The Gift of Pets: Stories Only a Vet Could Tell

by Bruce R. Coston

  Lisa was silent for a long time. Then I noticed her lip beginning to quiver and her eyes filling with tears. Lisa began to cry on my shoulder. She cried for a long time, emptying a full container of emotional detritus that had collected over the last month or two of X-rays, of blood tests, of MRIs, and doctor’s visits, of bad news and worse news, of maintaining a strong facade for Melanie and Steven and Amelia. These were the first and last tears I saw Lisa cry over her own illness. And when the tears finally ceased, she seemed a bit more at ease. I left that evening feeling confident that Lisa knew Cynthia and I were on her side and were cheering her on and hoping against all expectations, against all the medical literature, against even the fates that seemed once again to have lined up against her, that this time she might win; that this time Lisa’s luck would hold and the cancer would shrink and shiver and shrivel up to nothing. That’s all we could do—support her and hope and pray. And that’s what we did.

  Max’s Crisis

  “Looks like your girlfriend may be coming in this morning,” Susan said, smiling conspiratorially, as I walked into the hospital early one Wednesday morning.

  “My girlfriend?”

  “Yes. Elaine Farmer has an appointment.”

  “Oh,” I replied. “You mean my girlfriend Megan. Is there something wrong with her?”

  “No. The appointment book says that we need to check Max’s breathing. But Elaine usually brings Megan along when she comes, so she can see you.”

  I sorted through a list of reasons why Max might need to have his breathing checked. At only about six or seven years old, he was too young to be in heart failure, I thought. Usually, heart disease afflicts senior dogs. Perhaps he’d developed pneumonia or even something as mild as an upper respiratory virus. Anyway, I wouldn’t have to wait long to find out. Max’s appointment was fairly early in the morning. I was looking forward to seeing my girlfriend anyway.

  When Elaine and Max came through the door an hour or two later, however, Megan wasn’t with them. As usual, Max was not eager to come into the building, dodging instead down the handicapped ramp. With effort, Elaine tugged on the leash, finally coercing Max to enter the lobby. He immediately hunkered down under the bench seat, hiding behind Elaine’s legs as soon as she sat down.

  They had to wait only a few minutes before Lisa escorted them into an exam room and got Max’s weight and temperature. As I finished writing the record from my previous patient, Lisa emerged from the room and handed me Max’s chart.

  “Something’s really not right with Max,” she reported, a look of dread on her face. “He’s lost almost six pounds since he was here last month. And, man, is he tugging to breathe. He breathes about like me.”

  Elaine had on a pair of faded jeans and a light jacket. But she was also clothed with worry. It was in her eyes, the set of her jaw, and the slump of her shoulders. It filled the room; I could feel it as I entered. And it extended to my patient, as well. Whether Max had sensed it from Elaine’s emotional cues or felt it himself, I wasn’t sure. But there was concern and fear in his eyes, too—fear that was more than the usual anxiety about being in the hospital and being probed with a thermometer. He seemed aware that something just wasn’t right.

  The reason for this worry was evident right away. It didn’t take a medical genius to see that Max was struggling for each breath. My immediate impression was that Max was not in heart failure. Cardiac patients have a particular presentation, one that, after so many years, I sense almost intuitively. Which subtle cue it was in Max that made me think his heart was not the problem was not immediately apparent. Perhaps it was the glint of confusion, almost panic, in his eyes as he tugged at the air, willing a little oxygen into the depths of his lungs. That was it, the sheer effort it took for Max to suck the breath into his chest—effort he exerted in his belly to suction in even the little bit he could, each attempt seeming to corral only the tiniest bit of coveted air.

  Heart patients’ breathing is different. While they breathe hard, too, it isn’t with this same effort just to draw in the air. The act of breathing isn’t the problem for a heart patient. The problem is in exchanging the oxygen taken in. Patients with lung disease breathe in a different way, too. Their difficulty is not with drawing in the air but with exhaling it. Their abdominal effort comes as they breathe out; a final squeeze with their tummies at the end of each breath to chase a little more of the air out of their diseased lungs. Max’s pattern was neither of these.

  As I listened to his chest, I involuntarily furrowed my brow with concentration. I would be a poor poker player. This flinching of my face is my tell to worried clients that something about their pet’s case is puzzling me. Sometimes it’s just a sign of the extra intensity required to hear a heart that is beating four times faster than ours that does it. But often it is because there is a murmur, a missed beat, or fluid crackling in the lungs. In Max’s case, it was due to the fact that I could hear vigorous air movement in the upper portions of his lung fields, but below a line I could draw horizontally across his chest, there was nothing. I should have been able to hear air rushing through his airways down there as well, but even his pounding heart was muffled as I listened.

  “You look worried,” Elaine said, her own concern springing afresh to her face. “What are you hearing?”

  “It’s what I’m not hearing that has me concerned. I should be able to hear it all over his chest as the air moves in his lungs. But I can hear no air movement below here,” I said, drawing my finger across Max’s chest from front to back.

  “That’s not good.”

  “No, it’s not,” I agreed. “That’s probably why he’s working so hard to breathe. Something is preventing him from pulling a full breath. Did this start all at once? Or did it slowly get worse and worse?”

  “I honestly don’t know, Dr. Coston.” Elaine shook her head in confusion. “Max took off and was gone for a few days. He was fine when he left. But when he came back, he was breathing like this. So I don’t know if it came on slowly over a few days or started quickly.”

  “Were there any signs of injury that you noticed?”

  “None that I could see, though he was moving pretty slowly, now that you mention it.” Elaine paused a moment, remembering back over the course of events. “So what would make it so you couldn’t hear lung sounds down there?”

  “Well, it could be a bunch of different things: fluid buildup, air accumulation around the lungs, a mass in the chest, or a ruptured diaphragm. We’re going to need X-rays to help us sort that out.”

  “Do whatever you need to do. I can’t stand to see him like this.”

  Elaine left Max with me, making me promise to call her as soon as I had any information. I took Max into the treatment room and had Lisa get blood work and take pictures of his chest as quickly as possible. Within an hour I was holding his lab results. They were normal. Whatever was causing this problem was not related to organ failure. The X-rays, hopefully, would make the diagnosis evident.

  The picture that greeted me when I placed Max’s chest X-rays on the lighted view box was a strange one. Where there should have been dark, air-filled lungs, I saw instead a very white pattern in the bottom half of the lung fields. Scattered throughout this white background were dark streaks of gas patterns that looked exactly like the gas seen occasionally in intestines. And the starkly contrasting curved sheet of diaphragm which normally separates the chest cavity from the abdomen was evident only in the top of the picture. Somehow Max had ruptured his diaphragm.

  Two things make breathing difficult when a diaphragm is torn. First, the plunger function of this sheet of muscle tissue is lost, making it very difficult to pull air into the lungs, just as a syringe would be useless without the rubber stopper at the end of the plunger that allows negative pressure to develop within the barrel of the syringe as the plunger is pulled back. Second, liver and intestines often spill through the hole in the diaphragm and take up the space in the chest cavity normally occupied by the lungs.
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  This situation needed to be corrected—and fast. In these cases, a demanding surgery to repair the defect in the diaphragm is usually curative. The tricky part of this surgery is breathing for the patient when the abdominal cavity is opened, since, with the hole in the diaphragm, there can be no negative pressure generated and the lungs simply cannot fill with air on their own. This makes it necessary for the surgical team to ventilate the patient mechanically fifteen or more times each minute, forcing air into the lungs. This artificial respiration must be carefully coordinated with the work of the surgeon, who, between each hand-pumped breath, must return all the abdominal organs to their normal positions and sew the huge hole in the diaphragm closed, creating a tight seal and leaving no leaks. For the surgeon, coordinating all these intricate details is like directing a symphony.

  I called Ms. Farmer and outlined the diagnosis and the surgery that would need to be done in order to correct the condition. She, as always, calmly took the information in stride.

  “What do you think caused the diaphragm to tear?”

  “It’s usually a traumatic event. If I was a betting man, I’d say that Max got bumped by a car during the time he was gone.”

  “That makes sense. Maybe that’s why it took him so long to make his way home.”

  “I’m sure you’re right.”

  “When will you do the surgery?”

  “I think it needs to be done right away. My staff is already clearing my schedule. As soon as we have a catheter in place and get the surgery suite set up, we’ll get right on it.”

  “Okay,” she replied. “I have absolute confidence in you. Do what you need to do. Remember, Max is very important to me. I know I may lose him, but do your best. That’s all I ask.”

  It is always with a deep respect, an overwhelming sense of awe, and a keen awareness of the importance of each patient that I embark upon the task of treating a beloved pet. This feeling is magnified when I do surgery, especially a challenging one like the repair of a diaphragmatic hernia. But when a client sets the stage for a procedure as Elaine had, the pressure upon me to perform at my peak is so much the greater. I knew exactly what I needed to do and had done it many times before, but it was with an extra degree of nervous energy that I paused with my scalpel above Max’s belly that day. Bolstered by Elaine’s vote of confidence, I made a bold incision.

  What I found was not a surprise. About a third of Max’s liver had found its way into his chest cavity. Part of the spleen and a few loops of bowel had followed. It was a simple thing to pull these back into his abdomen. I could watch, through the gaping hole in the diaphragm, the pink lungs fill with air as the assistant squeezed the breathing bag. I could see how much easier they were able to fill. And I could see the heart beating vigorously inside the pericardial sac and could feel its vitality with my gloved finger. The edges of the rent in the diaphragm were pulled together with strong sutures, by my placing the needle through the muscle tissues carefully between breaths. After tying the last knot in the suture line on the diaphragm, I tested the seal by inflating the lungs to capacity with the breathing bag and listening for bubbles to escape through the suture line. There were none—no leaks. What remained was to place a tube into the chest cavity. The tube exited through the skin; it allowed me to evacuate the residual air around the lungs and any blood or fluids that might accumulate. Finally, I closed the abdominal wall and sutured the skin.

  The surgery had taken over two hours to complete and I was drained. But Max was recovering nicely and already breathing more easily. I was pleased with the day’s work. As promised, I called Elaine and reported that the surgery was over and had been successful. I expected to keep Max in the hospital for at least two days, until the amount of material sucked from the tube in his chest had subsided enough to allow its removal.

  Elaine brought Megan in to visit Max and me on Friday. While it was wonderful to see her, the effect on Max was not what I expected. Instead of perking him up, Megan’s visit seemed to increase his stress, shooting his respiratory rate up and tiring him noticeably.

  The day after surgery I was able to remove a few milliliters of fluid and a couple of syringefuls of air from Max’s chest. By that Friday, the amount had decreased even more. Even so, Max was not bouncing back as quickly as I had expected him to. I decided that he needed continued care over the weekend, and I told Elaine I thought he should stay with me. She seemed relieved.

  When I came in to the hospital on Saturday morning, I found Max’s breathing to be labored again. What worried me just as much was the look of anxiety that had crept back onto his face. I suspected air or fluid was leaking into the chest cavity. But when I aspirated the tube with the syringe, nothing came out. I needed X-rays to evaluate the problem, and I needed help to take them. Fortunately, Susan was willing to come from home to assist me.

  When, in less than an hour, I was once again placing Max’s chest X-rays up on the view box, I was shocked to see a pattern almost identical to the films I had taken before surgery. There was the same light density at the bottom of the film, the same intestinal gas pattern where it shouldn’t have been, the same discontinuity to the diaphragmatic shadow.

  “Oh no,” I said, letting out a deep sigh. “It looks like the whole incision line in the diaphragm has broken down. We’re going to have to go back in.”

  “You’re kidding!” Susan had enough track record with my sense of humor to think I was pulling her leg.

  “No, Susan. I wish I was kidding, but I’m not! And what’s worse, I don’t think it should wait till we’re open again on Monday. I think we ought to do it today.”

  “Okay. But we will need extra help, won’t we?”

  “Yes. We’ll need at least one more person. You can scrub in to assist me. We’ll need someone to ventilate Max and monitor the anesthesia.”

  “Lisa’s out of town, you know.”

  “Oh shoot,” I responded. The anesthesia for a case like this was especially difficult, and Lisa was the only licensed technician at the hospital at that time. “We’ll have to call in Ginny. We can walk her through the procedure beforehand. You call her and I’ll call Elaine.”

  This was not a call I particularly relished. Ms. Farmer was expecting a routine update on Max’s continuing recovery. What she was going to hear instead was that another frightening surgery was necessary. I picked up the phone with a measure of dread. But I needn’t have worried. Elaine was her usual unflappable and controlled self when I told her the news.

  “Well, that’s not what I wanted to hear, but I had a feeling things were not going as well as we wanted them to when I was in to visit him yesterday. Even Megan couldn’t spark any enthusiasm. And that’s not like Max at all.” She paused for a moment before continuing. “Say, Dr. Coston. Would you mind if I came in and observed the surgery? I wanted to watch the first one, but I was too busy to get away. I do have time today, though.”

  I choked a bit on the phone, and she sensed my hesitation. “That is, if it’s okay with you. I wouldn’t want to go against your better judgment.”

  It was indeed against my better judgment to let owners observe surgeries on their pets. There had just been too many times over the years when such a plan had injected unnecessary drama into an otherwise-routine procedure. But this was different. Elaine had quite a bit of clinical experience in her work. She probably would not get queasy. She was also very educated and levelheaded. Nor did I have a great deal of high ground to stand on. This was, after all, the second time I was going to have to do surgery for the same problem. Accommodating her request, I thought, was wise, though there was still trepidation in my heart. Had she not been so magnanimous, I probably would have said no.

  “Okay. If you really want to, I’ll let you come. But it can be a pretty tense operation. I don’t want you to be alarmed with the process—no matter what happens, okay?” But I wasn’t really concerned about Elaine. She was just so self-possessed. I expected no problems from her.

  Ginny arrived a
few minutes later. Ginny was a short, lean woman about thirty-five years old. A no-nonsense, take-charge person, she was extremely capable and committed to doing everything just right. She had been a loyal client before approaching me for a job, timing her query just when I needed someone as an assistant. The vast array of individual tasks and the intensity and quantity of work done in the hospital had surprised her, as it does most new staff members. As she did not always feel proficient enough to perform to the level she expected of herself or at the speed she wished, this frustrated her.

  I often recall with a chuckle her response to me one busy day when I added a new task to her already-long list of chores. She fixed me with a look mixed with equal parts humor and irritation and said, “Well, just stick a broom in my behind and I can sweep while I walk!”

  I could see the exasperation on her face as soon as Ginny walked into the treatment room, where Susan and I were going over the materials we would need for the surgery. I knew that it was not from frustration at having to come in on a weekend. Ginny wasn’t like that. It was instead concern that she would not be able to do what I asked of her. There was foreboding on her face as I outlined exactly what she would do. But when I told her that Elaine was going to come in and observe, I thought she might just kick me.

  Susan and I had given Max the anesthetics through his catheter and were inserting into his airway the tube through which we would administer the anesthetic gases when Elaine arrived. Ginny escorted her into the treatment room. Quickly I secured the endotracheal tube in place by pulling it to the roof of Max’s mouth and tying it around his nose and upper jaw with a length of gauze.

  Susan and Ginny busied themselves scrubbing and sterilizing the surgery site. Max was laid out on his back, his front legs pulled over his head and the surgery table tilted dramatically so his head was lower than his chest. I gave Elaine a quick summary of the task at hand and what she would be seeing. I was careful to explain the process of manual ventilation, which the tear in the diaphragm made necessary. Then I began the ten-minute process of scrubbing my hands, donning a surgical gown, and pulling on a pair of sterile gloves in preparation for surgery.