"And, when you want something, the entire Universe conspires in helping you to achieve it." -The Alchemist, by Paulo Coehlo



Thursday, September 25, 2014

Tales From The Trenches: When You Know They're Going To Die

I will start this post saying that if you want to read this, do so promptly because I might decide to remove it after publishing. It is a strange post and a dark one, and one that has been wanting to be written for a long time now. Months.

Over the winter I had started my Tales From The Trenches series and then it came to a grinding halt when we started a bad run of euthanasias at work. There were more bad endings than happy endings, and I simply didn't want to talk nor think about work when I wasn't physically at the veterinary hospital, so I stopped writing about it. 

There is no doubt in anyone's mind that euthanasia is the hardest part of the veterinary profession. I don't care if you don't agree with the concept: I think it is a wonderful thing and I wish with all my heart that it was a legal option for humans with debilitating and/or terminal illnesses with poor quality of life. Who wants to slowly die of cancer? I sure don't. Why? Why do we have to suffer for months in pain in a hospital bed until our bodies give up? Why??

When a pet is euthanized, they are often given a strong sedative and then the lethal injection itself. In our hospital, we always always place an IV catheter for this purpose, whether the owner chooses to be present or not, as it makes things go so much more smoothly. And what is it like when it goes smoothly? The pet falls asleep and is gone within seconds. Peacefully. Painlessly. Quickly. They literally look like they have fallen asleep, enough so that sometimes owners have a hard time believing that they are gone. 

I can't think of a better way to go. For man or beast.

It still doesn't make it any easier for the owner that has to make this decision nor for the veterinary staff that work with this scenario day in and day out. One of the major drawbacks of emergency and critical care is that there is SO MUCH death. We see the worst of the worst. It is wonderful when an animal defeats all odds and makes it. But more often than not, the miracle does not occur and they don't survive. Or the owner can't afford the cost of the treatment that might not save the pet anyway. Or the animal is just too far gone with too many issues.

One of the skills the experienced ER tech develops is an uncanny ability for knowing when an animal appears fine but is critical, and when they appear to be very sick but in fact are not.

One time we had an older Golden Retriever walk in the door. I assessed him in the lobby while his owner told me his story. He was 10 years old and had been brought in for suddenly not acting like his usual self at home. He was wagging his tail, but I just got this bad feeling while looking at him. I couldn't pinpoint why. The dog was panting happily and he had pink mucous membranes with a normal capillary refill time of less than 2 seconds.  I checked his femoral pulse: it was very fast at 170 beats per minute, and thready. Not nice and steady. Red alert: this dog was in the beginnings of shock and doing a good job of hiding it. His owner needed to fill out paperwork at the front desk so he could get checked in, so I asked for permission to take his dog back to the ER treatment area so the doctor could take a look at him. The owner had no problem with this, so I borrowed the dog. Dr. J was in the ER waiting. "There is something really wrong with this dog. I think he could be a hemoabdomen." 

Hemoabdomen literally means "blood in the abdomen". They can be caused by trauma like being hit by a car, but most often they are the result of a bleeding tumor, usually in the spleen or liver. They commonly present with pale gums, bounding pulses and a distended abdomen, none of which this dog had. The inciting factor in having the dog brought to the ER is most often a sudden collapse at home +/- a vomiting episode. It is a death or death situation: take the dog to surgery and remove the spleen or affected liver lobe (unless the cancer has taken over the whole liver, in which case the patient must be euthanized. You can't live without your liver) and prolong their life for a few months whether you put the dog through chemotherapy or not...or don't do surgery and have to euthanize because the dog will bleed to death otherwise. Hemoabdomens can be caused by a slow bleed, where you see a dog with less severe symptoms if the owner catches it early, or they can be caused by a sudden massive bleed where the dog goes downhill rapidly, sometimes in a matter of hours. It is the tumor that decides how fast it will bleed. It is a devastating emergency because most of the time, these dogs are absolutely fine up until the moment their body can't compensate for the bleeding anymore, and it catches their owners completely by surprise.

Now, there are exceptions: every once in a blue moon, you get a hemoabdomen resulting from a benign splenic mass. You remove it and the dog lives a long happy life. In 7 years working in this field, I have sadly only witnessed this twice. :(

Dr. J assessed the dog and thought maybe there was something wrong with his heart. We took chest radiographs and in a corner of the view, you could see a glimpse of the abdomen. It didn't look normal. The dog also was starting to look less and less bright as the minutes ticked on. Some dogs will put up a facade for their owners to hide that they are not feeling well, but once in the ER with us will tell us the truth. This dog was telling us what was going on. Dr. J used our ultrasound machine (sonogram in human medicine) to take a quick peek in the patient's belly.

There was free fluid. He ran out of the ER to talk to the dog's owners to let them know what was going on, and returned to obtain a quick sample of the abdominal fluid we had just seen.

It was blood. Diagnosis confirmed.

I was praised for my wildly accurate instincts in this case but it's not the kind of thing that you want to be right about. 

This dog went to surgery and made it, but the tumor in the removed spleen was not a benign one. I don't know what the owners elected after that, nor how much time he had remaining after his surgery. I just know that he walked out of the hospital alive, and sometimes that is enough.

Dr. J is one of our senior staff doctors. He is in his early 30's and is one of the ER favorites both amongst techs and doctors. Everyone loves working with him. His medicine is honest and matter-of-fact, and he has a great sarcastic sense of humor and a mind like a whip. He's one of those people that can positively change the atmosphere in a room just by walking into it. He is one of our most efficient doctors, seeing triple the amount of cases that the other vets will see in the same time frame. Which also means he is the one that euthanizes the most animals. It is just a matter of numbers: a third to half of the patients we see in the ER will die.

He'd been having a particularly bad run when this kitten was brought into our ER. She had all sorts of things wrong with her and was barely a year old. The issues were mostly congenital. It was a wonder she had lived as long as she had.


The owners elected euthanasia. It was the right thing to do given the circumstances. The owners chose to be present for the procedure, which was done in an exam room.

Dr. J brought the kitten's body back into the ER afterwards, bundled up in a towel pressed to his chest. His face was red, and he gently lay the kitty on the table in front of me so I could process her body while he silently stepped out of the room. We didn't see him again for a while.

I took the kitten's body back to the morgue afterwards where, in solitude, I was able to cry myself.

It is so much harder with the young ones. The young patients and the young doctors.

This week we had a gorgeous cat brought in in the evening. His owners were hysterical. The cat was screaming. His hind legs and tail were limp and cold.

A saddle thrombus.

Saddle thrombi are one of the worst feline emergencies. Like hemoabdomens, they don't have happy endings. The saddle is the bifurcation of the aorta, where it branches into each hind leg. Kitties with heart disease will often throw a large clot (thrombus) that will lodge in the saddle, cutting off circulation to the hind legs. It is one of the most painful things that can happen to a cat. You can recognize a saddle thrombus by the wails of the cat as they are being brought into the veterinary hospital. If caught promptly, the cat can recover use of his hind legs with medication to help dissolve the clot. The heart disease that caused the problem will need to be addressed. Often times, the saddle thrombus is the first sign of heart disease, which sucks. Even then, only 50% of cases will survive to leave the hospital. Even then, the average surviving saddle thrombus cat will only live for 2 more months. 1/4 of the cats that survive and receive treatment will have another thromboembolic episode within the next 6 to 12 months. Chances of survival are greater if the clot occurred in a front leg or if only one hind leg was affected. If the cat's rectal body temperature on presentation is lower than 98.9, the chances of survival drop rapidly.

This kitty's rectal temperature was 97.2.

He was vocalizing and I told the doctor we needed pain meds for him STAT. She gave us a dose to give IV via injection. The problem with that is that we only had 2 front legs to work with: you don't want to inject anything IV in hind legs with compromised circulation. And we would need to place an IV catheter whether the owners decided to treat or not, and it would have to go in a front leg. The doctor gave permission for us to just place the catheter and give the injection through it.

Most saddle thrombus cats are in so much pain that they will try to bite anything and everything that attempts to touch them: not even owners are exempt. They don't want to be touched, and it is understandable.

This cat was wiggly and he tried to push our hands away with his paws, but he never once tried to bite. Not once. We were able to quickly place the IV catheter and give him his pain medication. We placed him in a kitty bed so that he would feel safe and let him chill in one of our ER cages. I stayed close by to make sure he didn't have a bad reaction to the pain medication. Some cats don't quite know what to do with themselves and will flail.

The pain relief was instant for him. Once he found himself in the cage, he straightened his shoulders and looked about. He had stopped vocalizing. I opened the cage door to reassure him. He was lucid and now that he had relaxed, there was an almost regal quality about him.

Brilliant liquid green eyes met mine. The cat half closed his eyes at me, giving me a "kitty kiss." "Thank you for making me feel better," he said. My eyes teared up as I reached over and rubbed my hand against his cheek. He leaned into my touch, his eyes holding mine. "I'm so sorry," I whispered to him. "I will be okay," he said.

Since he was comfortable, I gently closed the cage door and turned away. We had other emergencies that needed treatment and it was a good way to distract myself from the sudden wave of grief I was feeling.

I was relieved when one of my coworkers took care of him after he was gone. They all get to you, but every once in a while there is one that gets to you more. This was one of them.

We fight the battle between life and death every shift that we are in the ER, dancing in the line between the two worlds, trying to hold back death for one more day, one more month, one more year, one more decade. We know that sooner or later, death will ultimately win. It is the only certain thing about life. But we fight the battle anyway.

I went to Catholic school but always had my own opinions on things that I kept mostly to myself outside of our home. My family was a funny mix of Catholic, Buddhist and New Age. We took what we liked of each religion and chose what we wanted to believe in. There are no absolutes in life other than death itself. Why should a belief be absolute? We would later discover that our beliefs pretty much matched the Wiccan beliefs, so nowadays when anyone asks me what religion I am and I want to shock them, I'll just tell them I'm Wiccan. I like the idea of praying to a Mother Goddess either way.

I would not be able to do this job if I didn't believe what I believe. If I believed that life ends at death, I would not be able to cope. I believe that all living things, from the spider in your closet to the tree outside your door to your canine companion to you yourself have souls. That we come back sooner or later, and so do our animals. I believe that most of the people that we know in this life we have met before: they were our sisters, brothers, fathers, significant others, or just very good friends. We fought in wars with them, raised families with them, moved across a continent with them. I don't believe in love at first sight; I believe in love at first memory. That relative with whom you just can't get along, you've had a dispute with over centuries and you will keep having difficulties with that person for centuries more if you don't resolve your disagreements now. (Ha! Believing in that doesn't mean I want to deal with it!) I believe in karma and can tell you that it exists. I believe that the animals that we love and need the most come back to us. Sometimes repeatedly in the same journey if we live long enough.

And I may lose followers for sharing all this, but I need to share it to explain to you that even believing this does not make working with death every day any easier. It only makes it easier to recognize. It is a door I opened to allow me to better do my job, but I am not able to close it at will now. I often refrain from touching friends' animals, especially dogs, especially older dogs, because I don't want to know. I don't want to know how that dog will die.

We had just euthanized yet another last night. An advanced heart failure case. If the owners had not elected euthanasia, the little one would have drowned in the excess fluid produced by his failing heart: a slow and horrific death. It is a hospital policy that we make paw prints of the pets that have died; they are mailed to the clients afterwards as a last remembrance. I was working intently on the final details of this paw print: choosing the stamp font and wondering, as I always do, if it would be appreciated by the owner. Grief is an unpredictable thing, unique to each person that goes through it. Most people love the paw prints and cherish them forever, but some people don't, and I can understand that. And as I smoothed out the clay around the paw print, I thought about writing this post. And then Dr. J, who had been leaning silently against the counter next to me and apparently watching my efforts, suddenly said, "We do good things here."

I glanced up in surprise. He had a sad half smile that I returned. I couldn't say anything. I finished stamping the pet's name on the paw print as Dr. J looked straight ahead, lost in his own thoughts. I asked him about the case that he was working on. He was waiting for the owners to make a decision. It would be another case that would end in death during our watch. 

Yes, we do good things. We just wish death wasn't one of them.


37 comments:

  1. This.. is so beautiful and sad and you'd never lose me as a follower.

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  2. You should edit this to warn that no one should read it at work. I am in tears right now.

    I have personally lost so many beloved 4-legged friends, and it is so very hard. I can't imagine how you can feel after a bad day at work where you lose so many, feel your own grief and see the grief on the pet's owner's faces. You do good things, that is right, but it is not always easy.

    We need people like you to help us, and I for one certainly appreciate the kind-hearted veterinary workers that have helped me over the years. I have found very few human medical workers that have been as compassionate during tough times as those who have taken care of my animals.

    Thank you for everything you do.

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    1. Aww I'm sorry I made you cry at work Judi!

      One of the oddities of veterinary medicine is that we get trained, both techs and doctors, to work with the animals, but we don't really get proper training on working with people. I think some vet schools now are offering psych courses and you can do continued education on how to help grieving clients, but it's not a commonplace thing. Unlike in human medicine. I'm always astounded by the lack of compassion and empathy in the human medical field, despite the fact that they are specifically trained to work with people.

      I have no good explanation for this phenomena, other than maybe it's because we work with patients who can't speak so the empathy and compassion we feel towards our patients translates into the way we communicate with the pet owner.

      I've always said that if I ever am critically ill, I would wish I could elect to be treated by a veterinarian.

      Thank you for your comment! <3

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  3. You've successfully thrown me straight back into the horror of it. So much good is done, but at the end of the day, the month, the year, the decade, death always wins.

    I agree with a lot of your thoughts here; that it should be accessible to people (and shouldn't have such a taint when people find their own means); that those old souls stick around us; that death can be gift.

    One of the last surgeries at my old practice, the emergency practice, was an attempted splenectomy. The mass was the size of a basketball in a large lab mix. She didn't make it.

    A riding buddy was confessing about her hard day, having found her young cat deceased. My immediate response: saddle thrombus. The secret killer of cats that you don't even think about until the screams reach you. Only comparable to a prolonged blockage. We never even attempted treatment on the saddle thrombi cats. Immediate pain meds, an explanation, a release.

    It's good that you wrote this, even if you delete it. It was cathartic for both of us.

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  4. Letting my dear Sweetpea go was one of the hardest things I've ever had to do.

    One thing which made it bearable, was the peaceful minutes between the sedative and the final injection. She'd suffered with Cushing's for almost five years, and after that shot was the first time I'd seen her relax since her diagnosis.

    The other was the absolute compassion of the vet who put Sweetpea down. I hope you know how appreciated you are for your kindness and professionalism.

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    1. I'm so sorry Calm.

      Ironically, the most thank you cards we receive from pet owners are the ones whose pets we have sent onto their next journey. It doesn't make it easier for us, but it does help to know that we helped console the pet parent during the loss of their loved ones.

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  5. Thank you for sharing your heart. And thank you as always for all you do for our beloved animals. I love the pawprints. We once had a dog put down--at the Humane Society actually I think, because the vet refused--they sent us a card afterward. It's a gesture I still remember today.

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  6. Wow. Beautifully said, and you're certainly not losing THIS reader. I am glad you have this outlet to help you process the emotional pain you deal with on a daily basis. I am glad you have readers like me who can begin to understand. I don't say totally, because I never worked in an emergency practice and am fortunate that all the euths I was present for as an assistant were in elderly, end-stage animals who were ready to go.

    However, I have also been present for euths of my own pets, the worst of which was my very young doggie (16 mo). I had poured my heart and soul for months into trying to save her from severe epilepsy. It was devastating to have to give up and lay my beautiful, precious girl to rest.

    I found out three days later I was expecting my first child, and my daughter was born almost exactly three years to the date and hour of the dog's birth (seven hours difference). Do you think that was a coincidence, or that it was a coincidence that we named the baby something that rhymed with the dog's name? (Which I actually didn't think about at the time) Nope. I have always felt that some spark, some piece of my first "child" was captured in my little human.

    Now I have my aging (11.5 y,o.) heart dog. I KNOW with every fiber of my being that she will be with me ALWAYS (just like my dad is). I am grateful that she's lived as long as she has, and enjoy every single minute I have with her. Just had to put her on PPA 'cuz she's got a little leakage problem, her fur is patchy from low thyroid that we're still straightening out (but I think we've got it now), her eyes are dimming and her hearing is going to pot, but by God I love every cell in her body and I just pray that the last thing she hears is my voice and the last thing she knows is her mommy telling her, "Good girl, I love you." Either that or she slips away quietly in her sleep...

    Note: she still bounds up the stairs/onto bed, plays, rolls, runs "crazy laps," has a good heart and good blood values, so *knock on wood like a maniac* I think and pray that I've got some time yet. :)

    Now, wait until you hear this: TODAY I found out from a coworker that her dog, a 6 y.o. Lab mix, had a splenic mass removed three days ago. A 6.5 lb. tumor... that was BENIGN!!! Can you believe it??? I didn't know much about them until I opened this blog post and started reading about, of all things, splenic tumors. Holy crap! Coworker didn't know if it was cancer or not, rolled the dice to the tune of $3K and found out today it was benign. Unbelievable. O.o. So there you go, a "miracle dog" story for you. :D

    (Details, because of course I asked: Coworker actually felt a hard mass in dog's abdomen - no other symptoms. Rushed to Emergency vet. X-rays and CT revealed the tumor. You know what would have happened if she hadn't caught it, benign or not. SOOOOOO lucky!)

    I admire what you do beyond belief, your strength and moral fortitude, and that of all the great folks you work with. I am so sorry you have to deal with loss every day.

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    1. RiderWriter, thank you. Your stories here made me smile. Your girl sounds absolutely wonderful, and I hope with all my heart that you enjoy many more happy years with her!

      This is funny, but one of our techs owns a 6 yo Lab mix that came in for a hemoabdomen...and it also turned out to be a benign tumor. (I've actually had the story on that case in my Drafts for months now.) Interesting that it is the exact same age and breed mix as your coworker's dog! These benign splenic tumors are more common in younger dogs. The two cases of this I've seen were our tech's dog and one other, also on a younger dog, at my current hospital. Happy endings are the best!

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  7. Beautifully written.

    Don't know how y'all hold the kind of jobs you do, but thankful for it.

    (Sorry I can't write more right now, but I'm all hormonal in a bad way and I'm trying to super resist being more weapy than I've been the past day and a half!)

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  8. Just wanted to add that I agree 100% with CFS - the compassion of the vet who had to put my Sallie to sleep (and the other vet who's done my guinea pigs) will also stay with me. I appreciated it beyond measure, as I'm sure all of your patient's parents do. It makes a tremendous difference. I didn't even know the vet who PTS Sallie - we were visiting my in-laws and she totally crashed and had to be rushed to the nearest vet hospital. That young woman cried right along with us, regardless. One of the blackest days of my life, but I still remember her kindness.

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    1. They do. The vets and techs at our hospital are exceptional. We have clients that prefer to come to us to PTS rather than go to their regular vets because of the compassionate care they have received with previous pets. Makes it hard for us, but it's always good to know it makes a difference to the pet parents. It really is.

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  9. Oh dear one, I had no idea. Yes, I am in tears, raining grief down on my desk at work, struggling to find the words that might offer some comfort in lieu of the hug I really want to give you.

    First, I have to say thank you for the work that you do. You and the docs probably don't hear this enough, but it makes a difference in the passing to have quiet competence and grace help your beloved pet to the other side. It makes a difference at the end when letting them go to know that the shot will be quick and the step over easy.

    Second, the feet prints and tail impression we received from the hospital when Ash died was one of the few things that helped T get past losing his first bearded dragon. It makes a difference.

    I too believe in the circle of life, rather than the linear path so many cling to. I believe that our beloved Red is housed in Lily's body, so similar in personality and behavior and looks and the deep love she feels for our boy. I am so thankful she has given me a second chance to be a better owner and trainer, partner and friend, even if she does steal the covers and most of the bed.

    Last and always, I believe, had you been born when the Mother was worshipped openly, that you would have been one of Her Priestesses. One that warded the door to the other world and all of the responsibilities that would have entailed. Death, as you know I believe, is just another step in this wonderous journey; a time to reflect and learn from the past, before stepping into another.

    It is a sadness. One that I have had to deal with several times in the past couple of years. One that I will continue to have to deal with going forward, for years to come, because at the end of the day I choose to love those outside of myself. To put my heart in the hands, paws and hoofs of other creatures for the joy and the sorrow that loving brings.

    So, dear one, as we approach the time when the veils are thinnest between the worlds, gather your dead, all those you have eased over, and let them go. May you be blessed and may peace be upon you and yours.

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    1. Karen, I have no words. Thank you. I've read your comment 3 times now, and each time I've cried. Thank you.

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  10. So many careers that I have considered over the years, but then dismissed because I wondered if I could stand it or if I would turn into a heartless cynic. The veterinary field, a nurse, a police officer, an EMT, a counselor/social worker. You are far more courageous than I am - you do what many of us can't.

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    1. Thank you Melissa, and likewise: I admire tremendously our people that serve/have served in the military for exactly the same reason!

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  11. The hubby is a vet and worked in a city ER while I went to medical school. He is extremely good at what he does and most of the time he handles this part of the job with grace and empathy. I will never forget the day he had to put a man's seeing eye dog to sleep. He came home crying that night. It is a difficult job that gets very little recognition for the things he knows and does.

    Having had to put my best friend of 14 years down this summer, this is the single most difficult yet sincere decision you can make for your struggling pet.

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    1. I'm always astounded by how little people know of the "backstage" part of veterinary medicine, which is part of the reason why I had started this series. Also to help me focus on the good cases (all of the previous installments had had happy endings). It's wonderful that your hubby is a vet and you're an MD. Charles and I are similar: he's an ER RN. One of the best things when having to work with difficult, sad situations is being able to come home and having the option of talking about it to someone who really gets it.

      And yes, it really is. Working in the profession almost makes it even harder when it's time for your own pets.

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  12. Love this post. I can't imagine doing what you do, but your attitude is incredible and the world is a better place because of you and people like you. I hope that I find such compassion and love when I have to make that hard decision with my pets.

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    1. Thank you Lauren. I hope you enjoy many, many more years with your crew!

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  13. Jesus, I should have known from the title that this would be the kind of post that leaves me sobbing on the floor in a fetal position:) It was beautifully written. As someone who has had to make that decision for my pets three times so far, all I can say is thank you for what you do.

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  14. I have so much respect for you. It's not just that you are able to do your job, but that you have so much compassion and empathy. You haven't gotten numb to it like I've seen people do. Thank you for sharing this.

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  15. This is the most beautiful thing I have read in a really long time. I am a blubbery mess after reading this. I just hope the day I have to make that hard choice with one of my family members (pets), I have such a companionate tech as you are!

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    1. Thank you JWall. <3 Everybody should find only compassion and love when having to make such a difficult decision.

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  16. Having euthanized two of my own horses (and having watched a third die before he could get the euth solution on board), and just recently having had my old greyhound euth'd (AND my childhood cat), I wholeheartedly 100% believe that euthanasia one of the best gifts we can give them, second only to a good life in a loving home.

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  17. I too work in an animal ER as a vet tech. I completely understand and agree with you. It's a hard thing to do but I'm glad we can offer the release from pain and suffering.

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  18. This has me in tears as well. You would never lose me as a follower for sharing your thoughts and beliefs! I also wanted to say I'm one of those people who cherishes the paw print. I'm so thankful my vet did one of Storm for me. I don't know how you do it. I would cry everyday if I had to work in a vet emergency room. The times we had to euthanize one at the regular vet where I worked were hard but thankfully very few.

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