Working in the veterinary ER is working in a world of almost mathematical opposites.
I often go from one exam room after delivering a litter of mewling, squirming newborn puppies into another with a family making the decision to euthanize their beloved pet. I have had occasion to actually physically wipe the smile off my face as I shift from the happy new puppy parents into the arena of death and grief. ER doctors often have to juggle a spreadsheet of four or five cases simultaneously, and the spectrum of what they are dealing with can range from the absurd, quotidian or comical to the deadly serious – all in the space of a few minutes. It requires nimble thinking and emotional lability; it can at times make you feel like either a chameleon or a sociopath.
There are those cases that tread the thin line between life and death – these patients are riding the fence between plus and minus, living in the shadowy netherworld of purgatory. As a 15-year veteran of the emergency wars, I have had countless cases that have not yet chosen which side of the life-death equation they will sum up on. My job is to make sure as many end up in the black as I can, and, for those in the red, to help owners who choose to end their pet’s life do it with a clear conscience if I can.
Both sides of that equation are fairly known quantities in the ER and ICU for the experienced; the ones that take us by surprise and the ones we expect. For the ones that take us by surprise, we are often too late to intervene and make a difference; most do not survive. For the expected ones, their death is often a relief for them and the family after a quagmire of medical futility.
As death approaches, there are certain signs we look for in patients to spur us into action – the heart rate may suddenly drop or inexplicably speed up, breathing may become erratic, or they may adopt a rather gruesome posture called opisthotonus, where the head is thrown back and the legs stand out stiffly, as if they are being pulled apart by unseen hands. Death is the unexpected outcome for some patients, arriving on the scene and snatching them away before we are even aware of a problem, or it may be the expected and predicted outcome of a serious illness, as if death was lingering outside of ICU and waiting for the right moment to make an entrance.
As grim as it is, there is a certain comfort in this predictability; we never wish ill on our patients, but if we can identify who is likely to live and who is not, it makes us better able to help pet owners make decisions on pursuing therapy or not. If we can honestly say “I have never seen a case like this survive”, most owners know that the effort may be long, heart-breaking and expensive. For those who we encourage with positive predictions, they can take some confidence that they are not putting themselves or their pets through needless medical tests or treatments.
The middle of the equation, however, is an uneasy place. There is a stage of shock known as terminal shock – these patients are dead but don’t know it yet. As a doctor, you can get everything letter-perfect in their care and still end up with a dead patient in most cases. For a small number of these cases, somehow, they dodge the bullet and end up living, often in sharp contrast to our dire predictions of doom. These patients – the ones who made it but shouldn’t have – are fascinating examples of both the unpredictability of complex systems, and our utter infancy in diagnosing and treating disease. They are also a testament to the love and commitment of pet owners, and an example of the best in medical care (and luck). They are the cases we relate to co-workers and family, and write about when we need blog material.
And so, I introduce you to Patches and Allie Reeves.
The Reeves were an average suburban family – Mrs. Reeves was a librarian; I never learned Mr. Reeve’s occupation. The lived in a well-to-do suburb of a major city, and (luckily) did not have to worry about the cost of care for their pets. They were smart and affable people in their 60’s with an easy demeanor and sharp minds. Their 2 dogs, Patches and Allie, were their entire universe now that their kids were grown. Patches was a 10 year-old Border collie mix, and Allie was a 12 year-old Labrador mix with floppity ears and a goofy grin. Both dogs were happy go lucky tail-waggers who had never met a stranger.
Veterinarians hear every week “Doc, our pets are like our kids”, but for the Reeves this was more than lip service. As their story unfolded and I became involved in their tale, I grew to admire, and, at times, curse their utter devotion to their dogs. All of the Reeves, Patches and Allie included, taught me much about what it is to be an animal doctor and forever changed the way that I look at outcomes of the cases that I am involved in.
Patches took ill first. He was diagnosed with lymphoma, or cancer of the lymph nodes. After discussing various options with their family veterinarian, they elected to pursue chemotherapy with the oncology team at the large emergency and specialty hospital where I worked. Many owners have an immediate and negative reaction to the thought of animals on chemotherapy, and the objections usually take one of two forms. They are either averse to it because they fear the side effects that they have witnessed in people undergoing chemo, or opposed to it from a moral (or possibly financial) standpoint. Some people feel it is a misallocation of resources to treat pets with cutting-edge therapies. Thankfully, these people are few and far-between.
To allay the fears of the former group, veterinary oncologists usually point out that we don’t treat dogs and cats with the same degree of aggression that human oncologists practice. The drugs are largely the same (which people often find amusing), but the doses and regimens that are followed are modified for pets. For a person stricken with cancer, the intent is to eradicate all cancerous cells and provide the patient with a more-or-less normal lifespan. There is also a sophisticated medical infrastructure for people to treat the inevitable side effects of very aggressive cancer treatments.
A human cancer patient, if cured, may have decades of life ahead of them, and the chance that they will receive advanced treatment for any complications is quite high. A veterinary cancer patient is often near the end of their expected lifespan, and the vast majority of pet owners will only tolerate one or two complications before they decide to not pursue any further chemotherapy. For them, the intent is to strike that delicate balance between beating back the cancer to improve life, and the avoidance of side effects. The net result is that the treatments for pets are designed for maximum effect with minimum toxicity.
The Reeves did not have any objection to pursuing chemotherapy, and they met with oncologist to devise a plan for treating Patches’ lymphoma. There are many different protocols to choose from, so oncologists feel out their clients to see which one fits with their lifestyle, budget and tolerance for adverse events. The Reeves chose a protocol that offered a significant chance of at least 18-month survival with a modest chance of side effects. The cost for this would be about four or five thousand dollars over the coming year. They agreed to proceed, and started chemo that day. Patches would be monitored for the most common complication through blood tests prior to each intravenous treatment. He would also be on daily oral medications. A complete blood count (or CBC) would be performed to check for bone marrow suppression from the potent medications – if the white blood cell count (or WBC – we love acronyms) dipped too low, the treatment would be skipped or postponed.
At first, all seemed to go quite well. Patches’ previously enlarged lymph nodes shrank down in size over the initial few weeks, and his energy level and appetite improved greatly. He had no evidence of complications on his first CBC and the oncologist was pleased with the progress that Patches had made. The Reeves were encouraged as well, and began to forget the dark days when his lymph nodes were the size of tennis balls and all he did was sleep. His treatment regimen continued on schedule.
One day, something went awry. Mrs. Reeves knew something was amiss when Patches skipped breakfast and slept through lunch. She brought Patches in to see his normal veterinarian. The news from the physical exam and CBC was not encouraging; his WBC was dangerously low and he had a fever. His lymph nodes were still normal sized, but he felt lethargic and refused to move, eat or drink water.
When the WBC is low (a condition called leukopenia), patients are highly susceptible to infection. The white blood cells typically kill viruses and bacteria, and if they are not there in sufficient numbers the patient is left without any defenses. If the infection is able to gain a stronghold and enters the circulation, this is known as sepsis and carries a very significant risk of death. It is the most dreaded complication of chemotherapy. Many owners assume that something was done wrong – some dose was miscalculated, some detail was overlooked. These things do happen, but in the vast majority of patients with chemotherapy induced infection or sepsis it is nothing more than bad luck and coincidence.
Such was the case with Patches. Records were reviewed and it was determined that no gross errors had occurred. His number was simply up that day. Further lab tests showed some of the hallmark signs of a gathering storm of sepsis; his blood sugar was dropping and his platelet levels were also too low (platelets are cells that form clots and stop bleeding).
The primary care veterinarian looked at Patches, looked at the data and made the call to refer Patches and the Reeves to the ICU at the specialty center were I (and his oncologist) worked. It was uncertain at this point just how bad things were, but Patches seemed to be losing steam by the minute. The Reeves packed him into their car and made the hour-long drive to our hospital.
In the coming weeks I will continue the story of Patches, Allie and the Reeves family – and my involvement in their complicated and unpredictable medical drama.
Photo credit: Lab coat and hallway, flickr creative commons (The Doctr)
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