Even though you prepare for the worst outcome, can you really ever be prepared. I feel like I jinxed it or cursed her recovery by sharing enthusiasm in her progress. Abby was doing so well and just like that nature reminds us we have no control, no cure. She started seizuring last night and the difficult decision to let her go was made this morning.
“Miss me but let me go, for this is the journey we all must take and each must go alone. It’s all part of the Master’s Plan, a step on the road to home.”
Goodbye sweet little dog….
“Grief is the last act of love we have to give to those we loved. Where there is deep grief, there was great love.”
How blessed we are to share our lives with these creatures that don’t speak our words yet can so powerfully bond with us, forever capturing a piece of our hearts.
I heard the cries and screaming vocalization in the background with my own mother’s voice on the phone saying
“Abby’s in real pain. I can’t even touch her without her biting. What should I do?”
There is always a desperation in the call for help but when it is your own mother you can hear the unspoken words, the anguish in seeing her beloved little dog so painful she would bite in opposition to handling.
Abby is a senior Dachshund and had fallen from the couch earlier that week and had been a bit sore. I recommended some pain meds and rest. With a Dachshund it is always their back until proven otherwise. I had years before stood on the other side of the exam table with their other Dachshund, Harley, when he had back pain secondary to intervertebral disc disease, and progressive paralysis. There comes a point in this disease when it progresses fast enough or far enough that surgery or a humane goodbye become the two options.
I saw the bottle of euthanasia out of the corner of my eye while we discussed the options. My father hadn’t handled it well and was reliving goodbyes from years ago and was essentially distant from any reasonable discussion and my mother held the weight of the decision on her shoulders. While Harley’s body was failing him his brain was very much intact and aware of his distraught owners. They had elected to drive all night for imaging and surgery. Harley walked again but now how has neurologic deficits and was never 100% normal again. Now it was Abby, their other Dachshund. They had been down this heartbreaking and difficult road before.
“I knew the discussion would come…wait and see, referral for imaging and surgery…or euthanasia.”
It was decided that we could try what we could here but the option of referral and surgery just wouldn’t be available. Abby had been on a variety of pain medications including a Fentanyl patch but nothing was touching her pain. She was even sedated for radiographs and bit me as I was trying to touch her. The happy little dog at your feet just waiting for a crumb to drop had transformed into a screaming painful feral creature.
We breed these lovable little dogs for their long backs but with that comes the risk of instability of the discs between the vertebrae. They can bulge and burst, pushing on the spine or nerves, causing unbearable pain or even complete paralysis.
I started a morphine/lidocaine/ketamine continuous rate infusion and intermittently just sedated her to facilitate her pain. I brought her home and kept her by my bed in a tote. The Kiddo peeked into the tote and with concerned eyes asked if she would need to go to puppy heaven. My heart ached.
It had been two days and I couldn’t touch her without the screaming and biting and she had progressed with motor loss on her left hind. The bulging vertebral disc was pushing on spinal nerves and her spinal cord, causing pain and loss of function. First it is conscious proprioception…knowing where your feet are…then paralysis…then superficial pain…and then at the end there is no pain sensation left at all.
We made the decision to pick up the “supplies” that would be needed to end it all…the strong sedation and thick blue syrup that would stop all her earthly pain, but open up a pain for those that knew and loved her.
“With our animal companions, I have seen the struggle to know “when”. Do we allow a day’s worth of suffering so they may enjoy a lifetime without? Do we allow no suffering at all?”
It is emotionally tasking to watch pain in an animal knowing they can’t communicate if it is all too much or they are willing to keep going. I had stopped her MLK drip, continuing her other pain meds, with the decision that if she couldn’t maintain comfort without it, it was unfair to continue.
I continued her therapy exercises, hoping and praying those little neural pathways would be stimulated, that the unstable disc would stop its pathway to paralysis. I stimulated her toes, did bicycle motions, stretches, massages, even took a electric toothbrush to her toes to stimulate her nervous system.
With clients there are lots of words and discussion, the knowing when, the hows, the questions. With my own family I found it harder to find the words. When someone has know you your entire life, they can read your face, your ticks, your eyes, and hear the words unsaid. So much of the discussion wasn’t a discussion at all but a knowing. I wanted to make the right decision for Abby.
The bag of “supplies” lie on my vehicle’s floor board and as we drove home my mind spun, dreading the moment, trying to push the details out of my mind. I felt frustrated that it had come to this. Should I have ended the pain sooner? Should I hold on for a miracle?
I peeked into the tote and Abby was bright, alert, more upbeat than I had seen her. The test would be could I pick her up without the screaming. I could and she even wanted to eat something. Could 5 hours have brought a miracle, a turning point? I knew the drugs would affect her and cause her to be dysphoric but I hadn’t expected her pain to be controlled without them.
I texted an update and said let’s give her more time. Thru the weekend she was able to start moving, placing her left hind leg that previously was worthless. I did her sessions at least 3 times a day…stretching, massaging, stimulating, hoping. A new day came and her appetite improved, her attitude improved, her function improved. Had the suffering she endured been worth it to get to this point?
We added acupuncture and continued laser treatments and she went home with my parents yesterday. Is she out of the clear…I don’t know. Will she ever be 100% normal…I don’t know. She has chronic changes that will probably always be a risk…and lead to a relapse. But at least we have hope, though prepared for what may be.
“How do we define the end? We all share so much earthly emotional and physical suffering that we want none of it for our animal companions.”
Was her suffering selfish? Maybe. Was her suffering worth it if she can recover to enjoy another day? I look back and say yes now.
This isn’t the first time I was disheartened, preparing for the worst, wondering if we humans were selfishly keeping a patient alive for our own purposes, only to be amazed at the recovery that can be made. I have literally had the euthanasia solution in hand walking to the exam room when the owner cried out the door “He tried to walk!!!” The paralyzed HBC (hit by car) dog had pulled himself to his unsteady feet after no improvement while hospitalized and there were simply no more financial resources to continue the effort. He made that first step and didn’t look back making a near full recovery. As a new vet it was a powerful lesson about making that decision for our pets which we do from a place of love and concern for their suffering, but sometimes they decide it just isn’t time and want to keep fighting. I am forever amazed at the healing and recovery possible.
“As a veterinarian, the struggle comes with trying to predict that recovery, only having the info available at that moment, with no magic ball to guide decisions.”
*Update on Abby. She had some regressions with her rehab and became a somewhat difficult patient. She has since been staying with me to continue her exercises and monitor her recovery. She is still periodically weak in the back end and mis-steps occasional. While she may never be 100%, we are hopefully she will recover to enjoy more quality time, with her pain controlled. Her spirit is definitely back.
It came up in a conversation at work this week. When you work with a crowd of similar animal lovers and you meet hundreds of animals a week it seems natural to want to assign them a voice. The question was “Do you talk for your pets?” “Do you share their inner dialogue?” “How accurate are we really in knowing that voice?” Besides our own pets we know and love well, we may even assign the voice and thoughts to our patients during their exam or hospital stay with us.
We often give clients an assumed dialogue from their dog’s perspective after their adventure with us. This can be after a brief stay for testing or when we return them to the owner after a quick trip to the treatment area for a blood draw. In a given day, I’d say I meet quite a few animals that would be up for making casual small talk if it were possible but I’d say there are a fair amount that we would talk thru a panic attack or grimace at the shouted explicits. I often wonder if our dialogue and “voice” given matches that which the owner may have.
In some ways, we create this inner dialogue for them to ease our own concerns for them. When your child is hurt you say comforting words and you hope they understand those words and respond with trust and feel safe and comforted. Our patients may understand the soothing tone but they don’t know the words “We are here to help.” or “It is really important we get this sample and it will only hurt a second.” We make verbal promises of care and relief from pain and fear they really can’t understand.
I think it is natural to want to know them better or question the inner workings of their minds since they are such a large part of our families and world. Voice and language are such a huge part of how we communicate. I sit in anticipation and sometimes frustration as I communicate with a toddler on the verge of language explosion. Sure they are words but we still communicate with grunts, gestures, pointing, and body language. In a year, I will probably be requesting a break from the chatter of the inner workings of a busy toddler brain but today I just want the words to come so as to open that connection.
Many of my pets have a “voice”, but especially my dogs. The dialect, pitch, cadence all contribute to the personality I have created and that which has come forth. Roscoe, our former Newfoundland, was assigned a simpleton, sort of dumb voice really. His name also alluded to that personality. He was goofy, comical, immature, and sometimes a royal pain in the you know what.
This is the first picture I ever took of Roscoe so it is no wonder I didn’t assign him a voice of a British intellect. It was 2009 and he quickly got the knick name “Big Dumb”. But maybe I was wrong? Maybe he was an intellect with a large and impressive vocabulary. I just heard the demanding bark of a hungry dog that had us well trained to deliver dinner.
Cassy, our Lab Collie mix, is a bit of a frantic, anxious, overzealous pleaser. So we don’t have deep “conversations”. Most include a discussion of retrieving and balls, and throwing the ball again and again. I hear her voice as “Oh, a ball. I love balls. I really love balls. Please throw the ball. Please. Please. Please. Oh, you threw the ball. I love running to get the ball. Oh again, again!”. She isn’t a calm minded creature so when I hear her voice it is a high pitched, fast paced question, always a question….”What do you want me to do now? I can sit? Or bring you a ball? Did you want me to sit? Just tell me what you want and I will do it!”
I meet a lot of dogs in a day and some very clearly have a voice and often it is associated with a breed. Call it stereotyping if you will. Well groomed Poodle. You probably get a classy snooty diva voice. Big Mastiff or overweight Lab. Sorry you probably get a slower paced simpleton voice with a focus on food. So do we create our pets voice or do they have a voice of their own we bring to life? Shelby, our miniature poodle’s voice has likely changed from her previous life with a Senior Citizen woman to her current life as the
Ripp, the Australian Shepherd puppy… well he is finding his voice. He is this obnoxious testing teenager now so in a way his voice is being found and than changing just as I can see the voice of my own Kiddo changing. How it was always “Mommy” and now I hear “Mom” sneaking in that vocabulary more and more.
Does your pet have a voice? Are we accurate in our idea of that voice? What do you think…do you wish pets could talk? As a vet, there are plenty of times I wish they could just tell me already but I also know I would get cussed out and that may change my level of career satisfaction. I think I like the world as it where we create the voice and build a relationship with our pets beyond words.
*Disclosure- I wrote this months ago and it sat…I was not quite ready for the world to read my thoughts. But I keep coming back to the purpose of story-telling in veterinary medicine. In our work, we gather and share hundreds of stories of our days working with patients and clients. *
Don’t we all just want to be heard? I recently stumbled upon the topic of “Narrative Medicine”. It is a topic well recognized in human medicine and makings it entry into veterinary medicine. Narrative Medicine seeks to honor patient stories from a literary persepective. It goes beyond the medical interview and seeks to understand the psychosocial and spiritual perspective. In reviewing the whats and whys of Narrative Medicine I think it boils down to learning to listen…Doctor to Patient and Patient to Doctor. In veterinary medicine it may be complicated by having a sentinent being with feelings of fear, pain, and happiness but no way to communicate in our language. So we rely on the stories of their caretakers.
Do you still remember the veterinarian you took your childhood pets to? You might still picture the waiting room or the smell of cleaning chemicals or pet odors. If you lived in a small town you likely had a relationship with your veterinary, pediatrician, and veterinarian. They knew our story and we knew theirs, for good or for bad. I still enjoy a small town feel and generally tight-knit community but veterinary medicine is changing as it evolves with increasing services and specialization. That connection and relationship has changed. The friendly, all knowing veterinarian down the street has changed.
Narrative medicine seeks to change that connection to a time of yesteryear where we knew each other beyond the exam room walls. So it goes that in our profession we complain about the numbness of repetition of vaccination after vaccination or the pain of compassion fatigue, the giving of yourself without thought for self-care and restoration. On an average full day I may talk to 20-30+ people in a day and some days I feel completely depleted and mentally gone. My sanctuary is my home and my family and on those days of sanctuary I prefer my days filled with casual togetherness and laughter, not words and demands. Those I converse with are carefully selected and the only outsider is the FedEx delivery man, delivering my mail order packages. The energy of the crowded stores, booming music, and bright lights can just be too much after a day of boisterous greetings, goodbyes, and the emotions of helping client’s pet thru disease and death. There is this balance of connection and relationship while maintaining a distance safe enough to prevent injury from the pains of the profession.
In our lives, we all seek meaning and to find our purpose. A wooden plaque with the words “If you love what you do, you’ll never work a day in your life” sits on my shelf as a reminder of finding passion and purpose. But some days are hard…it is hard to give another round of bad news, to share textbook of knowledge regarding a diagnosis starting slow then gaining momentum as the words spill out of my mouth. I see the facial expressions, some empty, sad, upset, angry, or just plain empty as the news hits their minds.
We celebrate the human-animal bond but what a gradient of affections. For some this pet right here, right now is all they have, their companion in life and for others it is as replaceable as the tires on their car and they grumble about the expense of doing so. For me to find purpose and enjoyment in this profession, I find myself needing to look past the signalment. Buddy is more than just a 2 year old neutered male, Golden Retriever. Buddy may well be the best friend to a 4 year old autistic boy and the one to whom it speaks. We celebrate that bond, the specialness of animals in our lives.
With narrative medicine, they look for words or phrases and don’t start with the checklist but ask the question “Why are you here today?”. It is a request to be invited into our patients or clients stories. For some clients I know the story of their pet followed over years, with chapters read here or there. The time they ate the garbage and had explosive diarrhea, the adjustment to the family when the new baby came. Each chapter strengthens the bond of the family and the pet. The most intimate invitation is often at the end of life.
At the end of life there is no longer a race against death, a need to win but an acceptance. For some it is just a dog or just a cat but for others I am one of the few that has read the story of this pet’s life, to understand its meaning and the bond that was shared. In that story, I have seen men fold over weeping for a pet when they didn’t shed a tear for a parent or the woman that holds her beloved pet lost to cancer and in that moment a flood of memories of the loss of her own mother too lost to cancer. I hold that invitation with great reverence.
So when you think of your childhood vet what do you remember? I sometimes ask myself how I want to be remembered. I can give a vaccine, diagnosis diabetes, or spay a cat but there is this deeper psychosocial aspect of veterinary medicine; that call to narrative medicine, where we understand the story behind the medicine.
As a helper and caretaker it can bring great frustration and even anger when I perceive I care more than the actual owner of a pet. In these moments narrative medicine calls for a more mindful detached compassion. One can quickly drown under the tidal waves of poor life choices, painful lives, or just plain indifference that some bring to the exam room.
So I ask “What brings you in today?” and realize mankind is this diverse, never fully understood complexity. We all bring our stories of youth, growth, adversity, sadness or joy when we meet in that exam room.
Narrative, story-telling…we are all connected by our stories. Story-telling and narrative has survived the centuries and though our world has changed, it all comes back to the connection and sharing of our stories.
Everyone of us has a story, whether we share it or not. Our stories come alive because of the details…the words the author chooses to share cause us to we feel, see, taste, and touch. The details of our days bring the ordinary to life and create the extraordinary.
In the veterinary world, the story often starts a mystery…the villain is disease and dysfunction; the detective is me. People see their pets everyday and I often ask the question “How did they not see this?”. Sometimes it is just a matter of “We don’t see what we look at every day” but years of training in detection and deduction allows me to see the details when others simply don’t look or can’t see. It is those skills which define the veterinarian’s skill and competence.
Like a photographer that starts with a wide-angle lens I note the posture, behavior, general overview of the animal and then zoom in until I have a macrolens. Most clients just assume I am petting their dog or cat. But it is a systematic uncovering of details.
I start at the eyes…the windows to the soul and teller of what lies beneath. Move to the ears…teeth…gums. I run my hands under the fur and feel boney protrubances, palpate the tendon attachments, all while looking for the subtle discussion my patient may start…a look of worry, a grimace…Most owners assume their pet will cry or tell of pain but in nature pain is hidden and reserved for the weak.
My nose seeks scents that may indicate infection or a change of the breath that tells of disease within. The little dogs and cats often smell of their owner’s perfume as they spend most of their day’s minutes in arm or cuddled.
I feel the fur thru my hands, matting or greasiness a detail not missed. The rounding of the mid-section with ribs deep below tell of a meals too large and walks too short. I slip the loops of intestine thru my fingers, seeking the details that tell of infiltrative disease or function not perfect. The cat’s bean-shaped kidneys should be smooth and without pain and in our senior friends a finding of irregularity or smallness tell of aging that has been unkind.
The detective has many tools at hand. To ausculate means to listen and so I auscultate to the heart and lungs. To hear a crackle or wheeze of air that doesn’t follow its set path thru the trachea and bronchi to fill the microscopic sacs of air that form our lungs. The heart beats its song of “lub-dub”, “lub-dub”, lub-dub”. A missed beat, the song too fast or too slow, an irregularity in the lyrics tell of cardiac disease.
In the geriatric small breed dogs, I often hear a quiet whisper that sneaks its way in between those lubs and dubs…”lub-shhh-dub”. The details tells the story of a heart valve that was once smooth and efficient, a door ushering the blood between the rooms of the heart. As I hear the “lub-shhh-dub” I visualize that blood now turbulent and paint a picture in my mind of a valve now nobby and irregular, the victim of degenerative disease.
I collect a blood sample. How spectacular is the story that blood can tell. Within the liquid life are cells, hormones, and enzymes that tell the details of the inner organs. Within the blood are cells and under the microscope I can see warrior immune cells. With the subtle changes within them I can tell if the army is just being mobilized or if they are battle wary and fighting for the life of the pet.
And as the technology advances it takes the story and gives us more details… more ways to enter into the fascinating world. How clever are nature’s systems and we the detectives that seek to uncover the complexities, abnormalities, and find attackers and invaders.
Within minutes, the details tell the story of health and wellness or disease and dysfunction. While I chat and pet and give treats my hands, my mind, my nose seek the details that make the story. For my patients that can’t talk I write the story of their health. In the discovery of details I often put a voice to their pains, aches, dysfunction, and disease.
Each of us have days filled with details. What details tell your story? The details of my work have become an almost meditative invitation. I sought the extraordinary but found it in the ordinary.
As a veterinarian, I help clients say goodbye to beloved pets nearly every day. There are those geriatric pets whose age or disease has finally got the best of them. I say things like “They enjoyed a wonderful and long life.” “When we open our hearts to know their love, so do we open our hearts to the heartache of their departure” “It is our final gift to give to relieve their suffering.”
Then there are the tragic unexpected losses where you just try to hold them up while emotions of disbelief, guilt, rage, anger, among others wash over them. Perhaps they want comfort to know their pet went quickly and without pain. You assure them it isn’t fair, that it was chance or poor luck.
I have been awash in loss this past year. Expected loss of dogs from cancer and heart failure to the sudden losses due to tragedy or an undiscovered disease. I don’t know if one is better or worse than the other. With the terminal pets I felt waves of anticipatory grief. As much as I held on to the idea of “enjoying every day given” where there was joy in that day there was fear that this day was the end, that I didn’t know that moment would come and couldn’t control the end. Here I sat a veterinarian and I couldn’t save my own.
With each client I felt the need to take away the pain of grief and put in on my own back to bear so as to reliever their own suffering. I put myself in their shoes and felt my own losses, either those that had happened or those yet to come. I couldn’t go on in that way as a veterinarian helping. Instead I started thinking of grief as blanket and it was my job to hold a space for them, to wrap a blanket of understanding and support around them. I could share the grief but I could not shoulder it. My quote of choice became: “Grief is the final act of love we have to give to those we have loved. Where there is great grief there as great love.” And then loss hit again today….and a wave of anger and grief once washed over me knocking me over.
Maxx was a miracle, a PITA butthead, bully, and I loved to hate him. He would even spend time on kitty Prozac for his inappropriate marking behavior.
It was a typical afternoon at the clinic, when an older gentleman brought in an overly friendly overweight tabby cat with a thick red collar. Just 20 minutes after his exam and vaccines that tabby showed up at our strip-mall veterinary clinic doorstep in respiratory distress and vomiting blood. His owner couldn’t be found and we feared the worse. We couldn’t wait any longer and so radiographs revealed the problem- he had a diaphragmatic hernia…basically his diaphragm had torn and his abdominal contents including stomach and liver were in his chest threatening his life.
The owner was located and couldn’t commit to the necessary surgery to save his life. Maxx had jumped out the car window on their departure. He could have ran under a car or to another business location but he seemed to beg for help by coming back to our doorstep. Maxx seemed a survivor and was owed the chance to prove it. I had him signed over and swore to do the best I could.
His breathing during surgery was provided by manual ventilation by a technician. Each breath provided by the careful squeezing of the reservoir bag, passing oxygen and anesthetic gases thru the tube in his trachea to inflate his lungs. The diaphragm tear was found and I saw his beating heart and removed what didn’t belong in his chest. I sutured his thin torn diaphragm back together. And he survived…and recovered…and I couldn’t let him go so he became mine.
Maxx was really the worst…overly loving but on his terms, a food loving fatty I feared would become diabetic, a bully to the outdoor cats, and destroyer of my belonging with his potent urination. But I loved him.
So when he was gone for more than a day I feared the worse. Brad searched and found him…and since I had been texting for updates I got the call…and all the grief came back. I couldn’t handle another loss…just weeks after our beloved dog and months after other pets. I was pissed…I have clients that bring their cats in once a lifetime at the age of 18. I did everything for this cat. I saved his life…he beat the odds so why the hell now!
Nature is a cruel bitch! As I see the pastures come alive I know she brings life and beauty and she takes it away in one moment. Maxx had been attacked and the evidence suggested by a coyote. His wounds not survivable. I was fearful I won’t be able to find the answers I always need but when I saw him it wasn’t him…he was gone and this worthless body left behind.
And I said all the things I share to others…”You saved him. He had a great life. He loved the outdoors (He was strictly indoors initially but seemed to hate it and needed more. His first adventure outdoors I swept him up from under a bush after spending the entire 10 minutes he was outdoors convince he was acquiring feline leukemia virus). I don’t understand nature…I have the training to diagnosis, prescribe, and treat but in the end nature wins…she always does…whether it be when it seems right after a long full life or in tragedy we can’t understand.
I hold gratitude I have my family, children, and loved ones…that perhaps “He was just a cat. That she was just a dog.”. But my heart hurts and so once again death comes and grief follows.