I drew two sharply angled parallel lines on my diagram connecting the aorta and the pulmonary artery and pushed the pad with the diagram towards the center of the exam table so all four human Chasens could see it. Bancroft wasn’t interested.
“As soon as the puppy is born and takes a couple of breaths, the lungs open up. When the alveoli, the little air sacs in the lungs open, the blood vessels in the lungs also open, and the blood pressure in the lungs drops way below the blood pressure in the arteries in the rest of the body. That causes the blood pressure in the pulmonary artery, here, to drop below the blood pressure in the aorta. This causes the aortic side of the ductus arteriosus to close since the ductus is more of a slit than a tube. Anyhow,” I continued, “normally the ductus closes shortly after the animal starts breathing. Unfortunately, sometimes, we don’t know why, the ductus stays open. When that happens, it’s called a patent ductus arteriosus. Since the pressure in the aorta is much higher than the pressure in the pulmonary artery, the blood leaks continuously through the opening into the pulmonary artery. With each heartbeat, the pressure increases in the aorta, and that causes the leak to be greater. That’s why we hear the sound that we do; it’s called a continuous murmur.”
“When we listen to the heart of a normal animal, it makes a noise that sounds like lub DUB... lub DUB... lub DUB.” I tried to mimic Dr. Smith. “A continuous murmur makes a whoosh, whoosh, whoosh sound. Do you want to hear it?” I asked Frankie.
He nodded that he did. I wiped off the ear pieces of my stethoscope with an alcohol-soaked cotton swab and placed them carefully in the boy’s ears. I then placed the head of the stethoscope over the left base of Bancroft’s heart.
“Did you hear it?” I asked when Frankie removed the earpieces from his ears.
He nodded but didn’t say anything.
“Jennifer, do you want to listen?” I asked, as I wiped off the earpieces again.
She listened for about fifteen seconds and then took off the stethoscope and handed it to me. “Just like you said, whoosh, whoosh, whoosh.”
The two adults took their turns, listening carefully.
“This is the only thing I’m aware of that can cause this kind of heart murmur,” I explained. “Unfortunately, there is nothing I can do to fix it. This defect causes both the left and right sides of the heart to work harder and harder. The heart enlarges, and finally it fails. Bancroft is already in the early stages of heart failure, and I’m afraid, he’s going to continue to get worse.”
***
Since those days, veterinary medicine has made enormous advances. We have board-certified veterinary surgeons who perform the relatively simple surgery and tie off the patent ductus. We also have board-certified veterinary cardiologists who, if they make the diagnosis early enough, can use a catheter system to deliver a plug to the ductus and correct the problem. I was doing well just to make the diagnosis.
***
Frankie reached up taking Bancroft off the table and into his arms. He patted the dog lightly on the head and then kissed him. The dog reached up and licked the boy’s face.
I looked over Frankie’s head and saw that Mrs. Chasen was silently weeping, tears carrying mascara down her cheeks.
Mr. Chasen cleared his throat, choking back emotion.
“This is very unhappy news, Dr. Gross. Is there nothing you can do?” he asked. “I should tell you that Frankie has a heart problem too. The cardiologist we took him to in Bismarck told us there is a surgeon in Salt Lake City who has developed some techniques and special instruments. The cardiologist thought he might be able to help Frankie. The Mormon Church is helping us contact the surgeon, Dr. Rumel, and hopefully we’ll get an appointment for him to see Frankie soon. With God’s help, Dr. Rumel will be able to correct the problem. Meanwhile Frankie’s on medication, and the cardiologist says the medication will slow the progression. We’re quite lucky that my company offers a very good health insurance plan to employees, and Frankie is getting the best care available. As you can see, he is very attached to the dog. There must be something you can do to at least slow down his disease.”
“Maybe,” I said. “But it will just delay the inevitable. I can put him on digitalis, and that should slow down his heart rate and possibly slow the progression. We can try that.”
“Digitalis, I think that’s one of the medicines they’re giving Frankie. Isn’t that right, Mother?”
Mrs. Chasen wiped her eyes with a wadded Kleenex and nodded. Jennifer was now stroking the dog with her right hand and her brother with her left.
“OK,” I said. “I’m pretty certain we have a bottle of digitalis in the pharmacy. I’ll get some for you to take with you, and I’ll show you how to give the pill to Bancroft. Are you going to be in charge of making sure he gets his pill every day, Frankie?”
“Yes, sir,” said the boy. “I can do that. After I take my pills, I’ll give him his. I’ll take good care of him.”
I nodded and gave Bancroft a pat on his rump, no room on his head. He twisted in Frankie’s arms to give my hand a lick.
“Good,” I said. “I’ll go get the pills.”
I showed Frankie how, with Bancroft sitting on the floor, to push the dog’s top lips over his upper teeth and then, with his other hand, to place the pill past the base of the tongue and hold the dog’s mouth closed until he swallowed.
“You see, Frankie; he sticks his tongue out through his front teeth when he swallows. When you see that, you know he has swallowed the pill, and you can let go of his mouth, but not until you see his tongue. Now here’s a vitamin pill. You try it with that.”
With serious concentration, Frankie did exactly as instructed, and Bancroft happily swallowed the vitamin. After Frankie released his muzzle, the dog immediately crawled into his arms.
***
The Chasens brought Bancroft back every two weeks. I gradually increased the dosage of digitalis, and the drug did slow his heart rate and seemed to improve his stamina.
Six weeks after the first time I saw them, Mr. Chasen told me the whole family, including Bancroft, were leaving the next day for Salt Lake City and Frankie’s appointment with Dr. Rumel.
“What did Frankie’s cardiologist tell you is wrong with his heart?” I asked.
Mrs. Chasen answered, “Frankie got rheumatic fever after having his tonsils out when he was four. The doctor told us that because of that his mitral valve was diseased. Apparently Dr. Rumel is one of very few surgeons in the world who has been successful at repairing that valve, so we are hopeful.”
“He actually repairs the mitral valve. That’s amazing,” I said. “Please try to get Dr. Rumel to explain everything he is going to do so you can tell me. I would love to learn how he does surgeries like that. If you get a chance, if he’s not too busy, ask him if he repairs children with PDA. I’ll bet he does. It should be a lot easier than repairing a heart valve.”
“What’s a PDA?” asked Frankie.
“Sorry, Frankie; we use a lot of initials instead of saying the whole disease. PDA stands for patent ductus arteriosus. Remember that’s what Bancroft has.”
“What’s my heart disease called?” he asked.
“Probably mitral insufficiency, sometimes we just call it by the initials, MI. I don’t know for sure, Frankie. You should ask Dr. Rumel when you see him.”
***
I next saw the family four weeks later. The LDS church had taken good care of them and arranged for them to stay in the Salt Lake City house of a church officer and his wife, who were gone for a month checking on the progress of missionaries in Peru.
After he examined Frankie, Dr. Rumel rearranged his surgery schedule. He repaired Frankie’s mitral valve just four days after his initial examination and subsequent work-up.
Now, only three weeks post-op, Frankie’s color was markedly improved, his eyes were brighter, and he seemed more animated, more bright, and alert.
“Well, Frankie,” I observed, “you look as though you are feeling much better th
an the last time I saw you.”
“Yes, sir,” he responded. “Dr. Rumel told me he fixed my valve and I should be able to do everything the boys in my grade at school do, except it might take me a while to catch up.”
He was holding Bancroft in his arms. The dog was trying to lick his face.
“Stop it, Bancroft,” he scolded.
The dog quieted, looking at me from under half-closed eyelids.
Both Mr. and Mrs. Chasen were beaming.
Mrs. Chasen spoke first. “When we told Dr. Rumel that Bancroft had a heart murmur and your diagnosis, he was impressed. He told us he didn’t know that dogs could have that problem. He told us that he had corrected dozens of them in children, and it was a simple operation. He even gave us a card to give you. He said if you called him he would let you know the next time he had a PDA scheduled. If you can go to Salt Lake, he said he would show you how to do the surgery. He said you wouldn’t need a heart-lung machine to do it.”
“That’s good,” I said, “because I haven’t the faintest idea what a heart-lung machine is, what it does, or how to use it.”
***
In the early 1960s, open-heart surgery was just starting to become routine. This came about with the advent of commercially available, disposable bubble oxygenators. Even more efficient and safe membrane oxygenators quickly followed that advance. The availability of these devices, as well as technical advances in the design of roller pumps, used to pump blood through the oxygenators and into the patient, created a new profession, men and women who run the pumps and monitor the blood going through them, perfusionists. They make adjustments in anesthetic agents, blood gases, and the rate at which the machines pump the blood. They can also cool and warm the blood and thus the patient. These advances in technology enabled thoracic surgeons to develop innovative techniques and special instrumentation for repairing a host of abnormalities of the heart. By cooling the patient with the heart-lung machine, metabolism is slowed putting the patient into a state resembling suspended animation. The surgeon can stop the heart and repair the problem while the perfusionists and the heart-lung machine take over for the heart and lungs. When the repair is complete, the patient is re-warmed, the heart restarted, and the patient gradually weaned from the heart-lung devices.
***
“Anyhow,” said Mr. Chasen, “here is Dr. Rumel’s card.”
“Thanks,” I said. “I’ll give him a call. I hope I can get away to see that operation. I would love to be able to do it. Maybe we can do something to help Bancroft after all.”
It didn’t happen. I called Dr. Rumel’s office but wasn’t able to actually talk to him. His secretary gave him the message that I had called and was interested. She was very nice and called me back to say they didn’t have a PDA scheduled in the coming two weeks, but she would call me when they had one. Then when the veterinary practice got very busy, Dr. Rumel’s secretary called to say they had a PDA scheduled, but I wasn’t able to get away. The notice was too short for me to free up the three or four days I would need to drive to Salt Lake City, observe the surgery, and get back.
Shortly after I missed the opportunity to witness the PDA operation, the Chasen family brought Bancroft in. He was in bad shape. I had increased the dose of digitalis again at his last visit, and now he had a severe arrhythmia, his heartbeat very irregular. He was showing more advanced signs of heart failure. We didn’t have an ECG machine in the practice, and even if we had, I probably would have missed the diagnosis of digitalis toxicity. I sent Bancroft home on an even higher dose of digitalis. That night he died.
I like to think that my treatment, as bad as it was, given today’s understanding and knowledge, prolonged Bancroft’s life long enough for him to help Frankie through his ordeal. There was certainly a strong bond between the two heart patients.
I recommended that the Chasens get a new puppy as soon as possible. A month later, they brought in another miniature schnauzer puppy for his shots. They named him “Bancroft Too.” Frankie formed a new bond, without forgetting the first.
Shortly after Bancroft’s demise, I read an article about digitals toxicity and realized that my treatment had, more than likely hastened his death. With experience, I was gaining some hard-won knowledge.
***
Rose Seglund was in the waiting room when I returned at noon to clean and refill the truck. There was an obese black and white cocker spaniel sitting comfortably in her lap. Checkers was a new patient. Mrs. Seglund and her husband had recently moved to Sidney from Billings after purchasing a partnership in the John Deere dealership. Mrs. Seglund was a slim, attractive woman in her early fifties with short-cut gray hair. Her eyes were an amazing sparkling blue, and her smile was huge.
“Well, it’s nice to meet you, Mrs. Seglund. What can I do for Checkers?”
“I don’t know, Doctor. He’s ten years old now, and he seems to tire more and more easily. I thought I had best get him in and have him checked over just in case something was wrong.”
“OK,” I said. “Let me put him up on the exam table, and we’ll see what, if anything we can find.”
The dog easily weighed forty-five or fifty pounds and was soft and flabby.
“Well, one thing he needs is less to eat and some exercise,” I said.
“I know, Doctor, but he’s such a beggar, and my husband, James, will not stop feeding him from the table.”
“Tell him he’s killing the dog with kindness,” I replied.
I gave the dog a complete physical. When I finally got around to auscultating the heart, I heard it. The sound was, “lub, whoosh, dub... lub, whoosh, dub,” a systolic murmur that I was able to hear loudest over the left base of the heart. That murmur I had heard before. I hoped this one would be easier to treat than the last heart case. Since my experience with Bancroft, I had been reading every article in the veterinary journals I could find about heart disease in dogs and cats. This was essentially the same heart problem as Frankie Chasen’s. It was not uncommon in older dogs, and usually the leaky valve didn’t leak enough to require surgery. I hoped this was one of those cases.
“Has your previous vet said anything about a heart problem with Checkers?”
Mrs. Seglund was immediately concerned. “No, he never said anything about a heart problem, but I don’t remember him ever listening to his heart with a stethoscope either.”
“Well,” I said, “he has a systolic murmur, but it’s not very loud. The murmur is caused by a leak in the valve between the left atrium, the heart chamber that collects blood coming from the lungs, and the left ventricle, the big, strong part of the heart that pumps blood out into the body through the aorta, the large artery coming out of the heart. The left atrium beats first and sends blood into the ventricle. Then the left ventricle contracts, and when it does, the valve between the two, called the mitral valve, closes so all the blood goes out into the aorta instead of back into the atrium. If there is a hole in the valve or a malformation of the valve or some lesions on the valve leaflets, it doesn’t close all the way. Some blood leaks back through the valve during systole, when the heart is contracting, and that causes the murmur.
“These murmurs are graded by loudness from one to four. I would say that Checkers’s is maybe a two. Loudness isn’t everything, though. Sometimes a big leak is quiet because so much blood is leaking back it doesn’t make much noise. But an animal with that problem goes into heart failure fast, and Checkers isn’t showing any signs of heart failure. Sometimes a very tiny hole will cause a very high velocity jet of blood. That can cause a loud murmur, but very little blood is leaking back, so that’s usually not a problem.
“I’m going to take some blood and run some tests to make sure his kidneys are working properly. If his heart is not pumping effectively, the kidneys do not function as well as they should. I’ll run that test this evening and let you know the results tomorrow sometime.”
Checkers was very calm. It wasn’t necessary to restrain him as I lifted his left foreleg, cli
pped the hair over his cephalic vein, held the vein off with my left thumb, and removed five cc of blood into the syringe I coated with heparin.
“It’s going to be very important for him to lose this weight,” I instructed as I rubbed the skin over the puncture wound I had just made.” Checkers reached over to lick the hand rubbing his leg. “You should be able to feel his ribs when he’s in proper shape, and he needs to be walked a couple of times a day. You must make sure he gets exercise. Will he retrieve a ball?”
“Yes,” she said. “He fetches but gets to be a pest about it.”
“That’s good,” I said. “Throw the ball for him for at least ten or fifteen minutes a day; that will be very good for him. The exercise will be very beneficial, but watch him. If he seems to tire, he’ll stop bringing the ball back; let him rest.
“His heart rate is a little faster than normal, so I’m going to put him on some heart medicine called digitalis. He’ll only need a half a pill a day to start with. We’ll have to check him every couple of weeks initially to make sure we get the dosage correct. After that, he should do just fine. Cocker spaniels typically live to be twelve to fourteen years old, so I would expect him to live about that long, providing we get him in shape. You must not allow him food from the table. How much dog kibble have you been feeding him?”
“He gets two cups in the morning and two more in the evening.”
“Well, that’s at least twice as much as he needs. Dick sells some very good dog food with high protein levels. A cup of that twice a day will be plenty for him. Any other questions?” I asked as I lifted Checkers from the table to the floor.
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