My Patients and Other Animals

by Suzy Fincham-Gray

  I waited until she’d exhausted her anxiety. I knew that the most likely problem was that Bagheera’s failing kidneys had caused severe blood pressure elevation, and he’d lost his sight due to a retinal hemorrhage—bleeding into the back of his eye.

  “Can you bring him in immediately?” I asked. I resisted telling her my concern. It was better to wait than to worry her unnecessarily, and I would know when I examined Bagheera.

  “I think so. I’m due in the lab at ten, but I can always stay late to finish up the experiment.”

  “You can drop him off for the day if that’s easier,” I said, realizing that her cat’s illness was only one of many stresses she was under as a geology PhD student. “Then we can take care of Bagheera and you can get to school.”

  “Thanks, that’s what I’ll do.” Her exhale was uneven. “But I hate leaving him; he’s spent enough time in a cage, and I promised him he’d never have to do that again.”

  I swallowed a gulp of sadness remembering her story of how, when she’d adopted him, the shelter volunteers had tried to dissuade her, saying he was shy and quiet, and not interested in playing or interacting. My guess was that loneliness had driven her to the shelter that day and she’d felt a resonance with the quiet, old black cat. My sadness grew not only from the isolation I imagined she felt and the life Bagheera had led before she saved him, but also from the loss she would inescapably suffer.

  “We’ll make sure to take extra-special care of him for you,” I replied. “You can pick him up whenever you’re able.”

  There was a faint rustle on the other end of the line and a moment’s pause, a silence so slight I might’ve missed it if I hadn’t been paying attention.

  “Do you think it’s time?” Her voice sounded muffled and distant. “I’ve never had a cat before, and he’s been such a great friend….I don’t want him to suffer. You’d tell me if you thought he was suffering, right? I’m worried I’m going to miss the signs. How will I know when it’s time to say goodbye? What should I be looking for?”

  “This sounds like an acute problem. And I’m hopeful we can get him back to where he was. I don’t think he’s suffering right now, but I’ll get a better sense when I see him. I would tell you if I thought he was in pain.”

  I thought of Monty.

  I’d answered the question How will I know? hundreds of times, gently suggesting that the decision be made when the bad days outnumbered the good and typical behaviors ceased. The signs of a diminished quality of life were as familiar to me as those of kidney failure, diabetes mellitus, or heart disease.

  “But,” I continued, “I can’t make Bagheera better. And I know his ongoing care is expensive both financially and emotionally. To decide not to go any further is a reasonable choice. I’m here to support whatever decision you make.”

  “You mean put him to sleep?”

  “If his care is becoming too much, then yes, that would be the best decision. Without everything you’re doing he probably wouldn’t still be here. But there are additional treatments to pursue if that’s what you’d like.”

  “I’m not ready to give up on him yet. I’ve got to give him a chance. He’s given me so much; he deserves that.”

  I was relieved. I’d soothed my ethical conscience, but the thought of euthanizing Bagheera was too close.

  When Bagheera arrived, one glance at his eyes told me I was right. The marbled grayness of his pupils stretched to the margins of his eyelids; only the faintest rims of his irises, slim enough to conceal their true color, remained. High blood pressure had caused bleeding into the back of his eyes, obscuring the light hitting his retinas and causing his pupils to dilate to allow every photon in. If I could lower Bagheera’s blood pressure into the normal range and keep it there, he might regain his sight.

  Bagheera returned to the clinic daily for the next few days for blood pressure measurement and for evaluation of the back of his eye—his owner rearranging her schedule to bring him in and take him back home before heading to the lab. By the third day of treatment his retina looked more normal and his pupils responded to light. He was regaining his vision. Excitedly, I described our success to Leslie, noting his constricting pupils and normalized blood pressure. I didn’t dwell on the medication that had been added to their daily routine or that his hypertension likely indicated worsening kidney disease.

  With rapid intervention and careful monitoring, we’d averted the crisis of Bagheera’s hypertension, which could have resulted in permanent blindness, seizures, and death. But there was no escaping that his disease was getting worse.

  At home, despite occasional glimmers of Monty’s old self, the broader landscape of his daily life was growing darker. His hoarse, old voice crying in the night sounded like a lament for an earlier time.

  I’d also come to doubt his vision. He could still navigate the house and occasionally landed a well-aimed swat at Emma’s nose, but, like Bagheera’s, his pupils were shallow, milky pools, and his flame-yellow irises were reduced to a scant rim.

  I realized that my cat, who’d survived the streets of West Philadelphia, tolerated a flight across the country while crouched under the seat in front of me, and made it through the addition of a dog to his household, was fading. I’d refused to quantify his decline clinically, so Monty’s demise wasn’t documented by blood pressure measurements or serum chemistry results like Bagheera’s, but rather by the steps he no longer took and the activities he no longer enjoyed.

  This was a dichotomy I didn’t examine too closely. I could justify the distinction between what I asked my clients to do for their pets and what I chose to do for my own. I was, after all, well qualified to make those decisions. But, regardless of my apparent certainty, when a colleague asked how Monty was doing, I still felt defensive that I wasn’t doing more.

  Even so, the abstract of when Monty dies wasn’t difficult to talk, or think, about. The gallows humor that carried me through rough days at the hospital rippled into my thoughts about Monty. At least we’ll get a good night’s sleep after he’s gone, I’d say to Rob when Monty’s confused, guttural crying woke us in the middle of the night. But my growing concern for my oldest pet was a topic Rob preferred to avoid. Monty was my cat, I was the veterinary internal medicine specialist, and Rob indicated that decisions about our pets’ healthcare were best left to me. It was a smart move on his part. He understood that I wanted his agreement, not his opinion, and given that my feelings about Monty swung from grief to denial to optimism, he could never give me the answer I wanted.

  When I compared Monty to my similarly ancient patients, there was one outcome I dreaded most—that he would die at home because I hadn’t seen the warning signs and had waited too long. His death without my intervention would be a failure. Concurrently, I panicked that I’d become inured to death and would choose to end his life when it was convenient for me rather than at the right time for him. Any decision carried an opportunity to second-guess myself.

  * * *

  —

  Death was the conclusion of many of the relationships I formed with my patients and their owners. Some, like Ned and Sweetie, I could discharge and return to their regular veterinarians’ care. But for my geriatric patients, the stepping up of treatments and inexorable stepping down of expectations was a more common progression, with the final act often being euthanasia.

  The term euthanasia originates from the Greek, eu meaning good and thanatos meaning death. It is a term that has been part of the veterinary vocabulary for decades, made unremarkable by the frequency of its use—an act made familiar by repetition.

  But euthanasia’s history in veterinary medicine is murky and difficult to track. Most of the documentation concerns the control of stray and unwanted cat and dog populations over the past one hundred years.

  The 2013 American Veterinary Medical Association guidelines indicate that humane euthanasia is best achie
ved by intravenous injection of an approved drug. And the vast majority of the deaths I’ve witnessed, and delivered, are a result of intravenous injection of euthanasia solution.

  Pentobarbital is the main ingredient. A barbiturate first used in humans in the 1930s to control epilepsy, it is now chiefly used by veterinarians for euthanasia. The solution also contains phenytoin—another anti-epileptic drug—and this combination, at high doses, causes respiratory arrest and cerebral death. Phenytoin contributes to cardiac suppression, and cessation of cardiac activity occurs after brain death. It can be used alone in conscious animals, but today’s recommendations, and my preferred method, is to administer a sedative and anesthetic first, to minimize the adverse and potentially distressing effects.

  When I arrived in the United States, where dogs are accidentally shot, police carry guns, and capital punishment is a fundamental part of the justice system, I had to quickly establish my relationship with animal death. I was a green intern, and during my first month practicing veterinary medicine I had to euthanize a patient. Without any guidance or supervision, I had graduated from the protective care of Peter and my other mentors.

  The examination room I’d used was the largest of the three at VHUP and had a door that connected directly to the treatment room, allowing the easy movement of patients—alive or dead—and making it the preferred location for euthanasia. The floor was gray, the lighting harsh, and the walls cheerless.

  I knew the patient, a cat, had been brought in for euthanasia. The owners had signed the paperwork at the front desk, and all that was required was for me to perform the requested procedure.

  I entered the exam room, already red-faced, and wiped my palms on my white coat before shaking the hands of the middle-aged couple sitting on chairs pushed against the wall. The carrier, with their cat inside, sat in the center of the metal exam table. I was struck by sadness for this cat who was separated from her owners by a few feet of scuffed linoleum.

  “Good afternoon, I’m Dr. Fincham,” I said, curtailing my smile into something more somber, which probably looked more like a grimace.

  “Good afternoon,” the man replied. He was white and heavyset, with a look that suggested he wanted this done so he could move on to something more important in his day, like watching a Phillies game. His wife didn’t say anything. She wouldn’t meet my eye, and her grip felt weak and ineffective in my hand.

  I stepped back toward the table and peered into the carrier to assess my patient. Inside was a petite calico cat. Her paws rested neatly in front of her, and her pink nose and green eyes were just a few inches from the bars of the door. She had a small, beautifully patterned, black, white, and orange face. I hovered, undecided, at the front of her cage. My directive was to euthanize my patient, not to examine her.

  “I’m so sorry to hear that Kitty isn’t feeling well,” I said, trying to catch the female owner’s eye.

  “Yep, well, the vet said she’s got bad kidneys, no cure for that,” the male owner said, “and we can’t take care of a sick cat, so it’s for the best, ain’t it?” His arms were crossed over his chest and with each word they seemed to inch higher beneath his chin.

  I nodded, feeling certain that Kitty’s owners could see my pulse pounding in my cheeks.

  “Now, can we get this moving?” he said. “This is gonna be quick, right? That’s what they told us.”

  I nodded again, forcing down the quaver rising in my voice. “Of course. I’ll just explain what’s going to happen and then I’ll take Kitty in the back to place her catheter.”

  “Get on with it then,” he said, turning to look at the wall.

  “Would you like to be with her when I put her to sleep?” It was a question I was determined not to forget; to get it wrong would be disastrous.

  “I don’t, but the wife does, so I guess we’ll both stay,” he said to the wall.

  “Good.” I paused, realizing that wasn’t the word I’d intended to use in this situation. “So, I’ll take Kitty into the back to place an intravenous catheter. When I bring her back, you can spend some time with her, if you’d like, before I administer the euthanasia solution.”

  “We won’t need any time; we’ve already said our goodbyes, haven’t we?” he said, not seeming to expect an answer.

  “Okay, then, when I bring her back I’ll bring the euthanasia solution with me. You can hold her, or she can sit on the exam table and you can stand next to her.”

  “What d’you wanna do, Donna?” the man asked, but she didn’t speak, only huddled closer to hide behind his broad, saggy biceps. “I guess you can just put her on the table, then,” he said. “Anything else?”

  “No, I don’t think so. Do you have any questions for me?”

  “Donna?” Another shrug. “Nah, we just wanna get this over.”

  I grabbed the carrier and headed for the door to the treatment room, already repeating to myself every word I’d rehearsed and forgotten to say.

  In the treatment area, once my hands had stopped shaking and I trusted my voice again, I evaluated my patient for the first time. I wondered, while I pulled her out of her carrier, if I could even call her a patient. And if not, then what was I? Once I had her out of the carrier, I could see that Kitty’s coat was sleek, and she didn’t have the skinny, hollowed-out appearance I would later learn was a sign of chronic illness. It was my first month out of school, and I lacked the experience and confidence to question her owners’ decision. I would do the job I’d been asked to do.

  Because the room where Kitty’s owners waited was directly off the treatment room, they couldn’t have failed to hear her screaming and yowling when we tried placing her intravenous catheter. “Typical calico,” the technician said, searching for a cat muzzle and a pair of leather gauntlets to restrain her. “They’re all like this, Jekyll and Hyde. Sweet as pie one minute, trying to rip your face off the next.”

  I nodded, hoping to imply my vast experience with calico cats and my similar frustration, while my hands fidgeted uselessly. I tried to ignore the terrible knowledge that these were the last moments of Kitty’s life.

  “How much do you want?” the technician asked when she’d placed the catheter.

  “Uh?” I replied, trying to remember the recommended dosage of euthanasia solution—one milliliter per ten pounds—and also estimate Kitty’s weight.

  “We usually use three for a cat,” the technician said.

  “That sounds right. And what do you normally give as a sedative?”

  “I’ll get you some thio, okay?”

  “Great, thanks,” I replied, hoping my relief at getting help didn’t sound like excitement.

  “Do you want an eighteen-gauge needle or do you want me to dilute it?” It was a question I hadn’t considered. “It’s super thick, and you’re not going to get it through a smaller needle. Some people dilute it; others just use the eighteen-gauge. What do you want?”

  I had no idea what to do. A larger-bore needle looked scary, whereas diluting the solution would increase the volume and take longer to give—an idea I didn’t relish. “I’ll take the eighteen-gauge, thanks.” The memory of the male owner’s attitude made my decision.

  I watched the technician draw up the syrupy solution. It seemed to ooze rather than flow into the syringe. The candy pink of Barbie cars and PowerPuff girls, it was shocking in its joviality. And unmistakable.

  Back in the consulting room, I placed Kitty on a folded towel on top of the steel table. I waited for a reference to the tumult I was sure they’d heard, but neither Donna nor her husband said anything. Donna came to stand next to her cat, one hand resting tentatively on Kitty’s back, the other grasping the edge of the table. Her husband sat unmoved.

  I fumbled the needle of the syringe into the port of her catheter, my fingers slick from nerves. When I grasped her front leg to better situate the needle, she neatly flicked her paw
, sending the needle and syringe skidding across the table. The uncapped needle pointed at me accusingly, but I felt only relief that I hadn’t stabbed myself or anyone else.

  “Maybe she’s not ready to go,” Donna said, while Kitty wriggled beneath her hand, and I scrambled to grab the syringe and recap the needle.

  “We’ve been through this,” the husband replied. “This is for the best, you know it is.” I looked down at the syringe wrapped tightly in my hand.

  When I asked Donna to hold her cat so I could better secure the needle that would deliver the deadly solution, I was surprised by the tight tang of regret and sorrow that grabbed my larynx. I remembered Peter’s words when I was holding a gun to a horse’s head: “Don’t close your eyes,” and I imagined him saying, “For God’s sake, don’t bloody cry.”

  I began again, relieved that the interruption would allow me to give the sedative I’d briefly forgotten about. The room was silent, and I wondered if I was the only one holding my breath. I administered the sedative, and the tension in Kitty’s body was replaced by absolute stillness. I was barely aware of Donna, whose tears were now pooling on the steel tabletop.

  All I wanted was for this moment to be over. I ignored the feeling that I was doing something wrong, that I should’ve spent longer talking to these people, even though I felt intimidated and uneasy. It was too late, and I was too naïve. And, I realized, if I didn’t perform this procedure, I couldn’t know what would happen to this small calico cat.

  I hadn’t yet formulated my script of platitudes to describe the process of death, the soothing words to put a grieving owner at ease and offer comfort. I said nothing. I remembered to listen to Kitty’s heart to ensure activity had ceased before confirming her death. I carefully wrapped her in the thin towel, providing some dignity to her loose, empty body, but her head flopped heavily out of my grasp, and she began to leak urine, which trickled warmly down the front of my white coat. I exited the exam room with an inelegant urgency and laid her on an empty table in the treatment room. I held my tears until I escaped to the nearest bathroom.