The previous two installments in this series on life and death have introduced you to my clients the Reeves and their dog Patches, who was diagnosed with lymphoma and became septic due to chemotherapy. This week, we will follow Patches on his journey through ICU and find out which side of the life-death equation he ended up on.
When dealing with any patient, be they trauma victims, poisoned pets or, like Patches, dealing with a life-threatening infection, the first priority of the doctor is to asses three vital things: their airway, their breathing and their circulation. These three things, conveniently folded into the acronym ‘ABC,’ need to be addressed before we tend to wounds, broken bones or other injuries. They are what keep the patients alive and in the black.
As the saying goes, the air goes in and out, the blood goes round and round. All else is details.
Patches was doing fine in the airway department. He was moving air through both nostrils, and there was nothing to indicate an obstruction to air flow. His breathing, the next to be assessed, also seemed to be adequate. There was no struggle to breathe (known as dyspnea) and no sickly blue discoloration to the tongue or gums (known as cyanosis). When I checked his circulation, by feeling his pulses and measuring his blood pressure (or BP), I found the first of many problems that day. We were starting off with a negative balance sheet, and I didn’t like it.
His blood pressure was desperately low. We are satisfied when a patient’s BP is above 90 millimeters of mercury and Patches’ was somewhere in the 50s. When BP is low, there is no force to move blood through the tissues and they become starved of oxygen. As cells and tissues start to die through lack of oxygen, organs start to fail because of the oxygen debt they owe. If this domino effect goes unchecked, the odds that the patient will end up in the red rise dramatically. Sepsis is a 50:50 bet on a good day, and as organs like the kidneys, lungs and liver start to fall by the wayside, the chance that a patient will die skyrockets.
As if this was not bad enough, low BP causes the heart and blood vessels to work less efficiently — the very organs that keep BP normal when patients are healthy. Patients start on a vicious cycle of low BP and poor heart function that often ends in a downward and deadly spiral.
To correct Patches’ low BP, I reached first for IV fluids. Given initially in large amounts called ‘boluses,’ fluids fill the blood vessels and give the heart something to pump around. Hopefully, they will increase the BP to the safe zone and prevent the development of organ failure. For Patches, this technique did nothing; his BP languished in the 60s, nearly unchanged despite large volumes of several different types of fluids.
The next step after IV fluids are powerful drugs called ‘pressors,’ drugs related to adrenaline. These drugs stimulate the heart to beat with greater vigor and the blood vessels to respond to the normal cues and constrict. They are fussy and somewhat dangerous drugs, and can have their fair share of side effects. They must be given by trained staff, closely watched and adjusted minute-by-minute.
In addition to trying to get Patches’ BP to rise, we also had to contend with all of his other problems. Doctors formulate a ‘problem list’ for all patients, which is a running tally of all the ways that the patient is deviating from normal. For poor Patches, this list ran to dozens of problems, from his original issues of lymphoma and sepsis, on through to the many things we had found on his initial lab tests: low white blood cell count, anemia, low blood sugar, elevated kidney values. It finished with a despairingly long list of complications like intestinal bleeding and low BP. Each problem has to be analyzed for its possible causes, and a treatment plan developed to address it.
His ICU sheet was 3 pages long. We had to Scotch tape extensions on it to hold all of his orders for medication and fluids.
We were battling death on many fronts and losing quite badly. Despite having loaded him with several different broad-spectrum antibiotics and a dozen other medications to combat his many simultaneous problems, Patches continued to linger in the uncomfortable gray zone between savable and doomed. Blood transfusions, oxygen, IV nutrition and intensive monitoring failed to make any appreciable difference in his condition.
We were several days into his hospitalization by this point. I kept the Reeves posted on his status by countless phone updates, and they visited him in ICU at least once daily, often more. I remember, during one of their many visits, they mentioned that their other dog, Allie, was not eating and lethargic and we surmised that she must be missing Patches.
The Reeves knew the names of all the nurses caring for Patches, knew the names of their kids, knew Patches’ drug regimens and lab test times, became accustomed to the rhythm of life and death in our ICU.
Every day, the Reeves looked for signs of hope, some small glimmer of improvement. Anything to say that we had something to show for all of this heartache and tense waiting. Often, there would be one or two small things that had improved — his blood sugar would normalize, or his oxygen level would be satisfactory for a time. But this was always outnumbered by a lengthening list of new problems or exacerbations in his old ones. It felt a little like discovering a twenty in your coat pocket when you still owed the IRS a hundred grand in back taxes.
The equation was shifting away from us, and I wanted to give the Reeves an out. ‘Cutting your losses’ is a terribly blunt and unfeeling way to describe the tactic I meant to discuss, but I feared this would not end well and wanted to make sure they knew that stopping and ending Patches’ suffering was OK. We had discussed this every day during visits and on the phone, but this time I called a special meeting with them to discuss the futility of what were doing. I had never seen a patient survive such a gargantuan problem list, and I was having moral qualms about going further, not to mention the hell that Patches and the Reeves were living through. The staff, dedicated and caring, were also beginning to feel that they were not fulfilling their mission of alleviating suffering. To their credit, though, they pressed on and kept Patches clean, cared for and with what I hope was a shred of dignity.
Many pet owners would have stopped on day one. Many more would have stopped after they tried for a few days and saw what we all thought was the writing on the wall. Even more would take a heart-to-heart discussion like the one I had with the Reeves that day as a sure sign that the outcome would not be the one we hoped.
Not the Reeves.
They listened attentively, asked intelligent questions, appreciated my honesty and candor, but said they did not believe in euthanasia and wished me to continue, doing my best to save Patches. The one thing I did manage to achieve that day was to get his CPR code changed from a ‘go’ to a ‘no go.’ This is also known as a DNR (Do Not Resuscitate) status. That meant that if his heart stopped or he stopped breathing, we would not engage in heroic measures to try and bring him back.
I had never before encountered such a high degree of either dedication or disconnection from reality — honestly, I never knew which it was.
If this was a human child, the euthanasia discussion would never have come up, and that was their mindset. Since I can’t euthanize a patient without the owners’ consent, my choice was either to take myself off the case or carry on.
I elected to carry on.
Patches died the next day.
He didn’t die with the Reeves there. He didn’t die with a friendly hand stroking his head and calling his name, telling him he was a good boy. He died in the afternoon in a bed in our ICU with a tube in every natural orifice and a few new ones that we had created for the occasion. His death came without warning from the monitors or to the people caring for him. He was there one second, then the next, he wasn’t. Someone had punched up the ‘equals’ button and Patches paid back all that was owed between one heartbeat and the next.
The details after this point are fuzzy for me. I called the Reeves at home to let them know he had died. They were not surprised; I had prepared them for this moment, and they were not so disconnected from reality to think death was an impossibility.
I know they came to visit with him after he died in our ‘grieving room.’ They made arrangements for cremation and paid their bill, which was astronomical by this point.
I had only known Patches while he was sick, never knew him in the flush of robust good health or saw him catch a ball or nap by the fire. What I felt was only a fraction of what the Reeves must have felt in terms of loss, but my feelings after he died were a queasy mix of sadness and relief. Relief for Patches, that he was no longer suffering. Nevertheless, if I am to be honest, I also felt a measure of relief for myself, my staff and the Reeves. We no longer had to hope for a miracle that was never going to happen.
I would only know later how wrong I was to think it was over.
Photo credit: Veterinary ICU, flickr creative commons (Karla Fernandez). EKG, Wikimedia.
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