Despite the recent FDA directive, the United States has yet to ban antimicrobials for growth promotion in animal feed, a measure the European Union introduced in January 2006. The U.S. debate about the use, or misuse, of these drugs in agriculture continues to rage, with the economic impact of banning antibiotics for growth promotion trumping concerns over antimicrobial resistance. To put the extent of agricultural antibiotic use into perspective, the Alliance for the Prudent Use of Antibiotics estimates that more than 70 percent of the antibiotics sold in the United States each year are used in food animal production.
The spotlight on antibiotic usage in veterinary medicine falls not only on livestock production. With growing antimicrobial resistance, the treatment of small animals also has come under close scrutiny. Today, the lives we share with our pets are intimate beyond an emotional connection. Beds and couches, counter space for food preparation, and even the plates we eat off are communal among human and four-legged family members. The antibiotics I give my patients, and those used in human medicine, are similar, if not identical.
Methicillin-resistant Staphylococcus aureus is one organism that humans and their pets share. Since the 1990s it has been documented in animals at veterinary hospitals, and identical strains have been cultured from human associates. The infection can pass from people to companion animals and, potentially, back again.
Antibiotic-resistant infections are particularly significant in the hospital environment, where pathogenic organisms can gain entry to the body via surgical wounds, compromised skin, or the respiratory, intestinal, or urinary tract. In critically ill patients like Grayling, factors including immunosuppression, multiple antibiotic exposures, and the presence of intravenous and urinary catheters increase the risk of developing a hospital-acquired, or nosocomial, infection.
I knew that aspects of Grayling’s care would increase her risk of developing an infection she hadn’t arrived with. If she made it through the next twenty-four hours she would likely be in the hospital for several more days, and the longer she spent with us the higher her risk of developing a nosocomial infection.
* * *
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I maintained a solicitous distance from the Dixons while they visited with Grayling. I could hear the murmur of their voices, but I couldn’t make out what they were saying over the familiar noise of the treatment room. They sat doubled over in their seats, with their heads almost touching. Each rested a hand on Grayling and, with the other, clutched their partner’s hand. I looked away; even my gaze felt like an intrusion.
“Has she urinated?” Dr. Dixon asked, and I realized that he’d moved from Grayling’s side to mine.
I knew the answer—it was a concern I had yet to resolve—but I reviewed her treatment sheet to double-check. “No. Not since she came in yesterday afternoon.”
“Is that normal?” he asked.
“I’d prefer if she’d urinated by now,” I replied. Grayling was a large, recumbent dog, and her ability to pass urine was a significant consideration. “She was dehydrated, so we first had to correct her fluid deficit, but we should be caught up by now.”
“Grayling is quite particular,” Dr. Dixon said. “She won’t urinate until she finds a spot she really likes. Her brothers will go on command, but not her.” It was a familiar observation. Many of my canine patients were fastidious about how, when, and where they would urinate—specific requirements might include being outside, the space and strength to posture adequately, and the right kind of surface.
“Unfortunately, I don’t think getting her outside is an option at the moment.” I pictured lifting Grayling onto a gurney, wheeling her through the narrow doorways, and then struggling to get her on her feet on the tiny patch of grass, in the hope that she’d like the spot we’d selected. Even if we succeeded, I worried that the stress of the trip could kill her.
“She might be willing to urinate while she’s lying down,” I said, sounding more hopeful than I felt. We couldn’t slide a bedpan underneath her and ask her to pee. The best we could expect was that she would go on the absorbent pad under her back end when she needed to—but I’d had patients refuse urination to the point of potentially permanent damage to the bladder wall muscle. Even if she did ultimately urinate, her fur and skin would become saturated, increasing her risk of developing the canine equivalent of bedsores.
“I don’t know about that,” said Dr. Dixon. “She’s quite fussy about that sort of thing. She’s never urinated in the house, not even when she was a puppy.” His eyes shifted; maybe he was thinking of Grayling years ago—paws and legs still to grow into, her coat whiskery soft. A tough contrast to the sick, sad dog lying five feet away.
“Given these factors, I think the best option would be to place a urinary catheter,” I said. “We can measure her urine output, and alleviate the potential for urine scald on her hind end.” I didn’t mention the increased risk of developing a hospital-acquired infection with the placement of a catheter. Given Grayling’s antibiotic exposure, any bacteria able to survive and set up home in her bladder would be resistant, and virtually impossible to treat. But that was a bridge I’d have to cross if and when we got to it.
I ushered Dr. Dixon back to Grayling and Mrs. Dixon’s side. He placed his hand lightly on his wife’s back. She sat up and turned to look at us. She tried to smile politely, but her eyes betrayed that she’d been crying.
“Come on, old girl,” Dr. Dixon said, bending to help her up. I wasn’t sure if he was talking to Grayling or his wife. His voice was gruff, the matter-of-fact veneer fractured for a moment to reveal the worry he must have felt.
The Dixons stood together. “All right, we’ll leave you to it, then,” Dr. Dixon said. “Not much we can do to help, is there?”
“Can we visit again later?” Mrs. Dixon asked.
“Of course,” I said. “We’re going to be busy with her most of the day, but we could arrange a visit later on this afternoon or early evening.”
“We walk the dogs around five thirty, so after that?” said Dr. Dixon. I sensed the change in his attitude to the more practical matters of daily duties.
“I think that would be fine. I’ll have someone call later to confirm.”
“Thank you, Doctor. We’ll look forward to hearing from you,” he said. He took his wife’s elbow and guided her out of the treatment room.
The results of Grayling’s bloodwork—handed to me half an hour later—revealed a deteriorating situation. Her white cell count had dropped, with an elevation in circulating immature white cells, meaning that her body wasn’t keeping up with the demand for infection-fighting cells. Her proteins were falling and her liver enzymes were rising: yet more indication that her body, although trying to overcome the infection, was instead becoming overwhelmed. Most concerning, however, were her prolonged blood-clotting times and decreased platelet count. These changes heralded the onset of DIC. The 50 percent chance I’d silently given her of surviving the infection dropped when I saw the results. There was no time to spare. If I didn’t find the right antibiotic in the coming twelve hours, Grayling wasn’t going to make it. An educated guess at the best treatment course was all I could make. The time to wait for culture results and sensitivity profiles had expired.
I found Corey at her desk in the corner of the treatment room. I needed to make changes to Grayling’s treatment plan before my first appointment, which was rapidly approaching. If I could give Grayling enough time for the new antibiotics to kick in, we might escape the spiraling devastation of DIC that had claimed Fritz.
“How much would a plasma transfusion for Grayling cost?” I asked.
“It depends on how much plasma you’re talking about,” she said. “She’s a big dog, right?”
“Right. She’s going to need five units twice a day.”
“Ten units, then. Do we even have that much in the hospital?” Corey raised her eyebrows at my
gargantuan demand.
“I don’t know. I’ll check. But theoretically, how much would it cost?”
Corey scrolled through the patient list on the screen and brought up Grayling’s estimate.
“The estimate for the next twenty-four hours is almost two thousand dollars,” she said. “With plasma it’s going to be more like four thousand.”
“Okay,” I said. “Can you call her owners to get permission for the plasma transfusion? I’ll call them later, but I want to get everything set up before my first appointment.”
“Sure, I’ll let you know what they say.”
“Thanks,” I said. “I’m going to check our supply.”
The in-house lab was situated off the treatment room. There was a fridge-freezer to the left of the lab for storing drugs such as insulin, and plasma in the upper freezer compartment. The hospital’s lead technician—Sylvia—was responsible for stocking our blood products, and we usually had a few units available, but depending on our caseload and product availability, our supply could change rapidly. Grayling could use our entire inventory in a day, leaving insufficient plasma for other patients until the next delivery. Sylvia was the gatekeeper of all blood products, and I had to obtain her approval before using any plasma for Grayling’s care. I was too anxious to wait for her permission, though, and I sneaked the door of the freezer open to assess our supply.
“I hear you’re looking for plasma.”
I jumped and turned quickly, feeling instant guilt. “Sylvia, I was just coming to look for you,” I said.
“You didn’t think I’d be in the freezer, did you?” Sylvia said, a broad grin betraying the sternness she was trying to keep in her dark brown eyes.
“I thought you might be. I didn’t see you in the treatment room.”
“Did you look? I was fixing your patient’s IV. Her fluid pump was alarming.”
“Busted,” I said. “Okay. I was checking our plasma supply. Grayling needs ten units in the next twenty-four hours.”
“You’re going to clean me out. Let’s take a look at the log.”
Sylvia was a lead technician on the emergency service. She also supervised the entire technical staff of the hospital, ordered all the supplies, and performed a plethora of other tasks that kept the hospital running smoothly without most of us realizing what they were. She was about my height with long, dark hair usually tied into a dense, wavy ponytail that attracted the envy of almost everyone. She was admired and respected by the hospital staff, and her integrity was beyond reproach. She regularly got up at four A.M. to bake delicious cakes for staff members’ birthdays.
Luckily, the log showed that we had four 240 ml double units and six 120 ml single units of fresh frozen plasma (FFP) in the freezer.
“How long is Grayling going to need plasma?” Sylvia asked.
“Today and tomorrow, if she hangs in. But I’ll need more if she’s coagulopathic after tomorrow.”
“I’ll call the blood bank and see what they can send. It’s good we have those double units; we don’t always get those. If I get in an order by noon today, we should get a shipment by tomorrow afternoon.”
“Great. I’m waiting for her owners’ approval, but I don’t think that’ll be a problem.”
“Do you want me to check with Corey for confirmation?”
“That’d be awesome. Then you can start her transfusion and order the extra units straightaway. I’ll probably be in appointments by then. Thanks, Sylvia.”
“You’re welcome.” Sylvia was already returning the log and heading to Corey’s desk.
My last task before starting on my day’s consulting schedule was to place Grayling’s urinary catheter, which was one thing that was actually made easier by her gigantic size. Finding the urethral opening inside the vaginal vault of a 140-pound dog was infinitely easier than in a six-pound Yorkie. I placed the catheter kneeling behind Grayling, who was lying on the floor, which made me worried that the pants I was wearing would become soaked in urine. I was relieved that by the end of the procedure I didn’t need to beg a pair of spare scrubs to get me through the day.
Once my appointment schedule began I would have to rely on snippets of information about Grayling, gathered whenever I entered the treatment room.
A bag of FFP hanging from an IV pole next to Grayling told me that her owners had approved the treatment.
The accelerated coursing of the QRS complex across the ECG monitor informed me that her condition remained critical.
The slow filling of her urinary collection bag with clear, faintly yellow urine showed that she wasn’t developing acute kidney failure—yet.
By midafternoon the plasma transfusion was finished, and her temperature had decreased by half a degree. It was too early to say if this was a positive trend or a blip, but the awkward position of Grayling’s legs made me think it was a blip. She looked too tired to arrange her limbs more comfortably, and they stuck directly out from her body at an unnatural angle.
I continued with my appointments, torn between my desire to stand vigil over my sickest patient and to take care of those who were less sick but still needed my help. And I hadn’t seen Emma all day; by late afternoon I realized she probably needed a walk, badly.
After I finished my last appointment, ensuring that medications had been dispensed and rechecks scheduled, I went to check on Emma, turning left down the hallway toward my office instead of right, toward the treatment room.
“Dr. Fincham?” The voice instantly conjured an image of jet black hair, ruby red lipstick, and a French manicure.
“Dr. Tyler,” I said, turning to my boss and feeling, for the second time that day, that I’d been caught doing something I shouldn’t. A prickle shivered along my spine; my hackles went up like Emma’s did on the rare occasion she met someone she didn’t like.
“Heading home?” she asked.
“No. I was about to take Emma for a quick walk. She hasn’t been out all day.”
“Good for you,” she said. Her simper was accentuated by her crimson lipstick. “I’m glad you’re thinking of Emma. I’ve got too much to do to even think of stepping outside right now.” I reflected her smile, hoping mine was more convincing. “I’ve just come from the treatment room,” she continued. “Grayling’s not looking too good, is she?”
“I’ve been monitoring her closely all day,” I replied, feeling her implied accusation ripple through me. “I’m certainly concerned. She’s not responding as well as I would like.” I felt defensive.
“Her owner’s a retired doctor, isn’t he? Not the litigious type, I hope.”
“Her owners are very nice and very dedicated to their dog,” I said, grabbing my hands behind my back and squeezing, hard.
Go away, I thought. Go away before I say something I’ll regret.
“I’d better be on my way,” she said. “More appointments to see, busy as usual. Good luck!”
I turned and continued to the office, determined not to let her see that she’d affected my plan. I closed the door behind me and leaned against it for a second, her “Good luck” ringing in my ears. I took a breath to steady the rage shuddering through me. I still hadn’t figured out how to conjure the Teflon skin I needed to interact with my boss and come away unscathed. Emma shimmied across the floor to meet me, her back end, propelled by her tail—which wagged furiously with delight—catching up to her head, so her body formed a U.
I greeted her like always, bending to pet her ears, but at the same moment she raised her nose to lick me in the face, smacking her muzzle under my chin.
“Emma!”
She immediately flung herself, startled, onto the floor, scrubbing her tail vigorously and looking at me out of the tops of her eyes.
“I’m sorry, sweetie. Come here.” I patted my leg and crouched down. I felt instant remorse that I’d taken my anger out on her. She
got up and slinked half-standing toward me. “Emma, I’m sorry. I didn’t mean to shout at you. It’s okay.” She slurped her tongue across my cheek and continued heartily licking. But I wasn’t letting myself off so easily. I rested my arm around the warmth of her body while I considered my options. It was perfectly reasonable to take Emma for a walk. She’d been inside all day, and it’d only take a few minutes. But I hadn’t checked on Grayling since before my last appointment. Maybe she’d deteriorated in the last hour. I wrestled for a moment longer, and made my decision. I’d find a technician assistant willing to take Emma out, and then I’d check on Grayling—using the back route to the treatment room so my boss wouldn’t know she’d won.
The changes that would indicate Grayling’s improvement were subtle. I reviewed her treatment sheet to assess the picture of her day. Her heart rate had remained elevated. Her temperature had fluctuated, but had hovered above 104°F. Her urine output was adequate, but not sufficient to account for all she was receiving, meaning that fluid was sequestering somewhere in her body. I looked at her respiratory rate. It hadn’t changed; at least the fluid wasn’t building up in her lungs.
I knelt next to Grayling to again perform the ritual of my physical exam. Her gums were florid and her pulse weak and thin, like the pinging of a narrow elastic band. Her limbs had a sickly fullness—the unaccounted-for fluid was accumulating under her skin. She had made little, if any, improvement. A clot of disquiet sat under my diaphragm. Her lack of response shifted the probability of her going home down another few points. Was there something else I should be doing? Something I was missing? What would Dr. Tyler do? I wryly asked myself, my earlier interaction with my boss reverberating. She’d shaken my confidence, a familiar consequence.
The Dixons arrived, as scheduled, after their evening walk. I guided them into an exam room to prepare them before taking them to see Grayling.
My Patients and Other Animals Page 19
