“We need to check his blood-clotting to see if he needs a plasma transfusion before I can place his feeding tube, and he needs an ultrasound, maybe a liver aspirate, chest X-rays, and a blood gas.” I checked each off on my fingers, which were vibrating with frustration.
“I know. But this isn’t Penn. It’s only me and Heather this afternoon, so you need to give me a break. Everyone has things they need me to do. Why don’t you go and work on records, and I’ll page you when we’re ready for the ultrasound.”
“And how long will that be?” I asked. She was treating me like a naughty child being sent to her room.
“An hour or so.”
“I’ll leave him here in his carrier, then?” I tried to keep my outrage from my voice.
“Sure, that’s fine.”
“See you soon, Zeke. We’re going to take really good care of you,” I said, leaving the treatment room before I could say something I’d regret.
The doctors’ office was in the basement. The walls were an uninspiring cream, and the furniture gray, which matched the carpet. The air smelled new—fresh paint and the woodiness of plyboard. I was the only one to use the office; my colleagues preferred to type records and return phone calls at workstations in the treatment room.
At my desk I kicked off my new shoes. After three years of wearing scrubs and sneakers, I’d splurged on a new wardrobe I’d thought appropriate for a young, confident veterinarian. Sensible but fashionable. Tailored pants and colored shirts that fit under my white coat, with coordinating cute shoes, which I quickly realized were not designed for crawling around on all fours examining a Great Dane.
I was twenty-seven, regularly carded in bars, and still challenged by clients asking “Are you a real doctor?” or commenting “Wow, they train ’em young these days.”
I’d decided that establishing my seniority was best achieved with wardrobe. And to some degree I’d been successful. However, I was still referred to as the “young one with the funny accent.” I had yet to realize that tap dancing in my fancy shoes on the polished hospital floor, testing how fast I could spin down the hall on the wheeled office chair, and singing to my patients while performing ultrasounds were doing more damage than a wardrobe could repair.
While I regained the feeling in my toes, I stared at the wall where I wasn’t permitted to affix anything. The cards and pictures I’d accumulated at Penn were reluctantly stored away. I opened Zeke’s chart to begin typing his record. It was a disadvantage of leaving academia that the mundanity of writing subjective, objective, assessment, and plan (SOAP) notes; case summaries; and discharge instructions now fell to me, not a student.
I turned first to the page of serum chemistry results and looked down the column of three-letter acronyms, with their corresponding numbers, conveniently identified as high or low based on a comparison to the normal range.
Although Zeke’s clinical picture most likely indicated hepatic lipidosis, I tested out the other possibilities on my list and felt a flop of hesitation. I knew the typical enzyme patterns associated with different types of liver disease, but not every patient followed the textbook, and I couldn’t review my differentials with an attending clinician, or bounce the case off a resident mate. Maybe I’d missed the atypical presentation of an infection or tumor in Zeke’s liver. Don’t chase zebras, I reminded myself.
I would run the standard tests: an abdominal ultrasound to look at his liver, and a tiny ultrasound-guided-needle aspiration to ensure his hepatocytes looked under the microscope as I imagined them. I would continue monitoring his liver enzymes to ensure they decreased, and add broad-spectrum antibiotics in case of a lurking infection. The plan was familiar, but there was no safety net. I could—and had to—practice medicine the way I wanted, and develop my own clinical intuition rather than rely on someone else’s.
“Hey, Suzy!”
I turned sharply. John, the head internal medicine specialist, stood in the doorway. Tall, with the slight stoop of a reluctant teenager embarrassed by his new height, he could summon an imposing demeanor when pressed, but goofy usually came to mind when I thought of him. John had taught in London for a few years; he had been one of my lecturers at the Royal Veterinary College, before returning to the United States and joining this internal medicine practice.
“Hi, John. How’s it going?” I fumbled my feet into the shoes discarded under my desk.
“Pretty good, just grabbing some lunch. I finished that ultrasound, so you’re up next.”
“Thanks. I’ll get started. Would you be able to take a look at it with me? I haven’t done many liver aspirates yet, and I’d really appreciate your help.”
“I can take a look when I get back—not sure how long I’m going to be gone, though. I’ve got some records to write up and then a few more appointments, but I can help if I’m available.”
I wanted to seem confident and competent, but I didn’t trust my ultrasound skills. I’d watched hundreds of abdominal ultrasounds, peering over the radiologist’s shoulder, trying to guess what the two-dimensional, monochrome image represented. Was it normal or abnormal? Enlarged or shrunken? With someone else holding the probe I was good at identifying the changes. But with it in my hands, all I could reveal was a sea of unidentifiable structures.
John was no longer my teacher, and the priorities in private practice were different. My entreaties were unlikely to be effective. Hours spent discussing cases or reviewing journal articles was time away from seeing cases—ultimately the only way the practice could survive. Suppliers of medications and equipment didn’t take IOUs, and the laboratories we sent samples to didn’t care if our clients paid their bills. I was acutely aware that every time I wanted to add a diagnostic test or treatment I had to obtain “approval from the owner.” There was no academic department to appeal to if care wasn’t approved, no fund of benefactors willing to help owners out. I had to be scrupulous.
John had at least ten years on me in the field, and he’d already warned me, “Be careful. You’re going to burn yourself out,” when I’d eagerly grabbed the phone with a referring vet on the other end. “Burnout” was something I couldn’t imagine. To me, more was better. I’d developed a habit of trawling the emergency room in our building for possible cases every day, peering through the cage bars, sneaking a look at treatment sheets, seeing if any of the patients might have a problem I could fix.
I’d found some cases that showed how much I’d learned during my residency. There was the skinny, rumpled, and sad-looking young corgi being treated for unresponsive kidney failure, whose prognosis was worsening by the day. I snagged the record, reviewed the labs, and diagnosed adrenal insufficiency. With some steroids on board, the dog fully recovered and became a long-term patient of mine.
Then there was the tan boxer who barely fit in the cage he occupied. He’d presented with abnormal behavior, due to a profound elevation of his blood sodium level, but no one could figure out why. Ask about his water consumption, I suggested. He hadn’t had water for days. His owners had restricted his access to stop him from peeing in the house. We carefully corrected his electrolyte levels and sent him home with more appropriate house-training recommendations. And then there was the case I was called in for to perform an emergency endoscopy. It was a dog who’d, ridiculously, swallowed a cheerleader’s baton, somehow cramming the entire thing from his larynx to his stomach. Unfortunately, as much as I wanted to remove the baton with endoscopic prowess, no instrument was large enough to fit through the two-millimeter scope channel and lasso the offending object. I had to relinquish the dog to surgery and go home, but not without first marveling at the X-ray for twenty minutes.
* * *
—
The fire exit slammed when John left the building for lunch. I headed for the treatment room, planning what I’d say to Shannon to advocate for Zeke and his care. I wasn’t taking no for an answer this time. I’d work
ed myself into a tizzy by the top of the stairs. Already infuriated by the imaginary argument we’d had in my head, I wasn’t looking forward to our conversation.
I burst into the treatment room with a falsely cheery smile. “All right. Let’s do this.”
“Shhh. Be quiet. We’re placing Zeke’s IV catheter,” Shannon replied.
I clenched my back teeth. Why was it taking so long? Why wasn’t he on intravenous fluids yet? Were his blood tests running so I’d have results to help plan my next steps? The empty tubes lying on the counter suggested this hadn’t happened, either.
“Is there anything I can do to help?” I managed.
“No,” Shannon replied. “We’re good. I guess you could set up the ultrasound if you want.”
“I was hoping Zeke would’ve started fluids by now. I’m worried that he’s dehydrated.”
“We haven’t had a chance. John’s ultrasound took longer, and then we had to do aspirates, so we’re getting to Zeke now.”
“I’m really worried about him. We should’ve started his treatments by now.” I knew it was the wrong thing to say.
“We’re getting to it. You’re not the only one with patients to take care of.” Shannon kept her back to me, carefully taping the catheter into Zeke’s vein. He hadn’t put up any resistance, another sign of his debilitated condition.
“I understand,” I said. “But Zeke’s really sick, and his treatments need to get going as soon as possible.”
“I know, you’ve already said that,” Shannon replied, hooking up the intravenous fluids hanging on the pole next to Zeke. “How much potassium do you want?”
“Do we have the results of the blood gas yet?” I asked.
“No.”
“I was waiting on those results before making a decision about supplementing potassium.” I felt her irritation pulse toward me. “I know you’ll have to go back and add it later,” I said, trying to strike a note of understanding. “But I want to do what’s best.”
“I do, too,” Shannon said, turning to me. “We’re still figuring out the way you like things, so you’re going to have to be patient.”
I heard the accusation in her voice, and I stepped away. This wasn’t a battle I’d win. “I’ll get the ultrasound set up, then,” I said. “Could someone run the coagulation profile to see if I can do a liver aspirate today? Thanks.”
I turned away before I could see the reply on Shannon’s face.
By the time I’d completed my ultrasound scan, the results of Zeke’s blood tests were available. They revealed that Zeke needed a plasma transfusion to replace the clotting factors his liver was unable to make, to reduce the risk of him bleeding uncontrollably from a liver aspiration or feeding tube placement.
Before I could give the transfusion, I had to call Mrs. James to obtain her permission and review the additional cost—carefully choosing my language to imply that Zeke was sick enough to need this extra step, but not that he was too sick to get better. Without placing a feeding tube, I couldn’t reverse the damage to his liver. Without a plasma transfusion, I couldn’t place the feeding tube.
Mrs. James agreed, and Zeke shuffled a step closer to recovery. He would need an extra night in the hospital before we could safely anesthetize him for feeding tube placement.
The next morning, I arrived early to assess Zeke. I’d made up my mind between midnight and my alarm going off that I was going to place his tube even if his blood-clotting times weren’t perfectly normal, and regardless of what Shannon had to say.
I lifted Zeke from his cage and noted that his abdomen was stained a deep yellow from the urine he’d passed overnight. He hadn’t the energy to move away, and it had soaked into his skin.
“Morning, Suzy. How’s Zeke? He still looks pretty yellow.” John had also made it in early.
“He’s okay, but his coags were prolonged yesterday, so I was hoping to place his feeding tube this morning. Do you think Shannon could monitor anesthesia and get it going before the day gets too busy?” With John’s approval, I knew Shannon would be more willing to help.
“I think so. Let’s look at the schedule. As long as Heather can help with appointments we should be fine.”
“Thanks. I’ve been worrying about him all night.”
“I know, but you’ve got to remember that this isn’t Penn, and you’re used to a different pace. Since you came on board the caseload has increased, and we’re all adjusting. We’ll probably add more technicians if things stay the way they are, but, for now, try easing off a little.”
John’s reprimand stung my cheeks, and I remembered the burnout warning he’d given me a few weeks earlier. I wasn’t worried about easing off. I was worried about being a disappointment, not practicing well enough, not working hard enough—those were the measures of success I thought everyone valued.
I swallowed my worry and forced neutrality into my voice. “Of course. It’s important that the plan works for everyone.”
I gently placed Zeke back in the cage, untangling the IV line caught underneath his plump body. He wasn’t interested in what I was doing. I wanted him to show me he was okay, maybe with an irritated flick of the paw when I straightened his IV or a swift bat when I opened his mouth to assess his gums, but he remained still.
My procedure was cleared on the schedule, and I prepared the instruments I needed. I caught Shannon appraising me out of the corner of my eye.
“I haven’t seen an esophageal tube placed before,” she said. “This is going to be a first.”
“It’s pretty straightforward. It only takes about ten minutes. I like the esophageal placement when I don’t want a patient under anesthesia for long.”
“John prefers to place gastric tubes. I feel comfortable with those, but for this you’re going to have to tell me exactly what you need.”
I looked at the materials I’d arranged on the Mayo instrument stand next to the treatment table. I reviewed my mental checklist.
“Do you have a lighter?” I asked.
“What for?” Shannon replied.
“I cut off the end of the catheter at an angle so food doesn’t get stuck at the bottom. And then I heat it gently with a lighter so there won’t be any sharp edges against the esophageal lining.”
“Yeah. I have one.” She pulled a lighter from her pocket.
Interesting, I thought. I didn’t know she smoked.
“I think we’re ready,” I said, reviewing my mental list. “Wait. Let me check one last thing.” I scuttled to the opposite side of the room to look at the printout I’d made of the technique the day before. Right side down, left side up, tube goes in the left side. It was what I’d thought, but in the final moment I wanted to be sure.
“Is there anything else you need to do before we start?” Shannon asked. “Your first appointment is in thirty minutes.”
I kept my back turned to the treatment area and grimaced my answer. My hands were already shaking, and I hadn’t picked up the scalpel yet. This would be my first time performing a procedure without the watchful eye of an experienced anesthesia technician and a senior clinician a pager bleep away.
“That’s everything,” I said. “The sooner we get the tube in, the sooner Zeke will feel better.” I kept my tone even and my hands stuffed into the pockets of my white coat until the last minute so Shannon wouldn’t notice them quivering.
Despite Shannon’s obvious doubts of my ability, once Zeke was anesthetized and she was in control of her patient, the procedure was smooth and uneventful. I showed her how to wrap the tube once I’d placed it, and she agreed to be Zeke’s primary caregiver for the remainder of his stay. I was eager to start Zeke’s feedings once he’d recovered, to begin reversing the fatty accumulation in his liver, but I had to be patient, gradually increasing his caloric intake over several days until we reached our goal. If he was still doing well at that
time, he would go home.
Over the next forty-eight hours we could see Zeke improving. He tolerated his feedings well, and he showed signs that his liver damage was reversing: He began to use the litter box and resumed a more cat-like posture. His lab results confirmed that his bilirubin was decreasing, even though his skin remained alarmingly yellow. His treatments were time-consuming; after the food had been prepared and warmed, it initially took forty-five minutes to administer, so his starved stomach could accommodate the food. Once the process was over, it had to be repeated only a few hours later.
Mrs. James visited daily, and by day four he began responding to her—a clear sign he was going to make it. With his intravenous fluids disconnected, and in an examination room for a visit, he began exploring the environment he was newly interested in. His belly swayed with each meandering step.
“I think he can go home tomorrow,” I said when Zeke flopped comfortably onto the floor.
“Are you sure?” Mrs. James asked. “Is he ready? I don’t want anything bad to happen at home.”
“I think he’s ready,” I said. “He’s feeling much better, and his lab values are all coming down. He’s doing very well.”
“It’s okay if he needs to stay longer. We’ve talked about it, and we want to do whatever’s best.”
“I know it seems overwhelming to think about taking him home, but he’s going to do just fine.”
I watched Mrs. James eye Zeke warily. “I’m not sure about that tube,” she said. “I didn’t realize it would be sticking out of his neck like that; I’m worried I’m going to hurt him.”
“You’ll do great. In a few days you’ll be a pro!” She couldn’t lose her nerve now, not after the thousands of dollars’ worth of care Zeke had received. “We’ll have everything ready for when you pick him up. Shannon’s going to do a feeding with you today as practice. That way it won’t seem so scary. I’m going to give you full written instructions, and we’ll send home everything you’ll need. Can your husband come in as well?”
My Patients and Other Animals Page 13