Sunday, August 19, 2012

To Break A Heart

I tell my clients that the last thing they want to do is to make my day interesting, for boring, even tedious, is generally better for their pet’s health and happiness, and as a consequence, theirs’. Bring me another flea bite allergy, another simple gastritis, yet another cat peeing outside the box. I do this all day long. Sometimes during the worst allergy season of the year, it seems like I could record my first office call of the day and then simply leave, for my staff could play the recording for each subsequent client, and it would fit. Sure, I’m being useful on days like this, but it’s not all that compelling for me. And after all the years, I’ve gotten these simple, routine things down pat. I’m helping, but I’m not all that interested. I’ve done this all before.

In this profession, when you are helping, doing the job, and just fixing the simple things, you can go home at night with some degree of satisfaction. We all know that the average day will not bring those overwhelmingly ecstatic moments that you might want to experience doing this. But usually we can look in the mirror without needing to explain to ourselves why we do this work.

Sometimes we get to deliver puppies, or remove the cancer that would kill and toss it away in the bucket. The simple application of the correct medication can affect a cure. And on occasion, when the need is evident to all, we are blessed to deliver the gift of a humane death to a beloved but aged four legged companion. On such days, we done good.

And then there are the days like this past Friday. Mrs. Greatclient has been visiting this practice since before I arrived, and I’ve been here four decades. She can rattle off the names of forty-five years of her dogs, fond memories all. Decades and generations of dogs that she has presented, for both routine care and problems large and small. Not wealthy, but employed, so she fits into the better half of my clients, she has always done the best she could to keep her dogs happy and healthy. So she brought Brandy in that day to see if I could discover what had gone wrong with her.

It’s been a long year for Brandy. A boxer, she’d been a rescue dog, relieved of her duties in a puppy mill to move in with the Goodclients. At best we have an estimate of her age. But she is a doll, always a joy to work with, a patient companion for their other boxer who is a bit shy. One never goes out without the other. And Mrs. Greatclient and her husband dote on the two of them. This spring, when Brandy came up lame on her front leg, and I couldn’t get to the root of the problem, I referred her to a surgeon friend of mine who has a knack for fixing such things to see if he might help. Turns out Brandy has two bad knees, and two bad elbows, and they aren’t candidates for surgical fix, so the right combination of drugs and supplements have been applied, and they have worked wonders so far.

Then last week Mrs. Greatclient called because Brandy just wasn’t herself. ADR. She ain’t doing right, Doc. Brandy just lacked energy. She wouldn’t eat her regular food, but would only take treats from the hand. She drank a ton of water, but didn’t want to play long with the other dog. You could look into her eyes and see something was amiss.  Something, but nothing in her history suggested any particular problem.

I could sense her lack of energy, but Brandy’s physical exam was unexciting. I couldn’t tell what was wrong from that. So I pulled the blood tests, and without suspecting anything exciting, I sent them off to the lab.

The results came back via the fax machine the next morning. Liver enzymes OK. Blood glucose OK. Kidney numbers OK. Serum proteins OK. Red and white blood cell counts OK. Electrolytes OK, except for the calcium, which was way high. That twitch in the hair on the back of my neck…. For now it had gotten interesting. And like the brilliant soft-spoken detective of a mystery novel, I set my thinker to work.

An elevated calcium level by itself generally doesn’t cause major havoc in a dog’s body, but the things that raise the calcium level can. Calcium is the smoke, and I needed to find the fire.

A bunch of things can go wrong to raise blood calcium levels. A long list of bunch. In this job you mentally go down the list. The first three or four most common causes are malignancies, the answer we were hoping not to find. Then you run into the kidney failures, various poisons, monstrous dietary mistake, major hiccups of the parathyroid glands, and few other rare and weird things. Many of these answers would be tragic too, but some were repairable. And since my physical exam and the first set of tests hadn’t turned any problems I could blame, the mystery deepened.

The first thing to do is make sure that the calcium level truly is that high. Sometimes somebody mishandles the blood sample or the lab’s machine screws up. No point going all bonkers if the number is simply a mistake. So we repeated that test on fresh blood, and added in the second way of counting up the calcium, just to confirm. Both were elevated.

I also took the opportunity to recheck some of Brandy’s body parts, her lymph nodes and that rude grope around of her belly that I had done earlier, just to make sure I hadn’t missed anything. And I snapped on the rubber glove for the rectal exam that should rule out one of those cancers that can raise calcium levels. No change. These parts all seemed fine.

Another test, a check of parathyroid hormone levels was needed next. This hormone is responsible for raising and lowering calcium levels, to keep things at the right level. When it goes wrong, calcium goes wrong. And while she’s here for that blood draw, let’s take some radiographs of her chest and abdomen, just to rule out some things. Mrs. Goodclient took time off from work for this visit, so we must get a much accomplished as we can.

My wife, who happens to be my assistant, called me when the films were developed. I hadn’t found anything nasty to this point in Brandy’s workup, so I was hoping these would be normal too. 

They weren’t.

You can’t see the lymph nodes in a dog’s chest when they are normal. When they have grown to the size of my fist, you can’t miss them. Lymphoma. Lymph node cancer. I’d found the fire. So I also drew the job of telling Mrs. Goodclient. 

She wasn’t surprised, for I had prepped her for this eventuality. Ya can’t ignore the statistical probabilities in this game. I was trying very hard to find something I could fix, and instead found the bad thing I can’t. My heart sank, but this was nothing compared to what I landed on her. She nearly collapsed in grief, and had not my wife rushed into hug her, so the tears could blast out and defuse some of the internal explosion, I feared I might be calling 911.

The next day I fielded the phone call. Was I sure? Can we do some surgery? How long does she have, and how much will she suffer? The questions that always accompany the sinking in of such news. I answered each as best I could, explained those frustratingly few things we can do to help her precious friend. 

All that schooling, all those years of practical experience, all my best intentions, and the best I could do is try to break her heart as gently as I could. You don’t want to keep me interested. Sometimes I don’t want it either.


  1. We all love our pets so much and they become a part of the family. It was for this scenario alone, I had put off getting a puppy. I dread the day something happens to her.
    Great post!

  2. I just had this same scenario, virtually. And then I euthanized her :(

    And, for the record, I hate these stupid real person commenter verification things. I can never read them.

  3. Awww. Sadness. It's true. A "boring" day is a good day for our patients. An "interesting" day is usually not so great for the patients.

  4. Through the grief, we appreciate your honesty, honest effort, and empathy.

    1. Yes...what the good Officer said. Thank you.

  5. I can see my last week, a cat with (possibly) one of the most frustrating disease: FIP.
    So sad and frustrating

  6. This is very true. I'll take a day of routine Carpal Tunnel Syndrome and migraines over "interesting" anytime.

  7. True dat. You never want to be interesting to your internist:-/

  8. I tell my patients that you don't WANT the doctor to know you...

  9. I have heard that there is a Chinese curse, that translates to "May you live in interesting times"

    I want my pets on the "uninteresting" list.

  10. *hugs* we had a rough day yesterday too, hope it gets better for ya doc.

    Vet Tech

  11. Thank you for the article of how it looks from your side. It reminded me how my cat was diagnosed with lung cancer...

  12. My dog was diagnosed with cancer a year ago, and she's been on palliative care ever since. Metronomic, aka low dose chemotherapy with an NSAID. It shockingly made her tumor decrease, then she had a bad reaction so we switched her chemo and her tumor slowly grows. Then we switch to the "good but bad" chemo for a week and her tumor shrinks. Back to "not as good but better for her" chemo for a few months, rinse and repeat. No one thought her cancer would respond that well to chemo, and I'm just happy to have a dog that acts like nothing is wrong with her.