“Dr. Jones said that Ned could have cancer in his nose,” Julie said. “And we won’t put him through a lot. We’ve talked, and we don’t want to spend money on expensive testing if we can’t do anything to help him.”
I listened to Julie’s tone and watched Karen’s expression. Had Maggie’s illness blunted their tolerance of veterinarians and medicine?
“We know people who’ve spent thousands of dollars on their pets only for them to die a few months later, right, Jules?”
I forced neutrality into my voice. “Of course, I know how worried you are. But I think that given Ned’s age and good health, it’s unlikely that he has cancer.”
Karen tightened her grip on Julie’s hand and nodded, as if in confirmation of what she’d thought all along.
“When a dog has one-sided nasal bleeding,” I continued, “it’s important to rule cancer out, but there are many other possible causes of Ned’s condition.”
Karen seemed more relaxed, but Julie remained soberly quiet.
“My recommendation is to perform a rhinoscopy.”
“What’s that?” Julie asked.
“It’s a procedure to look at the inside of Ned’s nasal passages. We pass a small scope with a camera on the end up his nose to evaluate the lining and biopsy any areas that are abnormal.”
“What do you expect to find?” asked Julie. My answer, If I knew, then I wouldn’t need to look, remained unsaid.
I shuffled the possibilities in my head. What was I willing to commit to? My clinical gestalt told me I could help Ned. His Mexican heritage nagged at me. What could he have been exposed to before arriving in San Diego?
“It would be uncommon for allergic or inflammatory disease to cause nasal bleeding from only one side,” I said. “Most dogs with this type of problem also have nasal discharge and congestion, which Ned doesn’t have.”
“We looked up nasal bleeding on the Internet when we realized where the blood was coming from,” said Karen. “And we kept coming across two diseases, cancer or a fungal infection. What was it called, Jules?”
“It began with a ‘P’ maybe?” Julie replied, squinting to envision the word.
“Aspergillosis?” I said, relieved that this time “Dr. Google” hadn’t led my clients down a completely crazy path. Karen nodded enthusiastically.
“Aspergillosis is a possibility. It does cause nasal bleeding, and I’ve diagnosed it several times in San Diego. But dogs with this infection are often uncomfortable and have changes in the pigmentation of their nose. I don’t see either with Ned.”
“That’s a relief, isn’t it, Jules? That fungus sounds terrible. The pictures of those poor dogs’ noses were awful.”
“But you haven’t told us what it could be,” Julie said, instantly sobering her partner’s mood.
“There are infectious diseases in Mexico that we don’t see in San Diego. Ned may have picked something up before you adopted him, and that’s what’s causing problems now.”
“Really? We’ve had him for months,” said Julie. “Why haven’t we seen a problem before?”
“The rescue said he was healthy, didn’t they, Jules? A vet in Mexico examined him before he was released, and he got all his shots. Our vet looked him over as soon as we got him, and she didn’t notice anything abnormal, either.”
“He certainly could’ve looked healthy and not shown any signs initially,” I said. “But sometimes, if the infection is hidden, signs can develop over a longer period of time.”
“We thought we were doing the right thing by adopting a dog from Mexico,” Karen said. “There are so many strays. And the pictures on the Internet are awful.”
* * *
—
I knew the pictures she was talking about. Emaciated dogs shrink-wrapped in their skin, rummaging through garbage to find something—anything—to eat. Dogs curled into cardboard boxes, impossible to tell from a single image if they were alive or dead. Dogs with mite infestations so severe they had pulled, ripped, and scratched out all their fur, their skin rumpled, thickened, and discolored, like the surface of some undiscovered planet. Despite the missing hair, muscle, eyes, and sometimes even limbs, there was still something essentially canine in each picture, the same dogginess that has drawn humans and canines together for millennia.
The ethical debate I was unwilling to open with Julie and Karen was one I considered each time I went to Petco. On my way to pick up cat food, litter, or other pet supplies, I’d walk past the playpens of puppies and dogs from Baja Dog Rescue and other organizations that had been set up for adoption events.
The adoption of dogs from developing nations, such as Mexico, Thailand, and India, is becoming an increasingly popular option for those considering a new pet. The Humane Society International (HSI), an animal welfare organization, estimates that the worldwide dog population stands at around 700 million, with 250 to 300 million—over a third—considered “street dogs,” without an owner, home, food, or healthcare. It is unsurprising that the average life expectancy of these dogs is less than four years. Improving the welfare of street dogs in countries where the human population endures similar struggles is challenging. Charities such as HSI work to improve conditions for these animals by providing healthcare services and population control in their native countries. Other organizations consider a better option to be exporting dogs and, less commonly, cats, to the United States for adoption.
A valid rabies certificate and a place on a flight—usually funded by the adopter and costing around $300—are the only two requirements for a dog to begin a new life in America, no matter its country of origin.
In 2014, the Winter Olympics in Sochi, Russia, threw an international spotlight on the plight of street dogs. Hundreds of pets were abandoned when their owners were forced out of their homes for construction of the Olympic stadium. Left to roam the streets of Sochi, these dogs were slated for government-sanctioned extermination prior to the opening of the Games. Private contractors killed upwards of three hundred dogs a month until the global media picked up the story, and the force of international opinion demanded an alternate solution. A few Olympic athletes adopted strays and returned with them to their home countries at the end of the Games, and a temporary shelter outside the city, funded by a Russian oligarch and now registered as a nonprofit, housed the thousands of stray dogs that would otherwise have been euthanized. The shelter is still in operation today, and they reported that by the end of 2015, sixty-five dogs had been rehomed outside Russia, costing 49 percent of their budget. Unfortunately, the wider street-dog problem in Russia—it’s estimated that thirty-five thousand stray dogs live in Moscow alone—has not garnered the same attention.
Without addressing the factors that drive the massive street-dog population in developing countries, the transportation of homeless animals to the United States for adoption will do little to solve the problem. And the potential trouble for importing countries could be significant. In May 2015, a young female dog rescued from the streets of Cairo, Egypt, was transported with seven other dogs and twenty-seven cats to the United States for adoption. Rabies vaccination documentation was believed valid, and the animals were distributed to a number of foster and adoptive homes on the East Coast.
A week later, the young female dog became sick with clinical signs consistent with rabies. After the dog was euthanized, testing confirmed the presence of canine-variant rabies, and the rescue organization ultimately admitted to falsification of the vaccine certificate that the dog had traveled with. Eighteen people underwent rabies postexposure prophylaxis—treatment to prevent the development of rabies in humans exposed to the virus—once the diagnosis was confirmed. Fortunately, none developed the disease.
Government agencies such as the U.S. Department of Agriculture and the Centers for Disease Control and Prevention continue to tighten regulations for the increasing number of dogs and cats arrivi
ng in the United States from rabies-endemic countries, but as the recent case from Egypt demonstrates, the risk clearly remains. Aside from rabies, a reportable disease, there are many unrecorded cases of imported animals carrying other infectious diseases into the country. And the potential for the introduction of diseases previously undocumented in the United States remains a concern.
But we also tend to forget, in light of those poignant videos from other countries, that the homeless pet problem has not yet been solved in America. It is estimated that around 6.5 million pets enter shelters each year. These cats and dogs may be strays, those abandoned and picked up by good samaritans or animal control officers, those relinquished by owners who can no longer care for them, or animals seized as a result of neglect or other welfare violations.
Statistics released by the American Society for the Prevention of Cruelty to Animals indicate that, on average, 1.5 million of these animals are euthanized every year. Some are considered unadoptable due to poor health or behavioral problems, but many are healthy yet are killed due to lack of shelter space and resources. This translates to a vast number of uncared-for, unwanted animals destroyed before they find a home.
Significant efforts are now being made in cities and counties across the United States to end the euthanasia of adoptable animals due to overcrowding and lack of shelter funding.
One solution is to transport unwanted animals from areas of socioeconomic depression, where intake rates are typically high and adoptions are low, to those in more affluent regions where widespread spay-neuter programs and better owner education result in lower shelter entry and higher adoption rates. Even in this model, the transport of infectious diseases along with their cat and dog hosts must be considered.
The displacement of approximately six hundred thousand cats and dogs following Hurricane Katrina in 2005 highlighted the problem of transporting animals of unknown health status, with no veterinary records. Animals who were relocated to rescue organizations across the country carried with them infectious organisms endemic to the Gulf Coast, the most common being Dirofilaria, the parasite responsible for potentially fatal heartworm disease. Dogs infected with heartworm who were transported to areas where the disease was uncommon ran the risk of delays in diagnosis and appropriate treatment.
I knew where Ned had come from. I wasn’t going to let that information slip through the cracks while I searched for the cause of his nosebleeds.
* * *
—
Surreptitiously checking the clock again, I saw that the hour for the appointment was almost over. To keep my day running smoothly I needed to finish up and have the financial estimate for my diagnostic plan approved. I didn’t like keeping my clients waiting, and I knew that an early disruption would result in apologies for the remainder of the day.
“We can schedule the rhinoscopy for later this week,” I said, “and hopefully get to the bottom of what’s going on.”
Karen and Julie turned to each other. “I think that’s how we’d like to proceed. What do you think, Jules?” Karen said.
“I think we should see the estimate first. But, yes, that sounds like the right thing to do.”
“I’ll get the estimate drawn up,” I said. “I perform procedures on Thursday mornings. Ned will need to be dropped off around eight, and he’ll stay until later in the afternoon, to make sure he recovers well.”
“Will he be under general anesthesia?” asked Julie.
“Yes, but Ned is a good candidate for anesthesia. There’s always a small risk, but his age and good health make that risk very low. And without performing rhinoscopy we won’t know why his nose is bleeding, or what we can do to help. I understand how worried you are, but I think he’s going to do well.”
Julie looked down at Ned, who’d hopped off their laps to sit expectantly at the consulting room door, suggesting that, for him at least, the appointment was over.
“All right, Ned, we’re almost done,” Karen said. “Come here, it’s not time to go yet.”
Ned looked over his shoulder, and then resumed staring at the door, pawing impatiently at the tan paint when it failed to open.
“Ned, you just have to wait a few more minutes and then you can be on your way, okay?” I said and squatted down to encourage his attention. He doodled over to me and began sniffing the pockets of my white coat. “I don’t think there’s anything in there you’ll like.” When I bent closer, the head of my stethoscope, which was hanging around my neck, swung forward and bonked him on the nose.
Ned let out a small, surprised yelp and backed away toward his owners.
“I’m sorry, little man,” I said. Great, hitting a dog with a nasal problem on the nose is really going to help the owners’ impression of me.
“It’s okay, Ned,” Karen said, scooping him from the floor. “It was an accident; you’re fine.”
“I’m going to get the estimate, and if you have any questions please let me know. Otherwise we’ll see Ned on Thursday morning. No food after eight P.M., but he can have free access to water.”
“It’s going to be a rough morning, Ned,” said Karen. “No breakfast. He’ll let us know about that, won’t he, Jules?”
“He’ll forgive you,” I said, smiling. “He seems like the forgiving type, right, Ned?”
He looked at me and wagged his tail in response.
“Wait here, and someone will be in with the estimate shortly.”
“Thanks, Doc,” said Karen. “We’ll see you on Thursday.”
After I gave Corey the information for the estimate, I headed back to my office thinking about Ned’s exploration of my pocket with his nose.
* * *
—
Karen and Julie approved the estimate, and the rhinoscopy was scheduled for Thursday morning. When the day arrived, I was impatient to get started, and hovered anxiously over my technicians while they double-checked the anesthetic protocol and setup for the procedure. Once Ned was anesthetized, I positioned him on his front with his head slightly raised on a folded towel, his nose parallel to the table. I resisted my urge to skip the preliminary steps and immediately scope the right side of his nose to try to determine where the bleeding was coming from. I didn’t want to be too hasty and miss something.
I started the way I began every rhinoscopy, by fully evaluating Ned’s mouth and pharynx to look for abnormalities that could cause nasal bleeding. I carefully examined his teeth for signs of infection, but they were pristine.
I palpated along his hard palate for areas of softness or swelling that might indicate a mass or site of infection. I looked in the back of his mouth to evaluate his tonsils—small, taffy-pink slivers of tissue peeking out of their crypts at the base of his tongue. Everything looked normal.
Next, I examined his nostrils and the bones of his face again—easier to do when he was asleep and not trying to lick me. There was nothing to find. So far, Ned looked completely healthy.
After I’d completed my examination, I evaluated the nasopharynx—the area above the soft palate that connects the nasal passages to the pharynx. I had to access the region by flexing the tip of my endoscope into a J to hook above the soft palate, which could be a tricky maneuver, especially in smaller dogs like Ned. After a few tries, some muttering, and a couple of swearwords, I positioned the scope correctly. I was looking for masses, polyps, or foreign bodies that could hide out in the small cave, but all I saw was the pink, smooth, normal mucosa, or mucous membranes, of the nasopharynx. There was nothing to indicate the source of his problem. I was starting to feel a little nervous. What if I didn’t find anything?
Next, I looked directly up his nostrils. Left side first, then right—normal to abnormal—but it was hard not to go straight for the right, where I knew the problem lay. The inside of a dog’s nose is packed with intricately scrolled, perfectly arranged turbinate bones. Covering these bones is a thin mucosa des
igned to humidify inspired air, trap particles and microorganisms, and provide a large surface area for the detection of odiferous particles—a component of a dog’s terrific sense of smell. The Italianate convolution of the turbinates is beautiful on a CT scan of a dog’s nose, but it’s a tight, difficult maze to navigate with a scope only a few millimeters smaller in diameter than a nostril. If the left side of Ned’s nose were normal, there would be little to see other than the smooth folds of mucosa crowding the tip of the scope.
After a few minutes of maneuvering around the left nasal passage, trying not to cause too much irritation, I’d failed to identify any abnormalities.
It was time to look in the right side of Ned’s nose. I hesitated, afraid that I wouldn’t be able to solve the mystery.
I first directed the scope into the lower section of the nasal passage. I inched along, looking for blood or discharge oozing between the turbinate bones—a path to its origin. I’d passed the scope only a centimeter into the nostril when I noted a raised bump of tissue on the floor of the nasal cavity that immediately started bleeding when my scope brushed against it. I’d found what I was looking for, but what was it?
Edging back a few millimeters, I flushed the area with saline to get a better view. When the swirling flames of blood dissipated I could clearly see a small raised mass, like an irregular toadstool head. I inserted a slim biopsy forceps and grabbed a piece of the tissue. An instant swell of blood overwhelmed my view, and I removed my scope to assess the biopsy—a few millimeters in size—before placing it in a formalin container.
The jaws of the biopsy instrument encompassed the tiny chunk of tissue, a small tag poking between the edges of the two cups that had closed to extract the piece. I opened the biopsy jaws and carefully removed the section of whatever was causing Ned’s nasal bleeding. I gently rolled the piece across a microscope slide to evaluate the cells—a sneak peek before the pathologist’s report came back.
My Patients and Other Animals Page 24