When I met Fritz for the first time he looked depressed—quiet, uninterested, and with low energy. He’d continued to vomit overnight and he had the queasy look of a reluctant sailor. He lay on his side, facing the back of his cage, and his only reaction to my approach was a disinterested flick of his ear. When I gently slid my hands under his slim body to pick him up, I felt a tense tremor that told me he was in pain. His back was instinctively arched to protect his abdomen, and a sticky gum of saliva coated his chin, reflecting his persistent nausea. His pulse was rapid—he wasn’t depressed from being away from home overnight; his elevated heart rate told me that his body was at battle. The soft skin of his abdomen felt too warm, and his last body temperature had been above the normal range—another sign he was deteriorating despite treatment.
I was learning to rely on my clinical skills—the information I could acquire with my hands, ears, and eyes by listening to a heart, interpreting a patient’s demeanor, and palpating an abdomen—in the same way that I’d relied on the diagnoses I’d memorized. I was gaining a wary trust of my gut feeling when something didn’t look right, and I was worried about Fritz.
My biggest concern, having taken Fritz’s physical examination, bloodwork, and X-rays into consideration, was that he had a condition called pancreatitis, an inflammation of the pancreas.
The pancreas is a complex organ, nestled between the duodenum—part of the small intestine—and stomach. It is intimately associated with the bile duct and lies close to the gallbladder and liver. Early in my training, when I still spent time in surgery suites, the mantra for abdominal exploratories was always Don’t piss off the pancreas. Like an irritable aunt at Christmas dinner, the merest look or touch could set off an angry inflammation. To me, the pancreas appeared pale and malevolent, hiding between the smooth, jolly pink intestines and the dense, bloody liver, a lumpy narrow irregularity of tissue waiting to catch an inexperienced surgeon out. An organ with its temperament doesn’t belong in the busy abdominal cavity; its pallid friability would be better suited to a more protected space. But there it is, secreting insulin and other hormones into the bloodstream and digestive enzymes into the gut.
In patients with pancreatitis, the meticulous delivery of enzymes to the intestine is disrupted by inflammation, which can be triggered by genetics, something indiscernible, or even a fatty meal, including a hot dog, fried chicken, or Bloomin’ Onion snatched from a kitchen counter, dug out of a trash can, or offered as a reward. In humans, the most common trigger of pancreatitis is alcohol consumption. This inflammation sends enzymes designed to digest food into the pancreas itself, the surrounding tissue, and, if things get bad, into the bloodstream. Enzymes do not discriminate, and once they escape their carefully marshaled delivery to the intestine they digest the proteins and fats wherever they land, a potentially catastrophic event that has little effective treatment.
I knew Fritz’s pancreatitis could confound every medical intervention I mustered against it and, although I could explain, pathophysiologically, every inflammatory pathway and its consequences, I knew that I might not be able to save him.
After I settled Fritz in the wards, persuaded the radiology technician to bump his ultrasound to the top of the list, and warned my student to contact me if Fritz’s condition changed, I headed to my office to call his owner. The internal medicine residents’ office was at least twice the size of the broom closet the interns shared. Each of the eight residents had a cubicle with a desk, computer, and phone. I decorated my cube with animal-themed newspaper cartoons clipped from The Guardian by my parents, and pictures and cards sent by the owners of my current and former patients—each one a small paper trophy affirming my worth.
Despite the solace I found in the cards, they carried their own sadness. The deepest thanks came from the owners of those I wasn’t able to save—animals who had been too sick to be helped, whom I’d euthanized, or who’d died despite my intervention. Sometimes I’d open a card and find a glossy photograph of my patient from happier times, healthy and vibrant, as their owner had known them. A calico cat sitting in her favorite sun spot, a black cocker spaniel dressed like a devil for a Halloween parade. Markers of a time in a pet’s life when veterinarians and hospitals were far away.
Regardless of the relative luxury of my new office space, making calls to owners was my least favorite part of the day. I felt a confusing ambivalence toward the humans in my patients’ lives, and I struggled to figure out how they fit into my practice. Their financial constraints limited the tests I could run and the treatments I could administer. And, even when money was no object, I felt inadequate to meet their expectations. People had emotional needs I didn’t understand and couldn’t navigate, and they required my time and patience, which I didn’t have enough of.
My veterinary school education hadn’t encompassed bedside manner, or owner communication skills. Humans had barely figured in our lectures—pet owners were anonymous beings who brought Fluffy and Fido to the hospital when something wasn’t right, and picked them up again when everything was better. Case studies were presented with a picture of the animal patient alone, in a vacuum, without human interference or companionship.
The expertise needed to counsel a grieving client, find the right words to explain a complicated disease to a layperson, or understand that an owner’s anger was often a manifestation of fear, were not requirements for graduation. To become a board-certified internal medicine specialist, I had to complete a residency, author a journal article, write three case reports, and pass two written examinations. There were procedures to master, diseases to diagnose and conquer, and standards of care to attain. These were measurable parameters, specific criteria to be fulfilled before the letters DACVIM (Diplomate of the American College of Veterinary Internal Medicine) could be tacked to the end of my name. Even through this advanced stage of training, owner communication remained little more than an abstract, a mysterious art absent from any training manual or rounds discussion.
The language we spoke in case rounds, in the wards to discuss patients, and in the basement lecture theater for grand rounds, was comforting in its precision. The Latin derivations made diseases that were ugly and sad seem exotic. Devastating, life-ending complications hid behind benign-sounding acronyms like DIC—disseminated intravascular coagulation, or, more realistically, death is coming. The visceral reality of watching a patient die from uncontrollable hemorrhage, or witnessing the suffocating distress of severe pulmonary edema, was lost in the formality of our academic language.
During my residency, I was discovering that this vocabulary was meaningless in the exam room. Using complex medical terminology resulted only in an owner’s confusion, and often a loss of their consent. I had to be an interpreter—both of what my client could and couldn’t tell me, and of what the test results and diagnoses meant to an owner who was terrified for the future of their pet. I had to find a common language for the sake of my patient, who couldn’t speak, and doing that was harder than any exam I’d taken.
Fritz’s owner answered my call on the first ring. I suspected that she’d been waiting by the phone.
“Good morning. This is Dr. Suzy Fincham calling from the Veterinary Hospital of the University of Pennsylvania. I’m Fritz’s new—”
“How is he?” The voice on the other end of the line was high-pitched and panicked.
“He’s stable, but I’m a little worried about his condition,” I replied.
“Why? What happened?”
My grip on the receiver tightened. I paused, immediately ruffled by the accusation I heard in her question.
“Ms. Whitney,” I continued, “nothing has happened to Fritz. He’s been transferred to the internal medicine service, and I’m his new doctor.”
“But, how is he?” You’re demanding, I thought. “Can I come and visit?”
I switched the receiver to my other ear and pushed my weight back in my chai
r. I wanted to discuss Fritz as a patient. I wanted to review his medical history and lay out my treatment and diagnostic recommendations in the clinical terms I felt most comfortable speaking, but his owner needed something else from me.
“He’s going to be okay, isn’t he?” she continued. “You can fix him, right? He’s my baby. You won’t let anything bad happen to him, will you?”
“I think Fritz has pancreatitis,” I replied. “We will do an ultrasound of his abdomen today to confirm this, but at the moment this is what we’re treating him for.”
“What? Pancreitis? I thought he just had an upset stomach. He was fine two days ago. Is he going to die?”
I felt the pull of her anxiety dragging the conversation away from the medical territory I was trying to maintain. “Pancreatitis can be serious, and in some cases life-threatening, but—”
“He seemed fine when I left yesterday. Now you’re saying he’s going to die?”
I swallowed, hearing panic rising in her voice.
“No, no, Ms. Whitney, I didn’t say Fritz is going to die. I just said that he has a potentially serious disease.”
She began sobbing, and my voice trailed off. I didn’t know how our conversation had gone so quickly from “hello” to Fritz’s death, and I was equally unsure of how to pull it back to a place of calm. I wanted to hang up and transfer Fritz’s care to one of the other residents, sure that they would be able to establish a relationship where I had failed.
I could intently monitor Fritz’s clinical progress over the next twenty-four hours. I could adjust his medications to control his pain and nausea. I could sit with him and feel the smooth softness of his ears. I could care for my patient, but I didn’t know how to do the same for his owner.
“An abdominal ultrasound will allow us to get a good look at his pancreas and the rest of his organs,” I continued. “We will also monitor his white blood cell count and liver enzymes, and we will increase his medications, because he still seems uncomfortable and nauseous. Once I’ve got more information, I’ll give you a call and then we can set up a visit. Does that sound okay?”
“Yes,” came her hiccupped reply.
“The business office will call you with an updated estimate, and I’ll speak to you later.”
“It doesn’t matter what it costs. Do whatever it takes to save him.”
“Try not to worry” was the only reply I could muster. As I hung up, my pager went off, informing me that Fritz was headed to ultrasound, stat.
In case rounds later that day we discussed pancreatitis. We debated the benefits of fresh frozen plasma and intravenous nutrition. We reviewed journal articles and scientific papers, paying attention to mortality rates, predictors of survival, and potential new treatments. I tried to focus on the discussion, but my mind kept drifting to Fritz, in cage 7. I thought of how he’d made small, uncomfortable grunts with each exhale during his ultrasound. How he’d developed leaking, greenish-black diarrhea. How he continued to vomit despite the multiple anti-emetics he was receiving. I didn’t like how he was doing, and I didn’t like the prospect of discussing this with his distressed owner.
At the end of rounds, I lingered to ask my senior clinician his advice. Dr. Goldman was a full professor and a world leader in veterinary gastroenterology. He was a short, compressed man. Dark hair cut close to his head, tight full beard—even his glasses seemed to absorb into his face rather than adorn it. His clothes were cut economically; nothing was extraneous.
“Dr. Goldman? I was wondering if I could get your opinion on something?”
He was already halfway to his office, and once the door was closed I wouldn’t have the nerve to bother him, but I was hoping he might share some wisdom to improve my relationship with Fritz’s owner.
“Dr. Fincham, very interesting case you’ve got there, nasty bit of pancreatitis. What was it he ate? A hamburger?”
“A hot dog. His owner thought it was a treat. She’s very worried about him.”
“I’m sure you’ve reassured her with your plan,” he replied. “She’s right to be worried about her little dog. I’m heading to the lab to check on some experiments, but then I’ll be in the wards. Come and find me if you have any other questions.”
“Thank you,” I managed to force out before watching him stride away. I was eager to make a good impression, and I didn’t have the courage to prolong our conversation. Dr. Goldman always wore a suit and tie, which never showed the dog and cat fur or other undesirable outputs that frequently adorned my outfits. He understood the gastrointestinal tract on a cellular level and could recite, in exquisite detail, his most recent work on promotility agents in the canine intestine. He could be relied upon to ask ponderous, challenging questions at grand rounds, regardless of subject, and had mastered a quizzical frown he employed while the quivering resident answered. His knowledge was awesome, but his focus was theoretical. I was alone in trying to decode disease for Fritz’s scared, ingenuous owner.
* * *
—
Ms. Whitney returned to the hospital later that day and, on sight, I had no doubt that she would do anything to save her dog. She came alone, no supportive friend, roommate, or partner, no protective parent. And it was her solitude, more than her designer jeans and white T-shirt, or her panicky grip on a Coach purse, that told me what Fritz was worth to her. She was alone in her love for this dog and, in turn, that love made her less alone.
She was petite—slim in the gaunt, brittle way of girls in their early twenties trying hard to be liked. I wanted to believe that we were nothing alike, that she was a daughter of privilege, living an easy life in a Rittenhouse Square apartment with her pampered dog, but I understood her desperation to save Fritz; I could barely imagine the desolation of life without Monty.
Fritz slumped listlessly on her lap. He’d summoned a dispirited tail wag when he first saw her, but he now looked miserable. She spoke softly to him. She gently laid her mouth close to his ear, urging him to keep fighting.
“I’ll give you some time,” I said, lingering awkwardly at the door before I stepped outside. I didn’t know how to soothe the anguish I read on her face as she held the weight of her dog’s illness in her arms.
I headed to the fourth-floor clinical pathology lab to check on Fritz’s blood results. I wanted to know what his pancreatitis meant for the rest of his body. My instinct said it wasn’t going to be good. Heading up the stairs I met Jean, a friend and senior resident, also on her way to the lab. We climbed the stairs chatting about our cases.
“How’re things going?” Jean asked.
“Urgh, I picked up a difficult case this morning. A young dachshund with bad pancreatitis. I expect he’ll be in the ICU by tonight. His ultrasound was ugly; he’s already got fluid in his belly.”
“Tough case. How’s his owner?”
“That’s the worst bit. She’s young and really emotional, and she doesn’t get how sick her dog is. I don’t know how she’ll react when I tell her he’s getting worse.”
“She’s probably really scared,” Jean said. “She might not have been through this kind of thing before.”
I nodded. “He’s probably sick because of a hot dog she fed him.”
“Poor thing, she must feel terrible,” Jean said.
“I feel worse for Fritz. Who’s stupid enough to feed their twelve-pound dog a hot dog?”
“I know, but we always see the worst of the worst, and most people don’t have a clue. They think dogs can eat anything. And some dogs can.”
Our voices echoed off the flat gray of the stairwell. The familiar beep of a pager sounded somewhere below us. We reached the basket for completed lab reports and began searching for our patients’ names.
“Not good.” Jean handed me a sheet with Fritz’s name in the top left corner.
“Everything looks worse,” I said, noting his rising liver enzymes
and falling blood proteins, both indicating that his body was taking a bad hit. His CBC showed that his white cell count was continuing to climb and his blood was no longer clotting normally; a dangerous combination suggesting the development of SIRS—systemic inflammatory response syndrome—a nasty acronym that might signal the beginning of a downward spiral I couldn’t halt. I pointed to his coagulation profile. “He’s heading to ICU,” I said.
“Looks like it,” Jean groaned. “Who are you on with?”
“Goldman,” I replied.
“Better keep him in the loop; he hates cases transferring without him knowing.”
I responded with a grunt and pulled out my pager. The bureaucratic hurdles I needed to jump to get Fritz into the ICU would occupy the next several hours of my day.
“Fancy a drink later?” Jean asked.
“You must’ve read my mind,” I replied.
“I’ll see what Gina and Mark are up to. Maybe we can head to the White Dog after work.”
“Jean, you’re a lifesaver.” I headed down the stairwell with renewed determination.
* * *
—
In the hierarchy of consents needed to move Fritz into the ICU, his owner was at the bottom. Goldman’s support was vital for my patient’s smooth passage through the doors of the critical care unit. Luckily, after reviewing Fritz’s lab results, he agreed that the dog’s condition warranted the high-level treatment the ICU would provide. The next step was to convince the senior ICU clinician that Fritz needed to be admitted. My success was dependent on who was on duty, the caseload, and the number of animals expected to arrive after surgical procedures.
I was welcomed into the ICU by the competing bleeps of ECG monitors, fluid pump alarms, and blood pressure monitors. Unlike the hectic bustle of the ER, the ICU had a hushed, somber air, even during the most harried of resuscitation efforts. I stood in the doorway and surveyed the territory before stepping over the threshold. There were two large oxygen cages stacked one on top of the other close to the door. Each was big enough to house a medium-sized dog, and could be partitioned for cats or small dogs. Next to the oxygen cages were two dog runs for the biggest patients, one of which Hercules had occupied. Adjacent to the runs was a wall of various-sized cages for smaller patients. I pictured Fritz in one of these, and wanted to get him there as soon as possible.
My Patients and Other Animals Page 9