My Patients and Other Animals

by Suzy Fincham-Gray

  Regardless of the social strata of my intern class, which had solidified over the months of our internship, Match Day was an accepted moment of obligated camaraderie. After clinics that day, we met at a Mexican restaurant a few blocks from the hospital for a dangerous mix of margaritas, commiseration, and celebration. Between the second and third round of drinks the muted delight of those who’d been matched and the fake cheer of those who hadn’t began to dissolve like the salt rims on our glasses. The group divided, with the couple of interns who hadn’t applied attempting to bridge the gap. But by the fourth round, a diffuse melancholy had settled on our group as we mulled the nine months we’d spent together, and considered the years that lay ahead.

  I felt a part of something that night. I stood on shared ground with my fellow interns; I understood their disappointment and joined their celebration. We’d come from different places, and after sharing a year of saving and ending lives, pushing the boundaries of our knowledge, skill, and emotional resilience, we were headed to different futures.

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  —

  My long-expected trip home in April acquired a particular significance when I found out I’d be staying in the United States for my residency. Over the next two years, this would be how I saw England and my family—in sporadic gulps of time snatched and cobbled together via short trips across the Atlantic. My preoccupation with the residency match and the long days on clinics meant that I’d had little time to consider that the place I was going home to may have changed from the one I’d left behind.

  In the early months of 2001, a crisis was unraveling in the United Kingdom—one that would forever change the fabric of my hometown and the British veterinary profession I’d known. The first case of foot and mouth disease (FMD) in Britain since 1967 was diagnosed on February 19, 2001. Like rabies, it was a scary but distant vet school disease. We’d learned about it with somber and dire warnings, but had never expected to see or diagnose a case. The consequences of FMD, though, are more complex than the inevitable death awaiting those infected with rabies. FMD is a large-animal disease—exclusively affecting cloven-hooved livestock such as cattle, sheep, and pigs—and the virus, which is airborne, is easily and rapidly transmitted, like the common cold. The disease is rarely fatal, and those infected can fully recover; however, it causes weight loss and decreased milk production due to painful, debilitating oral and pedal ulcers.

  For decades prior to the outbreak, the United Kingdom had been free of the disease without preventive vaccination. This gave the country a privileged position in the export of livestock, with a significant financial advantage. The 1980 European Union regulations prohibited the export of any animals exposed to the virus due to the severe economic consequences of an infection. EU countries with endemic disease could vaccinate their livestock to prevent infection until 1992, when the European Union banned the use of the vaccine because testing could not distinguish vaccinated from infected animals. This meant that when the disease was detected in the United Kingdom in 2001, the method for controlling the virus was to kill all infected and possibly exposed livestock. It was a purely economic decision, to protect the United Kingdom’s disease-free status, made with little regard for the welfare of the livestock involved, or the farmers who cared for them.

  By the time the first case was diagnosed the disease had already spread from the farm it was initially detected on—through the transport of infected pigs—across the countryside. When I heard the news a few days later, FMD had traveled from northern England to Herefordshire, more than two hundred miles away. I thought of the many farms I’d visited with Peter. I thought of my high school friend whose family owned a dairy and sheep farm on the Welsh border—the place I’d learned to dehorn calves, milk cows, and skid around a paddock at night searching for lambing ewes by the headlights of the pickup we rode in.

  Between the news of the first case in February and my April trip to the United Kingdom, I wondered what I would’ve done if I’d stayed in England. Would I have volunteered to inspect animals for signs of disease? Would I be signing the slaughter notices of those infected? Enforcing the cull of all livestock within the three-kilometer contiguous zone around the affected farm?

  * * *

  —

  After I met my dad at the airport, being in England felt like I was taking a deep breath after puffing through a straw for ten months. I recognized the voice of the DJ on Radio One; we were driving on the right—the correct—side of the road, and at the motorway services I stocked up on bottles of Ribena, bags of Walkers salt and vinegar crisps, and any kind of chocolate other than Hershey’s. We chatted about the family events I’d missed—my grandma’s eightieth birthday party, my sister’s new teaching job in Bournemouth—and a lightly polished version of my life in Philadelphia. When we left the urban sprawl of London and headed west to Hereford, I became aware of an insidious stillness hovering over the passing countryside. When I looked across the fields, it seemed that the skyline had been rubbed out with a dirty eraser, the distinction between land and sky hazy and gray.

  The dairy and beef cattle, ewes and month-old lambs that had been as much part of the landscape as the fields and hedgerows had vanished. Since seeing practice with Peter, I’d sewn the livestock deeply into the fabric of the land. My experience had reshaped the anonymous herds into a network of farmers, herdsmen, milking parlors, and lambing sheds. The empty fields symbolized more than the absence of their usual inhabitants. Each represented a fragment of a shattered community, a decimated livelihood.

  At the height of the FMD crisis, 80,000 to 93,000 animals were slaughtered weekly in an effort to control viral spread. But the government’s efforts to contain the virus unwittingly contributed to the persistence of the disease across the land. Infected carcasses were driven through uninfected areas, causing spread of the pathogen, and it was ultimately discovered that aerosolization of the virus during cremation resulted in dissemination, rather than destruction, of the viral particles.

  From the car window, as we traveled closer to Hereford, I noticed that the haze I’d seen earlier had transformed into a denser, black smoke. I clung to the possibility that farmers were burning stubble on arable land, or incinerating waste, but the acrid, terrible smell of burning hair, fleece, and hooves that seeped through the car’s air vents betrayed the smoke’s true origin. The infrastructure to dispose of the vast number of dead animals didn’t exist, and makeshift pyres smoldered across the landscape, bodies burning upon the land they’d once grazed.

  It was hard to grasp the devastation. These were small family-run farms, passed down through generations—100 to 150 cows, and perhaps a couple of hundred sheep. I’d met these farmers and witnessed how intimately they knew their animals; their dairy cows had names, personalities, and idiosyncrasies. They could predict the particular order their herd would walk into the milking shed, and remembered where each cow most liked to be scratched.

  I realized, driving home that day, and again during my stay in Hereford—the weekly cattle market canceled, all country walking trails closed—that British farming and my home would forever be changed by the FMD crisis. The impact stretched far beyond the farm gates: Country pubs and village shops were shuttered; the fear of viral transmission on clothing and footwear had paralyzed the rural economy.

  And then there was the human cost: the sixty suicides, the epidemic of depression that hit the farming community, and the loss of more than 7,800 jobs. The damage to the British economy was priced at £8 billion, split between the private and public sectors, a figure that included loss of tourism due to the closure of the countryside. Six million animals were slaughtered, but it was six months before the last case was diagnosed, on September 30, 2001, and almost twelve months before the final sheep were killed in January 2002.

  The distance created by the nine months I’d spent in the United States stopped me from reaching out to Peter and the farmers I’d met. M
y clinical life in Philadelphia was intensely focused on monitoring tenths of a point change in lab parameters, while livestock in the United Kingdom were being slaughtered by the thousands, on the farms where the farmers lived, and would go on living, even after their animals were gone. My idyllic, homesick imaginings fractured from the terrible truth of a crisis I was not a part of, and an experience from which I was isolated.

  I had been changed by my move to the United States, and my leaving had changed what I considered home. I couldn’t hold on to my memories of England; the country they represented no longer existed.

  After I’d slept off some of my jet lag and drunk enough English beer to remind myself of how a real pint should taste, it was time for my return trip to Heathrow. I’d missed Monty when I’d slept in my childhood bed every night, but going back to the States was hard. To ease my return to Philadelphia, I’d stocked my suitcase with minty toothpaste, Marmite, Wotsits, and English chocolate. I waved goodbye to my dad at the airport gate with promises to phone more, email more, and take care of myself. We didn’t talk about when I would visit again; neither of us acknowledged that my future—whatever it would be—was waiting for me across the ocean.

  * * *

  —

  Monty was happy to see me when I arrived back in Philadelphia, and his presence was a greater comfort than I’d anticipated. The last weeks of my internship passed in a similar flurry to those that had preceded it, and over one weekend in mid-June 2001 I graduated from intern to resident. My internal medicine residency began with a lecture about responsibility, commitment, privilege, and expectation by the director of VHUP. I paid cursory attention to his rousing words, instead trying to calm the nauseous trepidation that fizzed in my stomach and identify my fellow internal medicine residents among the other white coats. I was preparing for battle with my contemporaries, but if I’d stepped back I would’ve realized that the only competitor was me. The satisfaction of obtaining exactly what I wanted was undermined by my unrelenting desire for personal perfection, and the certainty that I couldn’t achieve it.

  Monty and I moved into a one-bedroom with a bathroom and kitchen all to ourselves, financed by my barely increased resident salary. The new place was a few blocks away from the hospital, and it was a relief to be out of the old one. I’d never bonded with my roommates, and even at the hospital the distance between us grew. Following our internship, Chris escaped the confines of academia to work in a private emergency practice in the Pacific Northwest, and, though Dave was staying for a surgery residency at Penn, there was never the assumption that we would continue to share our living space.

  The apartment was on the seventh floor of what, from a distance, looked like a stately older building. The mellow brick, the uniform rows of windows with pale stone accents, and the large gated courtyard that led to the impressive main entrance lent the place grandeur. Up close, however, the window frames were chipped and yellowed. The pieces of cardboard, old towels, and various items of clothing that were stuffed around air conditioners occupying every other window told a more accurate story.

  The building was popular accommodation for graduate students, interns, and residents, and I had lucked into a corner unit through a friend of a friend. Monty had a window to sit in, birds to watch, and swaths of sunlit floor to recline on. His litter box was now more than a foot from my bed, and we enjoyed breakfast together in the small dining area off the galley kitchen. It was the first time I’d lived in my own apartment and, although the cupboards didn’t close completely and a generation of dust occupied the space under the stove, I felt lucky. I’d chosen the shower curtain and bath mat, and arranged my toiletries on the slim window ledge behind the sink. The fridge contained only my food. My new apartment had been furnished through the kindness of final-year residents who were moving on; I got a free couch, coffee table, dining table, and chairs to fill what would otherwise have been an empty space.

  Monty still slept on the end of my bed, creating a permanent warm, hairy divot in the blanket. I continued to worry about his health. I urgently scheduled bloodwork and an abdominal ultrasound when he lost weight, only to realize that his new look was a result of the diet food I had accidentally purchased.

  I had an apartment and a competitive small-animal internal medicine residency. I had a ready-formed cadre of friends, and within that group I found those with whom I’d share dinners and drinks, and celebrate Thanksgiving and Christmas, and to whom I’d go to for advice on tough cases. But, despite this, at times I felt terrifyingly alone.

  Under the carapace of bright, eager energy I showed the world, I was at war. I snapped at the inexperienced vet students and testily disagreed with my fellow residents during rounds in an effort to prove myself. Then I spent evenings fretting over every time I’d cracked.

  Now that I’d achieved resident status, each new patient felt like a final exam to be failed. They were problems to be investigated in exhaustive lists. They were diagnoses to be nailed, treatment plans to be initiated, and discharges to be written. They were opportunities to gain the approval of senior clinicians and fellow residents that I relentlessly sought at case rounds.

  Transitioning from vet school to internship to residency was like learning to ride a bike only to discover that what was required was to unicycle backward, while wearing a blindfold and juggling. In every facet, becoming a resident demanded more than I’d thought possible. It wasn’t only the challenges of increased case responsibility, greater diagnostic independence, and higher expectations for clinical excellence that separated my first and second years at Penn.

  The rotating structure of the internship had shielded me from long-term case management and the development of deeper client relationships, which were the foundation my internal medicine career would be built on. Now there would be no moving on after a month, no ducking out of a difficult case, no citing inexperience. And the emotional stakes were higher than I’d foreseen; my patients were loved family pets, sole companions, and child substitutes that I became desperate to save for their people. They had finally become singular creatures beyond the diseases they carried, making my role as their doctor vital on a complex new level.

  * * *

  —

  A few months into my residency I’d established a daily routine, which was often interrupted by the beep of my pager signaling the constant demands of the sick animals under my care. My schedule was dictated by those goldenrod transfer sheets, which foretold the number and types of cases that would occupy each day. I still felt an undeniable excitement each transfer morning, a frisson of delight with each sheet and the internal medicine problems that were hidden between the lines.

  One morning I picked up a sick young dog. On presentation to the emergency room—a little less than twenty-four hours before his transfer into my care—Fritz was just another dog who’d eaten something he shouldn’t have. Countless canines arrived at the hospital after gobbling socks and wallets, cassette tapes, balls and other toys, unopened ten-pound bags of dog, cat, and even bird food, and disgusting rotten trash can contents best left unidentified. Not to mention those dogs who came in because of something their owners had fed them, often confessed only on the third round of questioning:

  “Are you sure he couldn’t have got into anything?”

  “Well, there was that Wendy’s hamburger, fries, and shake I shared with him on Friday, but that wouldn’t make him sick, would it?”

  The answer was always “Yes.”

  The morning Fritz arrived he hadn’t been interested in breakfast, a peculiarity rare enough to raise an alarm for his owner. When he’d started vomiting she’d rushed him to the emergency room. Factoring in “dog years,” Fritz, at three, and his owner, who was a young graduate student, were about the same age and were constant companions. He was a black and tan miniature dachshund. The sharpness of his pointed nose was softened by his overlarge, floppy ears and his dark, fluid eyes. He ha
d the tight glossy coat of a well-cared-for pet.

  The intern who’d examined Fritz noted that he was quiet and dehydrated, with discomfort on abdominal palpation. On closer history-taking, it emerged that Fritz and his owner, who shared most things, had shared a hot dog a day or so before the trouble began.

  There wasn’t an algorithm that could predict the outcome for dogs with “dietary indiscretion.” Breed, body weight, matter ingested, or frequency of ingestion didn’t appear to influence the probability of life-threatening complications. A poor pulse, high heart rate, and fever could indicate that further steps were needed—X-rays to look for an intestinal obstruction, bloodwork for signs of infection, or abdominal ultrasound to interrogate the abdominal organs. More often than not, though, the signs were vague. A patient’s elevated heart rate might be due to the car ride to the hospital and the scent of hundreds of other pets who’d passed through the emergency room. A faint pulse could be the result of nothing more than a timid intern’s fingers, but it could also mean that dehydration or shock was causing low blood pressure. Or it could be just another dog with garbage gut who’d been getting into the trash again, with no more serious repercussions than vomit on the carpet.

  Fritz’s discomfort and signs of nausea—lip licking and smacking, as though he had a bad taste in his mouth—recommended his admission to the hospital. His owner had readily agreed, with the confidence of a student who was used to her parents picking up the tab. A strip of fur on Fritz’s leg was clipped for intravenous catheter placement, and his treatments of intravenous fluids, antibiotics, and medications to control his pain and nausea were started. The results of his bloodwork showed dehydration and an elevated white cell count—a sign of possible inflammation or infection—but there was no evidence of an intestinal obstruction on his X-rays. These results illuminated what Fritz couldn’t tell us: He was sick, and the decision to admit him to the hospital was the right one.