My Patients and Other Animals

by Suzy Fincham-Gray

  “No. No. You can’t make me kill my dog.” I took a breath and asked her to meet me at the hospital. She agreed, and while I waited for the page to tell me she’d arrived I could only hope that she’d change her mind.

  Fifteen minutes later, I met Fritz’s owner in the lobby and accompanied her to the ICU. There was nothing more to say. She would not, or could not, change her mind, and inside the unit I stepped aside for the critical care resident to explain the compromise they’d reached.

  “We’re going to keep Fritz anesthetized and turn off the ventilator,” the resident said. “Without the machine breathing for him his tissues will quickly become starved of oxygen.”

  “But there’s a chance he could wake up, right? He might start breathing on his own and be okay.”

  “I’m very sorry, but I don’t think Fritz is going to wake up,” the resident continued. “His lungs are so damaged that even if he does breathe on his own, he won’t be able to take in enough oxygen.”

  “You’re telling me he’s going to die?”

  “Ms. Whitney, I’m so sorry. We’ve done everything we possibly can. There’s nothing more we can do.”

  “He’s going to die, then?” Fritz’s owner asked again.

  “Are you sure you won’t consider euthanasia?” I asked. “You could hold him. Fritz wouldn’t suffer at all.”

  “No. I’m gonna give him a chance. I won’t let you kill my dog.”

  I stepped back, silently hating her and her inability to do what I thought was right.

  “It’s okay, Ms. Whitney,” the ICU resident stepped in. “We’ll proceed as planned. I’m going to turn off the monitors so they don’t distract us.”

  The monitors would alarm when Fritz’s blood pressure, oxygen levels, and heart rate dropped. We didn’t need to be alerted. It was the order of death.

  Fritz’s owner stood at his head and the resident flanked the ventilator. I took another step back.

  The resident leaned forward. “Tell me when you’re ready.”

  Fritz’s owner’s denial turned into a terrible sobbing. Her body shook and she wrapped her arms tightly around herself. “I don’t think I can do this,” she said. “I can’t lose him; he means everything to me.”

  “I know how hard this must be,” the ICU resident said. “But you’re doing the right thing. Fritz isn’t going to get better.”

  Her sobbing rose to a wail of assent.

  The ventilator huffed its last breath, and for a moment nothing changed. Fritz didn’t move or take a breath. His tongue, stuck at an awkward angle from his mouth, remained pink. His owner grabbed his swollen paw, urgently whispering to him to breathe. I held my breath. I knew what was coming, what the process of dying looked like. But I felt no relief when Fritz began a gasping respiratory pattern. Each heave was a reminder of my failure. Anger built behind my larynx, and while Fritz continued to gasp, his tongue turning the purple-blue of cyanosis, a sob grabbed at my throat.

  I had witnessed the final breath of many animals, after administering euthanasia solution or during desperate resuscitation measures. But I’d never experienced the impotence I felt watching Fritz suffocate. I would not cry in the ICU. It was frowned upon. But the stifled sobs rippled through me, trying to escape. I turned away. I walked to the door of the ICU, stepped through, and closed it behind me.

  CHAPTER FIVE

  Zeke

  By 2003, I’d become as accustomed as possible to the putrid soup of Philadelphia summers. Nevertheless, I still found the rotten, swelling heat difficult to deal with. Walking home from the hospital at night, I passed brick walls of apartment buildings that radiated the sun they’d stored from the blazing day; the streets might as well have been lined with pizza ovens. The trash cans dotting each block stained the air with the odor of decaying food and dirty diapers.

  My life was dictated by the academic calendar. School started in September and finished in July, and internships and residencies began and ended in June. I was nearing the end of my residency and, rather than fireplaces in cozy British pubs and windblown rain seeping between narrow gaps in my clothing, I was greeted by languid, fetid heat after each shift. A year was marked by the graduation of students and the completion of training programs, not the bang of fireworks or the promise of New Year’s resolutions.

  I’d imagined that my life would be perpetually measured in school years, accumulating board certification, then a PhD, then a bibliography of first-authored papers in scientific journals. But the happiness that I’d anticipated would come from singularly pursuing veterinary medicine ebbed into the porous ground of my discontent.

  I had no real home. Life in America still seemed temporary. And my English friends had boyfriends I’d never met, listened to music I’d never hear, and told stories I didn’t understand. Unsurprising, then, that by the end of my residency I’d acquired a new family—my three cats, Monty, Fred, and Harry—to help soften the edge of my loneliness.

  Fred had arrived a little less than a year after Monty, about the time I was accepted for my residency. He was a three-month-old white kitten, with patches of striped brown tabby on his tail, sides, and ears. A technician at VHUP had found him clinging to her screen door. Facing the next two years in Philadelphia, I instantly decided that a new kitten was exactly what I—and Monty—needed, given the long hours I spent at the hospital. But Monty merely tolerated his frantic new companion. The cozy relationship I’d imagined between them never transpired.

  Monty liked to sit on the windowsill watching birds, lounge on the hardwood floor in swaths of sun, and sleep at the foot of my bed. Fred did not. He preferred to chase imaginary bugs up and down the walls, find ingenious places to hide, and keep his distance from the human and feline members of his family.

  A year later, about halfway through my residency, I adopted Harry to bridge the gap between Monty and Fred. He was an orange and white tabby, acquired by way of my resident mate Jean. He’d been evaluated for an unknown gastrointestinal disease, which had caused his previous owners to give him up to a rescue group. The problem turned out to be a penny lodged in his intestine, which was surgically removed. When I brought him home, Harry was a leggy, boisterous teenager, still with a hairless patch on his downy white belly clipped from surgery.

  I called him my rock star; he greeted everyone, hopping onto laps regardless of whether consent had been granted, and leaving a powdering of orange and white fur on suit trousers, smart dresses, scrubs, and jeans without discrimination. His eyes were a peculiar sea-glass green, and his coat had the soft nap of a wild creature. He was my once-in-a-lifetime cat, the one all others would be compared to and found lacking. With Harry, I felt like the unpopular girl in school who’d landed the hottest boyfriend. Harry proved to be the perfect addition to my feline family. He was happy to curl up for a nap with Monty or chase Fred around the apartment. And my three cats were the perfect welcome-home after a long day at the hospital.

  * * *

  —

  I had the notion, through veterinary school and my internship, that the senior clinicians I worked with were godlike. They were the people I aspired to be, the goal I might one day achieve. I thought that with an academic career, I could lose myself in microscopic minutiae, focused so intently on a single viewpoint that there would be no space for loneliness. But, with the passage of time, I came to realize that neither the study of infectious organisms and biochemical pathways, nor the number of journal articles authored, would bring the happiness I was seeking.

  In the final months of my residency, echoes of confrontations with my resident mates and senior clinicians haunted my days in the hospital. I was furious that the gods I’d created in my mind were, in reality, made of the exact same cells, proteins, and molecules as I was. The end of my residency drew closer, and my decision to stay in academia or to leave became inescapable.

  The point of combustion cam
e on a Sunday. It had been a long weekend—the pick-ups from the emergency room were an array of bad diseases with worse prognoses. I was the senior resident on service and had taken the brunt of the transfers. By Sunday afternoon I was stationed in the ICU fighting to save a young dog from dying of protein-losing nephropathy (PLN)—a disease where the kidneys’ filtration system is damaged by inflammation or infection. This injury causes large holes to form in the tightly regulated barrier of the kidney (glomerular) membrane, causing essential proteins to be lost into the urine. I had seen enough of the disease to know there was little I could do to alter the grave prognosis. My previous attempts at treatment had resulted in dogs drowning in the intravenous fluids I’d administered in an attempt to save their lives.

  My patient was a two-year-old black, male Labrador retriever. The flat, recycled air of the ICU couldn’t cool the anxiety that was rising between the nape of my neck and the collar of my white coat. The flimsy paper with my patient’s most recent blood gas analysis that was stuck to my damp fingertips revealed what I most dreaded. The fluids I’d gingerly administered and fastidiously monitored had oozed into his lungs. Now there was nothing more I could do.

  The senior internal medicine clinician on duty that weekend was a young, tall, friendly woman who I imagined to be better suited to a junior high school library than a veterinary ICU. She had blond hair, always tied back in a ponytail, and small features that crowded in the center of her face. I dreaded being on clinics with her. Her special topic of interest, which she would discuss at every opportunity, was Lyme disease, a tick-borne infection of growing reputation. The purported consequences ranged from PLN to seizures to heart failure.

  “Dr. Fincham,” she said from behind me. “I was just finishing up my rounds and wanted to check in.” I turned to face her, and she looked down at the clipboard she always carried in the clinic. “How’s Buddy?” She smiled encouragingly.

  I shrugged.

  “I didn’t realize he’d moved to the ICU,” she continued. “I was looking for you in wards.”

  “Sorry. I paged you earlier. I didn’t like how he was breathing, so I moved him over midmorning.”

  If she’d been another senior clinician, I might have felt guilt at my lack of communication. Instead, I felt a defiant, childish triumph that my case had transferred without her knowledge.

  “How are things going?” she asked.

  “His blood gas looks bad, he’s hypertensive, and I think he’s developing pulmonary edema.”

  “Oh dear. Do you have him on anti-emetics?”

  “Yes,” I replied. Of course I do. “I started them yesterday, along with antacids.”

  She nodded. “Good.”

  It’s not good, though, is it? I wanted to yell. Look at this dog. He’s two years old, and he’s going to die. Why can’t you help me?

  “Do we know the underlying cause of his protein-losing nephropathy?” she continued. “I was wondering if you’d considered infectious diseases?”

  Go on, I thought, anger creeping from the base of my skull. Tell me about your research on Lyme nephritis. The indignation jolted along my jawbone with an electricity that bordered on excitement. Tell me some esoteric fact about the pathogenesis of the infectious organism that won’t make the slightest difference to my patient.

  “Yes,” I answered. “The emergency doctor submitted a tick panel when he first presented. It was positive for Lyme.”

  “How exciting. Would his owners consider a kidney biopsy? I’m looking at some new tests we can use on tissue specimens to prove the causative relationship between the Borrelia organism and the lesions we are seeing in dogs with PLN.”

  A kidney biopsy? An invasive procedure requiring general anesthesia in a dog who was dying. A derisive laugh escaped.

  For a second Dr. Wilson continued smiling. But then she looked down, her eyes welling with shocked sadness.

  “I think it’s a bit late for that,” I said, my voice growing louder. “I don’t think biopsying his kidney now is going to help, is it?” I figured she could have as much kidney for her experiments as she wanted in a few hours, when my patient was dead.

  I needed you to help me, I wanted to say. You’ve let me down. You’re supposed to be better than me.

  I took a step backward, immediately feeling the weight of my disrespect in the shocked silence of the ICU. Remorse swept away my fury, but I was too proud to apologize, and instead I left with tears swarming to my eyes. I’d wanted to show that veterinary medicine wasn’t only clinical trials and laboratory experiments. I’d wanted to bring down the gods I’d become disillusioned with. But I’d taken my frustration out on the wrong person and, in doing so, realized only a deeper anger with myself.

  A meeting with the section chief the following morning, an official apology to the disrespected senior clinician, and my promise to behave more professionally could not seal the jagged cracks that had ripped through the vision of the future I’d been driving toward. My growing internal disillusionment had finally broken through the brittle carapace I had formed, and once it was out it could not be returned. It was this moment, more than any other, that determined my future in veterinary medicine.

  Although I would complete my residency in a few months, I needed another year of study before I could take the board examinations and qualify as a veterinary internal medicine specialist. Most of my resident mates would be staying on at Penn, taking yearlong staff clinician positions to complete board certification before deciding on their next steps, but I would not be offered this chance. My growing ire had burned bridges, and it was time to move on.

  For the first time since I’d resolved to become a veterinarian I had run out of path to blindly follow. I would be leaving academia at the end of my residency, and I didn’t know what would come next. My visa was expiring, and I had to make the decision, yet again, to stay in the United States or return to the United Kingdom.

  In the perfect plan I’d formulated, I was going to return to England with my board certification, ready to study for my PhD in veterinary immunology. I’d even decided that I’d work in the lab at my alma mater. But with my waning conviction that academic medicine was my future came the realization that England was no longer my home. The few friends I’d kept in touch with were scattered across the country, and private specialty practices were scarce. My loneliness couldn’t be soothed by driving on the left or buying a lifetime supply of Marmite, and I had to acknowledge that my desire to return to my country of birth was less potent than I’d expected. My growing feline family tied me to the United States, but I felt a deep guilt over remaining so far from my family in England.

  It was an uncomfortable decision, but I applied for positions in private specialty practices on the East Coast. I ignored the warnings of my senior clinicians that it would be hard to study for boards while working, and that I still had case reports to submit. I found a practice in Baltimore that seemed like a good fit, and that offered me a position to start at the end of my residency. By stepping away from the university I knew it was unlikely that I’d return. You were either in or out. I understood what I was giving up, but the more I’d learned, the more invested I’d become in the animals I treated. Greater than the science and the method, the discovery of my patients, the revelation of their temperaments, and the understanding of their relationships with their owners had gripped me. In private practice, I could focus on this aspect of veterinary medicine without the procedural bureaucracy of academia getting in the way.

  * * *

  —

  Despite my trepidation at leaving the protective custody of academia, graduating to the real world was thrilling. I bought my first car. I rented an apartment in a converted warehouse in Baltimore—with central air—and I could finally afford cable. My new Fells Point neighborhood was right on the harbor, in a historic part of the city. It was the perfect place for my freshly liberated
life. The cobblestone streets and pubs on every corner reminded me of home, and I could walk to enough independent shops and restaurants to put my increased salary to use. The one-bedroom had plenty of room for Monty, Fred, and Harry, who could chase imaginary bugs and watch seabirds all day, while also finding time to locate the best kitchen cupboard to sleep in. It was a twenty-minute drive to my new clinic in the suburbs, and I found a local radio station that played indie music close to my own taste. I worked just four days a week, and my vacation schedule wasn’t determined by the academic calendar. I felt free.

  One of the first patients I treated in Baltimore was Zeke, a decidedly American-sized cat who easily weighed sixteen pounds. The hospital was newly built and situated in a small retail park of blandly similar buildings. The gray uniformity of the interior echoed the exterior, but its most attractive feature was that it was clean: The physical assault of thousands of dog paws, millions of animal hairs, and a splattering of bodily secretions had not accumulated to any significant degree.

  At our first meeting, Zeke sat hunched uncomfortably on the examination table, more ovoid than cat-shaped. We were in a small consulting room that offered, through tinted windows, a banal view of a dirt lot. Zeke had arrived at the clinic after the bloodwork his family veterinarian had run that morning showed severely elevated liver enzymes. These results, along with other indicators of liver failure, warranted his immediate transfer for intensive care.

  Zeke was a silver-brown tabby, and his coloring initially made the yellow hue of his skin difficult to discern upon examination. He was jaundiced, or icteric; a yolky yellow pigment had been deposited in his skin due to the abnormal processing of bilirubin by his liver. When I assessed the inside of Zeke’s ears and the sparsely haired stripes running from his ears to his eyes, the accumulation of bilirubin was so severe that it looked like he’d been colored with a highlighter. His gums were tinged orange, like coral lipstick, rather than a healthy pink. And the whites of his eyes—evaluated by lifting his eyelid to examine the sclera—were pure yellow.