A metal table in front of the oxygen cages was the place for the most critical patients: those needing mechanical ventilation or one-on-one nursing care. The ICU staff, residents, and clinicians saw a case of this severity as a challenge, a test of skill, a battle to be fought and won, but I knew it was often the last stop before a final resting place, somewhere I didn’t want my patients to end up.
I felt a heightened anticipation. I was about to be questioned about my treatment choices, diagnostic plan, and case management by the senior ICU clinician, and the vet working that day was known for her uncompromising standards. In her unit, crying was more commonly due to her harsh appraisal of clinical acumen than a result of a patient’s demise.
I’d memorized Fritz’s lab values, and I silently inventoried my treatment decisions.
I stepped into the unit. “Dr. Roberts? Do you have a moment? I was hoping to transfer a case to the ICU today.”
“Dr. Fincham, how can I be of assistance?”
My heart rate escalated to match the rapid tracing of an ECG I could see behind her head. “I have a canine patient with pancreatitis. I’m worried he’s developing SIRS and might be going into DIC.”
“Is that how you present a case?” she asked. “I expect more from a medicine resident.”
“Sorry, yes, of course.” I’d already screwed up, and I’d uttered only a sentence. “Fritz is a three-year-old male, neutered miniature dachshund. He was presented to the emergency room yesterday for an acute onset of vomiting, anorexia, and depression.”
I continued to describe Fritz’s condition, trying to communicate my growing concerns. I couldn’t tell what Dr. Roberts was thinking. Her expression rarely changed with her mood. Her eyebrows typically remained in a serious line, and her laugh was a peculiar thing forced through her lips at unpredictable times.
“I was hoping that after Fritz finishes visiting with his owner we can transfer him directly to the ICU.”
“Is his owner on board with the plan?” Dr. Roberts asked.
“She wants to do everything, and finances aren’t an issue. I don’t think it will be a problem.”
“Of course, we have to get the owner’s approval first, don’t we, Dr. Fincham? But in principle, it would seem appropriate to transfer Fritz’s care to the ICU.”
“Great. Thank you.” My instant relief at her decision sent me scurrying to the door of the unit. “I’ll be back as soon as I can.”
“I’ll let Donna know so she can set up a cage. How are his jugulars?”
I hesitated. The integrity, or otherwise, of the two large, easily accessible veins running down Fritz’s neck could influence our treatment options. The jugular veins were the only vessels suitable for the placement of the large catheters essential for monitoring hydration and delivering multiple fluid types, including intravenous nutrition, at one time. They were also, however, the veins most commonly used for drawing blood with a needle and syringe, which, in a sick patient with poor clotting ability and inflamed blood vessels, could quickly cause sufficient damage to render them unsuitable for catheter placement.
Fritz’s veins were a problem. The consequence of his adorably short and twisted legs—apart from the multiple orthopedic problems they posed—was the roly-poly, awkward veins that ran down them. He had the type of blood vessels that were repellent to catheter placement or blood draws. That morning I’d noted that his leg veins were blown, his front leg catheter was tenuous, and one of his jugulars had already been damaged by venipuncture for blood sampling.
“One still looked good this morning,” I said.
“I hope so. If not, life will be much more difficult.”
I gave her a tight nod of agreement and headed to the stairs. I didn’t want to answer any more questions until Fritz was safely in the unit.
I knocked on the exam room door, not waiting for a reply before stepping inside. Fritz’s owner looked smaller and younger than I’d remembered, and Fritz looked ready for the ICU. I noticed that his chest was rising and falling with a deliberate effort.
“Sorry I took so long,” I said. “I was reviewing Fritz’s new lab results.”
“I didn’t notice. We’ve just been hanging out, haven’t we, Fritzy?” His tail flickered against her leg. “That’s a good sign, right? He must be feeling better if he’s wagging his tail.”
“I think he’s just responding to the sound of your voice,” I replied. “I’m very worried about Fritz. I think that his condition is getting worse.”
“I don’t understand. He seems fine, and the doctor in the emergency room told me he’d go home in a day or two.”
“Fritz isn’t going home yet. I know how worried you are about him, and how much you want him home with you, but pancreatitis is a very serious disease, and it can sometimes get worse no matter what we do. Despite doing everything we can, he’s not showing any improvement. I think we should move him to the intensive care unit.”
“ ‘Intensive care unit’? But that’s where the really sick dogs go, right? He only ate a hot dog; he can’t be that sick.”
A familiar frustration flushed my cheeks. I wanted to get Fritz to the ICU, to focus on medicine, and not on his owner’s emotional distress.
“Fritz’s best chance is if he goes to the ICU where he can be monitored more closely and receive additional treatment that we can’t give in the wards.”
“Like what?” she asked.
“He looks like he’s having a hard time breathing, and in the ICU we can supplement his oxygen to make things easier for him.”
“He usually breathes like this when he’s excited. I think he’s just excited to see me.”
I dropped my gaze. It was easier to look at Fritz struggling to breathe than it was to meet his owner’s eyes. “He doesn’t look very excited at the moment,” I said. “I’d like to get him to the ICU as soon as possible; that way we can see what’s going on and decide what to do next. Okay?”
Fritz’s owner lifted him to her chest and rested her chin on his head. Her tears rolled down his flank. He raised his nose to rest on her shoulder. His front leg, cheerfully wrapped in bright blue vet wrap, was sticking out awkwardly due to the IV catheter. It was a small movement, a sick dog seeking comfort from the person who loved him the most, but it took me outside my irritation, and beyond my doubts at my ability to help Fritz and his owner. It reminded me of Monty, and how, when he sensed that I was upset, he would sit on my lap while my tears fell onto his black coat.
“You can take him,” she said, without loosening her grip. “I don’t care how much it costs. I want Fritzy back. Do whatever you need to.”
I lifted Fritz gently out of her arms and felt the slightest resistance when I took him from her. I should’ve made her wait for the new estimate from the financial department, but I didn’t have the courage; it felt ugly and unpleasant to leave her to sit alone while I took Fritz to the ICU. I didn’t stop her when she accompanied us to the door of the exam room.
Once in the ICU, I placed Fritz on the central treatment table, and instantly technicians, residents, and the senior clinician surrounded him. His veins were evaluated, vital signs checked, and blood pressure and oxygenation status obtained. I could barely see my patient through the melee of white coats and blue scrubs.
The moment I placed him on the table, I became obsolete in Fritz’s care, although I would remain his primary doctor and the main contact for his owner. In the ICU I was merely an internal medicine resident, superseded by a rank of critical care doctors and technicians. I caught the attention of the resident long enough to tell her to page me if they needed me, before I headed back to the wards.
An hour later, I returned to the ICU. Fritz was in the oxygen cage; my concern about his breathing had been well founded. His lungs were filling with fluid and cells. His disease had moved into the territory of acronyms—SIRS (systemic inflammat
ory response syndrome) and ARDS (acute respiratory distress syndrome) had been added to his problem list. If we couldn’t get a handle on the devastating inflammation in his body, he was likely to develop MODS (multiple organ dysfunction syndrome) and DIC (disseminated intravascular coagulation). And death would become inevitable.
Fritz lay in the back of the cage. Even in the enriched air, his chest moved with an exaggerated force, his flooded lungs trying to capture sufficient oxygen. Through the faintly scratched Plexiglas cage door I could see the results of his hour in the ICU. He was dwarfed by the tangle of leads and lines that ran to and from his body. His essential dogginess lessened with each patch of hair clipped for ultrasound, catheter placement, and blood draw. He was still a dog, but I wasn’t sure if he was still Fritz.
I wouldn’t be going out for drinks that night. Even though there was little I could do, I would spend as long as I could in the ICU before going home, where I expected my pager and my anxiety would keep me awake. As much as his care was now out of my hands, I still felt an urgent need to stand watch, imagining that he would continue breathing only as long as I kept my eyes on the labored rise and fall of his chest.
“Dr. Fincham?” I turned to find Dr. Roberts standing behind me. “We got an arterial line in, quite an achievement, and here’s his blood gas. I wanted to see what you think.”
She handed me the small strip of paper that revealed exactly how badly Fritz’s lungs were doing. I looked at the numbers and reached for my calculator, hoping that my fumbling among the pens, hair, white tape, and other detritus at the bottom of my pocket would buy a minute for me to remember the formula I needed. It was a test. Dr. Roberts had already calculated the alveolar to arterial (A–a) oxygen gradient, which assessed how much oxygen was passing into the bloodstream, and therefore the severity of damage to the delicate permeable membrane of the alveolar walls. It would’ve been the first thing she did when the machine spat out the results. The formula for the A–a gradient was complicated, and given that Fritz was living in an oxygen cage, I knew it was abnormal.
The calculation was an exercise in academic medicine; the number wasn’t going to change Fritz’s treatment plan. But by calculating the gradient correctly my status in the ICU would incrementally increase.
I tried out the formula that came into my head. “Forty-four?”
“Are you asking me or telling me, Dr. Fincham?”
“Telling you. The A–a gradient is forty-four, which is abnormal. Fritz’s lung function is decreased.”
“Very good, and what does that mean for your patient?”
I looked at the small black and tan dachshund lying on a sunny baby blanket in the white noise of the oxygen cage. He’s going to die, I thought.
“If he doesn’t improve, then the only option will be to put him on the ventilator,” I said.
“I agree. Have you discussed this with his owner?”
“No. He wasn’t breathing this badly the last time we spoke. I can call her, but I think she will want to do everything.”
I watched Fritz struggle to breathe, the movement of his chest a deliberate, conscious effort, his abdomen expanding and contracting with the force of each breath. His head was raised in an awkward position, with his neck extended.
“Do you think putting him on the ventilator is the right thing to do?” I asked.
“We don’t have a choice. If this owner wants to save her dog it’s the only option.”
“But if we put him on the ventilator what are his chances of coming off it again and recovering?”
I was surprised to hear myself ask the question. I knew the answer; his prognosis was poor. While placing him under anesthesia and having a machine force oxygen into his lungs would help improve his blood oxygen level, it would do nothing to help the severe, cascading inflammation that was the root of the problem. Using the ventilator was our only chance of keeping him alive, but this chance—when we couldn’t control the pancreatitis that continued to rage through his body—was slight.
“It’s not our decision to make,” Dr. Roberts replied. “And without ventilation he won’t make it through the night. If we can give him enough time for his pancreatitis to resolve and his lung function to improve, he stands a good chance of making it home. I think he deserves that chance, don’t you?”
I paused, unsure how, or if, I was expected to answer her question.
Fritz was a young dog; he had a potentially curable disease with no long-term consequences, and an owner with apparently limitless finances.
Didn’t he deserve a chance? My gut told me that no matter how many catheters we placed, drugs we administered, or dollars we spent, Fritz was out of chances.
If this was the case, then was it right to put him and his owner through escalating invasive treatments? We had a choice to make. We didn’t have to keep going. But the only other option was euthanasia.
Did Fritz feel like he was suffocating?
Was the inflammation in his abdomen causing pain that we weren’t controlling?
Was the constant hum of the oxygen generator stressful?
I would never know how Fritz felt.
His owner would dictate his care, and I knew she would try anything to save this piece of her heart, regardless of his suffering. But when did the act of saving her dog become selfish?
* * *
—
By the time I got home the ventilator had been set up, the on-call resident paged, and the anesthetic drugs calculated. I no longer needed to stand watch over each of Fritz’s breaths; now a machine would be breathing for him. Sitting on the couch with Monty curled on my lap, I replayed the events of the day. I tried to pinpoint the moment Fritz had taken his downturn, and questioned the decisions I’d made, wondering how I could have stopped his decline. I was angry that I’d failed my patient and worried that I’d missed an opportunity to interrupt the spiraling cascade that had led him to the ventilator. I’d failed to stand up to his disease and the invasive treatments. A line had been crossed.
“I’ll never do that to you, I promise,” I whispered to Monty, feeling the vibration of his purr against my body. No matter how much I needed him in my life, I vowed that I’d never subject him to the extremes of intensive care. But did I really know?
I didn’t sleep that night, haunted by Fritz on a ventilator, Monty on a ventilator, Fritz dying, Monty dying—dangerously blurring the line between my personal and professional life.
* * *
—
The next morning, I arrived in the ICU to learn that Fritz’s respiratory function had continued to decline overnight. His ventilator settings had needed constant tweaking to match his need for oxygen. I didn’t want to examine him; he was absent, but his body was invaded—veins and arteries catheterized, an endotracheal tube securing access to his airway through his mouth, a nasogastric tube suctioning stomach contents, a urinary catheter accessing his bladder, and a rectal temperature probe.
Fritz lay swaddled in tubes and cables, sung to by the constant mechanical beep of his machines. His life had been reduced to rows of numbers, boxes filled in on a grid. The steps taken to save him had changed his body, and the disease had taken its toll.
Overnight, pancreatitis had spread through his body like an uncontrollable fire, and his blood vessels had become engulfed. The delicate, porous barrier that usually regulated the flow of fluid to and from tissues was damaged and ragged. Fritz had become a swollen, gelatinous version of the dog I remembered. Fluid had seeped into his lungs and vital organs, hastening the advancement of multi-organ failure. The fire had engulfed his foundations.
There was nothing more to do. His lungs were saturated, his kidneys failing. Within hours, regardless of what we did, he would be dead. I didn’t know if inside his bloated body a part of Fritz still lingered, but if there was any chance that an enduring sentience remained I wanted to rele
ase it. To give him back the dignity he’d been stripped of in the last hours of his life. But first I had to obtain his owner’s consent for euthanasia.
I picked up the phone, “Good morning, Ms. Whitney, it’s Dr. Fincham.”
“How’s Fritz. Is he alive? Is he breathing on his own?”
“Fritz made it through the night, but—”
“Thank goodness, I’ve been so worried. I knew he’d make it for me, he’s such a fighter.”
“But,” I continued, “unfortunately, despite everything we’ve done, his condition has continued to deteriorate.” I waited for a reply but there was silence. “Can you come to the hospital as soon as possible?”
“Why?” Her voice sounded breathless and thin. “Is he dying? Is he dying right now? Why didn’t you call sooner?”
Because it wouldn’t have changed anything. “Fritz is alive, but he’s very sick. His lungs and now his other internal organs, including his kidneys and liver, are failing. We need to think about how much further to go.”
“What are you saying? That I should give up? Is that what you’re telling me?”
“It’s not giving up. We’ve done everything, and there is nothing more we can do. I think it’s time to consider euthanasia.”
“He’s going to make it. I know he is. I’m not giving up on him, no matter what. I promised him that I would never leave him.”
“I know this is hard, but Fritz is dying. I’m worried that he’s suffering, and we can help him with that. You could be with him, and hold him. We can make it very peaceful.”
My Patients and Other Animals Page 10