* * *
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The history of rabies and its complex role in human-canine relationships extends back millennia. In ancient Egypt, around 2000 B.C., the Laws of Eshnunna penalized with a fine of forty pieces of silver the owner of a rabid dog who bit a man. From the traditional Indian medicine of Ayurveda to Aristotle and the ancient Greeks, the terrifying specter of rabies gripped the major medical minds of progressive civilizations. Over the centuries, our fight against rabies mirrors the evolution of scientific thinking, medical practice, and our relationship with dogs.
In the 1800s, Europe was faced with a rabies epidemic. It was the height of the Industrial Revolution, and people were moving to cities such as Paris and London and bringing their dogs with them. Strays roamed the city streets, maintaining a constant viral reservoir that could easily be transmitted—by bite—to humans or their pets, with fatal consequences. Even a country’s decision to slaughter stray dogs was not enough to stem the infection in mainland Europe, where rabid animals did not respect international borders.
It was Louis Pasteur, in 1885, who offered the first possibility of survival for those bitten by rabid dogs. By studying canine rabies—and accepting the personal risk that interacting with infected animals posed—he meticulously developed a vaccine that was widely administered to people and dogs. Pasteur first used the vaccine to save the life of an infected nine-year-old boy. Countless others would follow.
Heading into the twenty-first century, following the development of Pasteur’s vaccine and the United Kingdom’s subsequent eradication of rabies, it remained a sinister but remote threat in my home country.
In 1994, a few months before my first day at veterinary school, the Channel Tunnel connecting the United Kingdom to mainland Europe opened. Newspapers warned of an impending explosion of rabies cases when hordes of infected rats began pouring through the tunnel from France, eager to gnaw on our naïve British flesh. Wire mesh fences, electrified cattle grids, and security zones were erected to prevent the entry of adventurous, diseased animals onto British soil. But these measures did little to allay the public’s concerns.
Despite the mass tabloid hysteria, the predicted epidemic did not occur. Britain remained rabies free, and the disease remained absent from my differential diagnoses lists until I saw my first patient with neurologic signs in the emergency room at VHUP.
In reality, the likelihood of encountering rabies in inner-city Philadelphia was much the same as in London. Although we were required to submit the bodies of all deceased cats and dogs with suspicious clinical signs, and those who’d died within ten days of biting a human, for mandatory rabies testing, I never encountered a case of rabies. It turned out that, although rabies was often on my differential list, it never made it to the top.
Dogs have always dominated the headlines, and the textbooks, in the discussion of rabies, with cats generally being ignored. Although cats can contract, infect others, and die from rabies, the incidence of feline-human rabies transmission has been historically insignificant. Interestingly, though, while rabies in American dogs has decreased to the point that the canine rabies variant is considered eradicated, cats accounted for 61 percent of the total number of reported rabid domesticated animals in the United States in 2014. And although feline rabies vaccination is not a legal requirement in all states, as it is for dogs, the most recent Centers for Disease Control and Prevention report recommends vaccination of all cats, dogs, and ferrets. Today, it is cats that are more likely to interact with the raccoons, skunks, and bats that still harbor the rabies virus.
Even with these numbers, there have been only thirty-four U.S. cases of human rabies since 2003, and ten of those people contracted rabies outside the United States. In developing countries with large feral dog populations, and where the cost of widespread canine vaccination programs is prohibitive, rabies remains a massively deadly disease. It is estimated that more than seventy thousand people worldwide die each year from rabies, and over 95 percent of these cases result from dog bites.
* * *
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Despite my misgivings, Monty was dutifully vaccinated, examined, and blood-tested for routine health screening before I brought him home. Still, I knew I couldn’t insulate him from all disease, and regardless of the choices I made for him, I couldn’t prevent the inevitable. One day, he was going to get sick, with or without my veterinary degree. My understanding of disease offered no protection for my pet.
The feline medicine I’d spent years studying, however, developed a new, living dimension when I brought Monty into my life. From the pages of a textbook, or the seat of a lecture hall, disease and its consequences were abstract: something to be examined, learned, and understood. My patients were feats of biochemistry and cellular biology; I saw them on a microscopic level, a deft harmony of intricate systems borne within their skeletons. But Monty forced me to consider the dimension of disease that I’d yet to understand. His presence demanded that I acknowledge and comprehend the relationship my patients shared with the humans who brought them into my care.
From that first day, when Monty had introduced me to the particular timbre of his meow, I quickly came to look forward to the greeting he gave me each night when I got home. He would twist his long black body around my legs in tangled patterns until I sat down on the bed, so he could jump up next to me and rub his chin all over my hands in welcome. He relied on me for food, love, and a clean litter box, and I depended on him to be my family in the United States.
By the time Monty had settled in, my first patient with a gunshot wound had been superseded by a second and then a third. And bullets weren’t the only projectiles I had to consider. On a later rotation through the emergency room, I’d admitted a small tortoiseshell cat, Missy, who’d been impaled by an arrow. Her owners had found her between two parked cars, missile firmly lodged from one shoulder blade to the other, cruelly resembling a character in a comedy sketch, the grubby plume of neon yellow feathers adding to the ugly absurdity of the situation.
Studying the holes in Missy’s flanks where the arrow had entered and exited her body, I congratulated myself on keeping Monty as an indoor cat. Missy’s thoracic cavity was almost certainly penetrated—her normal respiration a result only of the puncture wound being plugged by the arrow’s shaft. Her predicament was challenging: If the arrow had passed through her chest cavity, then removal could result in instant death when air rushed in through the wound. A small crowd gathered to examine my reluctant patient, and a financial estimate was made for an emergency thoracotomy, chest tube placement, and the critical care that would follow.
This time, though, her owners shook their heads at the cost of saving their cat’s life. Missy wouldn’t be admitted to the ICU. I was angry over their financial limitations, and couldn’t help judging their decision to let their cat outside if they couldn’t afford the consequences. I wouldn’t allow anything like that to happen to Monty, I told myself. The costly estimate for specialist surgery was hastily amended. We drew up a plan to remove the arrow in the emergency room, all the while praying to Bastet, Saint Gertrude of Nivelles, or whoever would listen that the arrow had missed the privileged pleural space, and passed instead through the muscle and soft tissue surrounding the spine above the chest cavity. If the gods were listening, then Missy would survive; if not, she would need immediate euthanasia.
While technicians set up for the procedure and paged the on-call surgery resident, I tried to imagine Monty on the table in front of me. I prodded at the pool of fear that washed into my stomach when I thought of Monty being injured or sick. Was that how Missy’s owners felt, waiting for news of their cat? They couldn’t love Missy as much as I loved Monty, I reasoned.
A brief anesthesia and a pair of bolt cutters—used to remove the tip of the arrow—allowed the surgery resident to pull the shaft straight out of Missy’s body. While we held our breaths and watched her pulse oximetr
y reading, the numbers remained steady. Her breathing remained unchanged. She recovered fully, and the only signs of her brush with death were two small, square bald patches at the entry and exit sites. I discharged her later that day with prescriptions for pain medication and antibiotics, and my stern recommendation to keep her indoors. Despite my cool demeanor, her owners grabbed my hands in thanks, and I couldn’t ignore their genuine delight and relief. Perhaps my judgment of their pet ownership had been premature.
Later that night, after my shift ended, I took up my already familiar spot sitting on the edge of the bed in my small room, waiting for Monty to join me on the mattress. He jumped onto the blanket next to me, letting out a harrumphing purr when he landed. His coat shone the brown-black of newsprint left too long in the sun.
“Good evening,” I said to him. “What did you do today?”
He lay next to me and lazily stretched out a leg to place his foot on my thigh. “Really? That sounds interesting.”
I lifted him onto my lap and scratched him under his bulbous chin—his favorite spot. He rubbed it vigorously against my hand, and I noticed the whiskery baldness there, like the receding hairline of an old man. I could hear a muffled game playing on the TV in the main room where I knew Chris and Dave were probably drinking beer, and the smell of cat litter reminded me that I’d forgotten to scoop Monty’s box that morning. I was hungry, but I couldn’t bring myself to leave the comfort of Monty and my tiny room for the vast loneliness of the TV area and kitchen. Instead I settled more comfortably on my bed, trying to not disturb Monty while I moved my leg, which was falling asleep.
I thought of Missy and wondered if she’d been kept indoors that night. “I’m never going to let you outside, ever,” I said to Monty, but I realized that my promise was more to keep me safe than him. Monty had already survived an outdoor life. But his ability to jump from the floor into my arms on command wasn’t a trick he’d learned on the streets. He’d clearly been someone’s pet before he became mine. He’d lived a life with someone else. Someone I’d never know. Had he always been an outdoor cat and been erroneously saved by over-concerned students? Had his previous owner been an old woman who’d died alone? Did his owner get tired of him and force him out? Or did he sneak out and get lost in the unfamiliar smells of the city? I wondered if his owner had searched for him when he went missing. Did I love him more? Did he recognize the difference? Did it matter?
I caught a glimpse then, in imagining the life Monty might have led, of the empathy I’d lacked earlier in the day. The relationship my patients and their owners shared could not be measured like a blood glucose level, a white blood cell count, or the limits of a bank account. It was something less tangible, but more significant, and it was something, even with my own pet, I was only just starting to work out.
* * *
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By Christmas, I’d figured out how to snatch a meager handful of time for a British reprieve from the stale monotony of Philadelphia. I’d switched shifts and begged coverage from other interns to cobble together an extra-long holiday weekend to make a trip home. I’d arranged for my roommates to take care of Monty, and I was set to travel in mid-April, just in time for Easter. I had to make it through only four months before getting the time in Hereford I’d been craving.
In my homesickness, Peter and the other veterinarians I’d seen practice with took on the shape of everything I’d left behind. The months in Philadelphia passed in a flat ubiquity of air-conditioned days inside a windowless veterinary hospital that only sharpened the bucolic memory I’d created of my hometown. It took on the essence of a Herriot book, pastoral and jolly, and my drive to leave there was forgotten in the halcyon picture I’d conjured.
The truth of my relationship with Hereford and the family I’d left behind was less shiny and peaceful. By February 2001, I’d submitted my application for an internal medicine residency, potentially committing to a further two or three years in the United States. It was a decision I’d chosen to share only once it’d been made. I was homesick, but my desire to fulfill my goals exceeded my regret about abandoning my family.
I told my mum and dad in an email that I’d applied for the U.S. residency program; that way I didn’t have to hear my mum’s tone, which always betrayed her emotions. I was scared to learn what she really thought, and so I didn’t ask her opinion of my life-changing decision. It wasn’t going to be possible to hide behind email forever, though, and the residency selection results would be out before my trip home. I would witness firsthand what my parents thought when I arrived at Heathrow. For now, though, with my future undecided, I resolved to think only about their reaction if I matched for a residency. After all, there was still a chance I’d be returning home for good in June. In the meantime, at VHUP, the routines, bureaucracy, and hierarchies had settled into my daily routine. I knew the forms for bloodwork, X-rays, and ultrasound requests, and I’d learned which members of the senior staff to avoid.
One February morning, I was on my second rotation through the internal medicine service. I sat at the nurses station waiting for the residents to arrive and assign the case transfers from the emergency room. It was a daily formality. Cases that had arrived in the ER over the preceding twenty-four hours and needed ongoing care were transferred to the appropriate service in the hospital the following morning. The residents took the bulk of the patients, to gain as much experience as possible and protect the less-experienced interns, who were spending only a month on their service.
The internal medicine department was invariably the busiest for transfers. It was the catchall for any patient with an undetermined diagnosis or plan. Animals presenting with kidney failure, liver disease, intestinal problems, or endocrine and hematologic disease were considered “regular” internal medicine transfers, but the caseload was by no means limited to patients with these conditions. There were also the unfortunate sick cats and dogs who’d been dumped in the emergency room.
Sometimes owners would bring their pets in only to disappear before a consent form or fee estimate could be signed. Other times an owner might sign paperwork and give instructions to do whatever was necessary, but subsequent phone updates would reach a disconnected number. After seventy-two hours of attempting to contact the owner, ER staff would transfer the abandoned animal to the internal medicine service for ongoing care until it was healthy enough to be sent to the city shelter, or adopted by a veterinary student, intern, or other staff member who’d grown attached while nursing it back to health.
The patient transfer sheets were instantly recognizable, printed on bright goldenrod paper, and typically arrived by 6:30 A.M. But that morning, the emergency technician hadn’t brought them up to the ward yet—a crashing patient or a procrastinating, sleepy intern had delayed their arrival.
Veterinary students wearing short white coats clustered at the nurses station, or headed to the wards to check on their patients. The technicians were starting their day shifts, and the volume rose with dogs barking at their new audience and students chatting about the night before. The automatic door to the ward swung open, and ER technician Elisa strode through. She was holding the small sheaf of sheets I’d been waiting for.
“Many transfers today?” I asked.
She looked at the pages and shrugged slightly. “Not too bad for a Monday. What are you on?”
“Medicine,” I replied.
“Huh. Do you like it?”
The question was loaded. She would remember my answer for my next rotation through the emergency room—her domain. The truth was that internal medicine was the place I felt most comfortable, but I wasn’t about to tell her that.
“It’s good,” I said. “The cases are interesting. I miss the emergency room, though.”
“It’s pretty different up here,” Elisa replied, her gaze drifting down the hall with the casual intent of a predator gauging her attack. “I’d go crazy if I was stuck do
ing treatments all day.”
She surveyed the steady percolation of animals and people through the wards and treatment rooms. She was looking for someone. “What did you get up to this weekend?” she asked. “Any hot dates?”
“I was on pick-ups—didn’t have time for anything else.” I smiled, but she wasn’t looking at me. I tried to guess which male student, intern, or resident was her object of interest; there weren’t that many to choose from.
Elisa turned back to look at me, and I quickly dropped my eyes. “I guess you want these?” she said, flicking through the pages before handing me three sheets. She distributed the rest, a single leaf each, into the orthopedic and soft-tissue surgery boxes.
“Thanks,” I said, but Elisa was already heading out of the treatment area. Relieved to finally be in possession of the transfer sheets, I turned my attention to the pages. Each sparsely typed summary contained an animal, an owner, a disease to be diagnosed, and a treatment plan to be initiated. At the top, the signalment—age, sex, breed. At the bottom, the comments—maybe a note about financial considerations, or the last communication with the client. In between was a brief explanation of the case, the essence of the history obtained at two A.M. by an intern, a summary of the tests run and significant results, and the range of the financial estimate already approved. The sheets revealed an anemic dog, a cat with a urinary tract obstruction, and a dog with a fever of unknown origin.
My Patients and Other Animals Page 6
