Too soon, my technician showed up, hurrying me on to my next appointment. I needed to finish with my client and get on to the next, the constant mantra of the hospital. I reluctantly rose from the cage and patted Emma’s head. She subtly shrank from my touch, trying to mold herself to the rigid metal floor. Despite this, when I stepped away she lifted her head slightly as if she missed the pressure of my hand. I looked for the next break in my schedule when I could talk to the surgeon who’d performed her femoral head osteotomy, look at her radiographs to see why the head of her femur had to be removed, and review her bloodwork. My mind was already rearranging the places my three cats occupied, finding more than enough room for a black dog with brindle legs.
Rob and I began by fostering her. But, just like with Monty, I stocked all the necessities. I’d purchased a new brown bed and a matching collar and leash the evening before we took her home. She was discharged a day or two after surgery, with pain medications and instructions to care for her healing bone, muscle, and skin.
I tried to protect myself by thinking of her as Rob’s dog, maintaining my boundaries, keeping guard by one fraction of a degree of separation. In truth, there was only a binding and tightening of the bond, not only between Emma and me, but also between Rob and me. As we nursed her back to health, carried her upstairs to bed each night, performed physical therapy exercises for her right hip, and then began short leash walks together, our evolving family solidified. Something had shifted, opened; I’d found that unique place that only a dog could occupy, and Emma fit perfectly.
In those first few weeks we bought her toys and balls, but she wouldn’t touch them. She was undoggy in her solitude, making us wonder if something more terrible than a car had hit her. She was too young for such seriousness.
Gradually her leg healed, and her sutures were removed. While her hair grew back she began playing with the toys that had gone untouched for weeks, cautiously chewing on her favorite squeakers until she gained the confidence to rip the small plastic heart out with her strong jaws. And, once she was strong enough, Rob, Emma, and I began to venture out on longer walks together, and then short hikes and, ultimately, visits to Dog Beach. Emma gave us the opportunity to explore parts of San Diego—and our relationship—that we hadn’t discovered. She came to work with me and sat in my office while I saw patients. Sometimes I would be gone for hours, rushing between the consulting rooms, treatment room, and procedures area, only returning to the office to grab a file and pick up the contents of the trash can Emma had strewn across the floor in my absence. On the way home I’d call Rob and tell him about her day: the empty food containers she’d licked clean, how she thought anyone who came to the office was there to visit her, the number of times she’d peed and pooped. She was something Rob and I shared in the unforgiving singularity of my work.
* * *
—
About six months after we adopted Emma, I took a case from a referring veterinarian, who, after seeing her patient’s pale gums, had requested an emergency internal medicine appointment. Sweetie arrived within the hour.
I could tell by looking across the treatment room that she was a young pit bull terrier, not yet fully grown. Her ears had a soft puppyish flop, her white coat with dove-gray patches looked fresh, and the length of her legs told me she was probably eight or nine months old. She held herself tentatively, lying with her head flat between her front legs and her tail cautiously rubbing the floor whenever someone passed by.
I sat next to her and offered my hand. She raised herself onto her elbows and sniffed my palm.
I carefully petted her head. “Hi, Sweetie, how are you?” I said. But her flash of interest had disappeared and she slumped back onto the hard floor.
Resting my hand on the smooth nape of her neck, I continued talking to her. “I’m sorry you don’t feel so good. I’m just going to take a look at you, okay?” I slid my hand along her body and placed my fingers flat against the inside of her thigh. Her pulse felt frantic.
“Good girl. Are you anemic?” I moved back to her head and examined the color of her gums. I lifted her lip and noted the perfect whiteness of her teeth, confirming her age. Her gums were washed out, the pink of a drop of blood in a bowl of water. There was a faint muddy stain on her front legs that suggested she’d been bleeding from her nose or mouth and had licked away the blood, leaving a rusty smudge. This explained her weakness and reluctance to stand.
“You are anemic,” I said. “How did that happen?” I continued with my physical examination, palpating her lymph nodes, listening to her chest. I encouraged her to roll onto her side so I could evaluate the skin on her belly. The sparse hair there made identifying bruising or discoloration easier. She flopped more than rolled, and she let out a soft groan that reminded me of an elderly man lowering himself into an easy chair. I ran my hand over her abdomen where there were small, blooming splotches of purple-red blood collected beneath the skin.
The puce daub over Sweetie’s skin and her pale gums suggested an abnormally low platelet count with severe bleeding as a result. It was a condition I’d encountered before. I hadn’t yet taken a history from her owners or reviewed the medical record—it was still being faxed from her regular veterinarian—but I knew what was wrong. Leaving Sweetie, I lurched on half-asleep legs to the battered central desk in the treatment room and pulled out a pink treatment sheet before heading to the exam room.
Sweetie’s owners were seated on the short bench opposite the examination table. They were a young couple, huddled together on the thin blue vinyl cushion. They looked afraid. Their visit to their family vet to check on blood in Sweetie’s urine had turned into an urgent transfer to a specialty hospital.
The girl took my hand first. She had long, sunny blond hair that looked like she’d just stepped out of the ocean. She wore sweatpants designed to look casual and well worn, although the Abercrombie and Fitch logo told me they were more expensive than the pants I was wearing. The boy sitting next to her embraced the SoCal skater punk look, with a corresponding frown. They instantly reminded me of the cool group at school that I’d never been a part of and, despite my white coat and stethoscope, I felt dull and inadequate.
“Hi, I’m the internal medicine specialist taking care of Sweetie,” I said, smiling and trying to look professional and reassuring.
“Hi,” the girl said. “I’m Stacey. This is Brian.” She gestured casually to the boy, and his frown deepened.
“What’s wrong with Sweetie?” Stacey asked. “Do you know what’s wrong yet?”
“Let’s talk about that in a minute,” I replied. “First, I want to find out a little more about you and her and what’s been going on.” My thoughts flicked to Sweetie lying in the treatment room. I was intensely aware that with every minute she was losing more blood.
“Sure.” Stacey shifted her weight back and slumped slightly, like a teenager preparing for a parental lecture. Brian remained immobile next to her. They didn’t touch or look at each other.
“She was fine until this morning. Last night Brian noticed blood in her urine when she peed on the concrete, but she ate her dinner. This morning, though, she wouldn’t get out of bed when we got up, which is super unusual.”
“How long have you had Sweetie?” I asked.
“Since she was a puppy. She was about four months old, wasn’t she, Brian?” Brian nodded, his gaze fixed somewhere between his knees and the floor.
“A friend’s dog had puppies, and Brian had a dog when he was growing up so he wanted to get one. We weren’t allowed a dog in our apartment, but when the landlord met her he decided she could stay. That’s why she’s called Sweetie—she’s so sweet.”
I smiled at the image of my new patient as a puppy—the perfect pinkness of her newly made foot pads, and the puppyish thump of her paws on the floor of their apartment.
“She must’ve been so cute,” I said. “Has she been spaye
d?”
We continued through the routine questions. Though I knew that Sweetie was worsening while I was taking her history, I’d learned that skipping questions and cutting corners would come back to bite me.
“My biggest concern for Sweetie right now is that she’s bleeding,” I said after I finished taking her history. “I’m worried that she has a dangerously low platelet count which is causing her to bleed uncontrollably.” I looked for a sign of comprehension from Stacey, but she stared above my eyeline so intently I wondered if I had a pimple on my forehead I hadn’t noticed that morning.
“Platelets are tiny fragments of cells made in the bone marrow,” I continued. “They are essential for normal blood clotting, and are constantly plugging up tiny holes in our blood vessels. Without platelets these holes would result in bleeding from everyday activity and normal wear and tear.” Sweetie’s owners remained impassive. I didn’t know whether to interpret their silence as disinterest, or fear.
“Platelets decrease if the bone marrow stops making them or if the immune system destroys them. When the number gets low enough, there is a high risk of severe bleeding from the lining of the nose and mouth, intestinal tract, and urinary bladder. I think that’s why Sweetie has blood in her urine. Do you understand so far?”
“I think so,” said Stacey. She had shifted forward, resting her elbows on her knees, like she was watching a good TV show. “But what happened to her platelets?”
“That’s what we need to figure out. There are many diseases that can cause a low platelet count. There are infections, especially those carried by ticks—”
“I’ve never seen a tick on her,” Stacey interrupted. “Have you, Brian?” She turned to look at him. I caught an inflection of irritation in the question, a hint of accusation.
“Nah, she doesn’t go anywhere. She stays in the backyard, and sometimes we take her to Dog Beach.” Brian’s voice was higher pitched, younger sounding than I expected.
“Ticks aren’t common in San Diego,” I continued. “But other infections, including those of the urinary tract and skin, can trigger the immune system to eat up platelets like they were a virus or bacteria. Some medications, vaccines, and cancers can also trigger the immune system to destroy platelets. But, honestly, in most cases we never figure out what causes the immune system to turn on itself.”
Sweetie had most likely developed immune-mediated thrombocytopenia. Her white blood cells, like microscopic Pac-Men, were gobbling up every platelet in their path, their appetites so voracious that her bone marrow couldn’t keep up with demand, and her platelet number had dropped precariously low. Immune-mediated diseases—those that for an unknown or, more precisely, idiopathic, reason resulted in the immune system attacking and destroying the body’s own cells—were one of the types of condition I was most interested in.
Rebellious white blood cells didn’t have a taste only for platelets. Red blood cells, skin cells, joint cells, and even other types of white blood cells could all come under attack if the immune system was triggered in that specific, peculiar way.
After my second year of veterinary school, I’d taken an extra year to study for a bachelor of science in immunology at King’s College. I found the perfect symmetry of an antibody fitting one molecule of an antigen—the cascading dance of cells signaling to and joining one another, the nuanced specificity of one three-letter acronym to another—comforting in its rigor. I had briefly considered a lab-based future, at the forefront of discovery in veterinary immunology, but in clinics I discovered that immune cells were more interesting to me inside bodies than they were in petri dishes.
I liked the wily, fickle, and ruthless nature of an immune system gone rogue. Treating a dog with immune-mediated disease was a battle, and the medications we used to overpower the sophisticated insurgency of a perfectly orchestrated attack were crude, a blanket barrage designed to globally suppress the entire system. Overcoming a rampant immune system was often hard and unpredictable. I’d treated dogs with immune-mediated thrombocytopenia who’d bled uncontrollably and died from blood loss. Others required multiple blood transfusions and immunosuppressive drugs to survive. And some had relapsed one, six, twelve, or even more months later. I didn’t yet know which category Sweetie would be in, but I did know that, left untreated, she would be dead within twenty-four hours.
I continued discussing my plan in the exam room with urgency.
“What we need to do now is run some tests to confirm that Sweetie has immune-mediated disease and start treatment. Her age and otherwise good health are on her side, but she may still need to be in the hospital for several days.”
“How much is that going to cost?” Stacey asked.
“It’s difficult to say. It depends on how Sweetie responds. But it can take three to seven days for the medications to start working, and during that time Sweetie may need multiple blood transfusions. You could easily spend three to four thousand dollars over the next few days.”
Stacey looked at Brian and then down at her lap. Brian’s position didn’t change. They remained separated by a few inches of blue vinyl cushion, but the distance between them seemed greater.
“We don’t have that kind of money,” she said, not looking up. “Anyway, she was fine last night. I can’t believe she’s that sick.”
“I know it’s difficult to understand—how she seemed okay yesterday, and now I’m telling you she needs to be in the ICU,” I replied, “but our pets are really bad at letting us know when they’re sick, and most of the time we don’t realize something’s wrong until they’re really in trouble. It probably wasn’t until Sweetie’s platelet count got low enough to cause severe bleeding that she began to feel bad, and that can happen in a matter of hours.”
“Why can’t we take her home?” Brian asked.
I paused, considering what to say next. The words I used were often alienating in their multisyllabic, clinical nature, and Brian and Stacey had no reason to trust me, other than the authority my white coat suggested. If they took Sweetie home she would almost certainly die. Her gum color and pulse told me she’d already bled to a critical point—she wasn’t going to make it without a blood transfusion. Even with a transfusion and ICU care she might not go home. But she wasn’t even a year old, and if I could get her through this crisis, she could eventually have a normal life. The medications I’d prescribe to suppress her immune system would likely take a toll over the next four to six months, but in a year or so it might be possible to forget that she’d ever been sick.
More than this, I wanted to save Sweetie for myself. Being the hero felt good, and there was something about Sweetie that reminded me of the moment I met Emma. When I saw the familiar wary need in Sweetie’s eyes that day, I thought of the intimate life Rob, Emma, and I shared. The warmth of Emma’s body curled next to us on the couch, the smooth velvet of her tongue on the palm of my hand, her doggy, but unique, smell. The particular softness of her ears, and the mumbles, groans, and twitches of her dreams. I wondered if Stacey and Brian felt the same for Sweetie. I tried to imagine their life, how Sweetie greeted them at the door, what they liked to do on the weekend, where Sweetie slept at night.
How strong was the bond that drew these three together? At that moment, in that consulting room, I would put a price tag on Sweetie. It was unpleasant and uncomfortable that this young dog’s life depended on how much money her owners were willing—or able—to spend, but it was also reality.
Stacey and Brian faced a common modern dilemma regarding advanced veterinary care—a choice that wasn’t available fifty years ago, when veterinary specialties were in their infancy, and the range of medications, surgeries, and treatments for sick pets was restricted to those that could be easily transferred from the large animal world. Today, companion animals occupy a deeper and broader social, economic, and emotional space in our lives than at any time in history.
In 2016, U.S. pe
t owners spent $15.95 billion on veterinary care, and that number increases every year. The pursuit of expensive, intensive treatment for our feline and canine companions is a modern choice. And the emotional and financial toll of caring for a sick pet is a luxury afforded to those who choose this road.
Sweetie’s owners were young enough to be students, and I wondered if they’d experienced the illness of a loved one before. I didn’t know what I would have done if confronted with the same expense and turmoil when I’d been at vet school.
I brought my thoughts back to the two people sitting opposite me in the exam room. I could see the expanse between myself and Sweetie’s owners widening. “Sweetie can’t go home,” I said. “I know treatment is expensive, but she’s critically ill and needs a blood transfusion.”
“What happens if we don’t do that?” Brian asked.
“Bri, we can’t take her home. She’s going to die if we do, right?” Stacey replied, glancing at him. Brian deflated further into the bench.
“Right. I don’t think she’ll make it through the next twenty-four hours,” I said. “But I understand that it’s difficult. It’s a lot of money, especially when it’s unexpected.” I looked at Brian, trying to include him, but he refused to make eye contact.
The room suddenly seemed small and hot. “I’ll leave you guys to talk things over while I go and check on Sweetie,” I said, half-stepping backward toward the consulting room door. “I’ll also have a cost estimate made for the next twenty-four hours.”
Brian shrugged.
“Okay. Thanks,” Stacey replied, looking like she wanted to kick Brian in the shin.
Back in the treatment room, Sweetie was lying where I’d left her. I thought she looked quieter, more withdrawn, but I might’ve been projecting my anxiety. I found an unoccupied spot at the central doctor’s desk and cleared a space to finish writing up her treatment sheet. I reviewed the tests and treatment orders I’d planned so far. Sweetie’s life-threateningly low platelet count was most likely idiopathic—meaning I wouldn’t determine the underlying cause. However, the only way to make that diagnosis was to eliminate all other possibilities. This meant performing an array of tests: chest X-rays and abdominal ultrasound to look for infections or tumors, bloodwork for tick-borne organisms, a bone marrow aspiration to determine if platelets were being manufactured properly, and serial measurements of platelet count and red blood cell numbers, to decide ongoing treatment.
My Patients and Other Animals Page 15
