My Patients and Other Animals

by Suzy Fincham-Gray

  One unit of packed red blood cells would consume almost five hundred dollars, and until her platelet count increased Sweetie could continue to bleed excessively. One unit of blood could be a drop in the ocean. But what other options did I have?

  There was one, I realized.

  “Do we have any empty collection bags?” I asked Corey.

  “You’d have to check with Sylvia, but I think there are usually one or two in the hospital.”

  “Thanks,” I replied. I’d been asking myself what I’d do if Sweetie were my dog, since the thought of scooping her into my family first crossed my mind. I considered the slick, dense bag of packed red cells sitting in the refrigerator. We had one chance, and I doubted that a single bag was enough. But if I could find a donor to give a unit of fresh whole blood, I could deliver it immediately to Sweetie. It was likely that the extra clotting factors, the tiny number of functional platelets, and the fresh red cells would do more good than a unit of older, dying, red blood cells. Whole-blood donations were typically separated into cells and plasma to most fully utilize the components. With an on-site donor, maybe a young, healthy pit bull mix with a black coat and brindle legs, I could give a unit of fresh whole blood that was greater than the sum of its parts.

  Emma was sitting in my office. She was healthy and young; she was the right weight—the perfect donor. She and I could be heroes. I imagined an extra life-giving force infused with Emma’s blood into Sweetie’s veins once the transfusion began.

  That Emma was still nervous to the point of distress in unfamiliar situations, and that she cowered and hid at the sight of certain members of the hospital staff, didn’t deter me from granting her consent.

  Would Rob agree to Emma being a blood donor? I considered calling him, but it was the middle of the day, and he was probably busy. I didn’t have time to talk everything through with him. And ultimately, if he said no, I knew I wouldn’t abide by his decision. The needs of my patient were more pressing than Emma’s potential distress or my husband’s consent. I wanted to save Sweetie, and, if I gave her Emma’s blood, I could quantify her improvement by checking her bloodwork, feeling her pulse, and examining the color of her gums. There was no way to document Emma’s reaction in such a reassuring way. Even if Emma’s distress at being lifted onto a table and restrained on her side for twenty minutes—while her blood flowed from a large needle placed in her jugular vein, through transparent plastic tubing and into the collection bag—became too great, I was willing to give her sedation to obtain the lifesaving fluid if I needed to.

  The greater good, I told myself. Emma’s blink of discomfort could save Sweetie’s life. For me, it was an easy decision.

  Emma was reluctant to be led into the treatment room. The last time she’d been there, I realized, was the day we’d taken her home. At the treatment door, she lowered her head and braced her legs, as if the doorway was a cliff edge I was asking her to jump from.

  I tugged gently at her leash. “Come on, Emma, it’s going to be okay,” I said.

  We first needed to check Emma’s blood type and red blood cell count, and run a quick infectious disease screen, even though her chances of having contracted a transmissible disease were low, given her reluctance to do anything much more than lie on our couch. Sweetie also needed to be set up—have blood drawn, an intravenous catheter placed, and IV fluids started. And I had another patient waiting to be seen.

  Emma was a compatible donor, and Sweetie’s bloodwork confirmed that she needed a blood transfusion. Among appointments, checking on Sweetie, and the hustle of a regular workday, I tried to remain solicitous of Emma’s care. I’d entrusted her to Nicole, the head technician on the internal medicine service. Nicole was tall, slim, and blond in a way that could have been attractive but instead was angular and awkward. Her poorly veiled displeasure directed at me—the new doctor, trained on the East Coast, who didn’t do things the way they should be done, or, at least, not the way “the boss would do them”—made me miss cranky but straightforward Shannon from Baltimore.

  I’d become familiar with Nicole’s running commentary of “Are you sure?,” “I haven’t done it that way before,” and “Why don’t you check with the boss?” whenever I asked for a particular test or treatment to be performed in a specific way. Her constant doubt leached into the other technicians on the service, forming a divide that wasn’t easy to overcome. Despite this, I knew that Nicole was experienced and competent, and that she’d get the job done.

  “Emma needs sedation,” she told me on one of my visits to the treatment room between appointments.

  “Really?” I looked at Emma, who seemed to be suctioned to the floor, quivering as if she’d lost control of voluntary muscle movement. “What happened?”

  “She won’t sit still, and I don’t have time to wrestle with her.”

  “Have you tried less restraint? She’s really nervous. She might do better with that.”

  Nicole looked at me like she’d smelled something terrible. “She needs sedation,” she replied curtly.

  I hadn’t seriously considered sedation or Emma’s quivering fear when I’d thought up my brilliant, lifesaving plan.

  “How about if I try holding her?” I asked, glancing at the clock and realizing that I didn’t have time to do anything other than see my next patient.

  “You’ll probably make things worse,” Nicole replied. “Just write up the drugs you want so we can get this blood.” She turned away from me before I could respond. I located Emma’s treatment sheet to write up her sedation. It was a standard drug combination that I used on many patients when they were too nervous, uncomfortable, or wiggly to allow routine testing such as X-rays and ultrasound. But, even with the safest drugs, sedation could sometimes cause unexpected side effects, and there was always the risk of cardiovascular compromise. For a young, healthy dog like Emma, sedation was unlikely to cause a problem, but the thought of giving her drugs she didn’t need for a procedure that wasn’t going to help her was unpleasant and nerve-racking. Shit, what have I done? I thought. What if Emma had a reaction to the sedation or didn’t recover well? It was too late to back out. I turned away, not trusting the color rising to my cheeks.

  “Be gentle with her,” I said, heading out of the treatment room.

  Nicole didn’t reply.

  * * *

  —

  “Sweetie is stable,” I said to Stacey on the phone later that day. “She’s tolerating her blood transfusion well.”

  “What did her tests show?”

  “Her bloodwork confirms what we suspected—her platelet count is very low, and she’s very anemic.”

  “She has that thing you talked about? What’s it called?”

  “Immune-mediated thrombocytopenia—her immune system is eating up her platelets.”

  “Is she going to die? You said some dogs die from that disease, right?”

  “We have to see how she does after the transfusion. She’s stable right now, and hopefully she’ll feel better with more red blood cells.”

  “I feel so bad. It’s my fault if she dies,” Stacey said. I heard stifled sobbing coming from the phone. “Brian says we can’t spend any more money, and we have to take her home tomorrow, no matter what.” She hiccupped the last word.

  “It’s not even his money,” she continued. “But Brian says if we spend everything on Sweetie there won’t be enough left for the wedding.” She sniffed. “Can’t you help us out? I’d do anything to save her. I’d pay off her care, or you could give me a discount. I’m a student.”

  “Unfortunately, I don’t control the cost of Sweetie’s care. You can talk to Corey about the bill next time you speak.” I didn’t want to bargain over Sweetie’s life.

  “You’re doing everything you can,” I said. “We’re giving Sweetie the best care, and so far there’s no indication that she’s not going to make it.”

/>   I thought about telling her that Sweetie was receiving my own dog’s blood. That I meant it when I said we were doing everything possible. That I was already feeling remorse for my decision to help Stacey’s dog without regard for my own, for not telling Rob about what I’d done. But I decided against it. The whole thing was too personal to share with someone I didn’t know. I hung up, after promising updates if Sweetie worsened overnight, and a call in the morning once I’d assessed her. Before I’d called Stacey, I’d gently ushered Emma back to the office to continue recovering. She was still heavily sedated, and lay sprawled on the office floor. I hoped she’d wake up before it was time to leave.

  When Emma and I got home that night she was still disoriented and agitated. I had to help her out of the car under Rob’s quietly displeased gaze. My reasonable explanation for sedating our dog and taking her blood, without discussion, sounded dry and hollow when I gave it to Rob. In the hospital, Emma’s role in Sweetie’s care was barely acknowledged. In the veterinary world, it was ordinary, if not expected, that our personal pets would be a part of the treatment plan if required. Our list of blood donors extended to those healthy dogs and cats of the right age and weight owned by hospital employees.

  But the parameters of normal I was used to in the clinic didn’t extend beyond its automatic doors. Jokes about anal sac expression, and the gallows humor of caring for sick, dying animals every day, didn’t translate to after-work drinks banter with anyone other than vets. But Rob wasn’t a vet, and no matter how tolerant he was of the long hours, intrusive phone calls, canceled plans, and my growing list of work-related frustrations, I’d never before crossed the line between work and home so completely. I had stepped away from the implicit compact of our relationship by excluding him from a decision about Emma that, now that we were a family, he should’ve been a part of. I realized that he would’ve consented to Emma giving blood if I’d asked, would’ve trusted my judgment that I was making a choice that was reasonable and safe, but I hadn’t asked. I had chosen to pursue the course that best suited me, and the payoff for doing so, I recognized, was small.

  Rob’s annoyance was mild and short-lived, but my guilt was slower to fade, and Emma’s sedation didn’t fully wear off until the next morning. By then I was exhausted from a night interrupted by Emma’s confused and disoriented pacing and whining, and my own remorse.

  When I arrived at the hospital, Sweetie looked better. It was too early to expect her bruising to be fading, but she wagged her tail more vigorously when she saw me. Her gums, though still pale, were turning pink, and her heart rate had slowed, suggesting she was holding on to the red blood cells she’d received.

  Her test results confirmed that her anemia had improved, and she ate a little breakfast—a good indicator she was feeling better. I’d started immunosuppressive steroids the day before, but one dose couldn’t have influenced her platelet count yet. She wasn’t out of the woods. Until her platelet count increased she could bleed uncontrollably, and possibly fatally, at any time. I wanted Sweetie to stay in the hospital several more days, until her risk of bleeding diminished, but Stacey and Brian’s one thousand dollars would be gone by early evening, and Sweetie would be going home.

  I worried that what I’d put Emma through might not be enough to save Sweetie. I couldn’t control what would happen to her once she was out of the hospital. I could only give her owners discharge instructions and pill bottles. Whether Stacey remembered that Sweetie shouldn’t eat hard food or chew on toys until her platelet count was normal was out of my hands. I imagined Sweetie dying in the backyard, bleeding into the ground while Stacey was at class. I expected her to show up in the emergency room weak and lethargic, in need of another blood transfusion. And I thought, for a moment, about how she could’ve become my pet, and how, in that scenario, I’d be charged with the months of medications and monitoring I was entrusting to Stacey and Brian. An evanescent sadness left me with the relief that I wasn’t going to be the one to get up every two hours to take Sweetie outside to pee—a common side effect of steroids.

  “Call me if you have any questions,” I said, standing in the same exam room I’d met Stacey and Brian in only a little over twenty-four hours earlier. Stacey was alone. I didn’t ask where Brian was, but I wondered if they wouldn’t need the money for a wedding after all.

  “And remember that the emergency room is always open, so if you’re worried you can bring her in anytime.”

  “Do you think she’ll be okay?” Stacey asked.

  “If we can get her through the next few days and her platelet count comes up, then I think she’ll make a full recovery,” I replied, sidestepping the question.

  “I know you think we should be keeping her here longer, but she’ll be happier at home.” Stacey looked away. I imagined the conversation between her and Brian before she’d arrived at the hospital, convincing themselves that the reason they were bringing Sweetie home was that it was in her best interest.

  She had put herself in a tough position to save her dog. It was possible that the eight hundred dollars Stacey now owed her father would cause lingering arguments and resentment, and the money she and Brian had pitched in might mean they wouldn’t make that month’s rent. Was it going to be worth the sacrifice if Sweetie didn’t pull through?

  It was hard to accept that the rest of Sweetie’s recovery was beyond my influence. I couldn’t control her owners’ financial situation, and I couldn’t affect the choices they would make now that Sweetie was out of the hospital. It was hard watching her and Stacey leave that night, not knowing if I’d see Sweetie—who now carried something of Emma inside her—again. I’d scheduled Sweetie for a recheck in forty-eight hours—her platelet count would either be increasing or she’d need another blood transfusion by then. If she isn’t dead, I thought grimly.

  Two days later I waited impatiently for Sweetie to arrive for her recheck. I’d called Stacey the day before to check on them, but I’d only got a voicemail message. Did that mean Sweetie wasn’t doing well? Or was she doing better? Or was she dead? I tumbled the possibility over and over until she showed up in my exam room at her appointed time.

  My relief at seeing Sweetie was matched by her exuberant doggy greeting—all tail wag, pink tongue, and wiggling. She looked good. Her gums were pink and the bruising on her belly had faded to the mottled purple-yellow of a ripe Victoria plum. I felt confident that her platelet count would be in the normal range on her bloodwork. In my mind, Emma’s blood was rushing through Sweetie’s body vanquishing the rogue white blood cells. I was sure that Emma had given more to Sweetie than a mix of red and white cells; a few platelets; and the fluid, proteins, and other molecules of plasma. It was the same archaic belief the first physicians performing blood transfusions in the seventeenth century firmly adhered to: that the essence, or character, of the donor could be transferred to the recipient through blood.

  The results of Sweetie’s CBC showed that her platelet count had increased to 70,000, lower than the 200,000 considered normal but out of the danger zone. I predicted that it would continue to rise and that her bruises would fade over the next few days.

  Stacey and Sweetie returned again a week later. Sweetie’s platelet count had returned to normal—she’d survived the critical period. I warned Stacey that it was too early to alter her steroid dosage, but that if all went well, we would taper, and discontinue, the medication over the next four to six months. I warned her that Sweetie could relapse if medications were weaned too quickly, or if regular monitoring was missed. But I could already see the distance and complacency of invincible youth in Stacey’s eyes. The danger had passed, and Stacey was already remembering Sweetie’s illness differently. When she reluctantly agreed to bring Sweetie back in a month I wasn’t sure she’d keep the appointment. I considered, then, telling her the story of Emma. But it was too late. Sweetie was well. My revelation might garner a shrug or muttered thanks, but it wouldn’t gu
arantee that I’d see either of them again.

  After that visit Stacey would initially answer my phone calls and promise to bring Sweetie in, but they never appeared on my schedule.

  I’d saved Sweetie, using my knowledge and experience to treat her within her owners’ economic constraints. But the victory seemed slight. I’d crossed the line between my professional and private lives, and I’d drawn Emma into the battle without consideration of her welfare, or my husband’s consent. The edges of internal medicine had smoothed like a pebble tumbled by the tide of my patients, but I was still struggling to find the balance between my career and myself.

  CHAPTER SEVEN

  Grayling

  Dr. and Mrs. Dixon perched like hedgerow birds on chairs pushed against the wall of my consulting room. Their feet dangled childishly a few inches from the floor, and I loomed above them. Their dog, Grayling, was a six-year-old, 140-pound Irish wolfhound who’d been transferred into my care that morning from the emergency room. Each member of the small, older couple weighed significantly less than their choice of canine companion. I was intrigued.

  I was struggling to treat Grayling for an unknown but aggressive infection. She’d come into the hospital the previous afternoon with a fever, high heart rate, and reluctance to walk—I couldn’t help wondering how her owners had transported her. Although her physical examination and bloodwork had suggested a life-threatening bacterial infection—sepsis—her chest X-rays and abdominal ultrasound had failed to reveal the source of the infection, and she’d continued to decline overnight despite intravenous fluid and antibiotic therapy.