Tales From the Trenches: "Caution"

"Don't touch me."

I looked at the old Golden Retriever curled up at the back of the run, his front legs tucked up underneath him and his head placed flat against the bedding, nose turned off to the side. The only thing that moved about him were his chest as he breathed and his white-rimmed eyes as he warily watched us while his overnight nurse rounded me on his story.

This expression.
Not the dog in the story; photo from the internet.

I quietly studied him as I listened, while being careful to avoid direct eye contact with him, because body language is such an important part of an initial assessment. Whose body language? Both yours and the patient's, of course. How you approach and present yourself to the patient can change the entire course of their hospitalization because with high-strung animals, it can determine whether they see you as yet another source of stress during their stay or as the caring entity that you want to be for them. And how accurately you read their body language is going to determine how you react to their behavior throughout their stay: it can make or break a patient-nurse relationship.

There are shades of gray in between these categories, and a friendly but insecure dog can go from green to red within seconds. Context is really, really important when observing a patient's behavior. For example, one of the biggest causes of confusion in canine body language is a wagging tail: friendly dogs will wag their tails, but anxious/tense dogs will sometimes oscillate their tails as well, and that's not even mentioned in this chart. An individual's body language can also have subtle personal variations. 

To a casual observer, Rambo was a large older dog resting comfortably in the back of his kennel. To me, there was nothing comfortable about him. I saw the defensiveness of his position in the cage, more sideways than forward with head further towards the front of the cage than his hindquarters. I saw the lines of tension etched across his shoulders, back and forehead, the muscle wasting of his hind legs that pointed at either long-term arthritis of his hips, back and/or stifles, or at some mild neurological issue that was limiting his mobility in his old age. And I saw the soft, fluffy, shiny coat that is so often an indicator of owners who pay attention to detail when it comes to the care of their pets, but is also a sign of a healthy digestive tract that allows the animal to absorb all the nutrients from the diet they are fed at home. I saw an old dog that was painful and afraid and that was deeply loved.

Noticing the orange "Caution" sticker on his cage card, I asked the overnight nurse, "How much of a caution is he?" "Caution" is relative in vet med and we place the stickers on cage cards when warranted as a safety precaution for coworkers: it just means you have to be extra careful with a patient because they have certain triggers. For some it's taking their temperatures or touching their paws or giving them oral medications. Discussing these triggers is a routine part of nurse rounds because we are the ones providing the majority of the hands-on care to the patients, so we need to know how to avoid upsetting the patient whenever possible.

In Rambo's case, he was cage aggressive to the point of lunging at his overnight nurse when she had reached into his run. The trigger was thought to be fear of pain because initially he had arrived at the hospital so painful in his belly from the tumor that was threatening to burst, that touching him anywhere had caused a reaction. He had been started on pain medication immediately and once his pain was under control, his behavior had improved significantly when handled outside of his run. I was told to still be very careful when going into his kennel though.

I looked at the old man who was watching us so warily and just had a feeling. "You and I are going to be okay," I thought.

We finished rounds on my other patients for the day and I started on their 8:00 am treatments, saving Rambo for last so that I could take my time with him. It was wonderfully quiet in the main part of the ICU. The only sound was the low voices of the doctors seated at their desks in the treatment area while they did rounds.

Rambo was housed in the Dog Ward adjacent to the main floor of the ICU. It has glass walls and a glass door through which we can see the patients from anywhere in the ICU, but when the door is closed we can't really hear much of what is happening in there. It has the largest runs in the hospital though, so our bigger patients get housed there for their stays so they can be more comfortable. When we have critical patients in there, the door gets propped open so that we can hear them as well as see them.

I walked into the ward, picked up Rambo's own leash that was hanging in front of his run, and quietly opened the door, talking to him gently. "Will you let me come in? I need to do a whole bunch of things with you, but I need you to help me." I watched his body language while avoiding direct eye contact. Life is much easier if you avoid direct eye contact with nervous/scared/potentially aggressive dogs, and it is something that is taught in basic behavior courses in both veterinary and tech school. I let him see the leash: most dogs associate their leashes (vs the hospital leashes) with going outside and I've had the most fear-aggressive dogs change their demeanor completely when they catch sight of something familiar from home that they associate with good things.

If you're thinking right about now that my job sounds pretty dangerous, you are absolutely 100% correct. Fear and pain are the #1 causes of aggression in the veterinary environment, so we deal with this on the daily in the veterinary ER.

His expression softened. I carefully stepped into the run, one foot at a time, watching Rambo's body language. Everything about him remained soft, though his eyes again became guarded as I got closer. I showed him the leash again and he turned his eyes away, expectantly waiting for me to clip it to his collar. I did.

Click went the snap on his collar ring. "Come on, handsome," I said quietly.

Rambo heaved his front end up into a sitting position and from there physically pulled his hind legs up underneath himself until he could stand on all four feet. It was painful to watch. I wanted to help him so badly but it would involve touching his belly and I wasn't sure yet how much it still did or didn't hurt. Starting off on the right foot with him would make everything so much less stressful for both of us for the rest of the day, and inciting pain from the get-go is not the way to do this.

So I helped him by moving one step at a time out of the run and onto the floor of the treatment area. Once out of the ward, he was fine as long as we stayed on the rubberized mats we have all over the ICU to help our canines have traction on the otherwise slippery floors.

I took him out into the middle of the ICU where I could easily ask for help if Rambo decided to misbehave because I was amidst the doctors and techs.

"Sit Rambo," I said.

He sat down next to me with obvious relief at not having to continue to stand. "Good boy. Down, Rambo."

He lay down. "Good boy. Now stay."

He stayed. Thank God for well-trained dogs, because they are not common in the veterinary ER. A dog might be well-trained at home, but it is rare that one encounters canine patients that are so well-trained and well-socialized that they will still obey in high-stress environments with strangers.

I slowly sank down onto the floor next to him so that I was sitting right flush against his body. He was wearing a plastic cone for our own protection and being closer to him meant that I would be fully shielded by his cone if he decided to suddenly turn his head towards me.

Still talking to him and telling him what a good boy he was, I gently ran my hands all over his shoulders in a circular motion while watching his expression. He made no eye contact with me, but I saw when his eyes initially widened at being touched. He then blinked and visibly relaxed, "Petting is okay." I continued stroking his fur and slowly made my way down to his back leg, finding the shaved patch right above his big paw pad where I could place the Doppler probe to obtain his blood pressure. He objected to none of it: the cuff around his leg, the gel against the shaved spot, the pressure of the cuff. He just lay there quietly, seeming to be relieved at not having to do anything other than just rest, and closed his eyes.

Photo from here.

I continued to watch him carefully as I gently made my way over him, but he let me do everything to him by myself while napping peacefully in the middle of the ICU floor. I got a full set of vitals on him, including his temperature, and was able to obtain a small blood sample for the labwork his doctor wanted me to run. I needed no help whatsoever; nothing that I did disturbed him. I had somehow 100% earned his trust without really doing anything special at all.

While I had him out, I got up and fetched one of those Help 'Em Up harnesses that I've mentioned on here before. He continued to rest in his spot when I walked away. I returned and he continued to lie quietly while I fitted the harness to him. It would be so much easier to help him stand up and get going if I could have the extra assistance of one of those harnesses with the rigging around the hips.

His doctor came over to do his morning physical exam while I had Rambo out. Rambo continued to be compliant, not making a peep when we had him stand up again so the doctor could palpate his belly and check for more free fluid with the ultrasound probe. The vet wanted to switch our patient to oral pain medications and he wondered if I would be able to achieve this.

The challenge was that Rambo was not really interested in eating so I couldn't hide the pills in food or Pill Pockets. I would have to pill him, which meant having my hands around his mouth.

I had the distinct impression that Rambo would let me do it though. I slowly reached out to touch his head and he let me stroke his nose and muzzle without issue; his eyes continued to be soft as he looked at me.

The doctor saw my momentary hesitation though, and he changed his mind. "Don't worry about it; we'll continue to use injectables. It will be less stressful for him anyway."

The fluid in Rambo's belly had not worsened. All of his vital signs and blood work that morning indicated that he was stable. His owners did not want to take him to surgery to remove the bleeding tumor though: he was old and they didn't want to put him through such a rough recovery afterwards just to get a few more months of life out of him.

I called them later that morning to give them the nursing update on how Rambo was doing, and to set up a time for them to come pick him up that afternoon. Since he was stable, they would be taking him home to spend time.

I am an introvert that generally prefers to work silently over my patients to speaking with clients. When I'm focused on a pet in my care, the entire world ceases to exist and it's just me and that cat or dog, communicating back and forth with gestures and expressions that don't require verbal language. Words are used to express tone of voice that the animal can understand. But the brunt of communication does not really involve words. And so the ICU floor and the OR are my jam far more than the exam rooms. But time and experience have changed that to a degree. When I first started out as a tech, I had a hard time talking to clients because I wasn't always confident in what I could or could not share information-wise as the nurse, especially when dealing with defensive, worried, stressed pet owners that you want to reassure without creating false hope. Now? Now I enjoy it. Even when the news isn't the best, I try to reassure the owners that their pet is comfortable with us, that we are doing everything we can to ensure that, and go out of my way to mention little personality quirks that I discover about their pet during their stay with us. Most of the time, even when they know it might be a losing battle when it comes to saving them, knowing that their pet isn't stressed or in pain or suffering and that they are acting like their true selves with us is the greatest reassurance of all.

So that is what I gave Rambo's owners. And in exchange, I got to hear his story. It was a story like so many others, of a dog that had been owned since the time he was a puppy, of what a good dog he had always been, of how he lived on the owners' farm and had so much land to roam. He had always gotten along great despite having bad hips. In the story the dog ages and slows down and the owners assume that the slowing down is because of age. But then they realize he is slowing down a little too quickly and the dog gets brought into the vet and the cancer and the bleeding is discovered. A lot of times, the owners blame themselves. They think if they had brought the pet in sooner, the cancer could have been cured. Or if they hadn't walked the dog or let him jump into the car on x day, the bleeding wouldn't have started. Or if they had fed them differently or not gone on that trip they had been planning or if they had thought about it a little more, maybe their pet wouldn't be dying now.

Those are always so hard. Because no matter how much you reassure them that, most of the time, having done things differently would not have changed the outcome because you can't reverse age nor its biggest side effect: death...owners always blame themselves.

But these owners were different because they understood. They understood that this was the end of the road for Rambo. There was no guilt involved because they had done everything right. There was just sadness because a dog they loved so much would be missed once he was gone.

We set a time and I hung up the phone, and went over to Rambo's run. He looked up at me when I opened the run and I knelt on the floor. "Your owners love you," I told him. He made eye contact briefly and then looked away, closing his eyes. I stood up quietly and let him sleep.

The hours ticked by. It was an unusually quiet day in the ICU, which was good because it meant I could take my time with treatments. Rambo had to be taken out of his run every time I had to do things to him and it soon started to get old. He was tired and just wanted to rest. He never once growled at me though. He'd give me an initial hard look, then sigh and lurch to his feet. "Fine. I'll come with you." As he pushed himself up with his front legs, I'd catch the rear handle of the harness around his hips and we'd walk out of the run together.

And then he'd lie down on the ICU floor and patiently let me do whatever I had to do for his treatments before it was time to go back into his run.

His owners arrived in the afternoon. I went over their discharge instructions and the pain medications we were sending home. There were just enough to keep him comfortable over the weekend. Unless he got worse sooner, they would be taking him to their regular veterinarian on Monday morning to euthanize him. We all knew that that was what would happen, but we all skirted around it in conversation.

Rambo's doctor went in to touch base with them while I got the big Golden ready to go home. It involved coaxing him out of his run one more time. It was one time too many: as I reached for the handle on his harness to help him up, he finally protested with a deep rumbling growl. "I don't want to get up."

I stopped. "Rambo. You're going home. Please come with me. You won't have to stand up for me again," I said gently. He glared at me, then finally looked away. I reached down slowly and stroked his coat, then reached for the handle on the harness, which he now allowed me to do. With a groan he struggled to his feet and came with me.

I took him back out into the ICU and uneventfully removed his IV catheter, placing a bandage over the site. I then did what I had honestly been wanting to do all day, but had not been able to because we were respecting the fact that the dog was uncomfortable and could change his mind about us at any moment: I removed the darn cone from his head.

We walked across the ICU. Rambo came alive when he realized we were leaving the treatment area, suddenly gaining a new spring to his step. Like most dogs tend to do, it was him that led me to the room where his owners were, whom he greeted ecstatically.

His owners said hi to him with a mixture of happiness and sadness. They picked up their belongings to leave and Rambo, knowing what was coming next, came over to me, placed his head against my knees so that I could really pet him without the plastic cone in the way, and wagged his tail shyly at me. It was the first time he had wagged his tail at me. It is always such a special gift when they come over to say good-bye before they go. I rubbed his ears silently for a moment before he pulled away with a doggy grin and headed for the door. Smiling, I stepped back so the couple and their dog could leave.

Rambo's owners paused, teary-eyed, and thanked me for my help.  I told them they were very welcome. I stood for a second in the hallway watching them walk away, Rambo's plume of a tail held high over his back as he marched out of the hospital with his people, his age and weakness and pain forgotten.

I was watching an ending. His days were numbered but he didn't know that. All that mattered was that he got to go home to be on his farm with his family one more time. And that made his ending a happy one.

Like I've said before: in ICU and in Surgery, that is all that I ever want for them.

I turned around and walked back through the swinging doors of the ICU to take care of my other patients.