Love Is the Best Medicine

by Dr. Nick Trout

  “How long?” I asked, my question vague, but Dr. Maganiello instantly knew where I was going.

  “Couple of minutes in full cardiac arrest,” she said, reading the EKG monitor, making an interpretation of the changing situation, deciding to switch up to a different drug, dialing up the dose, overseeing the delivery, and watching for the response. It was like a game of chess, your opponent a macabre genius armed with merciless combinations. You must anticipate, react, and outsmart. A body trapped in an anesthetic crisis will fight to survive, will whisper clues and signs to outmaneuver, outplay, and defeat its deadly adversary, but as I glimpsed the pile of discarded syringes littering the table, I sensed the game was already swinging in the wrong direction.

  My hand reached inside Cleo’s thigh, feeling for her femoral artery. The pulse was weak at best and the technician performing cardiac massage winced through the painful cramps in her hand.

  “May I?” I said, eager to take over.

  Leaving my left hand in search of a pulse, I placed my right hand under Cleo’s chest, thumb on one side, four fingers on the other to offer resistance, and began squeezing, fast and hard, two beats per second, 120 beats per minute, a little rib and muscle all that separated my hand from her heart. And now I could feel it, the force of my compression pumping blood, producing a pulse under my fingers as it rushed through the artery.

  “Do we need to defibrillate?” I asked, finding it difficult to interpret the pattern of her EKG.

  Beth said, “No. She’s not in ventricular fibrillation. I wish she was.”

  I felt like there was something veiled in her response. I thought the technicians around me sensed it too. I took a second look at the empty syringes on the table. Each one was labeled for a specific drug. I couldn’t see them all, but of those I could read there was atropine, a drug used to speed up a slow heart rate; naloxone, an antidote to reverse the effect of any narcotic used in the anesthetic protocol; and epinephrine, synthetic adrenaline, used to increase the heart rate and force of contraction. There were many more I couldn’t read, but I began to suspect that Beth’s cryptic message meant she was running out of options.

  Time is the enemy during a resuscitative effort and it vanishes as easily as time spent watching a great movie or reading a good book. In just four or five minutes of cardiac arrest an animal will succumb to serious irreversible brain injury. Keeping positive, staying in the moment, I came to believe that if I could feel a pulse in Cleo’s back leg then oxygenated blood had to be reaching her brain. Acidic cramps were beginning to ripple through the meaty muscle of my thumb and palm, gathering intensity with every squeeze, and as I watched Beth pulling out all the stops but failing to jump-start her heart, I began to welcome the respite of a more physical pain.

  “Hold off a second,” said Beth and I knew she meant just that, enough time for her to study the cardiac monitor without the interference of my manual compressions.

  “Okay,” she said, and I started again.

  “What are you thinking?”

  Beth never skipped a beat, her delivery cold, clinical, and direct.

  “I’m pretty sure she has torsades de pointes. It’s a bizarre heart arrhythmia seen in people. Just stop for another second.”

  She pointed to the screen.

  “There. It’s a really fast rhythm, and see how the shape of the complexes is constantly changing. Carry on.”

  “So what can we do about it?”

  “There’s nothing to do. I’ve tried beta blockers but they’re supposed to be preventative, not therapeutic. It’s one of the leading causes of sudden death in young, otherwise healthy people. There is no treatment.”

  She had a pen light out, shone it in Cleo’s left eye, watched for a response, and swept it across to the right eye, like the beam from a lighthouse. I saw it all and she knew I saw it and neither of us needed to say it out loud. Cleo’s pupils were fixed, dilated, and unresponsive. Even if, by some miracle, we were able to get her heart pumping again, the absence of reaction to bright light shone directly into her eye suggested some degree of brain trauma had already occurred.

  “Do you want to open her chest?” said Beth.

  I felt the magnitude of this question, but my mind was elsewhere. Thus far I had been a clinician, waging physical and pharmacological war, concentrating on saving the life of an animal that happened to be my patient. And now, with this question, the patient transformed back into a dog named Cleo, a remarkable Min Pin, the beloved pet of a mother I had never met and a daughter haunted by guilt. These hands crawling all over her body, trying so hard to keep the life inside from slipping between our fingers, these hands weren’t enough hands to save poor Cleo.

  Some people refer to a cardiac or respiratory arrest as a crash, which sounds dramatic, chaotic, and violent. In truth, our response is prompt but measured, based on anticipation and an understanding of pathophysiology when systems begin to fail. It is the antithesis of chaos, a determined, coordinated, cohesive effort to resuscitate an animal in a crisis. There was no feeling left in my hand but it never lost a beat. If anything, this was when the real “crash” hit, my own emotional crash, when the certainty of losing her, all the evidence, the reality, rushed up to meet me, decelerating to a complete stop and in that instant I thought, “She is dead, and you are responsible.”

  “What?” I snapped back to the scene.

  “I said do you want to open her chest?”

  I was still with Cleo, attached and not letting go, but I began to feel the waves of doubt and disbelief. Up until this point there had been no pointing fingers, no recriminations. This was the situation and we had to deal with it. What went wrong and how we got here began as a hiss, a caustic whisper as I thought again of Sonja and her poor mother and what I was about to put them through.

  “What do you think?” I asked, though I already knew the answer and Beth’s hesitation was more than enough to tell me I was right.

  When external massage of the heart is failing, it is widely accepted that direct physical contact, internal massage, has a better chance of success. I don’t doubt that this is statistically true, but over the last twenty-five years I, personally, have never witnessed a single case in which a dog or cat in full cardiac arrest benefited from such a violent intervention. The chest overlying the heart is hurriedly shaved, and after a splash of antiseptic solution a scalpel blade slashes down and through skin and muscle, creating a rent between the ribs wide enough to squeeze in a gloved hand. It makes perfect sense that the quality of cardiac compressions will be superior, but internal massage can be physically challenging for small dogs and cats, the actual space available restrictive. Yes, you can inject drugs directly into the failing walls of the heart, apply direct electrical stimulation, but every arrest is unique and in this particular situation, based on the EKG, the sequence and nature of the drugs used, neither Dr. Maganiello nor I believed there was anything to be gained.

  “No. I don’t think so.” I stopped short of adding the word either because although I believed she agreed with me, this judgment call was mine and all mine.

  “Do you want to call the owner?” said Beth.

  I nodded and had someone replace me, to keep pumping her heart just in case. I found the hotel phone number and made my futile call, hearing it ring, praying Sonja would pick up and praying she wouldn’t.

  I came back.

  “I can’t reach the owner,” I said, hearing the flat defeat in my voice.

  Beth didn’t respond but met my eyes and said everything that needed to be said.

  ONE minute I was in the OR, dressed in blue surgical scrubs, paper mask, and bouffant cap, rummaging the shelves and sterile packages like some eccentric bargain hunter, and the next I was standing alone beside Cleo, surrounded by the medical detritus of life saving and the oppressive silence of failure. Before, everyone had gravitated to the scene, desperate to help and play their part. Now, bodies drifted away, awkward yet reverential, eyes averted or cast down, full of pain an
d incomprehension. How fast a wonderfully untroubled and ordinary day can change.

  I realized I had been stroking Cleo’s head and this didn’t feel strange in the slightest. I wasn’t thinking straight, but at that point one regret had managed to push its way to the front of a long line—if only I had been able to contact Sonja Rasmussen during the resuscitative effort. Part of me believed it might have helped mitigate some of the initial shock she would be subjected to when I saw her later. Though it is inconceivable how anyone can be capable of processing such information via a phone call, there could have been comfort in knowing what was happening to Cleo in real time, being involved in the decision of how far she wanted us to go, getting to the hospital as soon as possible. It wouldn’t have made the slightest difference in the outcome but perhaps she could have felt a part of process, connected, however remotely, to the passing of this special dog. As I ran my hand over Cleo’s body one last time, I began to realize the magnitude of the task before me—my obligation to inform this patient’s next of kin.

  WITHOUT it, none of this would have happened. Without it, Cleo would never have been admitted to the hospital, let alone undergone anesthesia. I’m talking about a consent form. It’s a rather simple sheet of paper on which is written a paragraph or two of dusty disclaimers in the hieroglyphics of legalese, but at the bottom of the page there is space reserved for written approval, room to sign away our own lives or the lives of those we love.

  Regardless of whether the patient has two legs, four legs, or no legs, informed consent creates a contract of trust, a statement of understanding that says “I know you will do your best, but I know there are no guarantees in life and I know that every medical intervention comes with risk.” But how many of us hesitate and realize the message might actually be aimed our way? How many of us seriously reconsider whether to go ahead? For most, the perfunctory language washes over our anxious, desensitized minds, hardly more relevant than a statement pointing out that people can be killed by lightning.

  And if I told you the statistics would it make your decision any easier? Roughly speaking, you have a one in fifty thousand risk of anesthetic death as a healthy human patient in the United States. In other words you are ten times more likely to die in an automobile accident than during a medical procedure that requires general anesthesia. But when it comes to our pets the stats become far more menacing. During the 1990s, peer-reviewed scientific studies looking at private veterinary practices in North America and South Africa reported the risk of anesthetic-related death in dogs to be approximately one in one thousand procedures. So why, in the twenty-first century, does it appear to be far more dangerous to go under the knife for a dog than a human being?

  Believe me, the last thing I want is to be a fearmonger among a group of understandably anxious pet owners contemplating anesthesia for their pets. Anesthetic risk is a complicated, multifaceted issue, and isolated statistics based on a limited number of studies hardly constitute a blanket statement. Some specialists in veterinary anesthesia have suggested our preoperative screening of animals is less thorough than that of our human counterparts, vets being constrained by the number of tests they can perform based on direct cost to the client. Perhaps some veterinarians offer less monitoring equipment for animals under anesthesia, less highly trained, specifically dedicated staff to oversee these patients in their unconscious state. In some cases, the surgeons themselves may be partly to blame. Veterinary anesthetists rarely get to meet the animal with the owner, possibly missing out on pertinent nuances of medical history. Rumor has it those of us wielding the scalpel are always in a hurry, resenting any bottleneck that encumbers the flow of cases into the bright lights of the operating rooms. It might be time for surgeons to take a breath and allow the “gas passers” their chance to review the patient’s entire record more thoroughly before doling out their magic potions. Whatever the reasons for this disparity between anesthetic risk in people and animals, owners should recognize that veterinarians are striving to close the gap while providing their pets with the safest, smoothest, and most painless temporary siesta possible.

  After all, what’s our alternative? Unless we want to revert to some sort of Civil War reenactment, knocking back a shot of whiskey and biting down on a bullet, modern surgery and all that it offers is only possible with our acceptance of the dark and mysterious art of general anesthesia. Huge gaps exist in our understanding of how chemicals produce a desirable state of unconsciousness, but we accept the ambiguities that surround this artificial sleep because the alternative is unthinkable. And for so much of what we do to cats and dogs, simpler, safer, less invasive options of sedation or local or regional anesthetics, let alone hypnosis, do not exist.

  Aside from the dangers of general anesthesia, the surgeon must also weigh the merits of surgery versus the potential for harm. We look at the primary disease, what it is going to take to fix it, the patient’s overall health, and the chance of complications. Realistically, for Cleo, her surgical risk was minimal. She was young and, aside from her broken leg, in great shape. Her preoperative workup had gone well above and beyond what might constitute a minimal database for a similar patient of this age with a similar problem. And yet here I was, faced with the worst-case scenario—the anesthetic death of a seemingly normal animal.

  Risk might be more acceptable, more forgivable, if pet owners and clinicians could anticipate the danger. But we know that the more serious the situation, the more involved the procedure, the more fragile this balance between risk and reward. If we decide to play golf in a thunderstorm we should be prepared to accept a higher risk of being struck by lightning.

  Beyond the consent form and passing references in conversation, I only ever focus on anesthetic risk with normal healthy animals for one of two reasons. Either I detect a peculiarity in the physical examination, on an X-ray, or hidden in the numbers of the blood work, or the owner pushes me for a money-back, lifetime warranty and a guarantee that all will be well, a 100 percent return to full function. Neither caveat had come up with Cleo, and though Sonja Rasmussen had appeared nervous and upset that her mother’s dog needed to undergo another major orthopedic surgery, I believed she had confidence and faith in my ability, and the ability of those who worked with me, to fix her dog and set Cleo on the road to recovery.

  In human hospitals it has been shown that relatives prefer to be present during a crisis, to witness the resuscitation. In this way there is no mystery, no wondering what happened, what more could have been done, and as they watch everything unfold, they sense the determination of those committed to the fight. Their fears and questions must be addressed by dedicated support staff, prepared to answer questions and educate, but in practice such disruptions do not occur. The comfort comes from proximity to those you love.

  For Sonja Rasmussen, any chance to prepare and brace for the bad news had passed. At five o’clock she was going to walk into this hospital, expecting me to smile, pat her on the shoulder, and let her know everything went fine. I gave her no reason to expect anything else. Sonja never had a chance to say anything other than a cursory good-bye to Cleo, and now she was about to live every parent’s worst nightmare, left with memories of a mundane, forgettable parting rather than something meaningful, something she would have cherished, if only she had known this would be their final farewell. Cleo was not the daughter who goes off to war. Cleo was the child who leaves for school and never comes home.

  Over the past twenty years, I can recall no more than a handful of unexpected anesthetic deaths (but still an uncomfortable number to think about). Every one requires the clinician to make a full report on the circumstances leading up to the crisis and the efforts taken to correct it, and to speculate on the reasons for the outcome. Debriefing of the entire team is essential. If we could not help Cleo, we owe it to her and her family to learn from her loss so that the next time, and sadly there will be a next time, a more fortunate animal may benefit from our understanding and experience.

  Beth
Maganiello had personally chosen all the anesthetic drugs, calculated their dosages, and performed the epidural injection herself. She had been circling around Cleo, trapped in a holding pattern of no more than ten feet throughout the entire brief period Cleo was under anesthesia. All the usual suspects—allergic reaction, drug overdose, excessive anesthetic depth, decreased ventilation of the lungs—and many, many more had been given serious consideration, but we lacked the hard evidence to point the finger of blame. Yes, we had all seen the bizarre heart arrhythmia on the monitor, tagged with its improbable French label, making it sound deceptively sexy or romantic as opposed to just plain deadly. But what caused it to occur? Was it genetically programmed as an electrical cardiac defect, invisible, impossible to predict, impossible to prevent? Was it triggered by a specific anesthetic drug? Chances were we would never know for sure. Torsades de pointes literally means “twisting of the points” and is supposed to describe the visual characteristics of the abnormal electrical activity on an EKG. For me this translation captured the sinister essence of what transpired, as though something cold and steely sharp had been at work. No matter what terminology I used, Sonja Rasmussen and her mother deserved to know why their dog had died and, for right now, I had no answer to give them.

  I STILL had two hours before my pager announced the arrival of Sonja Rasmussen. Two hours to think about nothing else. I could imagine her sitting in the waiting area, as before, alone, anxious, coiled, desperate to be sprung by my surgical success, reading the fear in me from the moment she saw my face. I cannot let this happen, I thought. I will not let her suffer this pain in public. Could I smile, act as though all had gone well, waving away her barrage of questions until I had her alone, behind closed doors, then drop the pretense and my bombshell? Could I try to catch her before she entered the hospital, on the sidewalk or in the parking lot? There appeared to be only one reasonable option. I called the front desk and informed them that Ms. Rasmussen would be arriving at five o’clock to meet with me. She should be escorted to an examination room and I should be paged. I purposely avoided detail. The last thing I wanted was a premature consolation, an ambiguous remark from a well-meaning stranger. All the same, I knew I was taking a chance and I remained concerned that the perceptive Ms. Rasmussen might sense some kind of a glitch—that this prearranged setting was a preface that could only mean bad news.