The hospital grapevine had already informed me that Dr. Dixon was a retired pediatric neurologist and his wife, a retired nurse. I suspected his attire of a gray tweed suit, with a hunter green pocket square, shirt, and tie, was similar to the outfit he’d worn each day to clinics before his retirement. Maybe back then, a reflex hammer poked from his jacket pocket or a stethoscope hung from his neck. Despite his sparse white hair and lightly angled posture, his eyes were vibrant. His wife’s hair was gray and closely cropped. She wore sensible brown shoes, a pair of what my grandmother called “slacks” in a comfortable, practical fabric, and a light sweater in a shade of mauve favored by those over sixty.
I expected that when they answered my questions they would speak with a Scots-Irish brogue. Dr. Dixon’s suit seemed more appropriate for the Scottish Highlands than a San Diego beach, and I imagined that the breed heritage of their dogs—two Irish wolfhounds and a Scottish deerhound—would be reflected in their nationality. I was slightly disappointed, then, when they spoke in well-clipped American, East Coast accents, reminiscent of a PBS history show.
Grayling was already occupying the floor next to the first large cage by the treatment room door—due not only to her gargantuan size but also the severity of her condition. Irish wolfhounds were relatively rare patients in San Diego. My typical canine population was tipped in favor of smaller breeds—Chihuahuas, various sizes and shapes of terrier, and a seemingly infinite variety of small, white, fluffy dogs. Then came the Labrador and golden retrievers, numerous iterations on the theme of pit bull terrier, and a smattering of dachshunds, schnauzers, pugs, boxers, and other breeds (or nonbreeds) that ranged in weight from one to greater than 180 pounds.
The difficulties of caring for a 140-pound dog weren’t limited to finding an adequately sized cage. From performing a physical examination to calculating the volume of antibiotics to administer, everything had to be super-sized for Grayling. That morning I’d encountered a recumbent dog who weighed more than I did. She was too weak to stand, which made performing a thorough physical examination to identify a possible source of infection surprisingly difficult.
Grayling lay on her side, and I sat on the floor next to her. She lifted her head an inch or so off the ground to acknowledge my presence, but then failed to respond to me further. Her coat was a light, silvery gray with the faintest sandy brown hair behind her ears, under her chin, and on her upper legs, and although it looked coarse and wiry, it was soft. She was a little overweight, likely a reflection of her San Diego lifestyle, where her daily exercise consisted of neighborhood walks, rather than the hunting and tracking in the Highlands she’d been designed for. I noticed that Grayling’s right legs were slightly swollen when compared to her left. This suggested that she’d been lying on her right side too long, despite the technicians’ efforts to keep her propped on her chest. I added two-hourly adjustments of her body position to her treatment sheet to prevent pressure sores, and dependent edema—fluid accumulation under the skin—from developing.
I began at her head, methodically working through the order of physical examination I’d performed thousands of times before. I was not only assessing her overall status, but was also looking for clues to how an infection had entered her body. I looked carefully in her mouth for signs of a tooth root abscess or areas where a piece of stick or other foreign material might have penetrated her oral mucosa. I palpated her peripheral lymph nodes, feeling for asymmetry or changes in shape, size, or texture that might hint at an initial site of infection. I auscultated her chest, listening for subtle signs of fluid in her lungs, but I couldn’t assess her right side. It was impossible for me to lift her chest high enough to slide my stethoscope between her and the vinyl-covered foam mat she lay on. Her abdominal palpation also proved challenging. Effectively palpating Grayling’s abdomen would have required her to stand so I could use both hands to feel for the margin of her liver, spleen, kidneys, and bladder, while also assessing for thickening, enlargements, or masses. But getting Grayling to stand was impossible, and even if I’d achieved this feat, discerning individual organ margins in her massive abdominal cavity would’ve been difficult. I knew I might miss important clues.
Sitting on the corner of the mat, I reviewed my findings. The physical examination had divulged little, other than my preference for patients I could pick up, so I turned my attention to other possible causes of her condition—a penetrating wound, a venomous spider or snake bite, or an infection originating in her intestinal tract that had leaked into her circulation. I combed my fingers through Grayling’s thick, silvery coat. The hair on her legs was dense, designed for tracking wolves through thick undergrowth. The bite of the black and brown widow spiders and the rattlesnakes that were native to San Diego could leave almost invisible puncture marks. Two tiny, perfectly spaced spots may be the only evidence, sometimes not apparent until a day or two later when the toxins injected under the skin caused necrosis and severe inflammation. Unless I knew exactly where she’d been bitten it was unlikely I’d find the punctures, if they existed.
I ran my hands down her legs, feeling for swelling or heat around her joints, parting her hair to look for reddening or bruising of her skin. She felt hot all over; her last recorded body temperature was significantly elevated, but it was hard to determine any heat differential through her coat. I considered finding help to encourage Grayling to stand while I evaluated her lungs and abdomen more fully. But the slick, easy-to-clean hospital flooring was a challenging surface for weak dogs with unsteady legs and slippery paws.
Grayling’s quiet demeanor was likely a combination of the severity of her illness and her natural disposition. A calm, stoic personality was a constant among the few Irish wolfhounds I’d cared for. They seemed most content lying on the exam room floor, nose between their outstretched legs, paying little attention to what was going on around them. Grayling’s owners indicated that she was of a similar nature, happiest when she was lying on the couch—I wondered if they perched, one on each arm of the sofa, or if they were forced to sit on the floor.
The thought of Grayling and her two humongous canine housemates living with Rob and me jumped into my head. I couldn’t picture even one of them joining us. We didn’t have the room or the time for the amount of hair they’d shed, food they’d eat, bowel movements they’d produce, and dirt they’d carry in on their paws. Patients like Grayling made me grateful that Emma could reasonably join me, Rob, and our three cats on our couch.
* * *
—
After performing Grayling’s physical exam, I shifted my attention to her owners. Dr. and Mrs. Dixon were deliberate and thoughtful in their answers to the questions I posed, with a synchronicity between them that was the result, I assumed, of a long and happy marriage. My history-taking, in contrast, felt urgent. I was desperate to determine the source of Grayling’s infection and improve our chances of effectively treating her given her poor response to antibiotic therapy over the previous twelve hours.
“Has Grayling traveled outside San Diego?” I asked.
“Oh yes, we take her and her brothers to Canada every summer,” said Mrs. Dixon.
“You do? How do you get there?”
“We drive,” Mrs. Dixon replied.
“All the way?”
“Well, yes. How else would we do it?” Dr. Dixon replied, smiling at his wife in response to my poorly veiled surprise. “We go in the minivan. A few days there, and a few back. We share the driving all the way to Vancouver. The dogs love the trip.”
I pictured a minivan crammed with three large dogs and all their accoutrements as well as Dr. and Mrs. Dixon. I stifled the many questions I wanted to ask and instead returned to the relevant ones. “When was the last time you were there?”
“Last summer,” said Dr. Dixon. “We usually go from June to the end of August. We were planning on leaving in a few weeks, but now we might have to wait for Grayling.”
“Has
she had any previous medical problems?” I continued.
“Not really,” Mrs. Dixon replied. She looked at her husband for confirmation.
“She had diarrhea last summer,” Dr. Dixon said. “They all did. The vet in Canada said it was giardia, most likely from the deer poop they were eating.”
A clue? But it was too long ago to be causing her current, acute problem.
“She hasn’t had diarrhea since?” I asked.
“No,” said Dr. Dixon, his wife concurring with a nod. “Everything was fine until yesterday morning, when she was suddenly not herself. By lunchtime she looked worse, and we decided to bring her to the emergency room.”
“And nothing’s changed recently? Could she have been bitten by a snake or spider?”
“I don’t think so,” said Mrs. Dixon. “We tend to just walk around the neighborhood in San Diego. The dogs prefer hiking in Canada, don’t they, dear?”
“That’s right,” Dr. Dixon said. “There’s been no change from our routine.”
I’d exhausted my questions, and I was no closer to solving the mystery.
“What we know so far is that Grayling most likely has an overwhelming bacterial infection causing sepsis,” I said. “But we don’t know where it’s coming from. We haven’t found pneumonia or a kidney or bladder infection, and I haven’t identified any wounds that could be seeding her blood with bacteria.”
“Could it be a viral infection? A viral meningitis, say?” asked Dr. Dixon, reminding me of his background in pediatric neurology.
“It’s possible,” I replied. “But viral infections in dogs are relatively uncommon. The only viral meningitis we see is caused by distemper, which is unlikely given Grayling’s age and vaccination status.”
“Where else could the infection be coming from? Do dogs get MRSA infections like people?” he asked.
MRSA—methicillin-resistant Staphylococcus aureus—was an acronym I’d been worrying over since I’d reviewed Grayling’s treatment sheet that morning. It was a highly resistant bacterium that didn’t respond to conventional antibiotics and could cause overwhelming and sometimes fatal infections in people and animals.
“It’s possible,” I replied. “We do see it in dogs and cats, although it’s usually associated with skin infections or wounds. I don’t see either with Grayling.”
“Are there additional diagnostics we should be considering?” he asked. “Possibly an MRI or CT scan to identify the site of infection?”
Mrs. Dixon was looking intently at her husband, nodding at each of his questions.
“I know in human medicine advanced imaging is often used in critical patients, but for veterinary patients these tests require general anesthesia, and Grayling isn’t stable enough for that right now.”
Dr. Dixon nodded. I was relieved that, despite his medical knowledge, he wasn’t trying to outdo me, an uncomfortable dynamic I’d encountered before when dealing with animals owned by human—or real, as they considered themselves—doctors.
When I applied for university, veterinary medicine was considered the more difficult discipline. Given its James Herriot–induced popularity and the small number of available schools, there were approximately fifteen applicants for every available spot, making acceptance rates much lower than for medicine. And the competition between human and animal doctors continued long after graduation, although the vet student comebacks remain my favorites—in particular a dig so popular it has graced T-shirts: “Real doctors treat more than one species.”
Despite our assertion that we were smarter and all-around better than MDs, the human medical profession has, until recently, considered the veterinary profession a poor relative, and even then only by marriage. In my examination room, I’d met physicians who professed surprise that modern veterinary medicine could diagnose and treat their pets, and who, with disdain, elected to pursue what they considered the best course of action based on their experience in the human field.
Although Dr. Dixon’s suggestion of advanced diagnostic imaging was not in Grayling’s best interest, his comment about MRSA had echoed my concerns that Grayling could be battling an antibiotic-resistant bacterium. She’d received two intravenous doses of a broad-spectrum antibiotic overnight, but she’d failed to respond in any measurable way—indicating that the antibiotic was inappropriate, the organism was resistant, or the infection was so overwhelming that it would take longer for the antibiotic to gain control.
Following the rule book of pure science, I would collect my cultures, await the results of the antibiotic sensitivity profiles, and use this information to guide my treatment. But I couldn’t wait the ninety-six hours these results would take to come back. I needed to change the treatment plan—fast—to get a hold on the infection. In the consulting room I tried to keep the urgency out of my voice.
“We’ll continue to search for the cause of Grayling’s infection,” I told the Dixons. “My plan is to perform blood and urine cultures and screen for rarer bacteria. But I also want to focus on her treatment, because she hasn’t responded to the antibiotics she’s been given.”
“Does she still have a fever?” Dr. Dixon asked.
“Yes,” I replied. “Her temperature at eight A.M. was 104.3, and she was very depressed when I evaluated her this morning.”
“She’s quite shy around new people,” Mrs. Dixon said. “And with her arthritis she doesn’t like these slippery floors. That could be why she’s depressed.”
I nodded. “Once we’ve finished here, I’ll take you back to visit, and we can see how she responds to you.” It was often easier for owners to understand the severity of their pets’ conditions when they were faced with the physical manifestation of the disease I was describing.
“We’d like that, wouldn’t we, dear?” Dr. Dixon said, reaching for his wife’s hand.
“Yes, but I don’t want to upset her,” Mrs. Dixon said. “I don’t want her believing she’s going home.” Her grip tightened on his, but her eyes were on me. “What do you think?” she asked.
“You should see her.” I knew that Grayling could deteriorate rapidly, leaving her owners no time to say another goodbye if she took a turn for the worse. “Would you like to come with me now to visit?” I asked. The Dixons looked at each other and nodded.
I walked slowly from the exam room to the treatment room, the Dixons following behind, their stance erect and somber. Our passage was more like a cortege than a hospital visit. Once in the treatment room, Dr. and Mrs. Dixon bent uncomfortably next to their recumbent dog. They seemed faded, older, in the face of Grayling’s illness. I hustled two interns off rolling chairs at the doctors’ desk so I could offer the elderly couple a seat, worried for their knees and backs. The hair and splotches of long-dried unidentifiable spills that patterned the seat cushions, which I’d previously paid little attention to, were suddenly embarrassing. I hoped the Dixons didn’t notice the mess when they cautiously lowered themselves into the chairs. Once seated, they both leaned forward to touch their dog. I stepped away, trying to offer some privacy, but the regular hospital activity I typically ignored seemed intrusive and loud.
The next twenty-four hours of Grayling’s care were outlined on the two-page treatment sheet I’d written up that morning, but the plan would likely change according to her response to therapy. I anticipated that her antibiotic choices and fluid types and rates would need adjustment, and further monitoring, including an ECG and blood pressure, would be necessary if she didn’t stabilize by the early afternoon.
The diagnostic plan was also laid out: an echocardiogram—or heart ultrasound—to look for infection of a heart valve; blood and urine cultures for anaerobic and aerobic bacteria; and regular monitoring of her complete blood count, clotting profile, and serum chemistries to assess her body’s response to, and gauge the success of, treatment.
I looked over my antibiotic choices again. I’d d
ecided to upgrade one to a potentiated penicillin, increase another to the maximum dose, and add a third to cover for less-common infectious agents. I was pulling out the big guns, something I hesitated to do without a documented reason. I was well aware of the risks of using multiple antibiotics without knowing which was needed; it was this type of practice that created drug-resistant bacterial strains.
* * *
—
Antimicrobial resistance in infectious organisms—including bacteria, viruses, fungi, and parasites—is an emerging and rapidly developing crisis of the twenty-first century. Antibiotic resistance in bacteria has been documented since 1928, only a short time after one of the first antibiotics—penicillin—was discovered. The solution at that time was to develop new agents to outwit the defense strategies of the ever-evolving targets. This proved effective until the late twentieth century and the advent of “superbugs,” unwittingly bred to escape the action of antibiotics. The development of new antibiotic classes and new agents within established classes has significantly decreased over the past forty years. Our technology cannot keep up with the genetic machinery of the bacteria we’re fighting, and the incidence of multi-drug resistance in previously treatable organisms is increasing.
Blame for the rise of multi-drug–resistant organisms rests uncomfortably on the shoulders of veterinarians and physicians due to their chronic over- and misuse of antibiotics. But they are not the only ones responsible: The use of antimicrobial additives in the food and water given to food-producing animals—to improve productivity and enhance growth at a lower cost—has also been widely condemned. Many of these antimicrobial-containing additives are available over the counter and can be administered without veterinary supervision, a practice that the FDA’s Veterinary Feed Directive, released in June 2015, aimed to control. This widespread and indiscriminate use of antimicrobials that are the same as, or similar to, those used in human medicine promotes resistance through prolonged, low-level exposure of bacteria to antibiotics, allowing resistant organisms to flourish once those sensitive to the antibiotic have been killed.
My Patients and Other Animals Page 18
