The Art of Medicine — Falling through the cracks

In clinical practice some memories never fade — for a variety of reasons.

Interested readers can now access my latest Art of Medicine column — Falling through the cracks: A matter of substance — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

The Art of Medicine — A Christmas gift

The mother sits quietly beside her husband, holding the swaddled infant in her arms. With pen in hand the father studies the form on the clipboard before him. Their 3-year-old son vies for his attention, then drops to the floor, whining by his feet. more»

Interested readers can now access my latest Art of Medicine column — A Christmas gift — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

Death of a dog

“How long has she been acting like this?” I say, dropping my valise by the corner hutch.

“All afternoon.” My wife pauses momentarily with her knitting. “I don’t think she hears.”

I step over the gate into the kitchen. The little dog continues to pace in circles clockwise, in and out from under the table, always to the right.

I call her name, softly at first, then louder. I clap my hands above her head as she circles; there is no response.

“Did you call the vet?”

“No. I wasn’t sure what to do.”

“Did she go out for a walk today?”

“Just down the street, but she wanted to come home right away. She ate a little bit this morning, but she won’t drink.” The knitting stops. “What should we do?”

I step back over the gate into the dining room and rummage through the stack of papers under the stand for the local telephone directory. I punch in the numbers and wait. Surprisingly, someone picks up on the other end after only two rings. I explain the situation and ask if the vet might be able see the dog.

“We’re all booked up today, tomorrow morning and Monday. The earliest I could get you in would be next Tuesday. I wouldn’t want the dog to wait that long. You could take her to the Veterinary Emergency Center this evening.”

I jot down the number and address. “Thanks for your help,” I say.

Back in the kitchen the dog continues to pace. The circles have gotten tighter and tighter. She approaches her dish in the corner, holds her muzzle above the fresh water, but won’t drink.

I dial the number for the Emergency Center and verify that they are open.

“I suppose we should take her down.”

Immediately, my wife drops her knitting, rises from the chair and reaches for the dog’s leash.

She climbs into the back seat of the SUV, holding the dog swaddled in a towel in her lap. The dog whines and pants. She has never been a good traveler in the car.

It’s a 25-minute ride as I race over winding back-country roads. “Can’t you slow down?” my wife says. “You’re scaring her!”

At last I pull into the small parking area in front of the white clapboard building. Formerly a house, it has been converted into a medical clinic. The front door is partially ajar. A sign on the wall outside says: “Please ring for attendant.” My wife pushes the door open with her foot and steps inside, cradling the swaddled dog in her arms. Across the room an attendant looks up from her desk and greets us with a smile.

“My husband called,” my wife starts to say. Almost immediately another attendant appears from the far door marked “Employees Only” and accepts the dog from my wife. “The doctor will assess the dog in the back,” she says. “We’ll come and get you.”

My wife takes a seat. I stand at the desk and complete the intake form and hand it to the attendant. Soon we are beckoned from the doorway of an exam room opposite. Inside, the dog paces the linoleum tile floor in circles, dragging her twisted leash behind.

The attendant asks us a series of questions: “When did the behavior start? Has the dog been eating? When did she poop last? Was she able to squat? Any recent illnesses? Who is your regular vet? Is the dog up to date on her immunizations?” She records our answers in the computer by the exam table. “The doctor will be in shortly,” she says and steps through the doorway, pulling the door closed behind her.

I sit and watch the dog continue to pace in circles. No amount of coaxing will break her out of it. I think back to our daily walks this past summer. Sometimes she would vomit without warning. Once or twice she collapsed on the ground during these episodes, momentarily losing consciousness. Periodically, her hindquarters would tremble for no apparent reason. Sometimes, as I sat on the front porch, the dog would suddenly start to lick my legs without pause for 20 minutes or more. My wife said she thought the dog craved the salt on my sweaty skin.

The door opens and a young woman appears. She introduces herself as the veterinarian and immediately observes the dog pacing about the room. Shortly, she steps over to the computer and studies the screen with a frown. “When did all of this start?” she asks. Once again, we rehearse our lines. Slowly, she nods her head and taps a few more keys on the keyboard.

The same attendant appears to assist with the examination. The dog resists having her ears looked into. The vet listens with her stethoscope and studies the dog’s eyes. Afterwards, the attendant lifts the dog down from the stainless steel table to the floor. The dog immediately resumes pacing in circles.

“Sometimes we see this behavior with ear infections,” the vet begins, “but there doesn’t seem to be much evidence of that on exam.” She clears her throat. “I’m worried that this behavior is being driven by some sort of neurological problem, probably in the brain.” She pauses a moment, then continues. “I doubt she’s had a stroke — there’s no unusual eye movements, and she’s able to keep her balance — but she could have a tumor in her head. We wouldn’t know that for sure without doing an imaging study. A complete work up would cost somewhere around $1500, and then you’d be looking at treatment options. Frankly, the outlook is not optimal.”

“As far as you can tell, could this be due to some sort of contagious disease. Would we be at risk by keeping her at home?”

“No, this isn’t a contagion. If you don’t feel comfortable taking her home, we could board her here overnight.”

I look over at my wife, who continues to watch the dog pace around the room. “Can you give her anything to calm her down?” she asks.

“We can give her a sedative and some steroids,” the vet says. “That would help get her through the night. You could call us tomorrow with an update. I’ll be here all weekend.”

I nod my head. “Let’s do that.”

Two attendants return with a set of syringes. One attendant lifts the dog back up onto the exam table and restrains her while the other injects the medicines into the dog’s hindquarters. They hand the dog to my wife and usher us out to the front, where I pay the bill.

Back home the dog once again resumes her endless pacing. My wife opens a box of chicken broth and pours some into the dog’s dish. She holds it up to the dog’s nose. Surprisingly, the dog begins to lap the fluid. She drains the bowl, turns her head to the right and immediately resumes her pacing.

Later, I awake in the dark and enter the kitchen to find the dog lying in her small bed, her tiny muzzle resting on the edge. Gently, I place my hand over her head. She opens her eyes, stares straight ahead, then closes them once again. Suddenly, she rises to her feet, steps out of the bed, circles the floor several times, stumbles back into her bed and buries her head in the fluffy lining.

The next morning I call the Emergency Veterinary Center to report the dog’s condition. “I think we need to bring her back in,” I tell the receptionist.

“I’ll let the doctor know you are coming.”

It’s a chore to get the dog into the car. My wife wraps her up in an old towel and climbs into the back seat. I can hear the dog whimpering the entire way down.

There is only one car in the small parking lot when we pull in. Inside, the attendant is waiting. She escorts the two of us into a back office. “The doctor will be in to talk with you shortly,” she says. She looks down at the dog pacing the floor in circles. “Poor thing,” she says, closing the door behind her.

We sit in padded leather chairs, watching the dog pace and pant. I search for the right words. “I don’t think she’s going to get any better,” I say.

“Neither do I,” my wife says. “I don’t want her to be in any more pain.”

Minutes elapse. The dog’s circles become smaller and smaller. Soon the leash is tangled in knots on the floor. Finally, the door opens and the doctor steps into the room. “How did it go last night?” she asks, hunkering down on her haunches to watch the dog.

“Not well. She was up all night, circling on the kitchen floor,” I say. “This morning I saw her pushing her head against the edge of her bed. She seems to be oblivious to both of us.”

“I don’t want her to suffer any more than she has already,” my wife says.

“Yes, I agree,” the doctor says. “These things usually don’t have a good outcome. I’ll have the attendant come to take her in the other room. We’ll give her a sedative to calm her down and put in an IV port. Then we’ll bring her back to you. Would you like to hold her in your lap while we give her the final injection?”

My wife nods. The doctor offers her a tissue from a box on the desk. “She’ll be back shortly,” she says and walks out.

The attendant returns. There are papers to sign, a check to be written. She takes the dog out on the leash. Minutes later she returns with the dog wrapped in a blanket and shifts the bundle to my wife’s arms. The dog’s forepaws are trembling. One foreleg is wrapped with a green elastic dressing. An IV site protrudes from the lower edge.

“I’ll give you a few minutes before the doctor comes in,” the attendant says.

My wife cuddles the dog as though it were a newborn baby. She strokes the fur on her muzzle and whispers into her ear. I stand by the desk, motionless, watching, waiting for the realization of what is happening to sink in.

The door opens and the doctor enters, kneeling down at the foot of my wife’s chair. “She’s heavily sedated,” she says, “not feeling any pain any longer. I’m going to flush the IV port, then administer the medicine.” She reaches into a sleeve on the side of her khaki trousers and withdraws a syringe. The clear fluid flows easily through the IV site. She caps the needle, then withdraws another syringe from an adjacent sleeve. I watch her push the opaque pink fluid into the port. Afterwards, she reaches for the stethoscope around her neck and slips the diaphragm under the dog’s foreleg.

Finally, she says: “She’s gone.”

“I’ll take her to the back and we’ll meet you at your car. Would you like us to remove the collar? You can exit here through the back door privately and walk around.”

Outside, my wife pauses at a flower garden by the walkway while I continue on to the car. The attendant exits the front center door carrying a small cardboard box in her arms. The dog’s collar dangles from her right hand.

I open the rear car door and rest the box on the seat. My wife appears and speaks briefly to the young attendant. I slide in to the driver’s seat while my wife climbs in behind me.

I back the car around and pull out onto the road. “Do you want to go directly home?” I ask, glancing into the rear view mirror.

“Where else would we go?” my wife says.

I shrug my shoulders and drive the rest of the way home in silence.