Place-Filler

Illustration by Kiel Murray (kielmurray.com), all rights reserved by DerekTheVet.com

     I stare absently through bleary eyes at the glowing computer screen, watching each section of the electronic medical record populate with my notes about my last case - a middle-aged Terrier that raced in during a seizure at 2am. I always choose the station on the left at this hospital because I like being able to look out through the large windows in front of and to the left of me at the gleaming stainless steel and poured concrete of the sprawling treatment room. My eyes flick to the clock and 3:27am glares at me unfeelingly.

     At the moment I write my name (my personal signal to myself that the record is complete), the door chimes loudly throughout the hospital, causing my spine to tense, my vision to sharpen, and my scalp to prickle. Dave, one of the two overnight technicians jogs toward the lobby.

Illustration by Kiel Murray (kielmurray.com), all rights reserved by DerekTheVet.com

     There’s typically a lull in emergency practices between midnight and morning, but cases between 2-6am are especially, mercifully, infrequent. During this time of night, the door chiming or a phone ringing always dumps adrenaline into my veins, a Pavlovian response to the anxiety and excitement of taking responsibility for whatever presents itself in front of me.

     Dave returns from the lobby through the the double swinging doors. He catches my eye through the doc pod window and says, “We got a euthanasia, Doc. Elderly lab with cancer.”

     “Got it.”

     The other technician, James, finishes logging a treatment on one of the hospital iPads and helps wheel the hydraulic gurney toward the lobby.

     I rub my eyes and thank the Emergency Gods for small mercies. This is my third 12- to 14-hour weekend overnight shift in a row, and I spent the first half of it with the worst migraine I’ve had in years. I can usually expect migraines when I don’t sleep enough, and joining a practice two hours from home has eaten large chunks of sleep time. I cut further into my sleep this weekend to attend an open house for an apartment that’ll shorten my commute.

     My migraines usually just involve a crippling throb in the upper half of my head, radiating deep into my brain, intensified by light and sound. Tonight, nausea had given the cranial pain a run for its money, an especially evil add-on because I couldn’t keep down medication, caffeine, food, or even water; I’d had to tough this one out - sweating, pale, and irritable - unaided by medical science. The pain was so intense, I’d thought seriously about how much of my life I’d trade to make the pain stop. Pain bullies everything else to the periphery and gobbles up all of my attention, it makes the world feel small. I have incredible respect for anyone who suffers chronic or recurrent pain and remains personable and productive.  

     Since I came out from under the migraine a couple of hours ago, I’d been riding a just-survived-a-life-threatening-accident high, including the sappy gratitude for simply being alive.

     All of this is to say: I’m thankful for a straightforward case, however sad it may be.

     The swinging doors thump open and the room fills with the sound of raspy, labored breathing. The patient is a huge, kind-faced Yellow Lab, and her coloring is true to the breed name - it's the hue of a manila folder with the electric vibrance of a Post-It. She lies on the gurney, her chest heaving with effort as she sucks in air. Contrasting with her intense effort to breathe, her face droops and her body remains still and untensed. This is a dog who is exhausted just performing the basic functions of life. She’s conscious, but won’t be for long.

Illustration by Kiel Murray (kielmurray.com), all rights reserved by DerekTheVet.com

     “They definitely said euthanasia?” I clarify to Dave.

     He already has an oxygen mask in front of the dog’s nose while James immediately starts prepping and IV catheter site.  “For sure,” Dave replies while James remains laser-focused on clipping the fur and wiping the skin on one of the patient's front legs.

     I decide to skip the exam for the moment and head straight to the lobby. I greet a tall, broad man with mostly-white hair and moustache, and a face as kind as his dog’s. His furrowed brow and glassy eyes show concern, but his calm resonant voice and warm handshake demonstrate a baseline serenity that I instantly connect with. His hand dwarfs mine as we shake and I start in with my pleasant-but-urgent voice, “Hello. I’m Dr. Calhoon. What’s your dog’s name?”

     “Oh, hello, Dr. Calhoon.” There’s genuine warmth, almost recognition, in his voice and I have a jolt of concern that I’ve met him before and don’t remember. “I'm...it’s Anna. Well...I mean…her name. Is. Nice to meet you.” He chuckles and grins and shakes his head.

Illustration by Kiel Murray (kielmurray.com), all rights reserved by DerekTheVet.com

     I can’t help but return the smile. “It's nice to meet you, too," I say honestly, "I’m sorry it’s under these circumstances. I don’t mean to make things harder on you than they are, but I wanted to confirm straight away that you’re wanting to euthanize? Otherwise I need to move aggressively to stabilize Anna’s breathing.”

     “No, no,” he waves both hands in front of him, “This is the end. She’s had cancer for sixteen months. She had her spleen out last year, chemo since then.”

     “Wow,” my eyebrows arch up, “That’s a long time for a lab with cancer.” It’s an over-simplification without knowing the type of cancer, but the context narrows the list to mostly crummy options.

     “Yeah, exactly. We’ve known this was coming. We thought it would be long ago. You’ve all taken such good care of her. We’re so grateful for the good time we’ve gotten. So...when she started getting worse...and then yesterday a lot worse...I was hoping to make it to morning. But she’s ready.” His face flushes and he stops to clear his throat, then he nods resolutely, “We’re ready.”

     Just as I’m about to ask about the “we,” his wife enters from outside, setting off the chime (giving me another reflexive dose of adrenaline), and crosses the lobby with tears streaming down her face. She’s a slight woman with red hair and she nearly disappears when her husband wraps his long arm around her shoulder. She tucks herself against his broad body, laying her cheek against his chest and her palm against his belly. They fit their mis-matched bodies wordlessly together with ease that only develops over decades of companionship.  

Illustration by Kiel Murray (kielmurray.com), all rights reserved by DerekTheVet.com

     As I introduce myself to her, Dave cracks the door next to the reception desk and nods, “Sorry, just checking on the chime.” He closes the door gently.

     “Again, I’m sorry to rush the pace more than I usually do, but I’m concerned that even just the stress of coming to the hospital might push Anna over the edge.”

     The man nods knowingly and says, “And she’s suffering. Don’t worry about us. We’ll follow you.”

     Sometimes people will say things they don’t mean or things they can’t know are true, especially in moments of crisis. Something in this man’s delivery makes me believe him, and I’m grateful for the ally. It hurts to chaperone people through pain. Un-shouldering even a little of the weight makes a huge difference.

     “Okay. Would you like to be present for the euthanasia?”

     “Yes.”

     “Have you been present for a euthanasia before?”

     “Yes.”

     “Okay. Let me go check on her, then I’ll talk to you about what’s going to happen. If she does start to go on her own while this is all happening, do I have your permission to just go ahead and euthanize?”

     The woman turns her face into her husband’s chest and he grips her more tightly. “Yes. Whatever is best for her. I trust you to make whatever decision you need to.”

     My throat thickens with emotion and I can only nod. As I cross the hallway to the treatment room double-doors, I ponder the the impossibility of a man I’ve never met trusting me with his dog’s death less than five minutes after meeting me. As I cross the treatment room floor, I can already see the answer to my question, “How’re we doing?”

     “Worse,” Dave and James both say in unison.

     Anna is more alert, but only because her breathing is now desperate. She repositions with each breath in a losing battle for air. As I approach, the technicians are placing an IV catheter in the hind leg and I’m unsurprised to see shaved fur on both front legs where previous attempts failed. Must be tough; these two are good at their job and rarely miss.

     “James, let me switch you out, grab me eight mils Propofol and ten mils Euthasol.” I want to be a team player, but I also don’t know the code for the drug safe. James peels off wordlessly and I grip Anna’s leg to increase pressure in the vein while Dave finally sets the catheter. There’s almost no flash of blood out the catheter, signalling very low blood pressure and explaining the previous failed attempts. I hear the drug safe keypad beep rapidly, then a heavy click, then Anna makes an enormous retching sound and regurgitates a huge puddle of foul-smelling brown fluid. Not a good sign.

     “Catheter’s in,” calls Dave calmly.

     Mopping up the fluid, hearing the new wet rattle in Anna’s breathing, I glance up at James. I see a syringe filled with milky white Propofol on the countertop. Euthasol is bright pink and has the thick viscosity of pancake syrup. I see it flowing from the bottle into the syringe fast, meaning James had grabbed a large needle. Told you these guys know the job.

Illustration by Kate Murray, all rights reserved by DerekTheVet.com

     Sometimes I mix the Propofol and Euthasol in one syringe, but it’s not necessary and I need to make Anna unconscious ASAP. I weigh the options for getting Anna relief while giving her owners the least traumatic memories possible. I make the call and tell Dave, “Help me wheel her into Room 1. James, bring that Euthasol when it’s ready.” Dave immediately starts wheeling the gurney away while I snatch up the Propofol syringe and jog to catch up.

     Without removing his eyes from the Euthasol syringe, James calls after me, “Diluted?”

     "Yeah.” I put the Propofol in my breast pocket and grab the trailing end of the gurney. James finishes with the Euthasol bottle, strides over to the sink, and tops the syringe up with tap water - dilution eases injection and sterility isn’t a concern in this context.

     There’s a flurry of crowded activity as we call the owners into the room, position the gurney, keep Anna from falling off, and pass off the syringes. Luckily, James remembered to grab me a flush. Praise Gods for good techs. When James and Dave leave, the room fills with Anna’s wet, gravelly respiratory noise, improved just a bit at seeing her family.

     As I work, I adopt a calm tone and tell the Anna’s owners, “Please feel free to get close. Let her know you’re here. I’m setting everything up back here.” The couple closes in around the front of the gurney. The man kneels to look at Anna eye-to-eye while I extend her catheterized leg to avoid a kinked vein. His wife stands close, but pulls physically inward.

     The man speaks, his wife does not. “Anna, we love you. Thank you so much. We love you and you’re perfect. I’m so sorry.”

     Having gotten the Propofol needle into the catheter port, I say, “Okay, everything is set. This is the first of two injections. This one will sedate her, then knock her out completely. Are you ready for me to proceed?” It’s habit to say that, but I’m prepared to just plunge in this case even without them being ready because it is absolutely in Anna’s best interest not to wait.

     Luckily, the man nods vigorously even has he continues talking to Anna.

     I inject the Propofol over a count of three. I brace for the initial excitation Propofol usually causes just before the profound sedation. Anna is either in enough distress that she skips right over the excitation, or it’s indistinguishable from her desperation. Before the end of my third count, she simply goes quiet and lays her head between her paws, small puffs of breath blowing out her lips every couple of seconds. With Anna’s sudden calm, the room expands and time feels less imperative.

     I remove the empty Propofol syringe and insert the large needle of the Euthasol syringe into the IV port. I say, “This is the final injection. It’s an overdose of anesthesia, so Anna will be completely unaware before she dies. She won’t experience any pain or distress, but there can sometimes be involuntary movements or big breaths. I don’t expect that now, but if they do happen, she does not experience any of it. Also, her eyes won’t close like the do in the movies. It’ll only take a few seconds and you may not even notice when it happens.”

     “Okay," the man's eyes never leave Anna's face, "Can she hear us right now?”

     “I don't believe so, it’s more likely that she’s completely unconscious, but you’re welcome to keep letting her know you’re here and that she’s loved.”

     Tearfully, the man presses his face into Anna’s and says, “Goodbye, Anna. We love you so much. You gave us so much. We’re so thankful.”

Illustration by Kiel Murray (kielmurray.com), all rights reserved by DerekTheVet.com

     “I’m starting to inject.” I press on the syringe slowly, partly to smooth out the effects and partly to avoid shooting the needle off the syringe fighting the thick Euthasol.

     The man’s voice becomes a whisper, “We love you Anna. We love you. We love you…”

     “Halfway there. She’s completely under anesthesia at this point.”

     Anna takes a somewhat bigger breath and her lips puff out and flap, then she’s completely still.

     “I think that was our moment. Nearly done with the injection.” I finish the injection and withdraw the needle. I insert the flush needle, “Now I’m going to flush the catheter and then listen for her heart and make sure we did everything right.”

     When I listen, I hear the faint flutter of ventricular fibrillation. “Anna’s heart is in the last stages of shutting down and is fluttering a little bit right now. I’m just going to listen until this stops. It’s not something she’s experiencing.” I continue listening to make sure Anna’s heart doesn’t pull the miraculous and convert back to a normal heart rhythm. It’s rare, but it happens, and I never want to experience the tragic irony of a “failed” euthanasia.

     The fibrillations dim over about ten seconds and then finally fall silent. I fight my brain’s reflexive hope as well as its involuntary impulse to detect patterns until I’m confident that I do not, in fact, hear any activity in the cavernous void. About fifteen seconds after heart death I lift my head and say, “That’s all. She’s completely gone.”

     If the dam is going to break, this is usually the moment. Instead, Anna’s owners each breathe a deep sigh and their faces relax into a pleasant exhaustion. Still petting Anna’s face absently with unfocused eyes, the man says, “Thank you so much, Dr. Calhoon. I Can’t tell you what this means to us. Thank you for being here.”

--

     I love that my job makes me a meaningful place-filler. Anna’s journey with this practice started before I knew it existed. I only joined the team a month before meeting her - I was still figuring out the employee email system. But when Anna unexpectedly reached the end of her path, I was present and able to help limit her suffering while she died. I’m proud to be part of a team that makes a man say, “I trust you with my dog’s life” immediately upon meeting me. I’m grateful to be part of a profession that makes a man face-to-face with his dead companion say, “Thank you.”

     Thank you to all of the place-fillers I meet, and those behind the scenes, who become meaningful people in my life, even momentarily.

     Sappy or not, I’m grateful to be alive and doing this work. Minus the fucking migraines.  

 

Moxie Gets Spayed

Pre-Surgery Review

I’m sitting between two of my best friends, both scary smart introverts, Ryan and Derek (I know, another Derek, what are the odds of two dudes with a name that means “The Chosen One”?). Along with a third of my fellow third-year veterinary students, we pay close attention to a bright projector screen while one of our surgery professors reviews anatomy and surgical technique. He’s tall, lanky, wears mint-green scrubs, and has salt-and-pepper hair that’s mostly pepper.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

The procedure, a cat spay, or ovariohysterectomy, is routine, but the circumstance isn't. His light and easy-going delivery clashes with the tension we all feel about the fact that we students are about to perform surgery for the first time in our lives. What’s more, I’ve committed to adopting my patient after surgery.

Having completed two-and-a-half years of mostly classroom learning, Junior Surgery is a dunk in the medical deep end that marks the beginning of our hands-on clinical training. We’ve broken into teams of three and will rotate through the roles of anesthetist, surgical assistant, and surgeon. I’m the first in my trio to cut, Derek will assist me, and Ryan will run anesthesia.

A photo flashes onto the screen of a cat’s open abdomen, organs visible. Gloved fingers grip a tiny bright pink tube of flesh attached to a transparent, paper-thin sheet of tissue that dives into a coil of other tiny bright pink tubes. Our professor points to the gripped tube and says, “This is the left horn of the uterus. We want to remove this.” He points to the coiled tubes and says, “This is the small intestine. We don’t want to remove this.”

Sweat seeps from my pores and blood rushes in my ears, my face feels hot. I glance sidelong at Derek and Ryan, and notice them glancing sidelong at me. I lean toward Ryan and whisper, “I can’t see the difference.”

His eyes are wide, “Me either, bro! What the fuck!”

The professor’s voice breaks through, “I know, I know, they’re hard to tell apart.” I relax a little. “But don’t mess it up.” He smiles big and my anxiety spikes right back up.

He continues, “The uterus has longitudinal muscles and no peristalsis.” He throws us a conspiratorial smile that says a wisecrack is coming and says, “It also has an ovary at the end.” His humor lands well; we know he’s on our side. He adopts a more sober tone and assures us, “All of you are prepared for this. You’ve gotten used to the preserved specimens, but you’ve all handled the living structures too. It just feels scarier when you’re the one responsible. You’re gonna do fine.”    

Another slide shows the gloved hand gripping the front end of the uterine horn, the dark pink shrouded ovary now visible just beyond. The whole thing now looks impossible to confuse for the small intestine. “Told ya,” he says, “No worries.”

The professor points to the leading edge of the transparent sheet of connective tissue running along the uterus. “This thickened cranial portion of the broad ligament is our suspensory ligament. You’ll have a nice, long incision today, so visualization won’t be an issue, but we want you to get comfortable tearing this thing. It sounds barbaric...well, it feels even worse...but when you can’t see what you’re cutting, it’s safer to tear it and you need to learn what it feels like. With that sucker torn, everything moves a lot easier and you’re less apt to tear something that’ll bleed.”

We wrap up the review and our flock of twenty-somethings and a few older-than-twenty-somethings shuffles over to the surgery room. I can feel the sweat accumulating under my arms and I silently curse the prohibition on under-shirts (one less thing to carry bacteria into the surgical space). As we walk, I glance around and don’t spot anyone who looks as nervous as I feel.

Derek says to me with his coastal Massachusetts accent, “Derek, you must be WICKED nervous!” His eyebrows are high and he grins widely, “I’m sure glad I’m not goin’ first.”

I smile back. “Thanks for the support, man.” I can feel sweat soaking into my scrubs under my arms. I glance around and my insecure, anxious brain sees only self assurance on the faces of my peers.

Pre-Surgery Set-Up

Our flock enters the surgery room, which is unlike any I’ve seen in person before or since in its scale. As I file into the cavernous rectangular space at the end of a long side, I pass a stainless steel scrubbing station on my right. As I turn left, long white walls on either side stretch away from me to large windows framing a set of double stainless steel swinging doors at the far end. Through the glass, I can make out steel kennels with soft bedding. Our patients wait inside with empty bellies, having been fasted overnight to avoid regurgitation while anesthetized.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

We spill into the central aisle and splinter off to five gleaming stainless steel surgical tables extending from each long wall. Ten surgical stations in one room is a LOT. Each table is lit by a powerful swing-arm overhead lamp and attended by a modular-looking anesthesia machine. The machines are a collection of canisters and tubes and valves and bags - they look somehow both antique and futuristic simultaneously. I wonder how after a hundred years of tinkering improvement, these life-saving machines still look like found object art. Stainless steel adjustable-height instrument tables round out each surgical station.

Staff and students begin the ritual of setting up and checking that the anesthesia machines are functioning properly. We plug green oxygen-supply hoses into the walls with a hiss and a metallic click. Kitties are small little creatures that lack the lung volume and power to push gas through a traditional circular rebreathing system. Instead, we attach a non-rebreathing system that directs exhaled air through a filter that traps excess CO2 and anesthetic gas. A series of pressure tests confirms our machine is good to go.

We place a v-shaped positioning trough on the table and cover it with clean towels to reduce heat transfer from the patient to the table. Atop the towel, we place a metal plate and connect its snaking wire to a cautery machine. The system works by forming an electrical connection with the patient and we use a saline-soaked pad to improve that connection (medicine learned this tidbit from its origin in making the electric chair more effective). Sometimes folks use alcohol on these pads, but that’s inadvisable with all of the sparking and oxygen nearby.

Pre-Anesthetic Exam

The Cat-Who-Will-Become-Moxie doesn’t have a name yet, just a number. She’s a petite Shorthair Russian Blue kitten, a few months old, with cuddly-soft gray fur. She reaches out at us playfully through the vertical stainless steel bars of her kennel door. She’s struggling with the tail end of a viral upper respiratory infection (URI) and her left eye is half-closed, the upper part of the cornea is gray instead of clear, and clear fluid runs down the side of her nose, leaving a light brown crust. She snuffles through a stuffy nose, but seems utterly unconcerned - she just wants to plaaaaaaay with us.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

I’m nervous taking responsibility for Moxie because Calicivirus and Herpesvirus, the most common causes of URI in cats, usually remain an intermittent lifelong nuisance. The severity and early onset permanently narrow the opening between the eyelids (palpebral fissure) in her left eye, so she develops a bit of a Sylvester Stallone look (though Sly’s face and eye droop resulted from forcep-induced nerve damage during birth). Her runny eye never improves either because the duct that normally carries tear film into the nasal passage (the nasolacrimal duct) becomes permanently blocked. Her eye clears up only partially as Inflammatory fluid in her cornea subsides. The result is a sleepy-looking half wink with a slight ghostly glow.

The remainder of Moxie’s physical exam is normal. With normal pre-anesthetic labwork and a resolving URI, Moxie is cleared for surgery. Anesthesia medications inhibit heart and respiratory function, so we reduce the overall doses needed by layering less risky medications. Protocols vary based on species, patient health status, planned procedure, and other factors. We start by pre-medicating Moxie with an injectable opiate pain medication. This has the double benefit of moderate sedation and preemptive pain control, but without affecting blood pressure. Fifteen minutes later, Moxie is dopey and pliable enough to place an IV catheter in her front leg without stress or pain. Derek and I then leave Moxie with Ryan to be anesthetized while we move on to scrub in.

Scrubbing-In

I tuck in my scrub top and tie on my surgical cap as we approach the silvery scrubbing station. The high arched faucets look like graceful gleaming goosenecks. I mention the imagery to Derek and he replies, “Alliteration, much?” I laugh and approach the station.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

From behind me, I hear Derek say, “Forgetting something?” I turn to see Derek peeling open his one-time-use sterile gown.

“Every time. At least I hadn’t sudsed up yet.” I join him and we unfurl the blue paper wrappers, careful not to touch or contaminate their contents, and leave the pre-folded gowns lying on top. We unfold sterile gloves (size 7 ½ for me) and leave them out as well.

As I tie on my surgical mask, I shoot Derek a sarcastically deferential look and he says, “There ya go. NOW you can scrub.”

I press down on the foot pedal and test the water with my fingers, then let it coat my arms down to my elbows. The start of the ritual settles my nerves. I peel open a brand new sponge pre-soaked in antimicrobial soap. The fingernail pick is no use to me - I have the high-strung habit of chewing my nails too short - so I toss it straight away. I squeeze the soft sponge under the faucet, adding water and bubbles to create a rich lather, which I spread all over my hands and forearms. I rinse this first lather to clear the larger debris and reapply.

Next, I vigorously scrub every square centimeter from my fingers to my elbows with the bristled side of the sponge for a full five minutes (try timing yourself next time you wash up). The action is carefully choreographed to assure sufficient contact time and agitation to well and truly rid every nook and cranny of all microbes and contaminants.

I turn to Derek, “At least we only have to worry about protecting our patients from us. I couldn’t handle worrying about getting something infectious from them.”

“Agreed.”

I rinse off the scrubbed lather, keeping my hands raised and making sure the water only flows away from my fingertips. Shaking the last drips from our elbows, Derek and I turn to our open gowns holding our hands aloft as if frozen in the middle of a lazy, back-handed patty-cake. Our newly clean hands can now only touch sterile objects until after surgery - a single mask adjustment, scratch of the nose, or graze of a table means an arduous re-decontamination process.

“Is ‘re-decontamination’ a word?” Derek ignores me; he’s focusing intensely on unfurling his full-length light blue paper gown without touching anything around him. He struggles tentatively and nearly flips one of his sleeves against the table at one point, but triumphs over the backwards-facing smock in the end. His grin is broad and beaming as our supervising technician fastens the Velcro neck and ties the internal waistband.

“I love watching you geniuses struggle like you’ve never gotten dressed before,” she teases. I follow suit and we both struggle through the deceivingly complex gloving procedure without our hands ever leaving the gown’s sleeves.

“Good, now dance with me,” she says.

We each dutifully hand her a tab attached to our outer waistband, spin in a circle, and grip the band while she pulls away the tab, leaving us in self-contained cocoons of sterility. We tie ourselves off and I move further into the surgery room with a stilted gait and hyper-awareness of my every movement.

I stand next to Derek as the room populates with identical stiff, light-blue-cocooned students. “My shoulders are already aching,” I say.

“So ah mine.”

“And I’m already sweating buckets.”

“Me too.”

“Are we really doing this?”

“You ah.”

Surgery Site Prep

Moxie and the other nine patients are stretched out on the tables anesthetized, prepped, and ready to go. Their delicate little bodies look vulnerable. Interconnected through the lines and canisters and tubes, through the building’s oxygen and scavenging systems, our patients and the building breathe as one. I’m humbled by the responsibility to keep my creature safe throughout an extreme invasion of her body. My stomach flutters hollowly as I walk down the center aisle with my colleagues the same way it always does when I approach a starting line, a first day of school, an exam. It says, “You’re meeting a moment that matters, and it won’t wait for you. Do well, or get the fuck out.”

Derek and I stand on opposite sides of the table and carefully affix towels to Moxie’s skin, leaving a bare rectangle in the center. We layer a large drape - with a pre-cut hole - over the top, obscuring the whole table and providing one continuous sterile surface, broken only by a narrow strip of Moxie’s bare belly.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

Both of us gaze at the incision site. I say to Derek, “The drapes really depersonalize the whole thing.”

“No kidding.” His eyes lift to meet mine, “I’m still wicked nervous, though.”

“YOU’RE nervous? I’m shitting my pants.” I turn to Ryan, “How we doing?”

He disengages his stethoscope from his ears and loops it behind his neck with jerking movements, as if his muscles are strung too tightly. His words are rapid-fire, “What? Sorry. I’m shitting my pants here, guys. What did you say?”

Derek and I both laugh, “Nothing. Nevermind.” Ryan nods imperceptibly and turns his laser focus on the anesthesia machine. It withstands the gaze admirably - it doesn’t even melt. Ryan grabs  a dial and makes a minute adjustment.

Surgery - Incision

Derek and I arrange our instruments, count our sponges, and wait. Eventually, the supervising surgeon, scrubbed in but not touching anything, makes his way to us. “Which one of you is the surgeon? You’re both Derek, get it? No, but seriously, who’s cutting?” I raise a gloved hand. “Okay, tell me what you’re gonna do.”

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

I regurgitate the textbook, “I’m going to make a ventral median skin incision, sharply and bluntly dissect until I visualize the linea alba, tent the linea alba with Adson-Brown forceps, turn my scalpel blade upward and make a nick incision, then use the Adson-Browns to tent the linea while I extend the celiotomy with my scalpel blade.”

“Yep. Have at it.”

Executing the process takes much longer than describing it. Despite my preparation, there’s no analog for the physical and emotional sensations of performing surgery on a live patient. Moxie’s skin is tougher than it has any business being for how thin it is - I take two tentative passes with my scalpel to get all the way through. When I wimp out on the incision length, the professor admonishes me, “They heal side-to-side, not end-to-end. Give yourself room to work safely.”

Moxie has more subcutaneous fat than I expect, an irregular layer of brilliant translucent white, like moonstone cottage cheese. Deep crimson blood seeps into the area, snaking delicate rivulets in every crevice it can find. I use the blunt tip and cutting edges of my scissors to clear away the fat until I encounter a smooth surface with a subtle rainbow sheen. This is the external rectus abdominus sheath, a tough fibrous envelope containing the abdominal muscles.

My target, the linea alba, is a narrow central strip where the left and right envelopes meet. The linea alba contains no blood vessels or nerves, making it the prime entry point for most abdominal surgery. (The first veterinarian I ever worked for, when I was in eighth grade, once pointed to the linea during a spay and said, “‘Linea alba’ means ‘white line’ in Latin. It’s like God’s ‘cut on the dotted line’ for abdominal surgery.”)

I know what it looks like, I can describe it in detail, I know where is should be...and for the life of me I cannot find it now that I need it. The professor’s encouraging voice breaks through my rising panic like a rescue boat out through fog, “It’s really tiny in kittens. They have very mobile skin. Try making small lateral excursions.”

I find it, but my entry into the abdomen veers off course slightly into the muscle next to the linea. “Not to worry. Unavoidable in this case,” says the professor.

The professor moves on to supervise the next incision. Derek looks at me and says, “Damn, dude, that was great! How d’you feel?”

“Sweaty.”

Surgery - Ovariohysterectomy

We fish around and closely inspect about fourteen loops of small intestine before we get ahold of a tube with an ovary at the end of it. “We found it!” I exclaim.

Derek’s laugh is loud and honest. “It’s embarrassing how excited we ah! Let’s nevah tell anyone about this.”

“Of course. Nobody’ll ever know.”

Having found the ovary, we wait for supervision before the next key step. Looming above me, the professor says, “Okay, tell me what you’re gonna do.”

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

“I’m going to grip just caudal to the ovary and stretch the suspensory ligament, then break the ligament with a ‘strumming’ motion. Then I’m going to triple-clamp, double-ligate, and transect the ovarian artery and vein. After checking that there’s no bleeding from the ovarian vessels, I’ll replace the pedicle in the abdomen, then tear the suspensory ligament and repeat the process on the other side.”

“Yep. Go for it.”

With my right hand, I grip the tough tissue just behind the ovary and pull. When I loop my left index finger over the suspensory ligament, it’s taut as a guitar string. I ‘strum’, or at least what I figure ‘strumming’ means in this context, and as nothing continues to happen in the face of my ‘strumming’, my apprehension turns to impatience. To the professor, I say, “So...when we say ‘strum’...”

“Just add steady pressure until it gives.”

I change my technique and start pulling...harder...and harder. I add pressure until the ligament starts to bite into my hooked finger and my brain yells with rising disbelief that this CAN’t be right. Just at my maximum-cringe-point, the ligament abruptly snaps loose from its deep anchor point and Moxie starts huffing and puffing forcefully. Her heaving breaths force her intestines to follow the path of least resistance, and more of them spill out through the incision with every breath.

Despite being intellectually prepared for this benign response to a painful stimulus, the reality feels alarming, even dangerous. I’m not the only one overwhelmed, either. As I reflexively lay my hand flat over Moxie’s incision to contain the organs, Ryan immediately reaches out to adjust the anesthetic level and turns it off momentarily before realizing the mistake and turning it back on and then up. I understand the impulse - all of us are deathly afraid of killing our patient, so our instinct is to shift toward a safe zone. In surgery, however, safety often lies in moving decisively forward.

The adjusted anesthetic and Moxie’s higher breathing rate bring her back to a deeper level of anesthesia. I take a deep breath and try to collect my wits. Freed from its main tether, I can move the ovary far more freely. I can feel how this maneuver will allow a much smaller incision in my future patients. The professor says, “Good job. Perfectly done. Now you’ll never forget what that feels like. Carry on.”

With several more pauses for supervision, I proceed to clamp and tie off the ovary’s blood supply, then cut it free. I check to make sure my ligatures are solid, see no bleeding from the cut vessels, and gently replace the ovarian pedicle back in the abdomen. Next, I tear the thin, transparent sheet of connective tissue attached to the uterine horn until I reach the uterine body. There, I pick up and follow the other uterine horn and repeat the whole process, which goes  goes more smoothly now that we’ve been through it once. Finally, I tie off and cut through the uterine body, and then lay the whole y-shaped uterus on the instrument table.

Surgery - Closure

While Derek and I count our sponges and instruments to make sure none of them accidentally ended up in Moxie’s abdomen, I say, “Tearing that ligament felt barbaric.”

Derek, being more interested in Large Animal medicine, says, “It looked like it. I’m glad we don’t spay horses.”

The professor circles back around and says to me, “Okay. Tell me what you’re gonna do.”

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

“I’m going to close the linea alba in a simple interrupted pattern using absorbable suture. Then I’ll close the subcuticular layer in a simple continuous pattern. Then I’ll close the skin in a continuous intradermal closure.”

“What’s the holding layer for the linea?”

“The external rectus abdominus sheath.”

“Great. Go for it.”

Being right-handed, I close from right to left. The synthetic suture is dyed dark blue for visibility and extends stiffly for about 18 inches from a pre-attached, curved needle. It looks not unlike a hair from a cheap blue wig. Using a specialized set of forceps that look like very delicate long-handled pliers, I drive the needle through the tough outer layer of the abdominal muscle sheath on both sides of the incision, draw the edges together, tie a stack of six knots, and trim the ends.

My progress is halting and maddeningly slow as I meticulously place twenty to thirty more such interrupted sutures with appropriate spacing, bite depth, distance from the edge, tension, and knot security. A continuous pattern, with knots only at the ends of the incision rather than between each pass of the needle, is faster, but then one knot failure could lead the entire incision to open back up. The trade-off today is that although our inexperience hands move slowly and our patients spend more time under anesthesia, many knots would have to fail for a significant problem to develop.

I take far less time closing the next two layers by using continuous patterns. I struggle with the technique of tying buried knots on the skin layer, but eventually prevail. All told, closure takes longer than the spay portion of the surgery, and my final surgery time from incision to closure (skin-to-skin) is around two-and-a-half hours. Later in my career, I’ll perform the same procedure in  fifteen to twenty minutes, sometimes ten or twenty a day.

Recovery

Derek and I gaze at our hard-won prize.

Derek says to me, “It’s embarrassing that it took us this long to remove that tiny little thing.”

“Don’t worry,” I assure him, “Nobody’ll ever know."

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

I step away from the surgery table and peel off my gloves and slingshot them into the kick bucket. As I pull off my paper gown, I feel a cold rush as the air hits my sweaty scrubs. The tunnel vision of surgery dissipates as I remove my cap and mask and take in the context of the room. Today’s surgeons and assistant surgeons emerge from their own sterile cocoons smiling broadly with flushed faces and hat-hair. The room is suffused by a gentle air of pride and camaraderie, some high-fives are exchanged, but celebration is curtailed while today’s anesthetists tend to our recovering patients.

I take a moment to soak in the sensations. My shoulders and neck ache as I stretch and breathe deeply. Sitting is a huge relief. My scrubs are soaked through with sweat and I long for a shower. I’m struck by waves of mental exhaustion, my first taste of how draining the intense focus required for surgery can be. Sitting on a step-stool with my head leaned back against the wall, I’m terrified that I made some critical, undetected mistake. I remind myself about the close supervision, but the responsibility of the role hangs on me like a heavy coat.

After a few minutes, Moxie wakes up enough to swallow and we remove her breathing tube before she can chew it in half. Her recovery is smooth and she eventually reaches a sluggish consciousness and looks up at me with her good eye, her squinty one only open a sliver. We confirm that her pain is well-managed and monitor her until she’s alert enough to be left alone. A bit later, we reintroduce food and she eats hungrily.

Home

That night, I take her home and set the carrier in the middle of the living room of my one-bedroom basement apartment. She marches out of the carrier and straight over to the litterbox I’ve set up in the bathroom. After christening the latrine, she explores confidently before choosing a spot on the arm of the sofa and falling asleep.

Later, when I crawl into bed, she jumps up and I decide it’s okay as long as she stays on the comforter. Over the next hour, she demonstrates that she will pleasantly, but invariably, do as she damn well pleases. A cat with her force of character can only be called “Moxie.”

Seeing Red

The sunlight is fading on a world-class California summer day as I arrive for the first time at a small emergency veterinary hospital nestled in a residential section of Palo Alto, California. As I stretch out the kinks in my legs and back from my two-hour commute, the still air and encroaching dusk make me think back to chasing a baseball on a darkening diamond as a youngster, convinced I could will the day to continue so I wouldn’t have to get back to real life.

                                                                   Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

But real life insists, so I enter the hospital, introduce myself to the staff, and learn about my first patient - she’s already roomed and waiting for me.

Lemon Drop is a stunning, if shy, 8-year-old female spayed tabby cat. Her coat is a vibrant cacophony of fine gold, brown, and black fur. Her soft coat makes me want to lift her from the exam table and hug her close, but her skeptical gaze and tense, hunched posture tell me she isn’t onboard with that plan. She looks like she’s trying to disappear into the surface of the table.

I need to put her at ease, so I fight the urge to stare directly into her alarmingly abnormal right eye. Instead, I direct my eyes and body across the table toward her owners and gently spin her around so we face the same direction, making sure she can see and feel an escape route. I place my elbows on either side of her, cradling the length of her body in my forearms. I cup my left hand around the front of her chest and pet her her above the shoulders with medium pressure and a calm tempo. Her purring, an effort to self-sooth, reverberates through my hands, arms, and chest. I can feel her relax ever so slightly.  

                        Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

When I address her owners, I maintain a quiet, even voice. “Tell me about what brought you in today with Lemon Drop.”

Lemon Drop’s owners are a clean-cut couple in their early or mid-twenties. Their faces are taut with apprehension, lines etched at the corners of their eyes and mouths. They glance at one another and silently agree that the boyfriend will talk first. “Well, we just came home from out of town. We were gone for three days. She had something like this before, but it wasn’t as bad. We were giving medication. Her eye, I mean.”

When taking a medical history, I try to keep it open ended at first because most of my rote questions get answered more thoroughly through the owner’s own words. When I get a jumbled narrative, however, I suggest a structure. “Tell me more about that first episode - when it was, what you noticed, how you addressed it, how it went.”

He nods and pauses to gather his thoughts. “There was a much smaller amount of blood in her eye a few months ago.”

“The same eye, same place?” I clarify.

“Yeah. The doctor that time gave use some drops.” He holds the container out to me, I take it and glance at the label - steroid drops. I put it aside. He continues, “It went away, so we stopped the drops, but it’s much worse now.”

“Any other eye problems or other non-eye problems between then and now?” I ask.

“No.”

“Okay, tell me about this episode.”

“Well, we came home and it looked like this. We just got home an hour ago. We put in one of the drops.”

“Did anyone have a chance to see Lemon Drop during your trip? A pet sitter, anything like that? I’m just trying to figure out when’s the earliest it might’ve started this time.”

“No, no pet sitter. She was alone for three days.” The couple exchange a sheepish look.

“Oh, it’s no problem, don’t beat yourself up. Building a timeline is just helpful for me to figure out what might be causing it.” They don’t look convinced. “Really, please, take a breath.” I smile big. “We’re gonna figure this out.” The owners relax. Slightly.

Lemon Drop feels more relaxed in my arms, but tenses when I shift to stand up. I catch her forward movement in my hand around her chest. The nonthreatening restraint is enough to keep her in place and she settles back into a looser hunch.

“I’m going to examine everything else before I mess with her eye,” I tell her owners. “I want to keep her as happy as possible for as long as possible.”

I examine Lemon Drop from back to front and find no problems to the rear of her neck. The opportunity to satisfy my curiosity has finally arrived. I rotate her 90 degrees with her head pointing to my right, which gives me a good view of her face without putting us nose to nose. Her right eye is squinting slightly. Her irises are a vivid mustard color - normal - and her left is significantly more dilated than her right - abnormal.

Sitting inside Lemon Drop’s eye, obscuring the bottom half of her right iris, is a deep crimson blood clot. It’s big enough that I saw it from the doorway when I first walked in, and it’s rare enough that I’ve never seen one like it in 6 years of practice. I tilt her head at various angles and the clot stays put. Looking from the side, I can see where it’s attached to the iris and is tethered in place, preventing dilation.

                 Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

I explain to the owners what I’ve seen and narrate what I do next. I tap the corners of Lemon Drop’s eyes and she blinks. “This is called the palpebral reflex and means her nerves can sense the touch and operate her eyelids.”

When I shine a light in her eyes, the pupils expand and contract as expected, but do so much less on the right side because of the tethered iris. “This is called the pupillary light reflex and means that her retinas can sense light and operate her irises. It’s limited in the right eye because of that clot.”

When I cover one eye and act like I’m about to tap the other, Lemon Drop flinches and shuts the open eye to protect it. “This is called the menace response and means that she can see in both eyes. That’s really good news because bleeding in the eye often damages the retina and can cause blindness.” I look directly at the owners and reiterate, “So no matter what else is or isn’t happening, we know she can see.” They both look relieved and settle into their chairs.

I use a lens to look at the retina in the back of Lemon Drop’s eyes and confirm that they both look normal. I let go of Lemon Drop and say, “Okay, she can relax and do what she likes while we talk.”

Inside, I’m simultaneously geeking out and worrying. “Any access to toxins? Do you use rat bait or other poisons? Does she have access to blood thinners in the household?”

The couple look at each other, alarmed. “No,” they reply in unison.

“Ok, good. I want to rule out a bleeding disorder, but based on the history, it’s unlikely. Usually, this kind of thing happens in cats with high blood pressure, which is very treatable.”

“High blood pressure?” The girlfriend cocks her head and half closes one eye suspiciously, “But, they didn’t mention that as a possibility before.”

I’m always cautious when questions or comparisons about another veterinarian come up during a case - there are so many traps on that path. Am I being asked to cast judgement? Am I being distrusted? Am I getting an accurate picture of what actually happened before? I’ve been burned on every side of these conversations. With limited information, it’s best not to get in the middle.

“I’m not sure why that would be. Having come into this situation for the first time tonight, without the record from the previous episode, I can only let you know what I’m seeing and what I think we should do about it.” This seems satisfactory, so I continue. “Head trauma can also do it. Is she a poor climber, have a tendency to fall over, any known head trauma?”

“No.”

“Okay. Infection, foreign material, or inflammation can also contribute. I don’t see a thorn or a splinter or anything, but they can be tiny. Beyond what caused the bleed, I’m concerned about what the clot can do. Nothing typically lives in the anterior chamber, where the clot is, except fluid. Movement of the iris is important for emptying fluid from the eye, so when it gets stuck in position, fluid can build up. When that fluid pressure gets high, that’s glaucoma, which is also dangerous to vision, but treatable. And remember, we know that she can see.”

Lemon Drop’s owners approve diagnostics to work our way through the list of possible causes. First, we measure her blood pressure - it’s sky high, even for a nervous cat. Next, we apply a stain to the surface of each eye that glows bright green under blacklight - no evidence of corneal injury. Next, we apply a topical anesthetic to numb the eyes and tap the surface gently with an instrument to measure pressure within the eye - no glaucoma. A blood test rules out a bleeding disorder.

I inform the owners of the results and prescribe blood pressure medication. Cats are stoic and even squinting can indicate pain, so we err on the side of caution and I send home some pain medication as well. At the end of the visit, we talk long-term plans, “There’s no way to remove or disrupt the clot without surgery or something invasive, so we’re just gonna to have to watch it and monitor for those complications I mentioned. Check in with your regular vet tomorrow and see how Lemon Drop’s blood pressure is doing. She’s probably going to need that blood pressure medication forever. Hold off on the steroid drops that you got before.”

We wrap up and Lemon Drop’s owners put the travel crate on the exam table. Lemon Drop darts in like she’s sliding into second base and the girlfriend laughs and says, “Geez! It was so difficult to get her in there on the way in!”

I smile and say, “That’s typical. Cats cling to the most familiar thing within reach. At home, the crate is foreign. At the hospital, it’s familiar.” I let them know that for planned vet visits, leaving the crate out the day before can give Lemon Drop time to settle down before forcing her into it.

                Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

We shake hands and the owner’s check out. They carry Lemon Drop outside, where darkness has fully fallen without adding a chill to the air.

A voice from behind me says, “Dr. Calhoon, your next patient is ready for you,” and I get back to work.