The abnormal results of her bloodwork had landed her in my consulting room. Their hope was that her elevated renal values were due to a kidney infection. But, after I’d closely studied her lab results and performed my exam, I suspected otherwise. Her thin body, low red blood cell count, and chronic apathy suggested her kidneys were failing for a more devastating and less treatable reason. An infection should have caused a sudden onset of clinical signs, maybe a fever or changes in her urination. But Delia’s clinical course had been more insidious, consistent with the slow burn of chronic disease originating from a congenital kidney disorder rather than something more hopeful.
* * *
—
By the time I met Delia, medicine had become woven into my life, and I saw animals, both in and out of the hospital, as expressions of the diseases they might one day suffer. In casual conversation, when the topic drifted to pets, I had to restrain myself from listing the potential genetic pitfalls—of which there were many—of the recently purchased, delightfully cute boxer puppy. I tried smiling instead of grimacing when acquaintances told me of their $1,500 Labradoodle puppy flown in from Florida. I couldn’t ignore its potential future orthopedic troubles. And when I saw a dachshund walking down the street, I tried to forget the intervertebral disc disease that was almost certainly in its future.
Dogs have proven themselves to be highly genetically malleable, with a greater than forty-fold difference in size between the smallest and largest breeds, and huge variations in coat color, facial structure, and demeanor, all due to human-controlled breeding. But the appearance of purebred dogs comes with a price. Hidden within the genetic makeup of the more than 350 dog breeds recognized worldwide is the highest number of heritable diseases characterized within a single species.
Strict “breed standards” determined by the American Kennel Club and other organizations specify the acceptable features of each recognized breed, including height at the shoulders, presence of dewclaws, tail length, and carriage, and disqualifying features, which might include incorrect eye color, the wrong shape of nose, or white spots on the coat. These requirements, which run two to three pages for each breed, include more than eighty desirable characteristics that, in reality, are disorders. For example, an open fontanel—or soft spot where the bones of the skull fail to fuse—is an accepted trait in some small breeds like the Chihuahua, and is often accompanied by hydrocephalus and severe neurologic consequences.
The required “adorably” smushed nose of pugs, bulldogs, and other brachycephalic breeds can lead to brachycephalic obstructive airway syndrome—a serious disorder that occurs due to a number of related abnormalities including pinched, stenotic nostrils, and redundant, folded soft tissue clogging the pharynx because the pharyngeal tissues do not shorten in relation to nose length. The consequences include obstreperous snoring, a continual struggle for breath, and a life-threatening tendency to overheat due to inefficient heat exchange in a respiratory tract crammed with awkward layers of soft tissue. In some cases, surgical correction of the abnormal anatomy can provide an improved quality of life; in others premature death is the inevitable outcome. A 2010 report in the Journal of Small Animal Practice documented that the life expectancy of the English bulldog was only a little over six years—each one spent struggling to breathe.
Breed-related disorders do not stop at the nose. The spinal column of the miniature dachshund is so long that intervertebral disc disease, with potential paralysis, is close to unavoidable. The English bulldog’s head-to-hip ratio is so extreme that puppies can be born only via cesarean section; without human intervention the breed would become extinct.
Beyond the disorders caused by conformation, genetic diseases are highly prevalent in purebred dogs. The University of Sydney’s Online Mendelian Inheritance in Animals database reveals how serious a problem human interference in canine genetics has become. In April 2017, the number of known genetic disorders in domestic dogs was 697. The number for cats was 336, and for horses 229. But the most striking indictment of dog breeding is that the number for the gray wolf, their closest wild relative, was six. Human breeding of dogs has evaded natural selection, but not the ramifications of ignoring health in pursuit of perceived beauty.
Hidden in the DNA that gives Cavalier King Charles spaniels their soft coats, liver-and-white coloring, small stature, and charming faces is a deadly heart disease. In 2004, a UK study found that 42 percent of deaths in the breed were due to this condition. Predispositions to blindness, orthopedic disease, and disorders of almost every body system are genetically inherited in many breeds. To date, sixty-three inherited disorders have been documented in the boxer and fifty-eight in the golden retriever. With advances in genetic technology, new heritable diseases are being decoded on an almost daily basis. Until breeders commit to ethical breeding practices and eradicating these preventable diseases, it is likely that my caseload will continue to be littered with the consequences of shoddy genetic manipulation. The price purebred dogs pay for being man’s best friend is high.
* * *
—
While Delia waited in the treatment room for her ultrasound, receptionists, technicians, and doctors on other services all came to revel in her cuteness. “What’s wrong with her?” they’d ask if they caught me between appointments. I’d tailor my answer based on the inquirer. For those with experience, I’d confess my concerns about her kidneys and the probability of a fatal outcome. But for the receptionists and others less acquainted with the cruelty of disease, I’d chat vaguely, because I knew my consternation would be met with incredulity—they were more familiar with puppies coming into the emergency room for vaccine reactions or with swollen faces from bee stings—and so I chose the easier route. But I didn’t have that option with her owners.
The results of Delia’s abdominal ultrasound revealed what I had feared—her kidneys were shriveled and shrunken: eighteen-year-old cat kidneys in a six-month-old puppy. Her kidneys had not formed properly in utero, and she had outgrown their limited function by the sixth month of her life. There was little to be done. I could prescribe fluids and medications to improve her appetite, decrease her nausea, and maybe prolong her life for a month or two. I could offer a referral to a university for an experimental renal transplant, which, at the time, had not been performed with any lasting success. Or I could offer euthanasia, knowing that her death was inevitable and that offering a peaceful, planned end might be better than a few months of life poisoned by the toxins her kidneys could no longer excrete.
I called her owners back to the hospital to discuss my findings, a conversation we needed to have in person, though I dreaded it. They’d been taciturn at the initial consultation, and I didn’t know how my diagnosis would be met. Later that day, I carefully led them through my findings. They remained impassive. My dread grew. At similar moments with other clients I’d been shouted at, blamed, doubted, or had witnessed the grief of understanding.
“If you decide to put her to sleep,” I said, “you could take her to your regular vet, or I could recommend someone who’d come to your home.”
“Can you do that here?” Mrs. Church asked. The light reflected off her glasses, making it difficult to see her eyes.
“Yes, we can. You could schedule an appointment with me, or our emergency room is open twenty-four hours,” I replied.
“I think we’d like to do it now,” she said.
Of the reactions I’d anticipated, this was not one of them. “Of course we can do that,” I said. “But you could take her home and spend some time with her before making that decision, if you’d like.” Maybe I was trying to avoid the sorrow of euthanizing such a young animal.
“No, we’ve already discussed this,” Mrs. Church said. “We knew something wasn’t right, and that she wasn’t going to get better. You’ve just confirmed that for us.”
Mr. Church nodded, his expression set. I understood, then, that I’d
misinterpreted their sorrow for reticence. They were already grieving.
“Yes, thank you, Doctor, for being honest,” Mr. Church said. “We knew something was badly wrong, but our vet kept telling us it was an infection. We wanted to give her a chance, and we’ve done that. But it’s not right to keep her alive. We’d be doing that for us, not for her.”
I took a moment to arrange my thoughts. I’d often advocated euthanasia for my patients when their disease was terminal, and I’d seen the devastating consequences of choosing another course, so why was I hesitating? Medically, I knew Delia’s prognosis was grave and that euthanasia was reasonable and humane. It was a decision I fundamentally agreed with, but I didn’t want to carry it out. You’re being weak, I scolded myself. You need to do what’s right, not what’s easy. I thought of the times I’d internally railed at people for not making the right decision, and here I was shrinking from my own conviction. Was it because Delia was young and cute that my moral substance was coming unglued?
It was difficult to speak around the claggy lump of guilt—or, could I admit, sadness—that rose in my throat. “I think you’re making the right decision,” I said. “But I know that doesn’t make it any easier.” I swallowed hard. I was close to tears, and I’d met this puppy and her owners only this morning.
Their stiffness slackened now that the decision had been made, their tension melting into sorrow. “Can we be with her?” Mrs. Church asked.
“Of course,” I replied. “We’ll place an intravenous catheter and then you can spend as long as you’d like visiting with her. I’ll come back when you’re ready.”
For the technicians who placed Delia’s catheter and drew up the euthanasia solution I knew the decision wouldn’t seem logical. It was hard to see why this friendly and adorable puppy was slated to be euthanized. Word quickly spread around the hospital, and I was confronted by the verbalization of the doubts I’d thrown at myself. She’s not that sick, is she? She looks so good. Were her owners making the right decision? My answers were curt and medical. I’d expended my empathy. Yes, she was really sick; yes, her owners were making the right decision; and no, there was nothing more to be done. I took my doubts out on the staff who questioned me.
I didn’t know if I was angry with the owners’ decision, my inability to save this dog, or my guilt at wanting to do more even though I knew that wouldn’t be in Delia’s best interest. Or was I angry at her disease or her breeders? Anger and regret were easier to hold than sadness, and I grabbed them when I thought of her lifetime of memories that would forever be unformed. I was used to death, had witnessed it hundreds of times, but euthanizing a puppy never got easier. I envied my surgical colleagues who saved the lives of young animals with fixable congenital abnormalities, and the referring vets who could defer the responsibility of revealing a terminal diagnosis to specialists like me. There was no amount of science or knowledge that could ameliorate the emotion of confronting mortality so directly.
Her owners didn’t spend long with Delia before I was called to the room to perform her euthanasia. I was nervous that the sedation drugs might not work predictably given her age, that she might become agitated and excited rather than peaceful. But I needn’t have worried. Curled between her owners on a blanket on the floor, Delia died without any more than a deep sigh.
* * *
—
To temper such devastation, and the disorder I encountered at work, my approach to each new patient was routine. I couldn’t let go of the seeming order that had first piqued my interest in science and medicine. To combat the chaos, I clung to systematically working through physical examinations and taking thorough histories. I clutched at the semi-quiet of my office, the sequence of my medical records, and the neatness of my paperwork to soothe my turmoil—internal or external—each time I stepped onto the clinic floor.
A typical day began with my firm intention to stay on track and keep on schedule. In the morning, Emma and I would enter the hospital through the back door and sneak to my office, with the goal of going unnoticed. I considered the space mine, but I actually shared it with my boss and the surgeon. They, however, had been working in the hospital for at least a decade longer than I, and had abandoned the office as a repository for moldering memories of medicine past. Instead, they worked from other areas of the clinic. Though their base operations had shifted, they had left behind a hair-coated, fading collection of tchotchkes and cards from clients, yearly conference proceedings dating back to the nineties, and the surgeon’s handwritten veterinary school notes from thirty years ago, cluttering every surface I hadn’t laid claim to.
One particular morning, about six months after I’d met Delia and her family, I was holed up among the jumble of my office, settled in to my typical task of reviewing the day’s schedule. Although I was lucky enough to have a window, the tinted glass and dust-caked blinds absorbed the light from the sunny, blue San Diego sky, making every day look like the end of the world. Despite the hour, the smell of burnt popcorn seeped through the cardboard-thin wall from the break room next door, along with the muted dialogue of a daytime soap opera.
I worked my way through my follow-up appointments, noting the bloodwork or other testing needed for each pet so I could review the day’s plans later with my technician, and then I turned my focus to the new patients scheduled for the day.
The first one piqued my interest. He was a young dog named Ned who had a bloody nose. My review of his previous medical record revealed little. Ned had developed intermittent bleeding from the right side of his nose a month prior. He’d undergone treatment with various antibiotics and antihistamines and had had a nasal flush under anesthesia with little improvement. I ordered the notes chronologically, separated out the bloodwork, and considered the possibilities for my new patient.
Unilateral epistaxis (one-sided nasal bleeding) was cause for concern. The list of diseases that commonly caused the problem was short and not particularly attractive, with a malignant nasal tumor and aspergillosis, an aggressive fungal infection, topping the list. I didn’t look forward to diagnosing or discussing either, especially in another young dog.
Across the hall from my office was a row of six exam rooms. I could tell, by the particular vibration caused by each door closing, which were occupied. The room closest to my office—room 6—was my preferred venue for consultations, and a familiar resonance suggested that Ned and his owners had arrived. A moment later a technician stuck her head around the door.
“Ned’s here,” she said. “I’m taking him back for his weight and vitals, if you want to come do your exam.”
“I’ll be right there,” I replied, gathering my white coat, stethoscope, and invisible armor for the day. I preferred to meet my patients before I met their families. Completing my physical exam away from what I imagined was the critical gaze of owners who often wanted to help, or interfere, was easier than trying to perform in front of them. Rectal exams, standing a cat on his hind legs so a recalcitrant right kidney could fall behind the rib cage and be palpable, fully evaluating the oral cavity to ensure there were no tumors hiding under the tongue, and trying to elicit the dance of a complete neurological assessment were all necessary, and easier to do, with the help of a competent technician rather than a nervous, questioning owner.
When I first examined a patient, I formed a picture of their owners in my mind. Grabbing clues from the smell of my patient’s fur or the contents of their carrier, I would guess at the type of home they lived in. Sometimes it was easy: the smell of cigarette smoke lingering long after the last puff, or the scent of lavender placed in the carrier to soothe the pet’s—or owner’s—anxiety. A smudge of pink lipstick on the head of a small, white, fluffy dog accompanied by rich floral perfume was a dead giveaway for an elderly female owner. Sometimes the clues were more temperamental than esthetic. There were the nervous cats whose owners, speaking in a whisper, would hover, wide-eyed and anxious in th
e corner of the exam room. Or the wild young dogs—often Labradors—whose family, including wild young children, would crowd around the table. Or the skinny, graying but poised geriatric cats, whose dignified owners, suited and similarly elegant, perched on the exam room bench.
These were the pets that mirrored their owners: the pampered pooches with hairdos matching their similarly coiffed humans’—I once cared for an impeccably groomed bichon frise whose fluffed ears poofed from the sides of her head in the same style as her owner’s gray-blond hair; the skinny, long-legged dogs with skinny, long-legged owners, both penned in and uncomfortable in the small exam room; and the cats and dogs with obesity, whose owners struggled with the same health problems.
Then there were the owners and pets that occupied opposite ends of the spectrum. There was the huge, confident American bulldog whose energy caused his older, more delicate owner to break her wrist while trying to restrain him; the two-hundred-pound Marine in motorcycle leathers who cradled a four-pound teacup Yorkshire terrier in one huge hand; and Grayling and her tiny owners.
It was entertaining to imagine the families of my patients before I met them, but it was imperative to form a connection to the actual people to understand the animals I cared for.
Experience had taught me to assess a patient’s demeanor before approaching them. It was a skill that had saved me from dog bites and cat scratches more than once. After my snap evaluation, I took in my patient’s physical condition—watching the rise and fall of their chest before I got out my stethoscope to auscultate the lungs; noticing their position, which might indicate an area of pain; observing their hair coat and fat distribution. I could no longer look at animals any other way. I would analyze the gait of a dog walking down the street in front of me—checking for lameness. Without thinking, I would reach for Emma’s pulse while she was lying next to me on the couch, or palpate the saphenous vein in her hind leg to assess for suitability for catheter placement.
My Patients and Other Animals Page 22
