Pierre

I recognized many years ago that I am a much better veterinarian to your pets than to my own. I think there are many reasons for this, but ultimately, I think that I simply lack objectivity.

Emotion is a powerful thing, and although it is the glue that holds relationships together, and likely the reason we are so successful as a species on the earth, you can’t turn it off.

At least I can’t.

We are right in the middle of a series of difficult decisions with our dog Pierre. For those of you that are new to my blog, Pierre was one of the dogs we acquired from Louisiana after Hurricane Katrina. Four members of the Knox County Humane Society went down with two vans and brought back 40 dogs. One of them was a small, heartworm-positive, papillon mix that was one of our earliest foster failures. We named him Pierre, because he always looked like he should have a beret and perhaps a cigarette. Since we don’t allow smoking in the house, we just imagined the beret part.

He was cute, but full of parasites and a little funny with people. He had been caught after the storm and the animal control officer had to use a rabies pole because he was aggressive. A rabies pole is a long pole that has a noose on the end to catch and hold biting animals away from you. It also works on Alligators.

It seemed so cruel to have caught such a small, innocent dog with a rabies pole, or so we thought as we merrily drove him home. I was a bit surprised a few days later when a neighborhood kid came over and I watched Pierre confidently bite him in the ankle.  We apologized for the unexpected bite and wrote it off to adjustment.

As the years went by, we learned that Pierre had a few rules.

If you hurt me, I will hurt you

If I don’t know you, do not touch me

If I don’t know you, i might bite you. But then again, I might not.

I like snuggling with people I know

Once I know you and like you, you are my friend forever.

I am a big fan of cheese.

With the rules in hand, he has had a great decade or so with us. His job in the family was to lick Mary repeatedly at bed time after she applied skin moisturizer. This habit was responsible for both a sharp spike in my blood pressure between 9 and 11 pm, but also Mary’s amazingly young complexion.

A  month or two ago he had an unexpected seizure before the moisturizer ritual.

Some inside veterinary information on that….seizures themselves are usually not dangerous, and in young dogs (less than 3) are usually caused by idiopathic epilepsy…we don’t know why it happens, but they tend to happen more and be benign. However, in dogs over 8 years old, if a seizure occurs for the first time it often signals the presence of a brain tumor.

We sat with that and cried. With brain tumors often come behavioral changes, and Mary had noticed that he was much more irritable over the previous few weeks and had started some new obsessive behaviors. He also didn’t want to eat well

For those of you who have read this blog before, you know that as vets, we deal with death more often than the average physician or human medical provider. That is simply a function of the average life span of our patients. It took me awhile to figure that out, and the longer I practice, the more I see my role as negotiator of that loss. Sometimes it happens tragically, and that is the most difficult. Sometimes it happens peacefully after a very long life and it can feel like a gift that we can give our beloved pets. Many times it is a negotiation we make together without such clear boundaries. Our job is to find that sweet spot with medical technology, but more importantly with our heart.

 Without opening a philosophical debate about the value of human vs animal life-since I am a veterinarian, I can’t help but to put myself not so much in the place of the human, but actually the pet.  What would I want in their situation…if it were me? Since euthanasia is an option in veterinary medicine in the United States, we face the decisions together. Action vs inaction, aggressive therapy vs wait and see. Life vs death.

A few years ago I read the book Being Mortal by Atul Gawande. Dr Gawande is a surgeon who, besides being an amazing writer, tackles the subtleties of how that is typically approached in his experience in human medicine. I walked away from reading that book inspired that end of life decisions are actually one of the most sacred ones there are for all of us. There is nothing more important than the attention we give to that. Walking the line between what can be done and what is the right thing to do is difficult for anyone. This is where my role as a veterinarian requires more listening skills than knowledge.

This is also where I suck with my own animals.

 In Pierre’s case, we decided to get more information from the veterinary neurologists in Portland. I have referred many cases to the Maine Veterinary Referral Center over the years and trust their common sense approach, but also their ability to get the job done when it comes to neurosurgery. Honestly, with Pierre now around 12 years old, we were cognizant of the fact that we were now in that place of negotiation.  I think that I speak for Mary when I say that although we make that kind of decision with our hearts, more information is usually better.

 We met with Dr Danielle Eifler and she discussed our options. An MRI would be the most likely way to find a tumor, but since it was a single seizure, we could also take a wait and see approach. She was honest, compassionate and respectful of us. Pierre also liked her immediately, and although we brought a muzzle, we never needed it.

We decided to at least find out if his seizures were because of a tumor, and after a thorough workup and MRI, we found out it was just that. On MRI, Pierre’s tumor had every sign of being a meningioma, which is a benign tumor of the delicate membrane that surrounds the brain. The tricky part is that it went into the sulcus-the division between the two hemispheres which made it impossible to remove totally.

Still, with no surgery the expected survival was 2-6 months, with surgery often greater than a year and with surgery and radiation 1-2 years plus. Since radiation required 4 weeks treatment in Waltham Mass, and since Pierre had an admittedly complicated set of rules, we only truly had to decide whether we would do medication and no surgery or surgery. As we reviewed the past few weeks, we attributed most of his behavioral changes to pain….it is hard to tell if a dog has a headache afterall…..

I shared the emotional side of this decision with my staff already when I said that I had never really been on the other side of the veterinarian/client bond before… at least not since vet school. One thing that many people have told us through the years is how appreciative they were for the compassion side of Kindred Spirits. I have always been appreciative of that feedback, but in all honesty, I have secretly thought you would have to be a sociopath to not have compassion for people and pets in a situation like that. As my wife would later point out, that was a tough place for me when it was my own pet. Dr Eifler gave it to all three of us, and I have a new appreciation for how that feels when you are faced with a difficult choice. For me to be the pet owner, the veterinarian and the husband is simply too much for me to balance.

Receiving Dr Eifler’s honesty and compassion, complete with uncertainty, and opinion, and her own tears was one of the most amazing experiences I have had…period. Mary stayed in the waiting room while Dr Eifler brought me back to see the MRI procedure. We watched the MRI images come up on the computer screen together and she broke the news to me as we saw it real time that Pierre had a mass, then she could tell it was outside the brain, then likely a meningioma.

Dr Eifler and I went out to share the news with Mary while the vet tech woke Pierre up from the anesthesia (an MRI took over an hour and as you know if you have had one you have to stay very still).  She encouraged Mary and I to break for lunch and discuss where to go next. We stopped at the nearest diner and before we finished lunch had decided to go with the surgery. It would improve his chances, give him more time, and although we were accepting that it was buying time, it would hopefully make him more comfortable. The biggest negative was the 25% chance of permanent neurological deficits….brain damage. It could be as subtle as a slight weakness on the opposite side of the tumor location, or as profound as a coma.

We scheduled the surgery for March 9th, last Wednesday.

Mary went down to Scarborough with Pierre and we waited as his surgery went from a 2-3 hour estimate to a 6 hour reality. When Dr Eifler was done she reported he had done well though the surgery, and that he would be on an IV and pain meds overnight. But the surgery itself went as well as she could hope. The next few days would tell what if any neurological deficits he might have, if any.

The next day she reported that he had blindness in the right eye and was not standing, but that many things were normal after brain surgery. By the afternoon he tried to stand, and by the next day he was walking (although with weakness on his right side). We brought him home on Saturday.

For those of you that saw me the end of last week, if I seemed distracted, I would like to apologize. I was experiencing what many of you have experienced under our care….the waiting, the worry, the anxiety.

The night we brought Pierre home he was agitated and would not settle. He paced, collapsing to his right side and circling. He could not get comfortable. I went up to our cliniic, breaking all controlled substances rules and brought him home some injectable pain medication and sedatives. He would rest, but as the drugs wore off he would pace, whine, paddle.

Sunday he did the same…all day. In one of my patients, I would give him meds as needed, but I have never done brain surgery, so I have no experience with the after care….and as a pet parent, I went straight to the worst possibilities. I called Dr Eifler. She had me increase meds but by midnight he was cycling from injection to injection and could not get comfortable.

I will never forget that feeling of helplessness that I had just two nights ago.  I accept that many things are possible depending on the personality of the animal, and usually by the next day they are much better. But now I know…really know… how it feels to have a frantic dog and be worried that it is the worst. For me, with the complexity of the decision, I feared that we had made the wrong choice for Pierre.

Long story short, I am out this week and in Portland. Pierre is hospitalized at the Maine Veterinary Referral Center and I emailed Vicki to get us through the week. Dr’s Pooler and Barry as you know, are amazing, and everyday I learn from them even before this crisis. Right now, my mind is totally mush, and I am so grateful that they and the team are at Kindred Spirits to take care of you all while we focus on Pierre. After all, I just told you guys that I was going to be the old guy in the practice now.

…and for the record, you can believe this humbling experience has reminded me what its like to be you.

Today I visited Pierre and he was better. A little bitty tech ( I estimated her as 7 years old, but maybe she was 20) brought him out wrapped in a  blanket. After ignoring me for a few minutes, he licked my hand. I brought him outside and he lifted his leg and urinated. and I did a little dance in the parking lot. When I brought him back in I handed him to the tech and I burst out in tears, relieved that he was better than the day before. She looked surprised. I know that I am not a quiet, manly crier….but I don’t think she did.

I will keep you posted, but tonight I am optimistic. No matter what the outcome, I am reminded of one thing :

Knowing that someone is on your side that cares makes all the difference in the world.

Wish us luck