Thursday, February 26, 2015

Dig Until You Get An Answer,, Even If You Are Fishing In Unfamiliar Waters. Isa's Canine Leukemia.

There are a few hidden talents to a vet who has been in the trenches for a few years. It is the simple accumulation of enough stories that allows you to see a common plot in a new patient with a particular shimmer of a tiny clue in the blink of their eyes. It is hard to explain, but the longer you practice the more your gut guides you.

I met Isa on a busy over burdened Sunday afternoon. She and another pup were waiting at the door twenty minutes before we opened with sobbing parents, (never a good sign).

Isa's vet visits had begun with diarrhea 5 days ago and progressed to include vomiting 2 days later. Isa, an older German Shepherd, was now lethargic, despondent, inappetant, and withdrawn. She was also pale, weak, and unable to walk.  Her mom was understandably emotionally exhausted and fearing the worst.

Over the previous two days blood work and x-rays had been done at the ER where she had been transferred for the weekend. And, yet, here she was back at the place that had been searching for her answers for over 72 hours looking like time was no longer on our side. We knew she was sick and we knew she was getting sicker... we just didn't know why.

That's what medicine is. A battle between wits, guesses, diagnostics, and determination. It can be frustrating. Sometimes you get a case that has minimal tools to help you through your puzzle, whether they be a lack of resources to chase down every possible disease, lack of free time to dilly-dally when your patient is making a run for the white light, or a client who lacks the patience to allow you to sift through the most likely culprits to get to that elusive rare disease hiding in the rule out haystack.

Isa had been tested and cleared of all of what we thought were the most likely "treatable" diagnosis scenarios. Yet, here she was still sick and now flirting with dying. Every seasoned vet will tell you that most likely scenarios don't have a name. They have a breed and an age and a prayer to build a wish upon. Terribly cold labels to paint on a beloved family pet. But, there is truth to those old broad sweeping, emotionally void labels. Isa was still an older German Shepherd  who looked like the first guess on the suspicion page and the least wanted scenario. She looked like cancer. We just couldn't find it. Everyone of us knew that we had to be looking for this, we just didn't know where it was lurking. She was now at the door, sicker, paler, and weaker than ever before.

The ER had suggested to Isa's family that she have an exploratory surgery. It was a realistic request, the problem was that this was a Sunday and an exploratory surgery requires more staff than we have on hand and an intense follow up after care plan. I tried to apologize to Isa's desperate mom, and I felt awful about it. I knew that there was a chance she wouldn't live another day, I knew the answer might lie in her belly, and I knew that even if I could open her up and reveal her mysterious illness she would have to go back to the ER.

I did what I always do in this pinch with my heavily burdened conscious. I left my phone number and told Isa's family to have her back with us in the morning. If they wanted an answer I was sure as heck not going to give up looking for it. There is truth to the adage "where there is a will, there is a way."

Isa, we believed, was in need of an exploratory surgery to remove a mass in her belly. The x-rays seem to suggest this, so we decided to confirm it with an ultrasound. Her ultrasound concurred there was something abnormal in the area of her stomach. As much as clients hope that we can come to a diagnosis affordably there are times that we have to run every single one we have in our arsenal.

By 10 am on Monday morning, after about a week of diarrhea, inappetance, and lethargy we were going to try to get an answer to Isa's woos. Isa's mom consented to the exploratory surgery she had asked for the day before. There was a new sense of optimism that we had her villain in the cross hairs.

Isa was on the operating table by 1030 am.

Her exploratory started out as good as one could hope. No visible bleeding in the abdomen, and doing well under general anesthesia.

 Isa's first big reveal. A very large spleen, and I do mean very large. 

The search widens..

And reveals,,,nothing. Another dead end.

Every inch of Isa's abdomen was inspected. Some by touch and some by visual recognition. But no organ, no area, no corner, nothing was missed. I reluctantly, begrudgingly closed her up.

And, damn it, as hard as you try, as much as you want it, there are those cases that stump you at every move. Isa was one of those girls. She was a shorter list of rule outs, a list of attempts, and a girl who still smiled, still wagged, and still wanted to be her families guardian. 

A week of every diagnostic option tried, and crossed off the list, and still we didn't have an answer, a reason, or guiding advise for Isa. There were three vets on her case and all of us knew the answer was out there. We also knew that when the easy answers are exhausted you sometimes get cornered into cancer. It was now at the top of the list. We needed Isa's family to allow us to keep digging, even after we admitted there was a slim chance that there would be a happy ending.

What do you do when you have looked and not found an answer?

You look again.. and you keep looking. I know it is hard to accept, infuriating to pay for, and yet it is real-life. So we started from the top. We re-examined her. questioned every decision over again. We talked about her case with every other vet in the building and repeated Isa's blood work. We were starting her on the only treatment option that we had left, steroids... massive amounts of steroids.

When your patient won't eat call in convincing reinforcements.
Isa's bloodwork now 2 weeks later was being sent to the lab again. This time the lab noted that there were significant unusual abnormalities and sent her blood to a pathologist for review.

And, there it was, finally an answer. Isa's diagnosis was confirmed by two pathologists at the reference lab. She had leukemia. It was a diagnosis we had feared and suspected all along, even if it took us a week to get.

Isa was started on steroids. It was her only option left. 

Her disease had quickly annihilated her bone marrow,, therefore she grew weaker and more anemic as the supply of her red blood cells collapsed. She, the prodigal German Shepherd was dying of a cancer we rarely see and more rarely have the opportunity to diagnose. She passed away two days later with her family who were grateful to know the answer to her illness and happy that she was with them until there was nothing left to do. She was loved. She was given every possible chance, and she was a smiling, gentle, majestic friend to all. I called her mom to send our condolences. A half apologetic somber extension of my grief, my angst, and my sorrow. Her mom just thanked us for never giving up on her, never being anything but kind and generous and always being supportive of her quest to save her girl. I told her how grateful we were to know her, to be a part of her life's journey. 

Leukemia, especially acute leukemia is a fatal insidious thief who steals life in about two weeks. Just like Isa the clinical signs are often lethargy, vomiting, weight loss, diarrhea, and anemia. It is most often diagnosed with a blood profile and bone marrow aspirate. There are no well documented treatment options with much measure of success. Here is the best article I found on more on this disease. National Canine Cancer Foundation, Lymphoid Leukemia.

I want to add a personal note to Isa's family. I will never forget you and Isa. She was a regal majestic sweet girl who reminded me to always keep focused on finding answers, fighting for every precious day and just being grateful to have them.

If you have a pet question, concerns about your pets condition or disease, or curious about what  might be happening with your pet please join me at the community dedicated to educating and inspiring other pet lovers, Pawbly is free for all to use and enjoy!

If you want to meet the amazing people of Jarrettsville Vet please stop by, or like us on Facebook, or Twitter @FreePetAdvice.

I am hoping to make veterinary medicine more transparent. I know that cost is a significant barrier to many people in the care of their pets.

Here is Isa's treatment plan and associated costs;

First visit for diarrhea; Exam $50, probiotics $29, fecal exam $30.

Second visit; Ultrasound $200, exploratory surgery w anesthesia iv catheter, fluids, antibiotics, pain management $700. 

Third visit; steroids and inpatient care per day $50. Isa stayed for the day for four days. Repeat bloodwork $130.

Fourth visit; euthanasia and private cremation $350.

1 comment:

  1. I am so glad there are vets like yourself out there. I have a vet just like this who helped me with my cats as each one was diagnosed with cancer. One had pancreatic cancer which was highly infiltrative, one had an inoperable tumor under her tongue and the other (almost age 20) a suspected brain tumor with seizures.

    She was able to guide me with questions, resources, consults and her expertise. She was also there for ME. It made a huge difference to know she tried so hard to help them - though in the end.......

    I will be forever grateful to her for that.