I know my alpha dog, Finn, is getting old. I see him slowing down. I even have a young dog coming up quickly through the ranks to take his place. In my mind though, he is immortal.
Just two weeks prior to what I am about to describe, he’d spent several hours in the mountains near Lexingtion, Va on a cadaver search. And was sounder, both mentally and physically, at 11, than my younger cadaver dog was when the search was over. This was all in the back of my mind when my search team, Blue and Gray Search and Rescue Dogs, were called out to assist in the search, rescue and recovery mission after the devastating tornadoes that flattened Glade Springs, Virginia at the end of April. Finn is an old hand at disaster work. He’s spent time in New Orleans after Katrina and knows how to navigate jungles, both the green ones and the steel ones. So he was the first one I got out of the truck.
He and I were walking down to the first rubble pile we were assigned, and he stumbled on smooth ground, doing a face plant. That had me a little worried. Then when he didn’t want get on the pile; this from a dog that climbed 30’ piles hour after hour in the 9th Ward, I wasn’t just worried, I knew there was something very wrong.
He never looked back. He came home on Saturday with an OMG huge incision on the left side of his chest. And other than a too fast drop in his blood calcium that I am supplementing right now, the biggest issue he’s got is pain from the cut muscles. The anti-climactic news was the biopsy confirmed it was a benign thymoma.
The following Monday, Finn got up on my picnic table, reluctantly let me hold off a vein and I got two tubes of blood to send into Antech. I don’t remember what I was expecting to see, maybe elevated BUN and Creatinine. Indicators of failing kidneys. I certainly wasn’t expecting to see a blood calcium level of 17.3. When the normal high is only 12.
Calcium is delicately held in balance by two pairs of parathyroid glands on either side of the thyroid glands in the neck:
Too high, cardiac arrhythmias occur. Too low, seizures and tetany occur. Both easily lead to death. Low calcium is something most dog breeders are very aware of. Bitches can develop low blood calcium when they are nursing a large litter and develop eclampsia. However, there are very few things that cause the blood calcium to go high, all of them devastating. In school I was taught when there is a high calcium level it is time to search for the tumor that is causing it.
I can deal with mayhem, destruction, broken bones, HBC’s and other assortments of catastrophes as long as it isn’t my dog. When one of my dogs ends up with even the most minor of problems, I become the veterinary client from hell. Irrational, illogical and very emotional. However, a small rational part of my brain was still working and it pushed me to start researching how to figure out what was happening to my heart dog.
As a veterinarian, I belong to a wonderful resource called Veterinary Information Network. With the click of a button, I can get questions answered, research obscure clinical signs, and get help putting all the pieces together. So that is where I started. First, I had to determine if the elevated calcium was a true number and not lab error. That required an ionized calcium level. If that was elevated then it truly was an accurate number and I need to continue to find the source of the elevation. This test requires a lot of special handling of the blood, the most important being the blood has to arrive at the lab frozen. Luckily, I have a lot of ice packs to use for my vaccine cooler and several were sacrificed to the cause. It only took a day to get those results back, and unfortunately it confirmed the levels as being a real number and not lab error.
Back to VIN I went. The next step is determining if the elevation is due to the parathyroids having a fit or if there was a tumor inducing the calcium levels to elevate. There is an interesting test from Michigan State University vet lab called the hypercalcemia of Malignancy Profile. It measures two specific hormones, the Parathyroid Hormone (PTH) and the Parathyroid Hormone related protein (PTHrP). PTH is the hormone that keeps the calcium levels, well, level. PTHrP mimics PTH causing the calcium levels to elevate. If the PTH is elevated, then the parathyroid glands are working over time. If the PTHrP is elevated that means a tumor is producing it making the calcium to go up.
Finn’s results were difficult to understand because not only was his PTH zero, so was his PTHrP. His parathyroids weren’t working and the tumor wasn’t producing PTHrP so what was making his calcium go so high? I’ll probably never know for sure, but all the specialists said to continue looking for a tumor.
In intact male dogs there are two places malignant tumors are most commonly found: in the prostate and in anal sacs. I couldn’t palpate a mass in either one of these places. And none of his external lymph nodes were enlarged (the first place lymphoma likes to pop up). But there are lymph nodes internally that aren’t readily palpable. The next step in this dance was chest radiographs and an abdominal ultrasound.
While I was doing office calls, my two technicians were able to get 3 views of his chest (which is standard when looking for tumors in the thorax). My heart almost literally stopped when I looked at the first radiograph. Sitting right in front of his heart was the tumor. An ugly malevolent mass taking up the first 1/3 of his chest. The first thought that went through my head was he had lymphoma and I only had my boy for another 2-3 months. The next thought was how in the hell can he still feel good enough to continue working? I mean he was just on a difficult mountain search not 2-3 weeks prior to this.
He still needed the abdominal ultrasound done, but I couldn’t stand to be around when it was done. I don’t think I could have held it together in front of all my co-workers if nastiness was found in Finn’s abdomen. So I left.
While Finn had his ultrasound done, I took his rads to the internal medicine DVM at Veterinary Internal Medicine Practice of Northern Virginia for an unbiased evaluation of what was in his chest. By the time I got back to the clinic the u/s was done. I asked them to just fax the results to me, because I was sure all his abdominal lymph nodes were enlarged and I wanted a few more hours of ignorance. Finn snored in the back of the truck on the way home, oblivious.
I got a call from the wonderful Dr. Deppe at VIMP before I even got home. He confirmed that it was a mass. But he gave me some hope when I told him that none of his external lymph nodes were enlarged, that we need to consider a thymoma. A benign tumor of the thymus. He opened up an appointment for my boy the next afternoon to try and get a fine needle aspirate of the mass. There was even better news sitting on the fax machine at home: his abdominal ultrasound was clean, even his spleen looked normal.
Turns out Finn is a grumpy drunk! He needed to be sedated for the ultrasound guided fine needle aspirate of the mass. Not that I am complaining, though. I didn’t want him moving while they were sticking a needle into his chest so close to his heart. But boy was he rumbly grumbly when I picked him up. I soon had the samples winging their way via FedEx air to Colorado State University lab for cytology and also to have a PARR test done. PARR is a test that helps to determine if the lymphocytes are reactive and come from many different lines or if they are neoplastic and all come from the clone of one lymph cell. It’s not cheap but helps with treatment options.
More good news when the cytology and PARR results came back. Cytology was suggestive of a thymoma and the PARR results also pointed in the direction of a thymoma. If you want an explaination of the PARR test click here: CSU PARR test
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I was ecstatic, Finn just wanted breakfast.
The results showed up on Monday morning. By Monday evening, Finn was scheduled for surgery Wednesday morning with Dr. Bradley at Veterinary Surgical Referral Practice of Northern Virginia. His clinic is in the same building as Dr. Deppe’s clinic, and I’ve referred many of my own clients to him. He is a surgeon with an unbelievable work ethic and astounding talent.
I was 95% sure I wanted to do this. But there was a small part of me that questioned my motives for doing such a massive, invasive surgery on an elderly dog. But he was healthy otherwise and there was an excellent chance that the tumor was benign. Combine all that with the fact that Finn has given me his all every time I asked him, quieted those doubts.
I had to be at Dr. Bradley’s by 7AM, so in the pre dawn light of Wednesday morning I loaded up Finn in the truck for the 2 hour drive to the clinic. I won’t lie and say I didn’t shed any tears on the way up there. My mind going to the worst case scenarios, all ending in death. And the little doubts that I thought I’d come to grips with were rising up and throwing themselves at me, making me so very conflicted. He just looked so healthy that the irrational part of my brain made me doubt there was really anything wrong with him. I couldn’t stop from trying to touch him the entire way up there. Finn on the other hand, got impatient with me, hurmphed at me and moved to the back of the truck to continue his snooze like he normal does when we are on a road trip.
Dr. Bradley explained how the surgery was going to go. He does his thorocotomies from the left side, and not through the sternum, because he feels they recover more quickly. The difficulty of this surgery was the mass was so far forward, he was going to need to make the incision farther forward than he normally does. That meant that the muscles of his shoulder were going to be involved, not just the intercostals muscles. But, I trusted him when he said that he’d get better exposure to the tumor and was more likely to get it all. As I was walking Finn back to his surgery cage, in the cage next to his was a dog that was going home that morning after her own thorocotomy for a lung lobe abscess. Seeing her made me more comfortable with my own decision to go ahead with Finn’s surgery.
His surgery was scheduled for 10AM and was supposed to be done by 12 noon. Dr. Bradley called me at 12:05 to tell me that it was a text book surgery and Finn was in recovery. I start letting everyone know my boy is doing well, and I am over the moon! My heart heads back to where it is supposed to be and not in my throat.
Everything comes to a crashing halt when I get another call from Dr. Bradley too soon after the first call. And the nightmare begins. Dr. Bradley is very specific when he says he’s going to call, and is never more than a couple of minutes off. If he calls at another time, he really doesn’t need say much, I already know Finn is either dead or dying.
He’d gone into respiratory arrest.
For some reason his lung stopped working and started filling with fluid. He couldn’t breathe, his lungs were so filled with fluid no oxygen could pass. They tried to pull off some of the fluid with Lasix, but it didn’t work well or quickly enough. So they put him on a ventilator. Later, both he and Dr. Deppe came up with a few reasons why it happened: re-expansion injury or neurogenic pulmonary edema. His radiographs really didn’t match up with either one, but there is not a lot of data on those conditions in dogs because they usually die. All we could hope for was that it was a solitary event and that the ventilator would keep him alive long enough for his lungs to repair themselves.
For some reason his lung stopped working and started filling with fluid. He couldn’t breathe, his lungs were so filled with fluid no oxygen could pass. They tried to pull off some of the fluid with Lasix, but it didn’t work well or quickly enough. So they put him on a ventilator. Later, both he and Dr. Deppe came up with a few reasons why it happened: re-expansion injury or neurogenic pulmonary edema. His radiographs really didn’t match up with either one, but there is not a lot of data on those conditions in dogs because they usually die. All we could hope for was that it was a solitary event and that the ventilator would keep him alive long enough for his lungs to repair themselves.
I called back shortly after Dr. Bradley's first call because I really couldn’t process what he told me during that phone call. Not surprising, after going from a high of him coming through surgery to having him put on a ventilator. Dr. Bradley didn’t give much different information from the first call, but at least now my brain had a better chance of trying to understand what was happening. Didn’t make it any easier though. My precious Finn, my heart dog, my partner, was dying and there wasn’t anything anyone could do about it.
I went around to the rest of my house calls, but I am not quite sure how much sense I made. I think I helped the vomiting dog and the diabetic cat, but I don’t remember. I was just waiting for the call. “The call”. I never wanted that call. I’ve had to make that call to my own clients, but it was shear torture being on the other side. My phone was now enemy number one, but also a life line. I didn’t know whether I should just throw it out the window or just sit and stare at it.
I finished my housecalls around 5PM, but I couldn't go home. He wasn’t there, might never be back there and I wasn’t prepared for empty hole that was there in his place. I tried distracting myself at Barnes and Noble, but kept getting strange looks as I wandered aimlessly around, picking up books, putting them down and the occasional tear. I finally left. There were 4 hungry dogs at home that needed to pee.
I finished my housecalls around 5PM, but I couldn't go home. He wasn’t there, might never be back there and I wasn’t prepared for empty hole that was there in his place. I tried distracting myself at Barnes and Noble, but kept getting strange looks as I wandered aimlessly around, picking up books, putting them down and the occasional tear. I finally left. There were 4 hungry dogs at home that needed to pee.
I almost made it home before I broke down. Driving and texting can’t hold a candle to how dangerous it is to drive when you can’t see the road for the tears. I don’t recommend it. Dr. Bradley had asked me earlier if I wanted to come up and visit with him. I just couldn’t do it. I wanted to remember him as I walked him back to his cage, tail wagging, talking smack to the dogs in the cages as he walked by (he’s good at that), not with tubes in him. That wasn’t him, just a facsimile of him.
Thunderstorms start rolling through as I was sitting at the computer in my office, aimlessly wandering around the internet, when Dr. Bradley’s number pops up on my phone. He was not supposed to call until 10PM when he went into check on Finn, and it is only 9:15PM. I didn’t want to pick it up, just stared at it and it wouldn't stop ringing. Surprisingly, my voice was actually half way normal when I finally answered the ring, when all I wanted to do is throw up. Nor did I drop the phone.
The thunderstorms that had rolled through my town, ended up in Manassass, where the clinic is located, knocking out power to the clinic. Two very quick thinking LVTs ran a power converter from a pick up truck in the parking lot into the clinic, plugged in an extension cord to it and attached the ventilator to the extension cord. Good Lord! A power failure, just makes the whole thing so much easier. Dr. Bradley was just calling after the fact to let me know what happened. His blood oxygen saturation never went below 85% and one of the LVTs hand bagged him until they got the extension cord set up. Ironically, the week before the clinics started a search for a generator large enough to power both clinics in case something like this happened.
I was told not to call before 7:30AM on Thursday. The fact that I got no further calls from Dr. Bradley was a little comforting. Again, I was surprised that I could hold the phone when I called, my hands were sweating and shaking so much. An interesting sensation, to be sitting a chair and feel like you've run a hundred yard sprint there is so much damned adrenaline pumping your body. My heart felt like it was about to explode.
Dr. Bradley calmly told me he’d taken Finn off the ventilator at 6:15 that morning and continued to breathe on his own, maintaining normal blood oxygen levels on room air. And that he continues to recover normally from anesthesia. Normally!
Dr. Bradley calmly told me he’d taken Finn off the ventilator at 6:15 that morning and continued to breathe on his own, maintaining normal blood oxygen levels on room air. And that he continues to recover normally from anesthesia. Normally!
When I went to visit him on Thursday evening, he was weak and unsteady, but who wouldn’t be? He ate like the Lab he is when I was there. While laying on the floor next to him, the LVTs and I talked a little about what happened. More light was shed on what happened, especially the detail about the power converter and the extra tidbit that Finn had turned an ugly shade of purple before he got on the ventilator. No one there really expected him to make it, including Dr. Bradley. Me either. Of all the dogs I know of that ended up on a ventilator, Finn is the only one that lived.
He is sleeping at my feet right now, and nothing is better than that.
My team mate Misty Sampson made this video of Finn working the 9th Ward after Katrina. It is one of my favorites:
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