My Patients and Other Animals

by Suzy Fincham-Gray

  The first twenty-four hours of testing would likely total over $1,000, not including the cost of hospitalization, intravenous fluids and medications, and, most critically, a blood transfusion, which would easily double the amount. If we were lucky, Sweetie might need only one blood transfusion, and a two-to-three-day stay in the hospital, but there was no way to determine if she would need one or five transfusions, or if her disease would stabilize in a day or two, or a week, or never.

  Stacey and Brian had already revealed their financial constraints, and my ideal treatment and diagnostic plans were likely beyond their means. If Sweetie’s owners became overwhelmed by the cost, I could lose the opportunity to treat her altogether. Cutting tests and treatments down to the minimum to get us through the next twenty-four hours would make the estimate smaller and less intimidating, but I would run the risk of missing something that could alter Sweetie’s outcome. My frustration was familiar and inextricable. What I wanted to do and what I could do for my patient were not the same.

  I grabbed a new treatment sheet from the file rack in front of me and threw away the one I’d been working on. I reconsidered my diagnostic plan and began removing tests. My heart accelerated when I imagined the conversation with my new boss. “That’s not what I would’ve done,” she would say, and proceed to tell me precisely what she would have done and why, which, I’d determined, rarely lined up with my intended course of action.

  For Sweetie, though, what I wanted—more than my boss’s approval—was to save her, and I needed to make some decisions before it was too late. I could see Sweetie from my spot at the central desk. Her white flank seemed dazzling in the fluorescent lighting, too clean and bright for the scuffed floor she lay on. I watched the effort she applied to each breath, and noticed the increased rate with which her chest rose and fell, a rapidity that should’ve been due to playing catch on the beach, rather than her tissues struggling to get enough oxygen because of her declining red cell count. She was too young to die of a potentially treatable disease. I needed to hurry up.

  I glanced furtively around the treatment room, looking for the large white-coated frame of my boss, although I would’ve heard her before seeing her. Her strident voice matched her crimson red lipstick, white-tipped French manicure, and Disney queen black hair. I tried to reassure myself that I knew what I was doing, bolstering my confidence by tallying the patients with idiopathic immune-mediated disease I’d seen, a number so large I couldn’t calculate it.

  I decided on my course of action and rewrote the treatment sheet. I’d ask the patient advocate—the person formulating and presenting the estimate to Stacey and Brian—to provide two versions of the plan. The first with everything I wanted to do, the second with only the absolute essentials of treatment and monitoring. It was a delicate balance. Often once an owner determined that the cost was too great, their decision became irreversible, no matter the adjustments made. At the same time, if the estimate underrepresented the expense of hospitalization, owners felt duped, angry that costs hadn’t been laid out more clearly. But disease was organic and unpredictable, and treatment courses had to be changed and changed again when new problems were discovered—these were factors that were not always possible to account for financially, and not always understandable for those footing the bill. The greatest conflict between my clients and myself in caring for my patients almost always surrounded money.

  I got up from the doctor’s desk to review my plan with Corey, the patient advocate. I was relieved that she was working the day shift. A small, pretty blonde with a sharp intellect, she had the understanding and empathy to easily make a connection with scared owners and explain treatment plans in a way I couldn’t.

  “What are they like?” she asked, looking over the treatment sheet.

  “They’re young, probably your age.”

  “Wow. I don’t have that kind of money.” Corey pointed to the four-figure number on her computer screen.

  “It’s a lot, but have you seen how cute Sweetie is? I think we can fix her, but she needs at least one blood transfusion.”

  “What’s wrong with her?”

  “I don’t know yet, but I’m guessing immune-mediated thrombocytopenia—the disease where the platelet count gets super low and they start bleeding everywhere.”

  “Like Patches?” Corey asked, referencing my boss’s patient from the month before.

  “Yes. But I hope Sweetie doesn’t end up like that. Poor dog, I thought her platelets were never going to increase. How many transfusions did she get?”

  “Four or five; her owners spent over two thousand dollars just on blood products,” Corey said.

  “Don’t tell Sweetie’s owners that,” I said.

  “Do they have the money?”

  “I’m not sure. They’re hard to read. I think the girl gets it, but the boy’s acting like he doesn’t care. If they don’t approve the full estimate, I’m hoping we can at least get blood into her and start immunosuppressants. I need you to figure out the most they can spend, so I can figure out what to do.”

  Corey looked at her computer screen. “We can cut some of the tests?”

  “Right,” I replied. “I’m hoping we’ll get lucky if we treat her for the most common thing.”

  “I’ll see what I can do. Are you going to be here or in your office?”

  “Here,” I said, feeling the need to stand vigil over my new patient while her fate was decided. “Good luck.”

  Corey got up from her desk and pushed through the double doors leading to the consulting rooms. All I could do was wait.

  Corey returned to the treatment room fifteen minutes later.

  “So?” I asked.

  “I don’t know yet. They don’t have the money. I gave them the CareCredit stuff, but they probably won’t qualify because they’re students. Stacey’s calling her dad to see if he’ll help out. If not, I don’t think they can even afford the CBC.”

  I looked at Sweetie and thought of Emma. “Maybe I could take her,” I said. “Maybe Emma needs a playmate.”

  “Are you kidding?” Corey asked.

  “I don’t know,” I replied. Imagining Emma and Sweetie curled on the couch, romping on the beach, walking on matching leashes. “She really reminds me of Emma, and if I don’t treat her, she’ll die.”

  Every day I encountered financial constraints—canceling diagnostics and omitting treatments. I’d euthanized patients due to the cost of necessary care and the lack of reasonable alternatives. If Sweetie’s owners declined the estimate, I had three choices: First, send her home with my best guess at treatment and hope she didn’t die from blood loss overnight. Second, I could assume her ownership and the associated treatment costs. Or third, I could put her to sleep, knowing that without a blood transfusion it was unlikely that she’d make it, and to send her home would only prolong her suffering.

  * * *

  —

  It wasn’t completely unprecedented for me to consider adopting Sweetie, but it was a scenario that hospital management tried to avoid—sometimes the original owner would have a change of heart and demand their pet be returned, or the staff member trying to do the right thing could be left with an unexpectedly large bill for which they were no more equipped to pay than the original owner.

  In most cases, animals were saved from euthanasia by the same complicated emotional connection I felt the first time I met Emma. A first-date kind of instinct that this pet was the right one—likely based on the same multitude of factors that determine the people we choose to surround ourselves with. In some cases, though, more pragmatic reasoning would result in an animal being saved. Young cats with urinary tract obstructions, like Tiger, who needed vital care but could fully recover, were occasionally adopted into the hospital’s feline blood donor program if their temperament was good and the only other option was euthanasia. After screening for the blood-borne infectiou
s diseases feline leukemia virus, feline immunodeficiency virus, and the red blood cell parasite Mycoplasma haemofelis, suitable cats would join the small colony of three to four others that lived at the hospital to provide blood for transfusion to critical feline patients.

  Cat blood was difficult to collect and store, making on-site donors the best option for supplying whole blood for transfusion to bleeding or anemic patients. By 2007, when I met Sweetie, canine blood banking in the United States was well established, but the technology for separating and storing feline blood components was still in its infancy.

  The first commercial U.S. canine blood banks were established in the late 1980s. Donor dogs, often from rescue organizations or specific breeding facilities, are screened for infectious diseases, temperament, and blood type, and then owned and housed by the blood bank. Animal Blood Resources International, the first commercial pet blood bank, reports that they rehome their in-house blood donors after one year of service. Hemopet, the first nonprofit animal blood bank, established in California in 1986, houses a closed colony of rescued greyhounds. They donate blood on average twice a month for twelve to eighteen months, and are then rehomed. These retired racing dogs seem like ideal blood donors, with their known medical history, docile personality, and perfect anatomy—prominent veins, a thin hair coat, and lean body condition.

  Since animal blood banks first became available, alternative methods for obtaining donors have become increasingly popular, given the potential animal welfare concerns about housing dogs solely for blood donation. Volunteer canine blood donation programs are now well established by universities and charitable organizations across the United States. Typically, healthy dogs over fifty pounds, between one and five years of age, and who test negative for blood-borne infectious disease, are eligible to become volunteer donors. Owners may bring their dogs to a set location, or mobile blood banks travel to communities to increase the accessible donor pool. The University of Pennsylvania’s Penn Vet Bloodmobile has pioneered this approach. Volunteer dogs are rewarded with a biscuit, a bandanna, and a belly rub. Their owners enjoy the knowledge that they are helping save other dogs’ lives, and both dogs and owners seem happy with the deal.

  In the late 1990s, when I was in vet school, British animal welfare laws dictated that blood could be drawn only from a live donor and given immediately to the recipient. The storage, or banking, of animal blood products was illegal. I understood the concerns of the British government—that for-profit blood-banking services might sacrifice animals for financial gain. Donor dogs exsanguinated to obtain blood products, and live donors kept in poor conditions to maximize the profit from their moneymaking donations, were practices whispered about in the United States. How, after all, did a dog provide consent for its donation of 450 milliliters of blood?

  It wasn’t until October 2005, after my arrival in San Diego, that British legislation permitted the banking of canine blood products by nonprofit organizations for transport to other veterinary facilities. By that time, I thought little about the ethical implications of using banked blood products; they were a standard part of my care for any animal that needed them.

  The feline donors in San Diego were typically those rescued from euthanasia for fixable problems. They led a decent life in a cat tree–adorned run in a quiet area of the hospital. They donated blood every sixty to ninety days, but I was guilty of flouting the rules when I had a critical patient in need of a transfusion and no donors were available. Sometimes the ethical considerations of feline blood donation tripped me up.

  Were we exploiting our donor cats for the sake of more-loved pets?

  It was a question I didn’t consider when ordering blood for my canine patients, but I thought more carefully when it came to cats. More recently the storage and separation of feline blood has become feasible, and blood banks now house colonies of cats to supply demand and, ultimately, be adopted out. But the long-term consequences of repeated sedation and blood donation can include renal failure, iron deficiency, and cardiac failure. These are risks that canine blood donors, due to their large size and ability to donate without sedation, do not run.

  Similar to humans, dogs and cats have specific blood types, with similarly serious consequences if incompatible blood is transfused. Cats, like humans, have naturally occurring antibodies to red blood cells of a different type, while dogs do not form antibodies to DEA (dog erythrocyte antigen) until they’ve been exposed to blood products. Blood-borne infectious disease screening, typing, and cross matching are necessary requirements in veterinary transfusion medicine, as they are in humans.

  I considered my options for Sweetie. She hadn’t received previous blood products, and I was willing to administer a red cell transfusion without a cross match. But I didn’t yet know if I’d be given the chance to try.

  * * *

  —

  I resumed my position on the floor next to Sweetie while Corey and I waited for her owners’ decision. I anticipated the flurry of technicians, catheters, and blood tubes once the estimate was agreed upon. I tested the idea of adopting Sweetie if her owners declined treatment, forming the picture of adding another dog to our family, prodding our routine gently like a Jenga tower to see if it would fall down. I would need to speak to Rob, and I could predict his practical answer, removed from the emotion of the treatment room. We didn’t have space for another dog in our lives.

  A receptionist popped her head round the treatment room door.

  “Corey, they’re ready for you again in five.”

  “Let me know if you need me,” I said when Corey passed by on her way to the exam room.

  Corey didn’t take long. “They want to talk to you,” she said. “Well, Stacey does; Brian’s outside smoking. It sounds like her dad might be up for lending her some money.”

  “Okay, wish me luck,” I said.

  In the consulting room Stacey seemed younger than she had fifteen minutes earlier. She was alone, and had pulled her feet onto the bench, hugging her knees. She seemed incapable of making a decision about what to eat for lunch, much less about whether to approve treatment for her dog.

  “Brian’s outside,” she said after I’d closed the door. “He’s freaking out about Sweetie. He really loves her.”

  “That’s okay. I’m sure everything seems overwhelming right now, and everyone handles stress differently.”

  Stacey shrugged. I wondered how much longer Brian would be around.

  “I spoke to my dad,” she continued. “He’s out of town, but he said he’d lend me the money. He always visits Sweetie when he’s around. Sometimes I think he likes her more than he likes me. He’ll lend me eight hundred, and I can get two hundred in the next day or so. There are some people who owe me money. Do you think that’s enough?”

  Stacey looked at me in a way I imagined she looked at Brian, or her dad, when she wanted something.

  A thousand dollars. A thousand dollars wasn’t much when it came to a dog in need of a blood transfusion and a hospital stay. “If Sweetie only needs one transfusion and we can get her home in a day or so I think we’ll be okay. I’m going to cut most of the tests to use the money for treatment,” I said.

  “Is she going to make it?”

  I paused. I didn’t know the answer. “I hope so,” I replied. “Most dogs with her condition do well with treatment, but occasionally, even with all the money in the world, we can’t save them.”

  “We could spend all this and Sweetie not come home?” Stacey frowned. “My dad’d kill me if she dies now.”

  “I wouldn’t recommend treating her if I didn’t think she had a good chance. But medicine isn’t exact, and we don’t know what’s going to happen until we try.”

  “We should treat her, then?”

  “Absolutely. I think we can get her through this.”

  “Okay, I guess. What do I do now? Can I see her?”

 
“I’ll have Corey go over the paperwork and then we’ll bring you back to see her.”

  I stepped out of the room and rearranged Sweetie’s plan in my head, tallying tests into essential, maybe, and not necessary columns on an imaginary worksheet. I walked back to Corey’s desk, considering how best to spend a thousand dollars.

  “What’s the deal?” Corey asked.

  “We have a thousand dollars. Most from her dad, and the rest she’s going to make up somehow.”

  “A thousand?” Corey looked skeptical. “The original estimate was for three.”

  “I know, but it’s all we’ve got. Let’s start again.”

  Corey pulled up a blank form on the monitor. I named a test or treatment, she typed it in, and we watched the number in the top right corner of the screen climb. We had enough funds for one night of hospitalization, routine bloodwork, a set of X-rays, and, most important, one blood transfusion.

  I thought about what a blood transfusion would provide. Sweetie’s main problem was a lack of platelets—which would not be replaced by a packed red blood cell transfusion. The best we could hope for was that the transfusion would buy us time while we waited and hoped for the immunosuppressants to kick in. Platelets are delicate, microscopic fragments of cells that are irretrievably damaged by the process of blood collection and storage—like fragile spring flowers that wilt and lose their color the moment they are plucked from the ground. Even if platelet-rich plasma, a costly and highly specific blood product, were available to replace her platelets, her overactive immune response would eat them as quickly as they could be poured in.