My Patients and Other Animals

by Suzy Fincham-Gray

  Like an excited child who, having learned to read, shouts out the wording on every street sign, I read every animal I met. The thousands and thousands of patients I had cared for taught me how to figure out an animal with my eyes, ears, and hands. It took longer to grasp that I needed to evaluate humans in a similar way. Just as I had discovered how best to approach an aggressive dog or nervous cat, I also had to modify my tone, manner, and vocabulary based on the people sitting across the exam room. I had to interpret their behavior and adapt mine accordingly in order for me to best help their pets.

  After nine years of practice, I was less in thrall of internal medicine, and the diseases I diagnosed and treated had become familiar, so I turned my attention to the owners of my patients, and I learned. I learned that, as a doctor, I could choose different ways of saying “I don’t know”: ways that inspired confidence and respect, and others that garnered skepticism and the loss of a client’s trust. I learned ways to ask questions and really listen to the answers, making it clear that I cared about what the owners had to say. I also learned to listen to what wasn’t said and to investigate the pauses in conversation to reveal the one piece of information a diagnosis might rest on.

  At every exam room door, I took a moment to connect with the version of myself that was empathetic and compassionate, regardless of how those sitting in front of me behaved.

  * * *

  —

  Ned was a small reddish-brown dog, with black tips to the whiskers of his snout. His hair had a wild wiriness that suggested some of his genes were of the terrier variety. His body-to-leg-length ratio was weighted in favor of rooting around under bushes rather than covering any significant distance at speed. I imagined that, if he could talk, his sentences would be finished with an exclamation mark. He was a children’s picture book–type dog, whom I expected to get into trouble with strings of sausages, cat chasing, and rumpuses at polite dinner parties.

  He was young, about two years old, and his delight at meeting new people made his physical examination challenging; only three paws contacted the ground at any time due to his inexhaustible energy.

  On my way to the exam room, with Ned skipping and doodling along next to me, tugging on his leash to get to the next adventure, I pictured his owners—from the pages of the same children’s book. A jolly family enjoying long walks, picnics, and romps on the beach.

  Entering the room, I was met by two smiling middle-aged women, who both stood up from the bench when Ned yanked his leash out of my hand and bounded across the small space toward them. He thumped his front paws onto the taller woman’s shin, and stood expectantly on his hind legs. She bent to pet his head and gently return all four of his feet to the floor before extending her hand.

  “Good morning, I’m Karen, and this is Julie. Clearly, you’ve already met Ned.” I shook their hands and met their smiles with my own before inviting them to sit. They were dressed similarly in blue jeans, light hiking shoes, and half-zip fleece sweaters in complementary shades of blue and green. They both wore plain gold bands on their ring fingers, but no other jewelry.

  Ned, now off his leash, sniffed around the perimeter of the room intently, scooping up scraps of forgotten fur with his whiskered nose. He sneezed exuberantly and a speckle of blood sprayed onto the pale floor. Julie wiped the splatter with a tissue from a jean pocket. When she looked up I noted the concern in her eyes. “This has been happening more and more,” Julie said. “Our floors are covered in old towels to protect the carpet—”

  “But we don’t worry about the carpet as much as we worry about Ned,” Karen interrupted, taking the bloodstained tissue from Julie and putting it in the trash can.

  “We’re so worried, aren’t we, Jules? Our vet said it could be something serious, and we haven’t slept since we saw her last week.”

  “I hope that by the end of your appointment today, we’ll have a better idea of what’s going on with Ned, and the best way to help him, okay?” I said.

  They nodded, Karen’s dark curly hair bobbing around her ears enthusiastically. Julie was more hesitant and restrained.

  “First, I’d like to go through Ned’s history,” I said, “get to know you and him a little better, discuss what might be going on, and then talk about where to go from here. I’ll start by asking some questions before explaining my thoughts, and then I can answer any questions you have.”

  Karen began describing the past few months of Ned’s life in a tumbling, contradicting narrative. She was clearly excited to have a chance to tell her dog’s story. Julie sat quietly by her side, comfortably listening.

  When Karen finally paused, I said, “It usually works best if I start by asking some routine questions, and then we can get to the more specific details.” I was relieved when they smiled at each other and then me. I hadn’t offended them. I doubted it was the first time Karen had been gently asked to be quiet.

  My order of history-taking was precise. From listening to hundreds and hundreds of stories, I’d honed my narrative and always repeated the same sequence of questions to ensure I didn’t leave anything out.

  “How old is Ned?”

  “He’s about two,” Julie said, her voice quieter than Karen’s but with a deeper resonant weight that drew my attention. Her hair was the color of weathered cedar, cut to her shoulders and tidily tucked behind her ears. While Karen seemed bouncy and fun, Julie had a seriousness less suited to my imaginary children’s book. I’d have to work hard to gain her trust. “Our vet said he was a year old when we got him. But we don’t know for sure.”

  “Where did you get him?”

  “We adopted him from Baja Dog Rescue,” Karen said. “Poor thing, he was living on the streets in Tijuana before the rescue picked him up. His life must’ve been awful.”

  Mexico. I tucked the information into the “important” file in my brain.

  “He was so skinny,” Karen continued, “but he was such a sweetheart, we fell in love with him instantly.”

  “Does he live with any other animals?”

  “Our old dog, Maggie, died last year,” Julie said. Karen gestured for her to continue. “She was sixteen and she had cancer. We got Ned a few months after we put her to sleep. She’d been with Karen since she was a puppy, and when we moved in together she became our dog.” Karen took Julie’s hand.

  “I’m sorry to hear about Maggie,” I said.

  “She’d been sick for a while, so it was the right thing to do,” Karen said. “But it was still really hard. Now our vet said that Ned could have cancer, too, and we just can’t believe it. He’s so young—it’s not possible, is it?” Both women moved closer together at the mention of cancer, and a hardness, like defiance, crossed their faces.

  “I don’t think so,” I said, wanting to silence the vibrating echo of “cancer,” because I understood the terrible significance it held. “But I don’t yet know what’s wrong with Ned. We’ll talk more about that once I can see a complete picture.”

  I glanced at the clock on the wall above Julie and Karen’s heads. I didn’t want them to feel rushed. Sometimes I’d joke that my appointments were more like an interrogation, and when I had to flip a question over and over until I asked it in a way my client understood, it did seem a little like a police interview.

  “When did you first know something was wrong with Ned?” I asked.

  “A while ago,” Julie replied. “A month or two before his first visit to the vet. You should have those records.”

  I looked at the papers on the exam table. “Yes. It looks like you took him in at the end of May, about six weeks ago?”

  “That sounds right, doesn’t it, Jules?” Karen said. “I think we noticed the problem with his nose in February.”

  “And what was your concern at that time?”

  “We found a spot of blood on his bed. But we didn’t know where it came from,” Julie said. “W
hen we called the vet they recommended monitoring him at home since he was feeling fine. Then there was nothing abnormal for a week or so.”

  “We thought maybe he’d caught a toenail,” Karen said, “or scratched himself on something. He loves rummaging around in the bushes at the bottom of the yard. But when we looked at his feet we didn’t find any blood. We couldn’t figure it out.”

  “Was there anything else out of the ordinary at that time? Was Ned’s appetite normal?”

  “He was perfectly fine,” Julie said, a hint of defensiveness in her voice. “He got up, ate breakfast like always, went on his walk, and chased squirrels. Nothing was wrong.”

  “Did you notice any sneezing or nasal discharge?”

  “No, nothing,” Julie continued, the opposition still there. “Of course, he sneezes sometimes when he’s sniffing around the garden, but he’s so nosy, he’s usually just snorted something up his nose.”

  I knew that it was worry driving her resistance. I understood the need for owners to blame someone, often themselves, for their pet’s illness. The questions of what they could’ve done differently or how they could’ve prevented their pet’s disease were a common part of an initial appointment. My answer was always the same—even if I knew that their smoking had most likely caused their cat’s asthma or feeding their dog table scraps had probably contributed to his pancreatitis: There’s nothing you could’ve done differently; you’ve taken excellent care of your pet; please don’t blame yourself. Apportioning accountability was not my role, but I’d realized that helping to heal not only my patient but also their owner was.

  “How often does he sneeze?” I asked.

  “Hardly ever,” Julie replied. She had contradicted herself. And I knew that “hardly ever” could mean once a day or once a month. “A while” could be a week or a year. The real answer about Ned’s clinical signs likely lay deeper, but Julie wasn’t ready to admit it yet.

  “Is that once a week? Once a month? More? Less?”

  “In the beginning, he was sneezing less than once a month, wouldn’t you say, Karen?”

  Karen nodded. “But now it’s more often,” she said. “More like once a day.”

  “How long has he been sneezing daily?” I continued.

  “Do you really think he sneezes that much?” Julie interrupted. “It’s not that bad. I’ve only heard him sneeze once in the past week.”

  “That’s because you’re out at work most days,” replied Karen, smiling gently at her partner, and Julie smiled back, letting her guard down for a moment.

  I was relieved they were smiling. I was often an uncomfortable witness to arguments between partners about what a pet was or wasn’t doing, how often it was doing it, and whether or not this constituted a problem. I wondered if MDs experienced such disagreement in their consulting rooms.

  “He’s been sneezing daily for the past two to three weeks,” said Karen. “He has a short episode after he wakes up or goes outside.”

  “Have you noticed any blood when he sneezes?”

  “Well, that’s how we realized the blood in his bed had come from his nose, right, Jules?”

  “That’s right,” Julie said, and Karen jumped in before she could say anything else.

  “It was a few weeks after we first noticed the spot. He sneezed and we saw a splatter of blood on the concrete outside, so then we realized that the blood must’ve come from his nose. We thought there might’ve been other times we weren’t aware of, but that was the first time we definitely saw blood coming from his nose.”

  “It stopped straight away,” said Julie. “And after the vet reassured us on the phone, and said it was probably allergies, we weren’t overly worried.”

  I continued to heighten the accuracy of my sketch of Ned’s disease, adding color and definition, and the third, emotional, dimension. The good news I would share was that my physical examination had failed to identify the typical changes I associated with serious nasal disease. Ned’s nose was a moist, even chestnut brown. Aspergillosis, a nasty fungal infection that, once established in the nose and sinuses, produces toxins that eat through the bone, causes a distinctive depigmentation around the affected nostril—a pale, nude pink against the deeper coloration.

  Additionally, the lymph nodes draining Ned’s nasal passages were normal in size and texture, and there was no distinctive, rotten odor to his breath suggesting a foreign body lodged in his nose, or an oronasal fistula connecting his oral and nasal cavities, setting up a foul infection. His face was symmetrical, and he didn’t exhibit pain when I palpated his facial bones, making a tumor less likely. And, finally, the airflow through both nasal passages was normal, suggesting there was no mass blocking the movement of air. Although I didn’t yet know the cause of Ned’s problem, I was beginning to drop diseases off my differential diagnosis list. And while the information from his examination and history settled in my mind, one morsel had risen to the top. Ned had been adopted from Mexico, and the diseases south of the border, despite Baja being only a half-hour drive away from San Diego, were different.

  Rob and I had ventured to Mexico only once after our arrival in San Diego. Tales of drug cartels, corrupt cops, and the potential for explosive diarrhea after drinking the water had discouraged our traveling there. But when friends suggested a beach camping/surfing weekend on the Baja peninsula, we gave in to our adventurous sides, despite my disinterest in either activity. We drove a short distance south on the I-805 to the Tijuana border crossing.

  The San Ysidro border between the United States and Mexico is the busiest land crossing in the world, with an estimated three hundred thousand people passing through the border by foot and motor vehicle daily. Scattered among those entering the United States are dogs, cats, and other animals. Some are pets returning from a family vacation. Others may have been taken to Mexico for more affordable veterinary care. Many are dogs and cats rescued from the streets of Tijuana and the Baja region who are being transported to the States for adoption.

  The requirements for importing an animal from Mexico—or any other country—to the United States are surprisingly minimal. Cats do not require documentation to cross the border. Dogs require a valid rabies certificate dated not less than thirty days and not greater than twelve months prior to travel. If screwworm is endemic in the country of origin, which it is not in Mexico, then the animal must be examined and declared screwworm free by a veterinary official five days prior to shipment. Border control has the authority to perform a physical examination to ensure the health of any animal prior to admittance into the United States, but it’s not reported how frequently such checks occur.

  Dogs imported from Mexico are unlikely to be carriers of rabies: The country is considered free from canine-transmitted human rabies. There are, however, other infectious diseases, typically transmitted by ticks and other arthropods, that can be carried invisibly. These infections may remain dormant until clinical signs appear weeks, months, or even years after the dogs have been adopted in the United States. Differences in climate, environment, and the wild animal populations that serve as hosts for insect vectors all affect the geographic distribution of disease.

  In order to diagnose an infectious disease, you first have to recognize the possibility of its presence. Testing for hundreds of different infectious organisms—viral, bacterial, fungal, protozoal, and parasitic—is specific, requiring either identification of the organism or of the body’s response to it. There is little, if any, overlap between tests, and selecting the most appropriate, based on history, physical exam, and other results, is essential.

  Given the variable geographic distribution of disease, a travel history is necessary to guide diagnostic choices. Without this knowledge, and an understanding of the diseases endemic to the region visited or lived in, a veterinarian may overlook or misdiagnose treatable conditions. This was a mistake I was determined not to make. To lose a patient
because I hadn’t asked the right question and hadn’t looked for the right disease was inexcusable. I’d come close on a couple of occasions, and had only identified the vital information after a repeat journey through a patient’s history when things didn’t add up and treatments weren’t working.

  * * *

  —

  Because Ned had lived in Mexico, the disease that immediately sprang to mind was ehrlichiosis—a tick-borne infection that can cause a decreased platelet count and subsequent nasal bleeding. It was a disease I rarely diagnosed in dogs native to San Diego, but tick infestation, and exposure to the Ehrlichia organism, was frequent in stray Mexican dogs. What didn’t fit this diagnosis, however, was that Ned’s bloodwork had been normal. His platelet count was within the reference range, and his blood globulin levels weren’t elevated—often a sign of chronic inflammation or infection. Given these results, it was difficult to justify testing for this disease, and I moved it to the bottom of my differential list.

  Ned had finally planted himself across Karen’s lap, his nose pointed to the floor like a bored child amusing himself by hanging off the edge of the couch. His back leg rested on Julie—a reassuring point of contact. The women sat with their thighs touching, and they ran their fingers unconsciously through Ned’s scruffy coat.

  After I’d asked my last question, I saw impatience on Julie’s face. I could tell there was something she wanted to say. I noticed Karen’s hand edge closer to Julie’s on Ned’s back. I wasn’t sure if the gesture was meant to hold Julie back, or to support the concerns she clearly wanted to express.