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.