The Hardest Part of the Job

No, it’s not euthanasia.

It’s making hard decisions that might not pan out the way you want them to. And knowing that with your decision, someone’s pet has to pay the cost. And a person who is not you, bears the lion’s share of the emotional burden.

Let me tell you two stories. Details have been changed to protect the innocent.

Smitty came in because he had a tumor on his back leg that was really nasty looking. I mean picture the worst tumor you have ever imagined and then put spiders all over it, it was that scary. He came in to have it evaluated and it was determined it would be best if the tumor went away. So we scheduled the surgery. We in this story is myself and the Smitty’s owners. We scheduled it on one of my colleague’s surgery days. A small piece of information that is maybe a little important, Smitty had had a cancerous mass removed a little over a year before.

The day of surgery arrived. My colleague examined Smitty and looked at the previous surgery notes. Looking at what had happened, how he was doing and what her surgical schedule looked like, she decided that particular day was not a good day for surgery. So we put the surgery off.

The owners were less than happy and mentioned that they really wanted the tumor gone. I struggled with the idea for a little bit but had successfully removed a tumor from him a year previously and wanted to make my clients happy. I agreed to do the surgery. We scheduled it for the next Wednesday and I removed the tumor without incident. Smitty recovered wonderfully from anesthesia and went home that evening. The tumor went out for histopathology. I went home happy I’d done right by the poor guy.

The pathology came back as cancer but importantly, the dog came back with some serious issues at the incision site, he wasn’t eating or acting like himself. Some diagnostic tests revealed that his immune system was breaking down his red blood cells and that he also had an infection at his incision site. This was a problem. Actually, it was two problems and they were working against each other. On the one hand, we needed to treat the infection and get Smitty’s incision to heal. On the other we needed to suppress Smitty’s immune system and stop his body from destroying it’s own red blood cells. We attempted to do both.

As it played out, Smitty’s body started to activate clotting factors within his blood vessels, this lead to large spread dissemination of clots throughout his vascular system and this very quickly escalated into a crisis. We put Smitty on oxygen, started to increase his blood volume and turned off his clotting factors but ultimately his owners decided we needed to let him go. Smitty was euthanized while on oxygen therapy.

I made all of the decisions along Smitty’s course of treatment that eventually lead to his being put to sleep. The owners had informed consent, sure but they couldn’t fully appreciate all the risks we were taking. After all, they weren’t really taking them, Smitty and I were. And Smitty was anything but consenting. Each path was more difficult than the one that preceded it. I couldn’t leave the tumor in place. I had to address both the immune mediated disease and the active infection. At the end of the day, we were still left with a horrible outcome and Smitty went through a lot of discomfort before he passed. It is difficult to pull the positives out of cases like that.

Suzie a beautiful tabby cat showed up in the middle of the night on emergency. She had vomited and defecated on the floor. She was acting odd, weak, not walking and her extremities felt cold to the touch. Her vitals were normal and prelimenary diagnostics did not reveal any concerns either. I gave her two different types of fluids to expand her blood volume and improve her perfusion- bring blood to her cold extremities – and a drug to battle any nausea and help with any discomfort along her stomach and intestines.

I looked at her intestines using ultrasound. I would simply lay her on the table and she wouldn’t move. Would just lay there and let me ultrasound her without protesting. Normally, this cat would be all over the place. Not aggressive. Just really wiggly. I noticed that her intestines were all distended, fluid filled and not moving. I couldn’t find a single painful spot or any evidence that she had any foreign material in her intestines. But still, I was worried about something blocking the intestines and keeping them from moving. So I put about half a cup of contrast material in her stomach, the contrast material – barium – helps to encourage her intestines to move and it will outline anything that shouldn’t be there.

Did I mention I was doing this by myself?

At 2 o’clock in the morning I decided that the last thing I would do was give her another small amount of fluids to maximize her perfusion and let her rest for the night. I started her fluids on a slow drip and went outside and smoked two cigarettes in a row. (I hope my wife doesn’t read this post) I do sometimes smoke when I’m really stressed and tired. I was both of these things.

I left her a little after two. Knowing I had done everything I could do for her on my own and hoping that it would be enough. I laid awake in my bed all night, trying to sleep and waking back up with thoughts of Suzie alone in the hospital. Did I make the right call’? Was she going to be alive in the morning? A twisted intestinal tract in a pet can cause death in a matter of hours. I have never seen that in a cat but there’s a first time for everything and I really hoped Suzie wasn’t going to be the first I saw. Especially if I saw it after the fact.

I finally gave in at a quarter to 6. I got out of bed, dressed and kissed my wife good bye. I did my best to ignore her look that was equal parts annoyed at me for running off in the morning to leave her with the kids and concerned for my mental health because I let myself get so stressed over these things that are beyond my control. But this was my choice, my decision and as I drove to work that morning I was fairly certain I had made the wrong decision. I was sure I was going to find Suzie, expired in her cage. I was going to have to make that call and let someone know that the pet they had entrusted in my care had not survived my best efforts. I have had to make that call on other occasions but this one seemed to hurt more. Maybe because I had been alone and this was one hundred percent my decision making. Maybe because I had a nagging suspicion before I left that the cat had something wrong with her intestines. I didn’t know why. I did know it was the longest 25 minute commute ever.

Suzie was looking out at me from behind the litter box I prop up in the back of the kennel to give cats a place to hide. When she saw me she chirped and purred and rubbed against the front of the kennel door. I opened the door and she rubbed against my hands. Her feet were warm and she ate the small amount of canned food I set down for her, nearly as soon as  I set it down.

Her owner agreed to leave with with me until a little after noon and just before she left, Suzie deposited a barium colored bowel movement in her litter box. It was the best present she could have given me. Everything was working as it should be.

Sometimes – often – we are tasked with making big decisions with a limited amount of information. There are many times where we are making the best decision we can arrive at in the time we have with the amount of information we have available to us. Sometimes we are forced into a decision we would rather not have to make, emergencies happen, diseases come to a head and we have to act now or lose for certain. The hardest part of this job is dragging you – our trusting clients – along as we charge ahead and meet these situations head on.

Thanks for reading.

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4 thoughts on “The Hardest Part of the Job

  1. This was compassionately eye-opening! Thank you for illuminating the times in between when the burden is yours even while the worry is shared.

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  2. I completely agree. I often struggle with knowing if I made the right decision. As a vet you know the owner is trusting you to make those decisions no matter how much information you give the owner. Case in point – dog with a bleeding splenic mass. He had low platelets and high blood pressure before surgery. I note the risks and discuss that those are bad things to have but we don’t have a lot of options and the spleen has to come out. After surgery the patient continues to have low platelets and high blood pressure, as well as heart arrhythmias and other problems. Now I think the bleeding splenic mass was a symptom and not the primary problem. Especially since the pathology comes back a benign fatty mass with bleeding.

    Cases that like weigh on your mind long after. I know it’s worse for the owner but I hope some realize that their doctors spend much of their time worrying as well. I hope to never lose that quality and become complacent but it does add much stress to life. Thanks for sharing those stories with pet owners.

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