My Patients and Other Animals

by Suzy Fincham-Gray

  “What about surgery?” Dr. Dixon asked.

  “I discussed it with the surgeon, and she recommends medical management at this time. Grayling’s condition is still very fragile, and we should give the new antibiotics more time. But if the infection continues to spread, limb amputation may be the only option.”

  The tightness returned to Mrs. Dixon’s face, and guilt stung mine—I knew my words had caused her distress. Dr. Dixon cupped his wife’s elbow, as if to guide her away from rocky territory. “We put Henry, one of our dogs before Grayling, through that,” Dr. Dixon said, shaking his head. “He had osteosarcoma. It was terrible.” They shrank closer, withering at the memory.

  Large dogs usually didn’t do well with limb amputations, especially with advancing age, and six was geriatric for an Irish wolfhound. Saving Grayling and getting her safely into the minivan and home meant also saving her limb—I hoped I could do both.

  * * *

  —

  The following morning, I arrived early to evaluate Grayling. When I approached she tried to lever herself onto her elbows to greet me. Her heart rate on the ECG elevated with the effort. I sat cross-legged next to her head, helping her shift her front legs more comfortably beneath her.

  “Hi, Grayling. How are you this morning?” Her head flopped back to the floor, her nose straight between her front legs. “Good girl,” I said. “You look like you feel better; how’s that leg?”

  I continued to speak softly while I performed the physical exam, and I realized that up to this moment, I hadn’t seen her as a dog. Her illness had shifted my perspective. Until now I’d seen her only as a sum of organs, systems, and numbers to order and control. I’d wanted to save her because she was loved, because I felt connected to her owners, because they had the money to pay for her treatment, and because that was what I was trained to do. But I couldn’t say that I’d wanted to save her for the dog she was—I was only just beginning to understand her as an animal.

  While I performed my exam, Grayling occasionally raised her head to inspect me over her shoulder. Her interest was a good sign, and I continued to give her encouragement. I examined her left hind leg last. The skin was uneven with splotches of blackened, irregular tissue sunk slightly below the surface, while other regions looked tense and ruddy. The redness hadn’t extended beyond the line I’d drawn the previous evening, but it hadn’t receded, either. I gloved up to evaluate the affected area. Her discomfort was clear when I palpated the edges of the region, but the center was less painful; the tissue had already died. I didn’t want to send Grayling to surgery, but my unease refused to settle.

  The surgeon, however, was unswayed. “She looks better this morning, don’t you think?” she said.

  “Yes, but that necrotic tissue looks scary.”

  “Oh yes, there’s bound to be tissue death,” she said. “But it’s better to let her body take care of it. I could make matters worse by going in and poking around.”

  She examined the tissue, directing her words toward Grayling. “If an area declares itself then I might consider surgery to debride and flush the region. But if we go in, there’s not going to be enough healthy tissue to close, and that location won’t heal well by second intention.”

  Grayling wouldn’t be going to surgery that day, or likely ever; once the surgeon had made up her mind she rarely changed it. I trusted her judgment, but that didn’t stop me from worrying at the decision, prodding at it like she’d done at Grayling’s leg, testing it at every opportunity to see if it held.

  Grayling continued to stabilize, but she’d been recumbent for three days, and it was going to take another twenty-four hours at least until I was willing to try balancing her upright, on her three good legs. I wanted to be sure her cardiovascular system was stable before it undertook the massive task of getting her giant body moving again.

  I tracked her improvement by her response to her owners when they came to visit—the best indicator of how she was feeling in the foreign hospital environment.

  That third night she propped herself on wobbly elbows and balanced there for a minute or so when the Dixons entered the treatment room. She nosed her muzzle into Mrs. Dixon’s lap once they were seated next to her, and weakly wagged her tail. It was the first time I’d seen Dr. and Mrs. Dixon smile.

  The next day I released her from her monitoring devices. The ECG had become a comfort more than a necessity—I no longer needed to see the regular tracing of her heartbeat across the screen to convince myself that she was getting better. It was hard to remove the leads, and for the first hour I rushed to check her pulse several times because she lay so quiet and still. I tried giving her food that fourth day, but she stubbornly refused—turning her head away at the smell of what I offered. It was essential for her recovery that she begin eating and drinking to maintain her hydration and energy levels, but I couldn’t tell from her disdain if she was refusing to eat because she was nauseous or because I was the one presenting the food.

  When the Dixons arrived with a small plastic container of white rice and boiled chicken that evening, I discovered the answer. I watched from the other side of the treatment room when Dr. Dixon opened the container and held it for Mrs. Dixon to scoop food with her fingers to offer Grayling. Despite their delight at her continued improvement, the weight of her illness was showing through their relief. They hung their heads over Grayling, their gaze intently fixed, willing her to eat. Mrs. Dixon inclined her head closer to Grayling’s long, gray snout, and offered her hand with sticky grains of rice on her fingers as if she were feeding a baby bird. Grayling sniffed her owner’s hand tentatively. Mrs. Dixon didn’t move. Grayling took another second, and licked a few grains from her owner’s outstretched hand. I held my breath, willing her to take more food. She nudged her owner’s hand with her nose and then lapped the chicken and rice more decisively. Dr. Dixon gripped his wife’s hand, resting the container of food precariously on his knee when he reached to pat Grayling’s flank.

  I turned and left the treatment room before they looked up. This was a moment for the Dixons and the dog they’d come so close to losing.

  The next day, the fifth of her hospitalization, it was time for Grayling to stand. Until she began moving, the persistent fluid accumulated in her swollen limbs wouldn’t dissipate. And until she could posture to urinate, her catheter would have to remain in place. Getting Grayling to stand on the slick treatment room floor on three and a bit legs seemed as unlikely as a newborn giraffe rising for the first time, and, at the last moment, I decided to gurney her outside to give her a better chance of remaining upright on a surface where she could gain more purchase.

  It took four of us to lift her onto a gurney and then wheel her, on a barely-big-enough-trolley, through the waiting room to the front lot of the hospital. Once outside, we lowered her cautiously to the ground and guided folded towels underneath her to use as slings. We eased her into a sitting position with her front legs straight without too much difficulty, and then, with coaxing, brute strength, and a lot of panting, we propped her up on all fours—well, threes anyway, her left hind leg dangling half an inch or so above the ground. We cheered, and Grayling took two tentative steps before sinking again.

  I removed her urinary catheter that day. Her only remaining tether was an intravenous catheter, and I was planning on removing that within twenty-four hours if she continued to eat.

  The results of the blood cultures I’d submitted at the beginning of her hospitalization came back that afternoon. They revealed that Grayling had a Group A Streptococcus in her blood: the type of “flesh-eating bacteria” that caused necrotizing fasciitis in people. I would never know if the bacteria entered her skin, and then her bloodstream, from a small, undetectable wound on her left hind leg, or if she’d acquired the infection some other way. When I searched online and found images of horrific tissue destruction caused by the same bacteria, I realized how lucky we’d b
een. I couldn’t explain how Grayling had survived such an overwhelming infection.

  She was ready to be discharged on the evening of day six. She’d continued to eat and drink, and she was getting around on three legs, although her left hind leg still looked like it belonged in a zombie movie. Even though I would be seeing Grayling again more certainly than other patients, like Sweetie, it was hard to say goodbye. The excitement I felt at sending her home was tempered by the knowledge that she may still lose her leg.

  After her discharge, Grayling came in daily to be reassessed. Her owners gave her meropenem at home for two weeks, injecting the medication under her skin every twelve hours. Then I switched her to oral antibiotics for another six weeks to eliminate any lingering bacteria. Her leg healed slowly, the skin puckered and tight over the wasted muscle beneath. She walked with a limp, which gradually lessened. New, darker hair grew around the edges of the wound, but in the center, where the tissue was most severely affected, a patch of pale, baby pink skin remained, hairless and soft to the touch.

  I continued to see Grayling even months later to ensure everything was returning to normal. The speed of her healing seemed proportional to her huge size—plodding and slow, like an elephant. During one visit, a few months after her hospitalization, I noticed that her heart rate was severely elevated—close to two hundred beats per minute.

  She was otherwise well—no fever, breathing normally, good appetite and energy level at home.

  She might just be nervous, I reasoned, but then why hadn’t her heart rate been elevated at previous visits?

  I tried to ignore the other possibility—underlying heart disease. After everything she’d been through surely Grayling didn’t deserve the dilated cardiomyopathy so common in her breed.

  I recommended ECG, chest X-rays, and cardiac ultrasound to alleviate my apprehension.

  “Why don’t we monitor her heart rate at home first?” Dr. Dixon said. He didn’t look at me when he reasoned that she was feeling fine and had no clinical signs—that there was no indication to do any testing because he was sure it was nothing. But Mrs. Dixon remained silent. They’d owned Irish wolfhounds for thirty years, and she clearly knew what they were ignoring. And, as much as my clinical gestalt informed me otherwise, after everything they’d been through I wanted to believe that her high heart rate was merely an anomaly as much as they did. I hesitantly agreed to do nothing.

  It carried on that way. Each time she came in I recorded her tachycardia. Each time her owners insisted that at home, on the couch, her heart rate was normal. Surely her heart would’ve been a problem while she was septic and dying, I told myself. Her echocardiogram hadn’t shown any heart muscle thinning or weakness when we searched for the root of her infection. But her heart rate, and her breed, nagged at me.

  Four months later I noticed Grayling on the appointment schedule, but not mine. She was scheduled to see the cardiologist. My heart beat faster, and a tangy, bilious guilt instantly rose to my mouth. I knew the precise reason for her visit and I felt inadequate. What I’d dreaded had happened, despite my fervent hopes. She’d seen her regular vet the week before with weakness and difficulty breathing, and she’d been diagnosed with heart failure. Her massive, globoid heart on X-ray suggested dilated cardiomyopathy (DCM), the hereditary heart disease of her breed.

  I was angry: This time there would be no saving her. The average life expectancy for a dog with DCM in congestive heart failure was less than six months. She’d survived the odds and beaten a vicious bacterial infection. We’d fought with everything we had. But we couldn’t beat her DNA. The cardiologist prescribed medications that might stabilize her condition and improve her quality of life for a few months. But was that good enough? Was that enough for the ten thousand dollars her owners spent? For the pain she must have suffered with the infection destroying her soft tissue? For the days of hospitalization, urinary catheterization, ECG leads, and intravenous catheters?

  I didn’t know, but a few months seemed insufficient. I wanted more. I wanted years of a good life for Grayling, of trips to Canada in the minivan, of napping on the couch.

  But I couldn’t determine how long my patients lived. How they would respond to medications. How far their owners would go in pursuit of their pets’ health. I could give survival rates and treatment-response percentages, and set the ethical boundaries I would not step beyond. I could improve prognosis with treatment, and I could perform euthanasia when the prognosis became too poor.

  But I couldn’t predict what would happen next, and whether, after the battle, the journey my clients and their pets had taken was worth it.

  CHAPTER EIGHT

  Ned

  The summer of 2009 marked my ninth year in America, and my fourth in San Diego. My visa had become a green card, and my family had stabilized at a husband, three cats, and one dog. My vowels had softened and elongated, and the cadence of my speech had shifted from clearly British to “Let me guess—Australian or South African?” I now called a moggy a “domestic short-haired cat” without hesitation. Despite settling in the North Park neighborhood of San Diego, I still considered home—the place to which I felt most loyalty and kinship—to be thousands of miles away, across a continent and an ocean.

  Even with a family, a mortgage, and all the other small and large things that made a life, I struggled to establish a deeper connection to the San Diego earth. I couldn’t find purchase in the sand at Coronado or beneath the ubiquitous palm trees. The sweaters I felt most comfortable wearing lay folded in a drawer; my wellies gathered dust in a closet. But swimsuits and flip-flops were alien to my British spirit. There was no denying my delight at riding my bike everywhere and not needing to pack a raincoat, and outdoor adventures were always a good idea, but I felt a tenuous bond to the place I’d lived in for the longest time since leaving England.

  In contrast to my search outside the hospital, the terrain of my veterinary life was familiar. The U.S. units for blood values came to me as naturally as a native dialect, and I automatically weighed all my patients in pounds and ounces. My vet school studies seemed arcane; what I’d once known about horse, pig, and cow diseases was buried under the minutiae of small-animal internal medicine. My world had contracted and deepened like a sunbeam concentrated through a lens. It had been so long since I’d performed basic surgeries—a dog spay or cat castration, or a simple laceration repair—that I felt as qualified to be in the operating room as I did to be on an operatic stage. I could spend hours talking about immunosuppressive drugs, the nuances of different canine and feline endocrine disorders, or the most appropriate diets for inflammatory bowel disease, but when asked about the newest flea preventive I needed to search the Internet.

  When I became an internal medicine specialist I gave up puppy and kitten checks and routine visits for vaccinations, ear infections, and itchy skin. And, most of the time, I didn’t miss the aspects of veterinary medicine I’d left behind. I definitely didn’t miss the glug of fear at the thought of performing surgery. But sometimes, when a dog with intractable diarrhea came back for the fifth time in a month because none of the treatments were working, or I had to inform a grieving widow that her husband’s dog—her one connection to her dead partner—was dying of untreatable cancer, I longed for a cute puppy to examine, snuggle, and send on its way.

  Unfortunately, a young animal on my schedule usually signaled heartbreak. My juvenile caseload included puppies that weren’t growing normally—perhaps due to a congenital, breed-related disease such as a portosystemic shunt, where blood from the intestine bypasses the liver’s purification system and instead flows straight into the circulation—and kittens with deadly diseases they’d acquired at birth or shortly thereafter, such as feline infectious peritonitis. My young patients had the types of diseases that carried prognoses expected for animals with their lives behind them rather than in front. In some cases, such as abnormal blood vessels that formed in utero, and
conditions like patent ductus arteriosus that occur when normal blood vessels fail to close at birth, a congenital abnormality may be corrected by a several-thousand-dollar surgery, with no lasting health problems. For others, with devastating, incurable diseases, all I could offer was palliative care, which might provide comfort for a few months. The most severely affected, with a poor quality of life and a worse prognosis, were destined for euthanasia. The memories of these young animals, with coats not yet thick enough to protect them from the world, lingered long after they were gone.

  Delia, a six-month-old Saint Bernard puppy, was better suited to the pages of a calendar than my examination room. Her coat was soft, with a newly washed vibrancy, the white of her paws and chest not yet stained with years of slobber. Through the fluffy exuberance of her coat I couldn’t tell how little she weighed—it was only when I placed my hands on her that I felt her bones pressed beneath her skin.

  Her owners were a late-middle-aged couple who had a decades-long history of Saint Bernard ownership. They were both heavyset, with frames that echoed their dogs’, and the husband appeared to be growing jowls to rival Delia’s. The resemblance would have been amusing under different circumstances. He wore the casual late fifties male uniform of Southern California—khakis, flip-flops, and a Tommy Bahama shirt. His wife was more formally attired, and, when she told me she was a school principal, I wasn’t surprised. The tight control she exhibited over her hairstyle confirmed her ability to command hundreds of children. They had recently lost an older male dog and had purchased Delia from their preferred breeder two months earlier.

  In the beginning, her quiet temperament had seemed nothing more than a stroke of luck. She was the perfect size for snuggling, and she had an appealing preference for cuddles on the couch over chewing the furniture. Her picky appetite, unusual for a puppy, was also considered a quirk of personality—initially at least. Her owners had diligently weighed her weekly, tracking her progress in a neat, lined notebook, and when the number had plateaued for two weeks they’d taken her to the veterinarian who’d cared for their dogs over the past thirty years.