We hugged one more time and then, in silence, I led the way toward the main hospital entrance.
Before we said good-bye, Sandi turned to me and said, “Be generous, and if you get a chance, please let me know what happens.”
She smiled and once more I felt myself having to fight against the grief and kindness in her eyes. How could someone in so much pain appreciate that loss was simply a part of life and not an end of life?
I watched her go, disappearing into a waiting room full of animals, watching her as she was forced to witness the reunion of humans and sick animals with a future together.
AS the daughter of a registered nurse, Eileen possessed a judicious balance of medical smarts and emotional sensitivity. And like so many other pet owners in her position, she dove into the Internet, attempting to discover the truth, to sift some nuggets of hope from the unfiltered mounds of negativity. She kept an open mind and focused on being informed, regardless of the injustice of what she discovered and how much it hurt.
The first surprise came packaged with an assurance that her spaniel Helen was not alone. Far from it. In fact, Eileen discovered, 45 percent of dogs that live to ten years of age or older ultimately die from cancer. That’s four million dogs in the United States developing cancer every year.
The second surprise came as a statement she needed to see in writing. She had heard it before on TV interviews, a well-intentioned platitude, easy to appreciate, even easier to brush off, reserved for the less fortunate few. This time, however, the phrase hit home and she grabbed it, grateful, vowing to keep it with her. It was nothing more than a simple sentence, but it would be her new philosophy.
“Cancer is not the same as death.”
A few days later when she and Helen returned to Angell, Eileen felt prepared, rational, and open-minded about what the oncologist might say.
Dr. Able was not the cancer specialist of her dreams. That is to say she had imagined a much older man with less hair on his head and more wisdom lining his face. This man seemed altogether too young for all those letters after his name, his double-boarded specialist status and all those years of training in both medical oncology and radiation oncology belying the gold-rimmed John Lennon glasses and a neatly gelled Tintin haircut. To her surprise and satisfaction though, Dr. Able seemed like a man used to the introductory reaction playing on Eileen’s face. Though secretly he might enjoy it, he was quick to prove he had earned his credentials.
He began with a detailed history, provided by Eileen as observer, running through her statement one more time and feeling frustrated by everything she didn’t know about Helen’s former life. They moved on to the physical examination, Helen at ease, tail wagging off the chart, apparently forgiving Dr. Able his joke about someone being in desperate need of a Tic Tac as he examined her mouth. He saved the stethoscope for last, taking his time, in no hurry now that her secret was out.
“There are two kinds of approaches we oncologists use,” he said, inviting Eileen and Helen to take a seat as he rolled closer in his swivel chair. “One could be described as a guardian, the other a teacher. Based on a given diagnosis a guardian will tell the owner how best to treat the problem without much input from the owner, whereas a teacher will educate the owner, give them all the data regarding treatment options, but not offer any help in the decision-making process. There are clearly flaws with both approaches.”
His smile did little to reduce Eileen’s confusion, so he pressed on.
“Some owners like to be guided, to have their vet make the tough calls for them. But if things turn out badly, then who foots the blame?”
Dr. Able drove a thumb into his chest.
“Some owners like to be involved in the decision-making process but sometimes this can feel frustrating, even overwhelming.”
“So what kind of an oncologist are you?” said Eileen.
“I’m like most oncologists,” said Dr. Able, “a bit of both. Mixing it up, focused on keeping our goals realistic and never losing sight of patient quality of life.”
Eileen saw that he meant what he said. She liked what he was saying and could feel her earlier apprehension about this young man beginning to subside.
“I’ve looked over all Helen’s blood work, her cardiac ultrasound, and her chest X-rays. Normally I would insist on a definitive diagnosis before recommending a specific treatment option but in Helen’s case I believe we can argue for an exception.”
“Because almost all canine lung cancers are malignant,” said Eileen.
If she was expecting to score points with an appreciative arching of a single eyebrow, Dr. Able did not deliver. Then again, she thought, almost by definition, if you have taken the time to seek out a veterinary oncologist, you are highly likely to go to your meeting armed with a wealth of pertinent cyberspace factoids. Perhaps Dr. Able would have been more surprised if she had kept quiet.
He rose to his feet and switched on the X-ray viewing box. Eileen instantly recognized the picture on the screen, the enormous white mass in Helen’s chest, an ominous moonlit cloud scudding across a night sky. Seeing it again was like recognizing your attacker in a lineup.
“Here’s the mass.” His index finger traced the outline. “It’s quite large for a dog of Helen’s size.”
He paused to look over at Helen snoozing on the floor, an apologetic expression on his face, as though he didn’t want to be talking about her behind her back.
“It’s also solitary, meaning it is more likely to originate in lung tissue rather than having spread to the lungs from somewhere else.”
A thought suddenly occurred to Eileen and she was surprised that it had not struck her sooner.
“Is it possible Helen spent her life among people who smoked?”
She was remembering Sam, the sad old golden retriever she had patted while waiting for Helen’s chest X-rays. The smell of nicotine and cigarettes had permeated the room. Had his frightened owner inadvertently contributed to his best friend’s demise?
Dr. Able frowned, a moment of deliberation playing over his features.
“The jury is still out on secondhand smoke increasing the risk of lung cancer in dogs, though it does appear to cause an increase in the frequency of certain cancers in cats. To be honest, I’m not sure it matters how it got there. What matters is how we deal with it from here on out. Most dogs with this disease would show up at their vets having been coughing for weeks or even months. An owner might report their dog had slowed down, been reluctant or unable to exercise. When it comes to Helen, I think you should consider yourself lucky to have found a problem you never even knew existed, before it could produce a single clinical sign. It’s called an incidental finding and we don’t get to find them too often.”
Eileen latched on to this word incidental. It sounded like something unplanned, casual, even minor, and for some reason she imagined a fender bender on the far side of a busy highway, something that makes you slow down and check it out but ultimately something you can choose to drive right by.
“Could it have been there for some time?”
Dr. Able answered without looking at the image, as though he no longer needed its help, as though he instinctively knew where Eileen was going.
“Maybe,” he said. “But probably not.”
He paused for a beat and added, “It can be a whole lot easier when disease comes packaged with a problem you can see or hear or smell. Owners often consider incidental findings to be a mixed blessing: for some they offer a welcome opportunity to act sooner, for others they create an unsolicited burden of having to act at all.”
He tapped the X-ray cloud twice with his finger.
“We can’t pretend this never happened. I think we have to accept it as the ultimate ‘heads up.’”
Eileen followed his finger and did not avert her eyes.
“So where do we go from here?”
Arguably, more than any other speciality, later, another difficult veterinary oncologists have chosen to deal with pet owner
s who are desperate for hope. A few of these owners will be on a reconnaissance mission, meeting with the oncologist in order to satisfy their curiosity and their conscience that at least they looked into the future and didn’t like what it held. And of course, there is absolutely nothing wrong with this motivation. Then there is the other end of the pet-owning spectrum, this meeting proof of their intent to keep their animal alive at all costs.
Dr. Able already appreciated that the old black spaniel sleeping on the floor in front of him was special. She had to be. She might be “the best dog in the world” or “the best dog Eileen has ever known.” Not that the malignant tendrils brooding inside this dog’s chest could give a damn. Courtesy and respect for this disease can only go so far. It will fight dirty and Dr. Able knew that sometimes you have to be prepared to give back as good as you get.
In formulating a plan of attack it pays to keep a grip on reality. Sugarcoated speculation is for the purveyors of snake oil. Dr. Able had a responsibility to scientific fact, evidence-based medicine, and the data of the journals he devours. It was time to balance empathy with honesty, to temper encouragement with the truth.
“It would be nice to have a biopsy but sticking a needle into a lung mass is not without risk, even with ultrasound guidance. In theory, taking it out gets rid of it and gives us our diagnosis.”
Eileen was all over the caveat.
“What do you mean ‘in theory’?”
Dr. Able pursed his lips and sucked back on his teeth.
“A couple of things about this mass bother me. First,” he extended his thumb, “its location. Ideally a tumor should be located on the edge of a lung lobe where it can be cut out more easily. Helen’s lump is deep, at the base of the lung, which makes it far more difficult to get.”
Eileen took a noisy, deep inhalation and let it out, thinking “Most people give out the good news first.”
“Second,” out came the index finger, “primary lung tumors have the best prognosis when you catch them early. A no-brainer really, the smaller the tumor, the less likely it is to have spread to the regional lymph nodes. X-rays are notoriously difficult for detecting enlarged lymph nodes but we do know that solitary masses less than five centimeters in diameter carry the best prognosis.”
“And how big is Helen’s mass?”
It was Dr. Able’s turn to take a deep breath.
“Please, I don’t want to overstate the significance of a single parameter.”
But he saw she was still waiting.
“Six and a half centimeters. Normally, after complete surgical excision, with clean nodes and a small well-differentiated tumor, I would be telling you that about half the dogs will live for one year.”
Eileen began working the math.
“You mean if the surgeon gets it all and it hasn’t spread there’s a 50 percent chance Helen could be alive this time next year.”
“That’s correct, but I’m telling you this thing is big and awkward. Helen’s cancer may not be quite so well behaved.”
“So what are we looking at?”
Dr. Able stewed, weighing the numbers like a used car dealer about to risk a lowball offer.
“I know it’s not a fair question,” said Eileen, softening, realizing too late that her question had sounded like a demand for a definitive answer. “I won’t hold you to it, but if you could give me your best guess.”
Dr. Able came right back.
“Less than eight months, maybe as little as four. But like you say it’s just a guess.”
Four months.
Eileen looked down at the star of the show, the shadow glued to her ankle. If she were to pat Helen’s head right then she knew with absolute certainty the dog would wake up, turn her way, and smile—content to stay, content to go. Worst of all, she knew that Helen was oblivious to both the malevolence looming inside her chest and the violent campaign to defeat it soon to be waged by those she trusted.
“It might be easier to make a decision if we get a CAT scan of Helen’s chest, that way we can see whether the mass is operable and have a better idea about the size of the lymph nodes.”
Four months would put us into the summer.
Dr. Able waited a beat and then said, “You know choosing not to do anything is also a reasonable option. You’ve already gone way above and beyond for a dog you’ve only known for a couple of months. This is asking a lot of you. Besides all the nursing care and the follow-up visits there’s the actual cost of all this treatment. You’re going to end up spending several thousand dollars before we even think about the possibility of using chemotherapy.”
Eileen was still lost to him, coming to terms with his worst-case offer—-four months—but Dr. Able saw that familiar flinch when the word chemotherapy snaps a person out of their trance.
“I know what you’re thinking,” he said. “You’re worried all her hair would fall out and she’d throw up and have blowout diarrhea the whole time. Truth is 75 percent of dogs on chemotherapy have no side effects whatsoever and the remaining 25 percent have the kind of minor stuff you can easily cope with at home. I’m not even sure chemotherapy is indicated but part of me thinks that if we’re going to get this thing, then let’s go at it with everything we’ve got.”
Eileen nodded, to be doing something. What she had discovered on the Internet had skirted around this subject. She shouldn’t have been surprised, but somehow the anonymous accrual of uncertain information had been tolerable. Here and now, whittled down to something precise and personal, the truth was worse than she had anticipated. She thought it would be bad but not this bad.
She had come armed to ask him what he would do if this were his dog, but even though this seemed like the right moment to ask, the words failed her, as though she were being unfair, assuming too much of a doctor she hardly knew.
“Can I talk it over with my husband?”
“Of course. Definitely.”
This time Eileen gently touched Helen’s head and, as predicted, Sleepy verified the source of the touch, approved, and bounced to her feet.
Dr. Able stepped forward.
“Here’s my card. And please, if you have any more questions for me, don’t hesitate to give me a call.”
They shook hands and then Dr. Able dipped down to pat Helen one last time. In doing so, he said something to her under his breath that Eileen couldn’t quite catch. She could have sworn he told Helen she was a lucky dog. But how could a dog with terminal cancer be so lucky?
TRAGEDY can demolish like an explosion—swift and indiscriminate and crushing and painful. But sometimes, for some people, what remains after the rubble of confusion has had a chance to settle is an amazing clarity. Suddenly, all the obstructions and debris and pointless minutiae of our life are wiped away, and for those who can open their minds, there are new, important vistas to take in, and a different way to look at the world.
To say that tragedy is unfair assumes that life can be led according to a set of rules, that by charting a certain course and staying between the lines, all will be well. Yet tragedy is pervasive, versatile, and ingrained as a universal component of life. It’s not sexist or ageist, it has no regard for socioeconomic standing, race, creed, or ethnicity. You can’t pay it off. It is the blackmailer who keeps coming back for more. It is a chameleon, a con artist, able to worm its way into any life at any time. It is ubiquitous and we need to be prepared to deal with it. Nothing can be more annoying to someone embroiled in tragedy than to overhear the whispered inanity “God only deals it out to those who can handle it.” Do they really think they couldn’t handle it, would be crushed by it, or worse still, are somehow above it? As I see it, tragedy will take its turn with all of us. Perhaps they should rephrase their platitude to “God only deals it out to see how we handle it.”
Lost and dazed in the aftermath of Cleo Rasmussen’s untimely death, I knew that throwing myself into work was a good thing. I could still feel a tightening in my guts whenever I thought about her, still hear Sandi Rasmussen’
s ethereal request rattling around inside my head like the ball in an eternal game of Pong, but the job offered a welcome distraction and something akin to relief. It had only been a few days since our encounter and I had yet to come to terms with the promise she had made me swear. What was she really asking me to do?
Promise me to take Cleo’s spirit on a journey, to realize all the wonderful qualities she embodied and to pour all the skill, effort, and talent you had intended for Cleo into the lives and health of other unfortunate animals.
This request was big, broad, and, from an objective, scientific point of view, flawed. Even so, I could see the conviction in Sandi’s eyes, assuring me this was possible. I had no idea how to make this happen, I simply knew I had to try. This could be the path to restitution I so craved, the chance to make things, if not right, better. At the same time, I didn’t want to feel rushed simply to scratch a check in a box so I could put this event behind me, move on, and forget. At the very least this mission deserved a little preparation and a good deal of thought. Besides, my meeting with Sandi had exposed a serious chink in my emotional armor. I needed to explore this wound, acknowledge its existence, and defend against future susceptibility.
The first unofficial report regarding Cleo’s postmortem examination reached me by e-mail. I should have been petrified, about to be unmasked as a sloppy, even dangerous clinician. But for some reason I wasn’t. I’m sure my encounter with Sandi made some of the difference, but there was conviction in my assertion that I would not have done anything different with my workup for Cleo. Fallibility and negligence are not the same thing.
Pathologists talk about “gross” findings, meaning blatant and obvious rather than disgusting and nausea inducing. Though there were still samples of tissue from vital organs awaiting microscopic examination, there was news to report. Based on visual inspection alone, Cleo’s heart appeared to be completely normal. There was nothing remarkable, brittle, or delicate about any of her bones. There was, however, something unusual about her kidneys, a finding both infrequent and incontrovertible. Cleo had been born with only one kidney, her left. Her right kidney was missing.
Love Is the Best Medicine Page 15
