when I let Max out. And before I noticed she was gone, she was swimming in the creek. The bandage is soaking wet. How do I get it to dry out?”
“You don’t,” I responded. “If the bandage is that wet, the only option is to bring her in and replace it. If we don’t, we’ll be sorry, and we’ll endanger all that we’ve accomplished with surgery.”
“I was afraid of that. Okay, I’ll bring her in.”
Megan was thrilled to see me when Elaine brought her in later that day. No reunion between parted lovers was ever more joyful. Her face shone with eagerness and her greeting was effusive as I met her in the lobby. While I removed the sodden mass of dripping cotton from her leg and replaced it with clean and dry bandage material, she lovingly caressed my hand with her paw and licked my arm tenderly. Before I sent them once again on their way, I reiterated my advice to keep her bandage clean and dry.
Despite my instructions to Elaine, and despite her most careful efforts to enforce them, over the next few weeks Megan became an accomplished escape artist. Whenever she was able to sneak out, she headed directly for the creek at the back of the Farmer property and plunged in for a swim, completely saturating the gauze and cotton bandage and necessitating a visit to our office for another bandage change.
Each time, Megan would bound through the front doors, tongue dangling in a sloppy smile and eyes bright with anticipation. When she caught sight of me behind the counter, she would woof excitedly, crouch down playfully, splay-legged, with her wagging hindquarters and flagging tail high in the air. Then she would run full tilt across the lobby, dragging Elaine at the end of the leash, and plop her front legs onto the countertop, complete with a sodden mass of bedraggled bandage.
I would, of course, reward such a shameless display of adoration with the lavish response it deserved. It underscored to me what a lucky breed we veterinarians are. What other doctors can interact with their patients so expressively and not get sued?
The problem was, however, that Megan began to look forward to our reunions altogether too much. In the eleven or twelve weeks after her injury, I replaced that bandage no fewer than ten times. I began to wonder if Megan was purposely soiling her bandage so she could see me again. Bandage changes became so routine for her that I’m sure Megan could have applied the bandage herself. But she wanted me to do it. During each rewrapping of the leg, she would occupy herself with loving, almost amorous, licking of my hands and face, resting her good leg comfortably on my shoulder. With each visit, it was obvious that her puppy love was growing.
After three months, the bones had healed adequately enough for me to remove the pins and wires and leave the bandage off. Megan was walking well, with hardly a trace of a limp, and her visits became infrequent. I missed seeing her so often. The staff teased me about being stood up by my mistress. But I knew better.
Megan was a patient of mine for many years—one of my favorites. A few gray hairs emerged on her muzzle a little earlier than I would have expected, a reflection perhaps of her trauma. Only a few things reminded us of those three long months. The wrist on her right leg didn’t bend quite as much as the left. A little scar from the surgery site decorated the inside of her leg like a tattoo. On cold mornings there was a little more stiffness when she first woke up. And whenever she saw me, there was always that special greeting, the unmistakable look of ardor in her eyes, the gentle tugging on my hand with soft teeth, and the unique connection between special friends. Megan was my girlfriend. Just don’t tell Cynthia!
Seventy-six Cents
Mrs. Garner and her mother were the proud companions of a lovely little Boston terrier named Mischief. Mischief was young, only about five years old, and was aptly named, given her penchant for always finding the perfect way to cause unmitigated consternation to her besotted owners. I had treated her through many bouts of gastrointestinal distress after she had consumed some offensive inedible she had found in the yard. Fortunately, she had always responded beautifully to these treatments and had bounced right back to her normal trouble-seeking self.
When I noticed Mischief’s name on the appointment book early one morning, I suspected another round of the same. But as soon as I entered the exam room, I knew this was a problem on a different order of magnitude. I could see it reflected on the faces of Mrs. Garner and her elderly mother; their faces were drawn and tense, their lips thin and tight with worry.
One look at Mischief and I knew that she was in danger. She, too, was tense and dull, her eyes cast in shadow and her short coiled tail still. For a moment she rallied when I entered the room, her tail making tiny circles and her face becoming animated. But before I could even respond to her, she was quiet again and panting heavily. Even that small an exertion had exhausted her.
“My goodness, Mischief is not feeling like herself at all, is she?” I asked, concerned.
“Not at all,” responded the elderly woman, her face etched with fear. “She’s been getting worse and worse over the last two days. Honestly, Dr. Coston, I don’t think she’s going to make it. Don’t you think we should just put her down? I hate to see her suffer.”
“I think it’s way too early to be making any decisions like that. I haven’t even examined her yet. When did all this start?”
“I first noticed her not feeling well maybe four or five days ago. I thought at the time it was probably the same old thing, so I didn’t worry too much about it. But it just kept getting worse. Now she won’t eat and is as weak as a dishrag.”
“Let’s take a look, why don’t we. Put her up on the table.”
Mrs. Garner lifted her onto the tabletop, where Mischief hunkered down, sad-eyed and submissive, bereft of any mischief at all. Having treated Mischief since puppyhood, I knew this lack of interest was foreign to her.
Every veterinarian develops his own systematic approach to examining a patient. This routine keeps one focused on the whole patient, rather than on just the most obvious problem. Such a comprehensive look has often saved me from making diagnostic mistakes that might have had life-threatening consequences. For me, this routine starts at the head. I examine the eyes and nose, then the mouth. From there, I feel the lymph nodes before listening carefully to the heart and the lungs with my stethoscope. I then turn my attention to the abdomen, probing with my fingers till I have felt the kidneys, the liver, the spleen, the bladder, and the intestines. I finish the examination by looking carefully at the skin and finally the musculoskeletal and nervous systems. It is important to perform the physical examination carefully on every patient, not being distracted from any part of it just because the problem seems immediately obvious. The additional information gleaned from a complete evaluation is often of vital importance.
Habits though, like rules, are made to be broken. And if there was ever a case where a problem seemed obvious upon initial evaluation, it was Mischief’s. As I lifted her lip and looked in her mouth, the sheer pallor of the oral tissues shocked me. So white were they that when I tried to blanch them by pressing on them with my finger to see how quickly the color would return, there was no discernible difference in the color of the gums. Mischief was terribly anemic. The remainder of my physical examination protocol was aborted as I whisked her away to collect blood for testing.
The results of the tests were just as alarming as the lack of color on her gums. The hematocrit, a measure of the red cell mass, was only 9 percent. It should have been at least 35 percent or so. Mischief had less than one-third of the red cells she needed to carry oxygen to her body—a level that, if it dropped any lower, would be fatal. Mischief’s condition was critical!
In this situation, it is the job of the clinician to identify the cause of this drop in red blood cells as quickly as possible and to institute treatment that will reverse it. The three categories of diseases that can cau
se these signs include blood loss, failure of the bone marrow to produce red cells, or destruction of red blood cells. Within each of these broad categories are a number of discrete causes, but getting to the correct category is the doctor’s first priority.
Blood loss is relatively easy to rule out. Since there were no external wounds on Mischief that were actively spurting blood, I needed to rule out blood loss in the gastrointestinal tract. This would show up in the colon as either bright red blood, if the bleeding was in the lower GI tract, or black and tarry stool if the blood loss was in the upper GI tract.
I pulled a glove out of the drawer below the examination table and pulled it on with a smart snapping of the latex at the wrist, a sound that usually evokes an emotional response from either the patient or the owner, and often both. The truth is, nothing pleasant can ever happen for a patient of any species after a doctor puts on a glove. Some orifice is about to be probed or some bodily fluid is about to be forfeited, against the wishes of the donor. These procedures are generally not consensual. In Mischief’s case, however, it was unavoidable. The normal-appearing stool on the finger of the glove ruled out blood loss as a cause of her anemia.
Red-cell production is measured by evaluating the number of immature red blood cells, called reticulocytes, which are present in the bloodstream. If the reticulocyte count is elevated, then it’s obvious that the bone marrow is doing its job at peak capacity. Mischief’s reticulocyte count had skyrocketed into the range where lack of red-cell production was inconceivable. That left only the category of red-cell destruction as the cause of her anemia.
This was not a surprise to me. In dogs of Mischief’s age, a condition called immune-mediated hemolytic anemia (IMHA) is by far the most common cause of profound anemia. IMHA is a disease that incites the immune system to turn the full brunt of its fury against a dog’s own red blood cells, destroying them with amazing ferocity and speed. On more than one occasion, I have helplessly watched with horror as a patient’s red-cell count dropped by half in the span of only three or four hours. It is a nail-biting race to see if powerful drugs with awful side effects can stop the carnage before too many of the red cells are wiped out. Some races are won, but all too many of these cases end in sadness.
The vast majority of IMHA cases are categorized as idiopathic. This is a word that few of my clients are familiar with. I describe it to them as meaning that none of us idiots can figure it out; and while that description may occasionally be an accurate one, technically it means that no specific cause can be found. So idiopathic has come to represent a category of diseases that just happen without apparent cause—unfortunate accidents of metabolism or malicious chance. While I usually look to find a cause for IMHA, seldom do I identify one—a reality that after many years can incite complacency for the search.
I had suspected IMHA the moment I lifted Mischief’s lip, and the results of the diagnostic tests had confirmed it. Given the invariably poor prognosis listed in all the veterinary textbooks and my own personal history with cases such as this, I was worried for Mischief. I gave Mrs. Garner and her mother a very guarded prognosis for her recovery.
When I laid out the odds for recovery and the treatment that would be required, they were quite reluctant to proceed, leaning instead toward a very difficult and irreversible decision. I encouraged them to stand firm and give the medication a day or two to work before giving up. But despite the encouragement I offered, I was none too confident about the outcome. With as much optimism as I could muster, I placed an intravenous catheter into her leg and began to pour a pharmacopoeia of drugs into her weakened system, hoping against hope that they would halt the red-cell destruction.
I fretted about Mischief all morning and into the early afternoon, pulling a tiny blood sample every hour to see if the red-cell count was dropping even lower or if the medications I was streaming into her were working. With intense interest, I watched her attitude to see if I could catch even a hint of a rally.
What it was that got me to go back and finish my aborted physical examination, I can no longer remember. I suspect it was the nagging suspicion that there was something I had missed that might give me the edge over such a formidable foe. So early in the afternoon, with no appreciable improvement in Mischief’s condition, I put her on the exam table again. This time my examination was slow and exhaustive. Even so, I came up with no additional information. Frustrated, I started again at her head and went through the process a second time. This time I was surprised to feel something slip through my fingers as I felt the abdominal cavity, an unexpected finding in the area of the stomach. I rushed her to the X-ray room for a quick picture.
As I slapped the developed film onto the lighted view box, I was surprised to see the outline of something odd in the stomach. I couldn’t identify exactly what it was, but it was obviously foreign, clearly metallic, and had the appearance of a little Oriental pagoda. In an instant of clarity as I looked at that X-ray, it all made sense. I knew with certainty that the foreign body was leaching trace amounts of a toxic heavy metal, which was causing the destruction of the red cells. I didn’t know yet exactly what the metal was, but I realized that this was the cause of all Mischief’s problems. That metal had to come out!
This conclusion was easier to reach than to accomplish, however. Mischief, in her current state, was anything but a good surgical candidate. But I also knew that until that foreign body was gone, she would not improve. Of that, I was convinced.
I called Mrs. Garner and described the situation in as much detail as possible. The surgery would be dicey, not because it would be a particularly difficult one but because Mischief’s profound anemia made her a tenuous patient. While there was a chance we would lose her during the procedure, there was no chance of recovery without it. And if we were successful, Mischief’s odds of complete recovery were excellent. After taking some time to discuss it with her mother, Mrs. Garner called back and gave me permission to proceed.
I immediately began to drip a transfusion of fresh blood into Mischief’s catheter as we prepared for the surgery. Within an hour or so, I was making my first incision through Mischief’s skin, holding my breath as I did so. It was a relatively simply thing to locate the stomach, make a quick incision through the pale wall, and fish out the heavy foreign body, which had sunk into the depths of the flaccid organ. What I pulled out was a stack of coins joined together by the sticky stomach contents: two quarters, two dimes, a nickel, and a penny—seventy-six cents worth of misery, illness, worry, and pain.
After closing the incision in the stomach, flushing the abdominal cavity with warm sterile saline, and placing a neat row of symmetrical stitches in Mischief’s skin, I examined the coins carefully. The pagoda shape I had seen on the X-rays was explained by the way the coins had stacked up on themselves in the stomach: both quarters, then a dime, then the nickel, another dime, and finally the penny. The quarters, dimes, and nickel appeared pristine, as if they had just been cleaned with a ring cleaner. But the penny had turned a strange dark color, almost black, and had a hole eaten completely through its center.
In 1982, as a cost-saving measure, the composition of pennies changed from 95 percent copper to 97.5 percent zinc with a thin overlay of copper. While this change has saved the government millions in precious metals, it has cost pet owners a considerable sum in veterinary bills. For some reason, stray change seems to be an irresistible treat for young dogs and cats, who gulp them down like hard candy. In the stomach, the thin copper layer of the penny is eaten away by the stomach acid. Because other coins are made of other metals, they do not suffer the same fate. This would be only a cosmetic issue for the penny, if not for the zinc underneath. The effect of zinc toxicity is to create a cascade of red-blood cell destruction, which presents as the quintessential case of IMHA.
This is what had occurred in Mischief. After the coins were removed from her stomach, her recovery was rapid and complete. Two weeks after the surgery, at the time of the suture removal, her red-cell
count had climbed back to normal and she was back to her mischievous ways. It was a joy to lift her lip and see the healthy glow of pinkness rush immediately back after I blanched the tissues with my finger. This, though, was hard to do with Mischief snorting and squirming and nipping playfully at my fingers. Her uninterested, dull demeanor seemed a distant memory. As I turned her on her side to remove the stitches from her shaved tummy, she wriggled and writhed in absolute glee, her short tail twisting in tight circles and her entire back end wagging excitedly.
“Wow, this is a different dog from the one you brought in two weeks ago!” I exclaimed with pleasure.
“You are so right. She’s completely back to her old self now. We can’t tell you how grateful we are to you. You saved her life.”
“I’m just glad you brought her in when you did. I don’t think she would have survived if you had waited any longer.”
“Now, I’m not complaining about the bill or anything, Dr. Coston,” Mrs. Garner said apologetically. “I know these things cost money. And I know how much more it would have been if I had had the same procedures done on myself. Mom just had a minor procedure done on an outpatient basis and it was way more than Mischief’s whole abdominal exploratory.”
It’s true. Veterinary medicine remains the best bargain in any branch of health care. Veterinarians appreciate the necessity of keeping costs as low as possible for pet owners, and we generally have done a great job of that. Procedures on our patients, for which we charge a few hundred dollars, easily cost tens of thousands in a human hospital. We veterinarians have the paradoxical luxury that the actual costs of medical decisions are borne by the ones who are making them for their beloved pet. This, unfortunately, forces loving pet owners to sometimes make heart-wrenching decisions on the basis of those costs. But it has also forced veterinarians to maintain tight controls on costs and fees, a necessity that no doubt would have protected the human health-care field from the current fiscal stresses upon it. In this area, human physicians could learn much from their veterinary counterparts.
The Gift of Pets: Stories Only a Vet Could Tell Page 19
