My Patients and Other Animals

by Suzy Fincham-Gray

  Despite my developing relationship with Monty, I had yet to find the empathy to view treating disease as something more meaningful than the solution to a medical conundrum. Discovering the possibilities of a problem list, and the pursuit of every potential diagnosis, was electrifying. To me, the ultimate glory lay in finding the most obscure differential for the commonest problem.

  I was intrigued by the rarest of diseases, determined to track down every case report of conditions that had been seen in only one or two animals. I would breathlessly suggest such diagnoses in rounds, thrilled by the idea that I had discovered the holy grail. The senior clinicians, however, were less impressed and would gently remind me that “when you hear hoofbeats think of horses, not zebras.” It was a saying that would become etched into my memory as a fledgling veterinarian—a useful reminder to rule out the more common causes of a problem before reaching for the diagnostic manual. Chasing zebras rarely ended in success, and more frequently resulted in a frustrated owner left with a large bill for the diagnostic tests performed.

  Even so, I wanted to chase the esoteric. Partly because I didn’t have the experience to distinguish between common and exotic disease, but mostly because I was scared that I would miss a diagnosis by not exploring every possibility, and in so doing cause harm to my patient. I’d graduated vet school by studying hard, and I thought that becoming a veterinarian required the same skills. So I tried to soothe my anxiety by the acquisition of knowledge, and chasing zebras worked in the same way. Although my worries weren’t that easily controlled, I continued to seek comfort in difficult internal medicine cases. But my intern status meant that I couldn’t, yet, choose the cases that I worked on, and I’d end up with the last pick after the residents.

  The medicine residents were generous. They knew I wanted to join them the following year, and they’d already passed me several interesting cases. I’d experienced the addicting rush of excitement when a test confirmed a tentative diagnosis, the thrill of figuring out the relationship between lab abnormalities, clinical signs, and disease, and I was hooked. It was the cognitive challenge, the gratification of solving the puzzle, that electrified me. But I hadn’t yet done my time in the isolation ward with abandoned parvo-positive puppies, or in the main medicine ward with urinary tract–obstructed cats; I had to prove myself with these cases before I could be selected for a residency.

  I handed over the transfers when Mark and Tracey, the internal medicine residents, arrived at the nurses station a few minutes later. I secretly hoped for the dog with the fever of unknown origin and an extensive diagnostic workup, but I was handed the sheet for the cat, a stable patient requiring minimal testing who would probably go home in a day or two. It was the perfect case for a green intern. I glanced at the top of the paper and found my patient’s name: Tiger. I wondered if he had the coat and temperament to match.

  With final case transfers complete and students assigned, it was time to move our patients from the first-floor ER to the third-floor wards. Along with a better understanding of hospital hierarchy, paperwork, and how to charm the technicians, my internship had also taught me a few things about male cats with urinary tract obstructions. I was introduced to techniques and skills not covered at veterinary school: how to slide the catheter into a swollen and delicate urethra, the best sedation protocols, and the volume of intravenous fluids to give.

  What I didn’t know, but would come to realize, was that each hospital, and each veterinarian, had a unique way of managing these ornery patients. A specific combination of hard science and harder-to-define clinical experience wove together to form the bed of medicine on which each doctor’s patients lay. After the rigidity of vet school, it was difficult to accept that experience sometimes equaled, if not surpassed, the recommended treatment regimen described in the most recent edition of Small Animal Internal Medicine.

  I was not yet intimately acquainted with the diseases I diagnosed. I viewed them through the pages of a textbook—a table of clinical signs, typical lab abnormalities, and differential diagnoses. I made meticulous notes during rounds, while the senior clinicians discussed their preferred treatment methods, using phrases like in my experience and evidence-based medicine to justify a course of action. I spent my off-hours memorizing survival statistics from the latest Journal of Veterinary Internal Medicine and Journal of the American Veterinary Medical Association. My medicine was as definitive as the black text on the white pages of the articles I read. I understood that there was nuance, but it remained beyond my reach, buried beneath the hundreds of patients I had yet to see.

  My new patient was a young cat, about three years old, who’d arrived in the emergency room the night before. His owner had rushed him in after she’d got home from work to find her healthy, energetic cat sprawled next to the litter box, barely responsive. He’d been normal that morning, if maybe a little slow to eat breakfast.

  On arrival at the emergency room, Tiger’s condition had prompted a stat triage. The technician answering the page would immediately have palpated his abdomen to assess his urinary bladder. Running her hands from behind his rib cage toward his tail, she would’ve encountered the turgid tennis ball of his dangerously enlarged bladder; he’d been struggling to urinate for hours, a gritty plug of cells, protein, and crystals obstructing his urethra.

  The technician’s announcement of “He’s blocked!” triggered a well-established routine: crash cart, IV catheter and fluids, blood gas measurement, sterile gloves, lube, tiny Tomcat urinary catheter, sterile saline for flushing all set up within a few minutes. His heart rate had been precariously low, his heart muscle cells stuporous from the massive amount of potassium circulating in his blood. Toxins and metabolic by-products that should’ve been excreted hours before were accumulating in a poisonous stew. I pictured Tiger lying in the emergency room, ECG hooked up, intravenous fluids and drugs to stabilize his heart running through a line into his vein, a technician shouting out the blood results that flashed up on the screen. I was relieved that it hadn’t been my shaky hands placing the urinary catheter. Tiger had stabilized overnight, his blood potassium, urea nitrogen, and creatinine slowly returning to normal with the large volumes of intravenous fluids he received.

  My job over the next few days was to keep watch over Tiger, continue to flush the toxins out of his body, and, at the critical moment, pull the urinary catheter and ensure he could urinate on his own. Timing was crucial. Remove the catheter too soon and re-blockage could occur, necessitating more time in the hospital and the possible euthanasia of a young cat with owners unprepared for such expense.

  Over the past few months, my thoughts, increasingly, had turned to Monty when considering my patients. I knew he spent most of his day asleep, safely sequestered in my small bedroom. He probably woke for the occasional snack of dry food, or to use the litter box I’d positioned in the farthest corner from my bed. Was that how Tiger had been spending his days? For Tiger, a sedentary, indoor lifestyle and dry food diet had caused him to get a little plump around the middle. I thought of Monty’s growing belly. This, along with Tiger’s gender and genetics, had likely caused the blockage that had endangered his life. Neutered male, indoor, overweight cats, eating dry food, and peeing in a box were the typical patients to develop feline lower urinary tract disease, which could culminate in the life-threatening urethral obstruction that had brought Tiger to VHUP.

  I doubted Tiger’s owner had considered any of these factors when she’d decided to own a cat. I, on the other hand, at times could think of nothing else. Should Monty be an outdoor cat if that decreased his chances of developing a urethral obstruction? Should I feed him inconvenient, smelly canned food instead of the kibble I shook into his bowl every day?

  I’d decided that Monty wasn’t going to be an outdoor cat, but the dry food I rattled into his bowl every morning spiked a more intense ambivalence. For some cats wet food was better, but the inconvenience of can openers and ha
lf-finished cans in the refrigerator was unappealing, as was the expense on an intern’s salary. I was a veterinarian, and my choices as a pet owner potentially put my cat at an increased risk of developing urinary tract problems because dry food was cheaper and more convenient. Practicing perfect cat husbandry had seemed easy sitting in a lecture hall, but Monty was teaching me that it wasn’t so simple.

  I identified Tiger by the empty bag outside his ER cage slowly filling with fluid. Were it not for the attachment to the urinary catheter, I wouldn’t have recognized it as urine. It was strawberry-hued, and small islands of blood clots and cellular debris turned the bag into a macabre snow globe. That’s one pissed-off bladder, I thought, crouching in front of the cat. My patient’s horizontal ears and immediate growl told me it wasn’t just his bladder that was pissed off.

  Tiger was flattened against the back of his cage. He didn’t take his eyes off me. I reached for his treatment sheet, and his rumbling growl peaked into an indignant hiss. His pupils were so dilated from adrenaline that I couldn’t discern the color of his eyes. He was a gray-brown tabby, with the tigerish stripes his name foretold. The white Elizabethan collar he wore to prevent him from removing his catheters lent a vaguely comedic cast to his rage. His face, framed by the plastic moon, reminded me of a sulking child in a school play. His black plume of a tail was deflated and bedraggled, but the tip flicked a warning that echoed his growl.

  Treatment sheet in hand, I stepped back from the cage. Reviewing his fluid shifts over the past twelve hours, I looked over his urine output, tallied his fluid input, and calculated the difference, acutely aware that I was delaying the moment of opening his cage door.

  The temperament of my patients was a bewildering addition to my problem list, a confounding factor that rarely worked in my favor. Frightened cats and dogs could be aggressive or stupefied, influencing the findings on physical examination and preventing the discovery of potentially vital clues. Despite Tiger and Monty’s similarities, they seemed separated by more than the few blocks it took to walk to the hospital each morning. Tiger’s fear, discomfort, and trip to the emergency room had changed him into a feral animal.

  Over-exuberant, friendly pets could prove equally challenging. A young, energetic chocolate Labrador retriever had taught me earlier that year that temperament wasn’t always a good assessment of disease severity. He’d greeted me with a vigorous lick and tail wag, and then dragged me, on the end of his leash, down the corridor to radiology, where an ultrasound confirmed an overwhelming, life-threatening infection in his abdominal cavity due to a barbeque skewer piercing his intestine. He’d skipped breakfast that morning—a never-before-witnessed event—then vomited and seemed out of sorts, but the excitement of a car ride to the hospital had overridden his discomfort. Fortunately, his insuppressible energy meant that he was discharged the day after surgery with no complications.

  I proceeded cautiously with Tiger. How could I perform a physical examination on a patient growling so loudly that I couldn’t hear his heart or lung sounds? How could I interpret a cat’s behavior when he was too frightened to do anything other than huddle in the corner of his carrier?

  When I was a student I’d been protected—there’d always been a more senior veterinarian or technician to intervene if the patient became too difficult. Now, I was responsible not only for the safety and well-being of Tiger, but also of the staff and students he interacted with.

  “Monty would never act like this,” I muttered, looking warily at Tiger.

  I considered my options for getting us both safely to the third-floor ward. Large towel? Cat gloves? Muzzle? This wasn’t the first time I’d felt inadequate in front of a twelve-pound patient. Asking for help seemed like admitting defeat, but I also didn’t want to get bitten. I felt an irrational flame of rage at Tiger’s low growl, fueled by my awareness of the damage he could inflict if I didn’t handle the situation appropriately. I wondered if his rabies vaccination was up to date.

  Time was running out. I’d been in the emergency room for fifteen minutes, and Tiger was no closer to transfer. Other patients and their coteries of students, interns, and residents had already left. My assigned student was missing, either busy with ward duties or loitering in a hallway having caught wind of our patient’s temper. Regardless, this was my responsibility. The buck—or tomcat—stopped with me.

  I tried summoning calm, hoping to dispel the tension with wishful thinking. I imagined what George would do—the lilt of his Scottish burr quietly reassuring his frightened patient. The capable breadth of his hands dwarfing even the largest and angriest cats.

  But summoning old mentors and wishful thinking weren’t going to alter my patient’s mood, or magic him upstairs and into the internal medicine ward. Instead, I had to rely on the help at hand; I needed to call on Elisa. I scanned the emergency room for any other technicians, but my attempt was halfhearted. Elisa was experienced and, when it came to handling an aggressive cat, I knew she could get Tiger out of his cage without significant damage to him or to us. I wrestled my pride down far enough to allow a deference to Elisa to rise before I walked toward her. Her ready response to my request suggested that she’d known I was going to need her help, but I hung on to my smile and listened to her expound on the best ways to handle a cross cat.

  With the swift dexterity of an experienced cat wrangler, Elisa pinned Tiger to the back of his cage with a large, dense blanket. The thick fabric shielded us from claws and teeth and muffled his escalating wail. In one quick movement she swept the blanket between him and the cage wall so he was wrapped completely in the material—an unpleasant burrito. She placed my very displeased patient on the waiting gurney, holding him in the blanket while I hastily grabbed his fluid pump and urinary catheter bag, trying to avoid yanking on any of his lines and causing a crisis. Once we started our unceremonious procession to the third floor ward, Tiger’s anger had abated, likely overcome by confusion at this new adventure.

  Throughout his stay Tiger was a challenging patient. He tested my confidence when his fierce demeanor forced me to concede my inability to perform a physical examination every morning. He tested my nerve when he chewed out and swallowed his urinary catheter the morning it was due to be removed. I administered an emetic and waited fifteen nerve-racking minutes for it to take effect. I’d never been so happy to see a patient vomit.

  At discharge, he was so difficult to take out of his cage that I asked his owner to come up to the wards to coax him into his carrier. I hovered a few feet away from Tiger’s cage while his owner—an ordinary middle-aged woman—approached. She was quiet and seemed nervous in the hospital, and I feared she was no match for Tiger’s ferocity. If he bit her, I would be responsible. She knelt in front of his cage and placed the carrier on the floor beside her. For a moment Tiger didn’t move, and then he noticed her and approached the front of the cage, flicking his tail in the air and rubbing his face and the length of his body along the cage door.

  “Tiger,” she said. “My handsome boy, I’ve been so worried about you.”

  He chirruped a meow at her voice. She opened the cage door and he dropped his head into her open hand.

  “You ready to go home?” she asked. And when she opened the carrier he hopped in.

  Something tight and unfamiliar caught in my chest when I watched Tiger with his owner. The animal I’d felt at war with, the medical problem I’d tried to solve, was suddenly a different creature. He was more than an angry bundle of fur with a urinary catheter; he was loved. I hadn’t possessed the right lens to see the essential, emotional connection each of my patients shared with their owners until Monty arrived. And I was still figuring out how to incorporate this new information into my practice. But the weight of Monty on my bed at night, the vital warmth of him in my arms and the discovery of the need I felt for him, demanded that I see the animals I cared for in a different way.

  CHAPTER FOUR

  Fritz


  On Match Day in mid-March 2001, I learned I would be staying at the University of Pennsylvania for at least two more years. The Veterinarian Internship and Residency Matching Program, or “the Match,” was the official program all intern and resident candidates applied to for a position at their preferred institutions. Through a combination of candidate and hospital rankings and a complex, mystical algorithm, positions were assigned in a method that seemed effective, but always provided enough confusing outcomes to obscure exactly how the system worked. Luckily, I had ranked Penn as my first choice, and I was excitedly relieved to be starting my internal medicine residency there in June.

  Philadelphia was finally becoming my home, and I wasn’t ready to trade it for another locale. It was not as unlike a British city as I’d first perceived. I’d found a tiny bakery next to a small park, Rittenhouse Square, that made the most delicious bread. I could walk there on a weekend day, and it reminded me of my time in central London. I’d settled on my favorite breakfast place, which was tucked into a beautiful Victorian home in the gritty center of West Philadelphia, and my friends had introduced me to the trails in Fairmount Park—a hidden oasis on the banks of the Schuylkill River with areas so densely wooded you couldn’t hear the traffic on the nearby freeway. On a good day, I could forget I wasn’t in England. My belongings had expanded beyond the two suitcases I’d checked on my flight from London, and my loneliness had been allayed by Monty’s arrival.

  Most of the interns in my class had applied for residencies—surgery, cardiology, internal medicine, oncology, critical care. The choice of specialty varied, but the significance of residency Match Day was the same. It was a day of absolutes: elation or despondency; acceptance or rejection. Those who were chosen had the next few years mapped out. But for the one or two who were passed over, plans had to be remade, goals flattened, and disappointments swallowed.