My Patients and Other Animals

by Suzy Fincham-Gray

  “In half an hour this dog could be dead,” said Elisa.

  I turned to Elisa. “What should we do?” Hercules was now my patient, and it was my job to save him. He was a young, handsome Doberman; the tan markings on his face were sharp against his black fur. His coat was shiny, his ears still puppyish and floppy. The two tan spots above the corner of each eye made it look like he was about to ask me a question.

  “Not much, without the owner’s permission,” Elisa replied. “But if you think his condition is life-threatening, we can administer emergency care to stabilize him.”

  I looked at Hercules. His breathing was ragged. The motion of his rib cage was exaggerated and irregular, each arc of bone distinct beneath his taut black skin. I cautiously pulled up his lip to look at his gums. His muzzle was downy and warm; I noted each of his black whiskers, the juvenile whiteness of his teeth, the weight of his head rested in my palm. His gums were pale—washed out rather than vibrant pink. He was bleeding more than the smear of blood on the table revealed. I needed to make a decision. Did I begin treatment without owner consent? Or did I wait for the owner to arrive, only for it to be too late when we finally obtained approval?

  “TPR?” I asked.

  “Temp 100.8, heart rate 180, resps 54.”

  His heart and respiratory rates were way too high. Was he in pain from the wound, or was he bleeding into his chest?

  “Okay,” I said. “Let’s get a front leg catheter in. What’s his weight?”

  “I’d guess about one hundred pounds,” Elisa replied. “We’re not getting him on the scale right now.”

  I pulled my calculator from my pocket to work out his body weight in kilos, trying to remember the conversion formula to calculate his shock fluid dose.

  “Do you want to bolus a liter?” Elisa suggested.

  I paused, the calculator gripped in my right hand. Hercules was losing blood, and I didn’t want to lose all credibility.

  “Sure,” I said. “A liter.”

  “How do his lungs sound?” Elisa asked.

  I grabbed my stethoscope and hastily shoved the two small black mushrooms into my ears. I hoped Hercules’s heart and lung sounds would drown out the doubt in my head. How had I not listened to his chest yet?

  I auscultated his heart first—hearing the crinkling rustle of his fur against my stethoscope every time he inhaled. There are subtleties in the way a heart sounds that can be detected only when you’ve listened to hundreds, if not thousands, of them. Hercules’s heart rate was too high, but I needed to determine if it sounded dull, which would suggest that fluid was building up in his thoracic cavity, in the space his lungs should occupy, or in the pericardial sac surrounding his heart. Was there an abnormal rhythm, suggesting damage to the heart muscle, detectable in the rapid hammering? It was my call. I listened to both sides of his chest. I wanted to be thorough, but I was also buying time. My next decisions could mean life or death for Hercules.

  I looked up from his black flank. “Let’s get an ECG and blood pressure,” I said. “Also, let’s pull for a CBC, chemistry panel, blood gas, PCV, and total solids and coagulation test.”

  “Do you want a lactate with that, too?” Elisa asked.

  “Yes, please.”

  “We’ve pulled the blood already,” Elisa replied. I hadn’t noticed, but when I looked down the darkly filled blue, purple, and red-topped tubes were lined on the tabletop.

  “Let’s run the PCV and blood gas first and send the rest to the lab,” I said.

  The liter of fluids dashed into Hercules’s intravenous catheter; the bag was almost finished. I checked his gums again. Still light pink. Felt his pulse. Not as strong. Hercules’s head rested on the table, his nose and front paws dangling off the edge. His claws were shiny in the overhead light, as if he’d had a pedicure on the way to the hospital, each nail completely black against the rich burnished tan of his feet and legs. I wanted to hold his paw, feel its weight and warmth, but I resisted, knowing it would comfort me more than him. I cautiously looked at the right side of Hercules’s rib cage. The lower part of his thorax lay flat against the table, but I could see that a small patch of his dark coat was stickily clumped and wet about halfway up his chest, behind his front leg. I touched the area, and when I pulled my fingers back, they were covered in blood. Hercules turned his head sharply, shooting me an accusatory look. I petted his snout, an apology for the pain I’d caused and the pain that was still to come.

  “Let’s clip this area here.” I gestured to where I’d touched. “I think that might be the bullet wound.”

  “Is there an exit wound?” asked Elisa.

  “A what?”

  “Usually if there’s an entry wound there’s another place where the bullet leaves. If not, that could be really bad; means he’ll need surgery.”

  I looked again at his chest. A bullet was so outside my frame of reference I hadn’t considered that it might still be inside Hercules.

  “I don’t see one,” I replied, but I didn’t know what I was looking for, or its likely location. I had a vague sense that a bullet’s trajectory depended on where it was shot from. My experience with guns was confined to a horse in a Herefordshire field.

  I looked at the clock. It was still half an hour until help arrived. I was on my own. I calculated what I knew: Hercules had been shot; it looked like he was bleeding, probably into his chest; his breathing was irregular and had not improved despite the liter of fluids he’d received. It didn’t look good. I worried that he had an ongoing bleed into his chest, which meant the bullet had hit a major blood vessel or lacerated his lung. In either case, he was going to need surgery, fast, if we were going to save him.

  Elisa began trimming the fur from the area of the suspected bullet wound, and the buzz of the clippers startled me into action. An assistant cradled Hercules’s head in the crook of her arm, holding him tight against her chest, as if shielding a child from the pain of an injection. The clipper blades were smeared with blood and small clumps of dark, matted hair. Beneath, an innocuous-looking pink hole about the size of a penny was exposed. It didn’t fit. The consequences seemed too brutal for this little mouth of tissue. It looked like his body was already trying to seal itself shut and forget what had happened. The size of the hole made me want to believe that things weren’t so bad, but the tracing on the electrocardiogram made me change my mind. The ragged green line scuttling across the screen showed that every ten to fifteen beats there was an ugly, abnormal complex, which meant that Hercules’s heart was irritated, either from being grazed by the bullet or from blood loss and lack of oxygen. The machine sounded an alarm every time his heart rate exceeded the normal parameters set, and my own pulse raced to keep time.

  “Let’s get him to X-ray,” I said. “We need to get a better look at what’s going on.”

  “Do you think he’s stable enough to move?” Elisa asked.

  “I’m not sure,” I replied. “We need to be quick, but I don’t know how else to figure out the damage and what we need to do. We’ll gurney him down and take a DV, not a VD, so he doesn’t have to lie on his back. Let’s take oxygen with us, too. I don’t like how he’s breathing.”

  “What about his fluids?” another technician asked.

  I resisted the urge to pull out my calculator; instead I clutched it through my coat pocket and hoped for the right calculation by osmosis.

  “What’s his PCV and total solids?” I asked.

  “PCV twenty-five percent, total solids five.”

  He was bleeding—the values were too low. Hercules needed a blood transfusion. His chest moved forcefully and he released a small shrug of a grunt on each exhale. He occasionally shifted his weight to a more comfortable position, but otherwise he’d become worryingly still.

  “Let’s take the fluids with us,” I said. “We’ll give another liter and then recheck his PCV and total s
olids. Can we get a blood type?”

  “There should be enough sample left,” the assistant said. “Do you want me to add that on at the lab?”

  “Yes, please. And we need to put a stat on that; I think he’s going to need some packed cells soon.”

  In a tangle of wires, IV lines, and oxygen hoses we moved Hercules from the table to a gurney, but his long legs were folded awkwardly and the ECG leads caught below his body, stretching and pulling at the machine. I didn’t want to lose the security of the green line tracing across the screen, but the ECG couldn’t go with us. I could rely on my fingers to feel his pulse and my ears to listen to his heart. We disconnected the leads and tugged them out from underneath him.

  I didn’t want Hercules to break the hospital maxim Nothing dies in radiology. I had to get him down the corridor and onto the X-ray table, get the X-rays taken, then get him back onto the gurney and returned to the relative safety of the emergency room as quickly as possible. Hercules rested precariously on the gurney; the blue straps we’d Velcroed loosely over his body looked too flimsy to hold him.

  Even though Hercules’s X-rays could be taken in a millisecond, positioning him appropriately without human restraint was a significant challenge. In order to examine his lungs, he needed to lie on his side on the radiology table with his front legs extended far enough forward that they would not overlie his chest, while also keeping perfectly still. Sandbags, bolsters, and other props could be used to keep him in place, but relying on these to restrain a large, struggling dog could prove particularly challenging. The alternative, of putting ourselves in line of the beam, even protected with lead-lined attire, was strongly discouraged due to the risk from repeated X-ray exposure.

  Once Hercules was positioned, the X-ray beam had to be collimated to the desired area, the plate positioned, and the exposure set based on his size. For Hercules, laboring to breathe and in pain, any one of these could be the critical step too far. For him, the danger was not the flash of X-ray exposure, but rather the preparation to obtain the image.

  In veterinary medicine, radiographs are widely employed as a first-line diagnostic for such diverse problems as limping, coughing, and vomiting. They add an essential dimension to our ability to investigate illness in patients who cannot verbally communicate. The results can be instantly revelatory and even illuminate the things our pets get up to while we’re out—a black-and-white universe of trash cans plundered, sock drawers ransacked, and treasures long forgotten under the couch. For Hercules, I was going to use radiographs to determine if the bullet was still in his chest, and the location and extent of the damage, which was vital information we could then use to formulate a plan—as long as he didn’t die in the process.

  We maneuvered out of the emergency room to make the sharp left into radiology. Hercules was sprawled on the gurney, his back legs curled to the side and his feet brushing the doorframe. I looked down the corridor and noted a tall male figure approaching. I was relieved by the sight of another veterinarian. He looked experienced, I didn’t recognize him as an intern, and he was wearing a long white coat, indicating that his rank was above that of a student. When we got closer I saw that he was smiling, and, despite his quick stride, he had a calm stillness about him.

  “Hi, Matt!” Elisa exclaimed, suddenly alert and attentive.

  “Hey, what’s up?” Matt turned to include me.

  “Hi.” I wasn’t sure if my blush was from relief or embarrassment.

  Elisa jumped in, “We’re trying to get this dog to radiology. He’s been shot. Cool case, huh?”

  I hoped she didn’t feel the pulse of anger I aimed at her when she usurped me.

  “D’you think he’s going to need surgery?” Matt asked.

  So far my plan for Hercules hadn’t extended much beyond the radiology department. But I realized that by placing an intravenous catheter, giving fluids, and initiating all the other steps I’d taken in the past half hour, I’d started a sequence of events that was bigger than any of those small actions. I had decided to treat Hercules without his owner’s permission, and I now had to follow that decision through.

  “Maybe?” I replied. I was trying to guess who Matt was, and frantically calculating whether I should ask him for help. “I’m not sure what’s going on, but I think he’s bleeding into his chest. He’s not breathing well, and he has an arrhythmia.” I glanced at my patient barely balanced on the gurney. “We were on our way to get chest rads.” I wanted to keep moving, to return Hercules to the relatively familiar safety of the emergency room, but no one else seemed to share my concern.

  “I’m Matt Thomas, a surgery resident.” He extended his hand. “I don’t think we’ve met.”

  “I’m Suzy,” I replied, trying to mirror his nonchalance. Maybe I was overreacting; maybe my anxiety was due to my inexperience and not my patient’s condition. “I’m a new intern. I’ve never seen a gunshot before.”

  “You can’t have been in Philly long, then,” Matt replied. Elisa nodded, I assumed at my naïveté.

  “No,” I said. “People don’t shoot dogs in England.” I turned to look at Hercules again, hiding my embarrassment in solicitude for my patient. His breathing seemed even more labored than it had a few minutes earlier. I moved to the front of the gurney, hoping to indicate the level of urgency I was feeling.

  “Is there anything I can do to help?” Matt asked, still smiling. He looked at Hercules. “Looks like we need to get this guy to radiology and back fast. Don’t want him dying while he’s down there.”

  I nodded. “If you’re not too busy, that would be great.” We began slowly moving down the corridor again, the weight of Hercules on the gurney taking a moment to catch up with our effort.

  “I’m going to page surgery and let them know this one might be coming up; he’s not looking so good,” Matt said. I nodded again, relieved that my concern was justified.

  “Is the owner on board?” Matt asked.

  The owner. I’d almost forgotten about him.

  “He’s not here yet,” I said. He was still nameless and faceless. All I knew was that he had a dog named Hercules. “I’m sure he’d want us to do everything we can.” I sounded more certain than I felt. I had no idea if what I’d said was true. I felt dangerously out of my depth. The implications of owner consent, payment for services, and the sometimes-testy relationship between veterinarians, their patients, and their clients was far off and peripheral in this overwhelming sea of newness.

  “We can figure that out later,” Matt said. “Right now, let’s find out what’s going on with this dog.”

  We formed a shambling procession to radiology, Elisa edging closer to Matt in the crowd, subtly shifting her attention from our patient to the new surgery resident.

  The gurney was almost too wide to fit through the door to the X-ray room, and it took more than one try to maneuver it through the space. Our arrival had done nothing to ease my tension. The X-ray technicians were fierce when it came to positioning patients correctly for radiographs and enforcing proper safety regulations. I had to watch Hercules from a small lead-lined box in the corner of the room while the technicians expertly arranged his limbs to get the best shot. Hercules was reluctant to extend his right front leg, likely due to the discomfort of the bullet wound on that side.

  “Has he had any pain medications?” Matt, standing next to me, asked.

  Pain meds? I’d forgotten that my patient was in pain during my effort to save his life.

  “No,” I replied.

  “Let’s see how this goes,” Matt replied. “But if he keeps struggling you might want to run and grab some hydro from the ER.”

  “Right,” I replied. I added pain control to my silent inventory of mistakes I’d made with Hercules. Running back to the emergency room and hiding under the doctor’s desk was an option I considered, but, with gentle persuasion, Hercules lay still long enough
to take the X-rays.

  The radiographs revealed that Hercules had blood in his chest and a bullet lodged in his lung. He needed surgery to remove the entire affected lung lobe and control the bleeding, and then an ICU stay with chest tubes, oxygen supplementation, an arterial line to monitor his blood pressure, and a jugular catheter for continuous venous access. The cost of his care would run into the thousands, and I hadn’t spoken to the person responsible for the bill. We were still waiting for his bus to arrive.

  Hercules’s case was gaining momentum. Each new finding led to a necessary treatment. His blood pressure told us he needed more fluids and blood products. His ECG told us he needed medication to stabilize his heart rhythm. Matt’s unbridled excitement at the prospect of an emergency thoracotomy on an otherwise slow Tuesday morning was evident when he hurried off to find the rest of the surgical team and alert the anesthesia staff. But I was increasingly struggling to identify the line between what needed to be done immediately and what could wait until I talked to the owner. Could Hercules go to surgery without his owner’s consent? I didn’t know the answer, and Matt was gone before I could ask.

  Despite the commotion around him, Hercules lay quietly on the ER table. He seemed smaller somehow—less animate than when he’d arrived. I called his name, trying to convince myself that he was bored or scared, but he didn’t lift his head, or even an eyebrow. It seemed that he had only enough energy to breathe, and even that was becoming exhausting.

  While I wrangled the needs of my patient and waited for his owner, the surgical team arrived. Surgeons in vet hospitals move in packs—a many-limbed, multi-headed beast that is difficult to stop once it gets moving. Even so, I was frustrated to be relegated to the back row of the gallery forming around my patient while Elisa stood resolutely at Hercules’s side. She was the smallest person in the group, but her rank and experience positioned her centrally. She was an accepted member of the hospital staff, her presence expected, while my stature was unproven and tentative.

  “Whose case is this?” asked one of the older-looking vets, glancing around. I didn’t know who he was.