When faced with a sick patient, medical people (both human and veterinary, and for all I know slimy 8-legged doctors on Alpha Centauri) formulate what is called a problem list.
This isn’t going to end well, I thought
The five of us stood in a semi-circle in ICU, trying to figure out what to do. Between us there must have been 30 years of clinical expertise at least, and we were at a loss. Among our number was an intern – a new veterinarian graduate from last year, the greenest of us all but could bring fresh knowledge to the problem, and had not yet felt the heavy chains of burnout. There was a resident, seeking advanced training in internal medicine in order to become a specialist through a 3-year rigorous program. And then there were the specialists ourselves: me, in critical care; a surgeon (whose case it was to begin with); and an internist, or internal medicine specialist. (Internists, often confused with interns, deal with the long-term sick. When the patients get really good and sick they usually get me involved. I have no long-term memory, so after I attempt to put the fire out, the patients usually go back to either an internist or their regular veterinarian for afters.)
We were all trying to solve the Trevor problem.
Trevor was our collective patient, a middle-aged and sweet dog who had diabetes and had recently undergone surgery for a liver biopsy and removal of his diseased spleen. He was not doing well, not doing well at all, and we were trying to find out a way to help him. At surgery, we had placed a feeding tube into his intestine to aid in the provision of nutrition. He had not eaten for several days before surgery, and it wasn’t looking like he was interested in ordering Chinese takeaway any time soon. He was also leaking a thick, bloody fluid that looked like tomato soup from a large abscess on his side and he was in extreme pain despite the cocktail of analgesics that were dripping into him.
Our current problem was his climbing white blood cell count and the pain. Trevor, as sweet as he is, was a mess, and he was our mess.
When faced with a sick patient (a really sick patient, not just “oh, I broke a toenail, thanks for asking”) medical people (both human and veterinary, and for all I know slimy 8-legged doctors on Alpha Centauri) formulate what is called a problem list. Simply stated, this is a running tally of all that separates a patient from his or her normal state: their problems. It is made up of any number of abnormalities, from things that have gone wrong on paper, like lab tests, to naughty things that the patient is doing, like vomiting, having cancer or being anemic. This deceptively simple concept is the key to imposing some order on the chaos that can come from any medical crisis.
If you have a truly sick patient, and this selfsame sick patient starts to accumulate problems like a light bulb draws moths, it is easy to become overwhelmed and lose sight of what is killing the patient in the face of all that stuff. The temptation is there to just throw up your hands and say “he’s too sick – I give up!”
The creation of a problem list allows you to quantify what is wrong, prioritize it and start chipping away at it.
Trevor’s problem list was growing exponentially, and we were waiting an interminable amount of time for the biopsy.
These types of cases are a terrible gamble for owners; we go in, remove what we hope is the root of the problem, ship them back to ICU and wait for the results with bated breath. If something goes wrong during the stay in ICU after surgery, things get really nasty. There seems to be a collective concept, probably deeply imprinted on us by too many hours in front of the TV, that everything will be fine after surgery; that stuff is fixed. Even surgeons themselves have an adage: a chance to cut (surgical parlance for performing surgery) is a chance to cure.
But from my perspective, sometimes that is exactly the spot where the problems begin.
Patients with complications after surgery can amass huge medical bills that make the surgeon’s fee look like chump change. ICU fees for post-operative care can run into the thousands, and without biopsy results in hand owners often don’t know if they are putting their pets through the medical grinder, and spending money like water, in vain. This was our precarious position right now. Luckily, in a perverse way, the discovery of the abscess on his side was helpful to us, and hopefully helpful to Trevor himself. We had been searching for a cause for the pain and skyrocketing white blood cell count (abbreviated to WBC, and not always associated with infection but usually a good bet that it is lurking somewhere). The abscess, which drained while we were examining him and changing his bandages, was likely the source of all of his new problems. The hope was that getting the infected goo out of there would bring about the change in course that we had hoped to see. He had been in ICU nearly a week already, and there had not been much of a light to guide us since surgery. With the discovery of the source of his fever, pain and climbing WBC, we thought we saw some small and distant twinkle in the dark; a beacon saying shore might be close at hand.
Once again, hope started to creep into ICU.
I have learned that this is not a good thing, despite whatever positive powers hope is said to have. Hope needs to be there; hell, hope is a natural part of our human makeup that helps us cope with situations like this. But hope too soon in the game is toxic. Hope, when your team is winning by a narrow margin before halftime, is too fragile a thing to be worth a tinker’s damn. It is too often smashed, and the sharp little shards it leaves behind are apt to do some damage. Hope, in my opinion, should be saved for when the opposing team is thoroughly vanquished and there are 0:02 seconds left on the clock; then it can be let out and acknowledged. Hope needs to have reality to back it up or it boomerangs on you.
Just as the surgeon was cleaning up the abscess and draining the fluid that was making Trevor sicker than he should have been, word came through from pathology; hemangiosarcoma.
Cancer is bad; hemangiosarcoma is worse.
It is an unusually ill-tempered and vicious type of cancer that arises from blood-forming organs like the spleen, which is where it was found in Trevor’s case. There are many types of cancers, and they are as varied as people are. Some are pokey and slow-growing, unlikely to kill the host before they die of some other ailment - like prostatic cancer in humans - while others are voracious black storms, devouring the host and spreading to every available niche with frightening speed.
Hemangiosarcoma is of the latter variety. Most patients live, on average, 3 months or so after a diagnosis is made. With the addition of medications to control cancer (chemotherapy) this can be extended by a few more months, but it is not the kind of cancer for which we can typically expect many months or years of good-quality life. It seems like the punch line to a rude joke, but it is bad cancer.
I am not sure what will happen; his family is on the way to discuss his present and his future. They have already expressed a reluctance to euthanize (the owner stated he would do himself in before he made the call to end Trevor’s life), but sometimes hearts and minds can change when faced with hard data and short survival times.
We have done a good job (I hope) of making Trevor as comfortable and cared for as we could. I hope, too, that he has some dignity left and he has not been in a great deal of pain. I know what I would do in these circumstances; lurching off course in ICU, flying a flag with a leering skull and crossbones. But I don’t know what Trevor’s family will do. At times like this, most would make the decision to have Trevor euthanized, to end his suffering. But not all. And the University is not like most veterinary hospitals; the families have been through several levels of the medical hierarchy before getting here, a process which usually leaves, for better or worse, the supremely dedicated, in some cases the pathologically attached and almost always the financially independent.
I have been pushed to go further a few times in my career, and this is where you tap into all sorts of skills you may not have known you were in possession of. And, at the edges of what most would consider the normal veterinary medicine map of the world, the usual right-vs.-wrong rules fail to apply. Here there be dragons. What if they decide to go ahead and he beats the odds and lives another five years of good life? What if they slog it out in ICU for 7 more days, spend countless thousands, only to lose him to infection, blood loss or one of the other myriad disorders that can make you shuffle off this mortal coil? Which was the right decision? The answer only comes after all is said and done, and whatever ship has sailed has come into port.
As a doctor, you also find you can do things you didn’t know you could in a crisis, but it comes at a price; am I doing the right thing? And if you are – for whom? The patient? The family? Yourself? The world at large? Amazing how such a simple little thing as a dog with an abscess in ICU can have global ramifications if you let it out far enough.
They will be here soon. I only hope they make the right call.
Whatever that is.