The Gift of Pets: Stories Only a Vet Could Tell (25 page)

This was not a surprise to me. In dogs of Mischief’s age, a condition called immune-mediated hemolytic anemia (IMHA) is by far the most common cause of profound anemia. IMHA is a disease that incites the immune system to turn the full brunt of its fury against a dog’s own red blood cells, destroying them with amazing ferocity and speed. On more than one occasion, I have helplessly watched with horror as a patient’s red-cell count dropped by half in the span of only three or four hours. It is a nail-biting race to see if powerful drugs with awful side effects can stop the carnage before too many of the red cells are wiped out. Some races are won, but all too many of these cases end in sadness.

The vast majority of IMHA cases are categorized as idiopathic. This is a word that few of my clients are familiar with. I describe it to them as meaning that none of us idiots can figure it out; and while that description may occasionally be an accurate one, technically it means that no specific cause can be found. So
idiopathic
has come to represent a category of diseases that just happen without apparent cause—unfortunate accidents of metabolism or malicious chance. While I usually look to find a cause for IMHA, seldom do I identify one—a reality that after many years can incite complacency for the search.

I had suspected IMHA the moment I lifted Mischief’s lip, and the results of the diagnostic tests had confirmed it. Given the invariably poor prognosis listed in all the veterinary textbooks and my own personal history with cases such as this, I was worried for Mischief. I gave Mrs. Garner and her mother a very guarded prognosis for her recovery.

When I laid out the odds for recovery and the treatment that would be required, they were quite reluctant to proceed, leaning instead toward a very difficult and irreversible decision. I encouraged them to stand firm and give the medication a day or two to work before giving up. But despite the encouragement I offered, I was none too confident about the outcome. With as much optimism as I could muster, I placed an intravenous catheter into her leg and began to pour a pharmacopoeia of drugs into her weakened system, hoping against hope that they would halt the red-cell destruction.

I fretted about Mischief all morning and into the early afternoon, pulling a tiny blood sample every hour to see if the red-cell count was dropping even lower or if the medications I was streaming into her were working. With intense interest, I watched her attitude to see if I could catch even a hint of a rally.

What it was that got me to go back and finish my aborted physical examination, I can no longer remember. I suspect it was the nagging suspicion that there was something I had missed that might give me the edge over such a formidable foe. So early in the afternoon, with no appreciable improvement in Mischief’s condition, I put her on the exam table again. This time my examination was slow and exhaustive. Even so, I came up with no additional information. Frustrated, I started again at her head and went through the process a second time. This time I was surprised to feel something slip through my fingers as I felt the abdominal cavity, an unexpected finding in the area of the stomach. I rushed her to the X-ray room for a quick picture.

As I slapped the developed film onto the lighted view box, I was surprised to see the outline of something odd in the stomach. I couldn’t identify exactly what it was, but it was obviously foreign, clearly metallic, and had the appearance of a little Oriental pagoda. In an instant of clarity as I looked at that X-ray, it all made sense. I knew with certainty that the foreign body was leaching trace amounts of a toxic heavy metal, which was causing the destruction of the red cells. I didn’t know yet exactly what the metal was, but I realized that this was the cause of all Mischief’s problems. That metal had to come out!

This conclusion was easier to reach than to accomplish, however. Mischief, in her current state, was anything but a good surgical candidate. But I also knew that until that foreign body was gone, she would not improve. Of that, I was convinced.

I called Mrs. Garner and described the situation in as much detail as possible. The surgery would be dicey, not because it would be a particularly difficult one but because Mischief’s profound anemia made her a tenuous patient. While there was a chance we would lose her during the procedure, there was no chance of recovery without it. And if we were successful, Mischief’s odds of complete recovery were excellent. After taking some time to discuss it with her mother, Mrs. Garner called back and gave me permission to proceed.

I immediately began to drip a transfusion of fresh blood into Mischief’s catheter as we prepared for the surgery. Within an hour or so, I was making my first incision through Mischief’s skin, holding my breath as I did so. It was a relatively simply thing to locate the stomach, make a quick incision through the pale wall, and fish out the heavy foreign body, which had sunk into the depths of the flaccid organ. What I pulled out was a stack of coins joined together by the sticky stomach contents: two quarters, two dimes, a nickel, and a penny—seventy-six cents worth of misery, illness, worry, and pain.

After closing the incision in the stomach, flushing the abdominal cavity with warm sterile saline, and placing a neat row of symmetrical stitches in Mischief’s skin, I examined the coins carefully. The pagoda shape I had seen on the X-rays was explained by the way the coins had stacked up on themselves in the stomach: both quarters, then a dime, then the nickel, another dime, and finally the penny. The quarters, dimes, and nickel appeared pristine, as if they had just been cleaned with a ring cleaner. But the penny had turned a strange dark color, almost black, and had a hole eaten completely through its center.

In 1982, as a cost-saving measure, the composition of pennies changed from 95 percent copper to 97.5 percent zinc with a thin overlay of copper. While this change has saved the government millions in precious metals, it has cost pet owners a considerable sum in veterinary bills. For some reason, stray change seems to be an irresistible treat for young dogs and cats, who gulp them down like hard candy. In the stomach, the thin copper layer of the penny is eaten away by the stomach acid. Because other coins are made of other metals, they do not suffer the same fate. This would be only a cosmetic issue for the penny, if not for the zinc underneath. The effect of zinc toxicity is to create a cascade of red-blood cell destruction, which presents as the quintessential case of IMHA.

This is what had occurred in Mischief. After the coins were removed from her stomach, her recovery was rapid and complete. Two weeks after the surgery, at the time of the suture removal, her red-cell count had climbed back to normal and she was back to her mischievous ways. It was a joy to lift her lip and see the healthy glow of pinkness rush immediately back after I blanched the tissues with my finger. This, though, was hard to do with Mischief snorting and squirming and nipping playfully at my fingers. Her uninterested, dull demeanor seemed a distant memory. As I turned her on her side to remove the stitches from her shaved tummy, she wriggled and writhed in absolute glee, her short tail twisting in tight circles and her entire back end wagging excitedly.

“Wow, this is a different dog from the one you brought in two weeks ago!” I exclaimed with pleasure.

“You are so right. She’s completely back to her old self now. We can’t tell you how grateful we are to you. You saved her life.”

“I’m just glad you brought her in when you did. I don’t think she would have survived if you had waited any longer.”

“Now, I’m not complaining about the bill or anything, Dr. Coston,” Mrs. Garner said apologetically. “I know these things cost money. And I know how much more it would have been if I had had the same procedures done on myself. Mom just had a minor procedure done on an outpatient basis and it was way more than Mischief’s whole abdominal exploratory.”

It’s true. Veterinary medicine remains the best bargain in any branch of health care. Veterinarians appreciate the necessity of keeping costs as low as possible for pet owners, and we generally have done a great job of that. Procedures on our patients, for which we charge a few hundred dollars, easily cost tens of thousands in a human hospital. We veterinarians have the paradoxical luxury that the actual costs of medical decisions are borne by the ones who are making them for their beloved pet. This, unfortunately, forces loving pet owners to sometimes make heart-wrenching decisions on the basis of those costs. But it has also forced veterinarians to maintain tight controls on costs and fees, a necessity that no doubt would have protected the human health-care field from the current fiscal stresses upon it. In this area, human physicians could learn much from their veterinary counterparts.

“We’d have paid anything to get Mischief back to health again. But it sure did set us back.” Mrs. Garner chuckled and gave me a good-natured shake of her head.

“I know the treatment was expensive, Mrs. Garner,” I said sympathetically. “But Mischief did do something that no other patient has ever done in all my years of practice.”

The two turned to me expectantly. “What was that?”

“Seventy-six cents may not be much, but she’s the first patient that has contributed cash to help pay the bill.”

Snakebite

I was delighted to see Megan dragging Elaine into the lobby of the hospital one warm late-summer morning. Though it had been a couple of years since her injury, Megan’s attachment to me had not flagged. She still came in the door each time looking for me, calling out to me with a little
boof,
ears erect as she listened for my response. Megan and Elaine, though, were not alone this particular morning. Max limped in behind them, completely devoid of Megan’s eagerness.

“Megan!” I said loudly. “How’s my girl?”

This greeting threw her into spasms of delight, her mouth wide and laughing as she strained against the leash. Elaine released the leather handle and Megan launched herself at me, vaulting onto the reception desk between us. I met her at its summit, to find my face slathered without apology by Megan’s licking tongue. It’s nice to be worshiped, to be viewed by another as wonderful, heroic, handsome, and worthy. Though I had been the one who had put her through the intense discomfort of treating her badly mangled leg, this is exactly how Megan saw me still. And it was flattering! I indulged in this completely unwarranted devotion shamelessly.

When we could finally dislodge Megan from the desktop and settle her enthusiasm, I recognized the reason for today’s visit. Max hunkered down behind Elaine, head low and tail between his legs, holding up one grisly front paw. He looked very much like Megan. Both had been adopted from a local shelter within a month or two of each other. As far as Ms. Farmer knew, there was no relation between them. But you would have expected them to be siblings, so similar were their markings, size, and features. Like Megan’s, Max’s nose was long and straight as a collie’s. He, too, was longhaired and brown, though shaded with deeper reds. Like her, he was lean and had a deep, narrow chest. But that’s where the similarities stopped. Max’s personality was much more reserved than his infatuated sister’s. Instead of incessantly seeking attention, he was more inclined to hide behind Megan or Elaine and act as if I was not present. Apparently, he had plenty of friends and felt no need to make more, especially one dressed in a white smock with a stethoscope around his neck and, God forbid, a thermometer in his hand.

Though he didn’t want me to see him, it was clear that he needed my attention. His left front leg was swollen from the elbow to the toes to three or four times its normal size. The skin was darkened from a strawberry red at the top to almost a plum purple color near the foot. The twin trails of dark blood that seeped from two small punctures on the inside of the leg, at which Max licked incessantly, made the diagnosis obvious. Snakebite!

“How long has Max’s leg been like that, Elaine?” I asked, concerned.

“Well, I didn’t think much about it at first. He came home two nights ago limping some. By yesterday morning it was pretty swollen. But it got really bad throughout the day yesterday, and I knew I had to bring him in this morning. It’s a snakebite, isn’t it?”

In Virginia we have two species of poisonous snakes, water moccasins and rattlesnakes. A bite from either can result in serious tissue damage. The consequences of a snakebite do not allow one to distinguish between the types of snakes. Neither did the location in which Ms. Farmer’s home was situated. Both species could be found in the Fort. So I wasn’t sure which kind of bite I was treating. In as rural a setting as that in which I practice, I have always been surprised that I don’t treat more snakebites. Because they are quite uncommon, though, I do not keep the extremely expensive antivenin on hand to treat them. Antivenin works best when it’s started soon after a bite, anyway. I knew it would have little effect if started this late. Fortunately, snakebites are not usually life-threatening problems.

Max’s temperature was elevated from the severe inflammatory response his body had mounted. He was dull and lethargic, and his leg was extremely tender to the touch. Even the slightest pressure of my probing fingers evoked from him a quiet whine of pain and a feeble attempt to wrest his hurting leg from my grasp. But, though he clearly was suffering intensely, he remained ever the gentleman, turning his head away from me in resigned submission, rather than challenging me, as many dogs would have done.

Treating snakebite patients in the absence of antivenin is a symptomatic endeavor. The pain is relieved with powerful drugs. Shock is countered with high doses of intravenous fluids and anti-inflammatory medications. Secondary infections are prevented with antibiotics. Hot and cold soaks help to reduce swelling and local tissue damage. Sometimes even these measures fail to combat the mounting pressure from the swelling, and incisions must be made in the area to release the buildup of fluids in the limb. All of these treatments were necessary for Max over the next several days.

Each day, Elaine brought Megan in to the hospital to visit her brother. They had become fast friends over the years, and she missed his presence at the house now. However those visits affected Megan, they were miraculous for Max. His ears would perk up and his nose would begin to twitch as soon as they entered the building, and he would commence to whining and nosing the cage door. After her first visit, Megan knew exactly which cage was Max’s; and once she had greeted me exuberantly, she would make her way there and return his affection through the bars. Though you would think this would have made Max depressed after she left, it was amazing how much he would settle down after her visit, eating his food only after Megan and Ms. Farmer had been to see him. His attitude would remain upbeat for an hour or two before sinking down again into his discomfort.