“How is she?” Mrs. Dixon asked. She sat with her hands gripped tightly in her lap, her feet dangling motionless.
“Grayling hasn’t made any significant improvement today,” I said. “Despite the plasma transfusion and new antibiotics, I’m sorry to say that she remains critical.”
Mrs. Dixon’s eyes were too bright in the fluorescent light. Dr. Dixon sat straight-backed, caught in his thoughts of Grayling.
“What else can be done?” Dr. Dixon asked. “We’re not ready to lose her.” His wife nodded and laid her hand on his. “She’s a good dog,” he continued. “One of the best. You have our permission to do whatever it takes.”
I looked away, but the urgency and desperation of his request trembled in the air between us.
“I understand how much she means to you, and we’ll do everything we can,” I said. My words felt insubstantial against the weight of their hope. “She’ll receive a second plasma transfusion tonight, and we’ll continue her other treatments and intense monitoring.” I paused. “But despite our best efforts, Grayling may not make it through the night. If she continues to deteriorate I’m worried that she could go into respiratory or cardiac arrest.”
I watched their faces, waiting for the impact to lessen before finishing what I needed to say. It was hard to witness. In that moment it didn’t matter that the Dixons had spent their lives in the human medical field. Their intellectual capacity to understand sepsis had no relevance. That they had counseled parents dealing with the illness of a child mattered little. They were two people who loved their dog, in the same way that parents love their children, and I was telling them that she could die.
“I’m sorry to ask,” I continued. “But, if Grayling were to arrest, we need to know your wishes. Would you want her to be resuscitated?”
“We would want to be with her,” said Dr. Dixon without hesitation.
“Of course. We’d do our best to contact you, but sometimes things change so rapidly that there’s not time for you to get here. So it’s important that we know what you would want ahead of time.”
“I see,” Dr. Dixon said. He paused, and I saw the effort it took him to keep his voice level. “We would want her resuscitated, wouldn’t we, dear?”
The brightness in Mrs. Dixon’s eyes turned to tears when she looked at her husband. “I don’t know. We don’t want Grayling to suffer, do we? Our girl doesn’t deserve that. I’d hate to see her tortured.”
“We can’t give up on her,” he replied. “We must give her every chance.”
I thought back over the many times I’d had this conversation. In these moments, the unique relationship each owner and their pet shared was distilled down to the most fundamental question of life and death.
“What would you do if she were your dog?” Mrs. Dixon asked.
It was a question I’d once been unwilling to answer, my trepidation at giving the wrong advice overwhelming my knowledge and clinical intuition. But the memory of Fritz, and the suffering I’d witnessed when treatment was pushed beyond the boundary I considered reasonable, impelled me to answer.
“I would let her go. That doesn’t mean that’s the choice you should make, but if she deteriorates to the point of needing resuscitation I would recommend putting her to sleep. She’s been through enough.” I felt a beat of trepidation. My opinion was not always welcome, even when it was asked for.
“Thank you, Doctor. We appreciate your honesty,” Mrs. Dixon said, a sob, almost like a yawn, stifled in her throat.
“I think we should discuss this further before making a decision,” Dr. Dixon said, not looking at his wife. The formality in his voice implied that no further discussion would be had with me.
“Of course,” I replied. “Why don’t you visit Grayling, and we can discuss any questions after that.”
I stepped out to check that Grayling was ready. I sat with her for a moment before escorting her owners to the treatment room, and tried to see her through their eyes. If this was Emma, would I be able to make the decision I’d told the Dixons I’d make? Would I be able to let her go? I liked to think that I would. But could I really know until it was time for me to make that choice?
After Grayling’s owners had visited her and had a conversation at her side I couldn’t hear, they agreed to a do-not-resuscitate order. Once they’d left the hospital, I spent hours poring over her treatment sheet and rechecking her vital signs. I then rounded her case to the overnight doctors, emphasizing that they were to call me immediately with any questions.
By the time I got home Rob was well established on the couch, looking suspiciously like he’d been napping.
“What’s the time?” he asked. “You’re home late.”
“After nine. I don’t know exactly.” I peered at the microwave clock. “Ten twenty.”
“Rough day?”
“Yeah, I took a sick Irish wolfhound from the emergency room. She weighs a hundred and forty pounds.”
“Wow, they’re cool-looking.”
“I guess,” I replied, distracted.
“You want something to eat?”
“I’m good. I don’t feel like eating, too stressed and tired.”
“Anything I can do?”
“No. She looked so bad when I left. I’m worried she won’t make it through the night.”
“I’m sorry, hon.” Rob patted the couch next to him. “Come here.”
Before I could make it across the room, Emma had leapt at Rob’s suggestion and was curling herself into a ball at his side, her head coming to rest on his thigh.
“It’s okay,” I said. “I’m going to bed.”
“I’ll be up in a bit. Are you sure you don’t need anything?”
“I’m good. Love you,” I said, and headed upstairs.
Harry, my white and orange cat, jumped off the cat tree at the bottom of the stairs and padded behind me, his presence accompanied by the jingle of his tags. I sat on the edge of the bed to take off my shoes, and he hopped up next to me, extravagantly throwing himself on his side to demand my attention. I smoothed his coat beneath my free hand, drawing comfort from each pass of my palm. It was going to be a long night. Any change in Grayling’s condition, or question about a treatment order, would mean an instant phone call, regardless of the hour. I felt a flash of resentment, but I’d moved across the country for the calls, the long hours, the constant caseload. There was no way to escape the hospital. If there wasn’t a call I would spend the night awake, worrying about why I wasn’t being contacted. If there was, I would spend the night on the phone.
I checked my ringer, turned the volume down to avoid waking Rob, and placed my mobile on the table next to the bed, hoping for a few hours of sleep before it rang.
* * *
—
The closed blind slapped gently at the open window, and the air felt middle-of-the-night cool. It took a moment to realize that I was awake. I instinctively reached for my phone, envisioning Grayling’s cardiac arrest, but it was silent. There were no missed calls. Emma was on the floor, gently moaning and sighing her dreams, her body indistinct against the dark carpet. Harry was curled in the warm triangle made by my bent knees, and Rob was asleep next to me. The red glow from the clock on the bedside table set the time at two twenty. There were hours yet until morning.
The threads of my anxiety crept closer—thoughts of Grayling and sepsis and antibiotics squeezing the remnants of sleep from my body. It was easy to believe in the early morning quiet that I’d missed something, not looked hard enough for the root of her infection, not tried the right combination of antibiotics, skipped a critical step.
Harry jumped off the bed with a soft thud and slinked away. But I was less willing to give up on sleep. Resolutely, I counted backward from ten, but all I saw were Grayling’s lab values. Next I pictured myself on a shimmering, deserted beach, but the sand was soo
n crowded with my patients. Grabbing my phone, I slipped out of bed. Emma lifted her head disinterestedly when I shuffled past, but she stayed put. I headed downstairs to try the couch as a better place to sleep, but I was too unsettled and so spent the rest of the night distractedly watching reruns of Mork & Mindy.
I was surprised that my phone hadn’t rung that night, although the silence had done little to alleviate my concern. I arrived early at the hospital the next morning, convinced that something terrible had happened and I hadn’t been informed. I hurried to resume my post next to Grayling, and while her mortal presence gave some relief, her awkward, still-recumbent position made me question how much longer she could hold on. Her survival for the last twelve hours gave me no hope for the coming twelve.
When I slid my hand between her upper left hind leg and body wall to feel her pulse I noticed that she flinched from my touch. Odd, that didn’t bother her yesterday. I moved my hand and she again withdrew her leg a centimeter or two. Temporarily forgetting her pulse, I palpated the limb for areas of swelling, or repeatable pain. The region from her stifle (or knee) to her toes was swollen with fluid beneath the skin, which made her tissues spongy and soft. Where I’d examined her leg, my fingers had left small pits, which slowly disappeared when the fluid flowed back to fill the indentations.
I scrutinized the rest of her leg, looking for changes in skin coloration, sensing the firmness of the tissue, the temperature of the surface. And in her calf muscle I noticed a hot hardness. On closer inspection there was a terrible purple reddening of the skin.
“Can you hand me a pair of clippers?” I asked a passing technician.
Tentatively, I removed the hair from the region, careful not to cut her skin. I expanded the tract when I saw the discoloration, like the pulp of a black plum, creeping outward. By the time I’d finished, I’d exposed the skin from above her knee to her hock (ankle)—the intense puce of the central region fading centrifugally to an angry, hot red, and then a ruddy pink.
So this is what I missed. I should’ve found it sooner.
“Make sure you clean those clippers thoroughly before using them again,” I said, handing them off to the technician.
The skin in the center of the area looked tight and shiny, like that of an overripe heirloom tomato. I peered cautiously at the source of her infection, unsure what to do next. Should I leave it alone? Stick a needle in it? Send her to surgery for debridement of the area? Amputate her limb?
I decided on a surgical consult, but the surgeon wasn’t in until nine. I’d have to wait. In the meantime, I wrote instructions warning Grayling’s attendants to wear gloves, and to ensure her leg stayed clean and dry. Then I reconsidered my antibiotic choices.
What were the possible causes of the blooming inflammation in her leg? It could be from a snake or spider bite, although I didn’t note any puncture wounds. It could be an abscess caused by a foreign body, like a foxtail, that had become trapped between her toes and then penetrated the skin and tracked up her leg. Or it could be the site of an infection caused by virulent bacteria that had directly entered the skin or been deposited from the bloodstream. None of the options were good. And although I’d found the mystery source of her sepsis I was no closer to finding the cure—if one existed.
In the half hour before the surgeon arrived, I returned to my office to research new antibiotic options. I remembered a recent discussion on the ACVIM mailing list about a potent penicillin-group antibiotic named meropenem, and I decided to focus my search on this drug.
I didn’t take the use of such an antibiotic lightly. Meropenem was the biggest of the big guns—a powerhouse reserved for life-threatening human infections—and every time I or my colleagues reached for such an advanced-generation antibiotic, we increased the risk of developing resistant organisms. If meropenem failed to kill the bacteria invading Grayling’s leg and bloodstream, I would have not only exhausted my treatment options, but also exposed the microbial population of the hospital to an important antibiotic—a potential problem for future susceptible patients.
I let the idea sit while I considered the rest of Grayling’s treatment plan. On review, there was little to be changed from the previous day:
Her ECG, blood pressure, and urine output would be closely monitored.
Her blood gas, glucose, and electrolytes would be checked every six hours.
Her temperature and vital parameters would be taken every four hours.
Her fluid rate would be adjusted every two hours based on her urine output, and her fluid type adjusted based on her electrolytes and plasma proteins.
She would receive another ten units of plasma.
The substantial list of intravenous medications would not change.
Her treatments and monitoring stretched over three pages, but I wasn’t sure it would be enough to keep her alive another twenty-four hours.
When the surgeon arrived, we donned sterile gloves and examined Grayling’s leg. The surgeon was a middle-aged woman with hennaed brown hair who displayed a brusque attitude outside, and brilliance within, the operating theater. I was hoping she’d provide a smart surgical solution to instantly cure my septic patient. Instead, after prodding the central region of inflamed tissue and commenting, “That looks pretty bad, doesn’t it?” she recommended taking samples for culture and cytology—which I’d already planned on doing—and waiting another day or so for the “region to declare itself.” I would add meropenem to my arsenal and wait; there was nothing else to do.
Our hospital didn’t stock meropenem because we used it so rarely, so I sent Sylvia to track some down at the UC San Diego Medical Center—the nearest human hospital willing to part with a few vials. An hour later they arrived, and we administered the medication immediately, but Grayling was running out of time. She was tiptoeing along the edge of a crevasse, but somehow her feet remained, for now, on solid ground. It would take little—the release of bacterial toxins to cause more inflammation or bacterial emboli showering her kidney or lungs—to tip the balance and for her to die.
Throughout the day I moved between two worlds, shuttling from the relative normalcy of the exam room—and chatting about the best diet for diarrhea or the diagnostic recommendations for a chronic snotty nose—to my critically ill hospitalized patient. I only had to step across a corridor and through a door to be with Grayling, and while I chatted with my clients, a part of my mind stayed with her. Holding the data of her lab results, body temperature, and blood pressure tightly, so I could instantly recall them for comparison when new information arrived, I chased the meropenem into her vein with white-blood-cell-rousing thoughts. I willed her fever to abate, her heart rate to lower. I waited.
Her body temperature two hours after the first dose of meropenem decreased by half a degree. Was this another blip or was my gust of optimism warranted? I asked my technician to retake Grayling’s temperature in an hour. If it was the same or lower, the blip could be considered a trend. If not, I’d have to keep waiting. Despite my internal optimism, I wasn’t ready to share my hope with the Dixons. Premature optimism for a critical patient with a capricious disease wasn’t a good idea. Assuring an owner of their pet’s improvement only to call back a few hours later with news of their deterioration, or even death, was something I knew to avoid. It had almost become a superstition, and I joked that I wouldn’t predict an animal’s discharge until they were in the car heading home.
An hour later, though, Grayling’s temperature had dropped another few points of a degree, and her heart rate had slowed—progress in the right direction. Her left hind leg, however, was deteriorating. A thin, red fluid oozed and slowly dripped from the sites of the needle aspirations I’d taken for culture and cytology. When I bent to examine the skin more closely, I caught the warm odor of rotting meat, but I couldn’t discern if it originated from my memory of pathology lab or from my patient’s tissues.
I’d called
the Dixons earlier in the day to arrange an evening visit. I’d given them a suitably guarded update with news of the apparent abscess and my plan. It was a small victory to have identified the source of Grayling’s infection, but that was all I was willing to concede.
By that evening, I felt more confident in the likelihood of Grayling’s ultimate discharge from the hospital. I was less confident, though, about her making it home with her leg. With each hour the florid redness had seeped farther under her skin, spreading like fluid blotted with a paper towel. I used a marker to outline the edges of the affected tissue to more objectively measure the infection’s spread. The new antibiotic was gaining control of her systemic infection, but poor blood supply to the compromised tissue of her leg could prevent good drug penetration, and allow ongoing damage.
I had to wait and see.
I met the Dixons in the same small examination room as the night before.
“Grayling has made some improvement today. She’s not out of the woods yet, but since starting the new antibiotic her temperature has decreased and her heart rate has stabilized.”
“Thank goodness. That is a relief,” said Mrs. Dixon, the tiny muscles around her eyes relaxing.
“I’m cautiously hopeful that she’ll continue to improve, but we won’t know if she’s in the clear until the next day or so.”
Dr. Dixon nodded.
I continued. “Although her systemic infection is improving, I’m concerned about her left hind leg. Has she ever been lame on that leg?”
“Not that we can recall,” said Dr. Dixon. “We’ve been thinking it over since your call this morning, and there isn’t anything. No injuries or scratches, nothing.”
“I don’t know if her leg is the original site of infection, or if bacteria from her circulation were deposited there due to a change in blood flow or a blood clot secondary to her illness.” I paused. “Her leg looks quite frightening, so don’t be alarmed when you see Grayling. Our surgeon consulted today and recommended keeping the area open, which is why there’s no bandage.”
My Patients and Other Animals Page 20
