Ms. Taylor’s chin started to quiver and the corners of her mouth turned down slightly as the news I was sharing with her sunk in. Tears welled up along her lower eyelids. Before they spilled onto her cheek, she dabbed them away with a tissue and looked away. Bonnie, her black lab nuzzled her hand and whined. Dogs have an amazing capacity to detect grief and offer timely consolation. Ms. Taylor stroked Bonnie’s head as she struggled to regain her composure. Clyde, Bonnie’s full brother from the same litter, began to sense that something was wrong and he limped over to offer his condolences as well. I stumbled over the rest of my findings and the treatment options. I felt awkward and uncomfortable sharing this painful moment with a client that I had only just met. I shifted my weight and squirmed nervously as I talked. Although I was very confident in my diagnosis, my stomach churned at the realization that my words were responsible for causing so much pain for another human being. I touched her shoulder and offered a helpless apology. She thanked me and told me she just needed some time to think. She promised she would call me in a couple of days and let me know what she had decided. I nodded in agreement and asked if she would be ok to drive home. She nodded her head without saying a word as she clipped a leash to Clyde’s collar and picked up her purse.
As I walked out of the exam room, I replayed the entire conversation in my head. I had purposefully tried to manage the flow of information to minimize the impact, but I wasn’t sure my strategy had mitigated the shock. Bad news is hard to hear, but unexpected bad news is even worse. I cursed my training for not better preparing me to handle these situations. I silently wondered if I should stop by the library after work. Maybe there were books I could read that could help me know what to say. Maybe I should’ve just taken more psychology courses in college. I tried to put the visit out of my mind, and move on mentally to my next appointment. However, I was having difficulty.
Ms. Taylor had come in that morning to get Clyde checked out. She thought he must have sprained his elbow or shoulder. She noticed him limping a week or so ago, and it just hadn’t improved. She decided at the last minute to bring Bonnie with her as well. There was a little lump under her chin that she had noticed a few weeks ago. It didn’t seem to bother Bonnie, but Ms. Taylor thought it best to get it checked out.
I suggested that we look at Clyde first. He was limping noticeably on his left front leg. I questioned her at length about any strenuous activity or recent injuries that he may have sustained. She couldn’t think of anything out of the ordinary. He stayed in the backyard with Bonnie during the day and they both came in at night or anytime Ms. Taylor was home. She was certain they would never fight with each other, and for the past few years they didn’t even play very rough. I watched him walk around the exam room as she was talking then I knelt down beside him to examine his leg. I started at his paw and worked my way up the limb. I felt each toe and put each joint through a range of motion. I did the same for the carpus. Then, I slowly moved up the radius and ulna firmly squeezing every few centimeters with my fingertips along the way. I examined the elbow with the tips of my fingers feeling for any effusion in the joint. I squeezed firmly across the condyles of the humerus then flexed and extended the elbow joint through a full range of motion. Clyde was being pretty cooperative during all this. He didn’t much care for all the squeezing, but he never really protested – until I squeezed just below his shoulder joint. Right there, in the proximal metaphysis of his humerus, when I squeezed he whimpered and pulled away. I squeezed again – more gently this time – same response. There was no doubt I had located the source of the pain. I silently wished it was in a different region of the limb.
One of my favorite instructors in vet school used to constantly remind us not to get “tunnel vision” when working up our cases. I tried not to let my mind immediately conclude what I was thinking, but this area of the bone was one of the most common areas for bone tumors to develop. I knew better than to let my thoughts be known at this point. I had no proof on which to build a case. I needed some evidence. I explained to Ms. Taylor that Clyde seemed most painful in his shoulder, and I felt like it would be wise at this point to take an x-ray. I went on to explain that sprain/strain injuries or other soft tissue disorders like tendonitis or bursitis would not likely show on the film, but arthritis and other bone abnormalities would be visible. Once we have a little better understanding of why he hurts, we could get a treatment plan in place. I would also be able to tell her much more accurately about what to expect in the future. She nodded in agreement. I walked Clyde back to x-ray to get a picture.
While his picture was developing, I suggested we take a look at Bonnie. Bonnie was not visibly ill and she wagged her whole body in anxious anticipation of receiving attention as I approached and knelt down in front of her. Ms. Taylor said the bump was under her chin. I patted her side and rubbed her belly just to get acquainted. Then, I carefully ran my fingers along her throatlatch and over the bottom edge of her left mandible. Immediately, I felt what she had felt at home, a firm, smooth, slightly lobulated structure under the skin right where her submandibular lymph node should be. Only, this was much larger than a normal lymph node. I felt along the ventral border of her right mandible. The lymph node on that side was enlarged as well. I maneuvered around behind her to get in a better position and I palpated the vertical depression in front of each shoulder where the neck blends into the foreleg. It was more difficult to feel through all the surrounding subcutaneous tissue and shoulder muscles, but the lymph nodes in this location were also abnormal. The last remaining pair of lymph nodes that are easy to feel in dogs are in the back legs, just behind the knee joint. I slipped my left hand under Bonnie’s abdomen and encouraged her to stand up for me. Once her back legs were straight, I gently pinched the flesh behind each of her knees and let it slip through my fingertips. I felt the lymph node squirt by. It was the size of a golf ball – at least three times larger than it should be. I sighed and sat back on my heels. Ms. Taylor’s expression was one of concern. I explained that the lump she felt under Bonnie’s chin was a lymph node. I went on to explain that lymph nodes are commonly enlarged when they are stimulated by an immune response in the body – bacteria from an infected wound, a virus or some other pathogenic microorganism that gains entrance to the body. All these are potential causes of lymph node enlargement. I asked Ms. Taylor if she had pulled any ticks off of Bonnie within the last few months. She was certain she had not. I went on to explain that we needed to know whether this lymph node was “reactive”, a term we use to describe a lymph node that is just highly stimulated from a normal immune response, or neoplastic, meaning enlarged by a population of abnormal cells that shouldn’t be there. I suggested that we obtain a very small core sample from one of the affected lymph nodes with a hypodermic needle and make a slide of the cells that could be examined under the microscope. In many instances it is possible to tell right away whether or not a swelling or a mass is really something to worry about. And, if there was any question about what I was seeing on the slides I would just send them on to a pathologist for an expert opinion. Ms. Taylor agreed and I stepped out to gather my supplies.
Bonnie squirmed a little when I poked my needle into the lymph nodes to get my sample, but it only took a second and we were done. I prepared the slide and peered into the microscope to examine the cells. As the cells begin to come into focus an uneasy feeling began to swell in my stomach. I had hoped to see a diverse population of different types of white blood cells. Lymph nodes are a nursery of sorts for developing white blood cells. If this lymph node was reactive I should be seeing large numbers of fully mature white blood cells like small lymphocytes, neutrophils, an occasional eosinophil mixed in with the resident population of immature or developing white blood cells. It’s not that difficult to tell the difference with a little practice. The immature white blood cells are physically larger, they all have large round nuclei and the chromatin in their nuclei is not condensed because the cell is has just recently divided. What I was seeing on Bonnie’s smear was a uniform population of immature lymphocytes – like a horde of zombies reproducing at an alarming rate, crowding out normal functional tissue and replacing it with non-functional cancerous tissue. I was looking at a battalion of neoplastic white blood cells gearing up for an offensive against Bonnie’s body. They would move stealthily through the lymphatics and infiltrate her internal organs – her lungs, her spleen, her liver- seeding themselves in the capillary beds and establishing new tumors that would gradually grow and crowd out normal tissue. I was looking at lymphosarcoma, and in my mind’s eye, as I sat in front of the microscope, I could see this insidious, destructive process taking place inside Bonnie.
My dismal thoughts were interrupted by Clyde dragging my technician through the pharmacy and back to the exam room. His x-rays were up. I got up from my seat in front of the microscope and headed back to the darkroom to examine his films. With one glance at the x-ray the uneasy feeling in my stomach began to swell again. There in black and white, right where Clyde was painful when I pressed, just below the shoulder joint, there was an unmistakable lesion. The normally uniform, homogenous, milky appearance of the cancellous bone was replaced by an irregular lytic pattern that more resembled swiss cheese with tiny holes. The cortex of the bone was no longer visible and the covering over the bone – the periosteum – displayed the characteristic “sunburst” pattern that distinguishes bone tumors from most other proliferative bone conditions. Clyde had a large bone tumor in his proximal humerus – most likely osteosarcoma. I sighed and glanced at my watch. Both Bonnie and Clyde had aggressive forms of cancer. It was only 10am. I dreaded going back into the exam room to face Ms. Taylor with the news. I began to formulate in my mind a plan for how I would report my findings.
Osteosarcoma was then and is still today one of the worst types of cancer we contend with in veterinary medicine. It is very biologically aggressive. Usually by the time we have a lesion large enough to detect on x-ray it has already spread somewhere else in the body. Early amputation of the affected limb is usually the prescribed treatment, but median survival time after surgery is still only a matter of months. Even with aggressive chemotherapy, the numbers aren’t much better. Lymphosarcoma, however, responds much better to chemotherapy. Over 85% of dogs with lymphosarcoma, with early detection and appropriate chemo will still be in remission 1-2 years after diagnosis. Most of these patients develop disease after middle age, so for an animal with a normal life span of only 12-14 years, that’s a considerable length of time.
It was about 6 months or so before I saw Ms. Taylor again. We had to help her get Clyde out of the car. He had lost about 30% of his body weight. His coat was dull and rough. He barely lifted his head up off the exam room table when I walked into the room. His front leg where the tumor originated barely resembled a leg. It was three or four times normal size and covered with weeping sores. It smelled like rotten flesh. Ms. Taylor knew his time had come. I secretly wished she would have acted sooner. I verified her intentions and got the appropriate paperwork together. Euthanizing a pet is always difficult and often owners wait too long. I have been guilty myself of waiting too long myself when my pets have reached that point in life.
Ms. Taylor stood across the table from me stroking Clyde’s fur as I tried to engage her in conversation. I asked about Bonnie. Without looking up, Ms. Taylor replied that she had been away for a few weeks not long after her last visit. Bonnie had begun to lose weight, and her lymph nodes had gotten much larger. Finally, while she was away, Bonnie stopped eating all together. Ms. Taylor took her to a veterinarian in the town where she was staying and had Bonnie put to sleep. Now, it was Clyde’s turn.
I slipped the needle into Clyde’s vein and a small plume of blood flashed into the barrel of my syringe. I loosened the tourniquet and slowly injected the thick, purple-ish liquid into his vein. His body relaxed. His breathing slowed. His heart beat ceased. He was gone. I stood there in front of Ms. Taylor. She was looking down at Clyde’s body. Her cheeks were wet with tears. Her shoulders heaved as she sobbed, but she barely made a noise. I sensed that her grief was especially profound. Everyone deals with death and loss differently, and I had witnessed grief many times in an assortment of presentations. But, something told me Ms. Taylor’s grief was different. I passed her a tissue and cupped my hand over her shoulder.
“Are you OK?” I asked. She hesitated.
“I had a son.” She replied. My heart caught in my throat, but I just listened.
“He was a beautiful little boy – my first born. He was born with a heart defect called Tetralogy of Fallot.”
I knew the disease from cardiology class in vet school, but I had never seen it in practice. I wasn’t certain I was remembering the details correctly, but I knew that Tetralogy of Fallot was a congenital heart defect where there are four very serious anatomical defects present all at the same time. She continued.
“The doctors told us there was a surgical procedure for correcting the defects, but it was very risky. We decided not to do the surgery right away. If he survived the next few weeks or months, we would consider it then. And, he did survive. He was the light of my life. He was never as big as the other kids his age. When he walked up the stairs his little lips turned blue, and he could barely catch his breath. My husband and I kept trying to convince ourselves that he would have an adequate quality of life without having to undergo surgery. The doctors had told us that the surgery would be easier if he were a little larger physically. So we waited. We were terrified of the prospect of surgery. But, when it came time for him to start kindergarten, we knew we had to do something. If he tried to run and play on the playground for even a minute, he turned blue and it took him twenty minutes to catch his breath. We agreed to have the surgery done. According to the surgeon, the surgery went well, but my little boy died in recovery. My world fell apart that day. I cried until the tears just stopped flowing. It was as if my soul dried up like an empty well. The next few months were a surreal blur of gray and darkness spent enveloped in a heavy blanket of grief and confusion. Familiar smells, sights and sounds brought back memories of time spent with my son that closed like fingers around my throat, stealing my breath but not merciful enough to suffocate me. My husband and I separated. The loss became an impenetrable barrier that prevented any form of communication or understanding. I prayed every day that the ground beneath me would just open up and swallow me. Rescue me from my torment. At the nadir of the most profound, empty, desolate loneliness that you can imagine, I decided to get a puppy – something to love in my hour of need that would love me back. When I got to the breeder’s house to meet the litter, there were only two left – a boy and a girl. I couldn’t bear the thought of separating them, so I took them both home with me. When it seemed that my life was slipping into an abyss of darkness and despair, the companionship of two puppies rescued me. I named them Bonnie and Clyde…and now they are gone.”
I stood across the table from Ms. Taylor in that moment, both of us staring blankly at Clyde’s lifeless body. I struggled to find a word or phrase to offer her some comfort or hope. After hearing her story, every thought that came to mind seemed cliché’ and callous. I just stood there with her as she stroked Clyde’s fur. After a long moment of silence, I put my hand on her hand and simply told her that I was sorry. Fate isn’t often fair when handing out hardship, and she had suffered more than her share. The words seemed pitifully inadequate, but she thanked me nonetheless as she gathered her purse to leave.
As clinicians, we are shaped by our experiences with our patients. In the aftermath of that visit, I contemplated the role of the veterinarian in society and in the lives of individual clients. I had never imagined that I would share in such a heart wrenching personal tragedy during an exam room visit. It highlighted for me just how multi-faceted and powerful the human-animal bond can be. And how, as a veterinarian, we are uniquely positioned to touch lives in ways that I never imagined when I was a naïve college student considering my career options. At the time, I felt overwhelmed by the realization of my potential influence in those end-of-life discussions with pet owners. Now, I feel blessed to have the opportunity to journey with my clients and to be the advisor that is uniquely qualified to counsel them through such difficult decision making. I am thankful that most of my interactions in the exam room and on the farm with my clients are happy occasions where we cuddle puppies and kittens and talk about anything other than euthanasia. However, when the time comes for that discussion to take place, my experience with Ms. Taylor forever changed the way that I think about my last visit with a pet.