Saturday, June 25, 2011

Aflack... Aflack... AAAFFLLAAAACK!

Finn's been poorly lately.

One day not long ago he was lying on the bed next to me, pressed hard up against me, a fine tremor of stress shivering through his tissues and vibrating through mine, waking me. He looked at me anxiously, ears flattened in distress, wagging his tail in a nervous, tentative way, and urinated where he lay. A lot. All over the bed.

This is MOST unlike Finn, so - apart from leaping to my feet and whipping the sodden blankets back before things could soak in to the mattress, I made immediate plans to pop him in and run some blood work.

The last time Finn peed on my bed, he'd leaped up one day while I was folding laundry on the foot of it. He walked with deliberation to the center of it, fixed me with a glance and, once he was sure I was watching him, urinated where he stood. Right in the middle of the down comforter. My immediate thought was AAACK! BAD DOG! - but the one hard on its heels was: Finn doesn't do things like that. Something's wrong. If he was just being inappropriate he'd have lifted his leg on the bedpost - but he didn't. He camped his back legs out behind him, slightly crouched as if something hurt him, and just emptied his bladder right there, all at once. So: No scolding, and yes workup.

I ran a urine sample the next day and sure enough: He had a bladder infection. Well, thanks for telling me, dude; it's harder to pick up in males because when they go out it's pretty much par for the course that they hike their leg about 71 times and pee a little bit on everything in creation. So unless they do something else - something abnormal - you have no way of knowing. He may not have thought of it in exactly those terms, but in his own way Finn was letting me know he was in distress and needed help.

Finn is a Border collie. They have a useful ability to use their eye to control livestock. Unlike my Raven dog, Finn isn't much of a stock dog. He's what is sometimes referred to as a "loose-eyed" dog, meaning that he hasn't got a lot of the vaunted and much-esteemed Border collie Eye. But there is one thing he can do with it that Raven can't. Finn has a particular way of looking at me that compels me to really look at him: Closely, carefully, with observance and attention.

Sometimes he uses this talent just for fun. One time I was hosing out the back of my pickup truck, which had a shell on it. Consequently I was duck-walking around under the low canopy, concentrating on flushing out a large quantity of sand and gravel from the bed. This was, unsurprisingly, taking a long time; sand and gravel sink below the water flow and tend to stay put. Finn was wandering around in the driveway with me, hopping into the truck bed every so often to inspect my progress. I'd given him a pig ear to help keep him occupied, and kept  half an eye on him while I worked.

At one point Finn jumped into the truck bed and gave me that Look; I could feel the weight of it resting on me, a gentle and persistent touch, quietly demanding my attention. I glanced up to see him gazing intently over his shoulder at me, pig ear clamped between his jaws, one corner of it pushing his lip up in an absurd lopsided grin. When he was sure he had my full attention he turned to face the lowered tailgate, tossed his pig ear high in the air, leaped out and caught it on the fly, and landed adroitly on the driveway. He turned around to look at me again, gently wagging, as if to say "What did you think of that? I invented a new game! Didja see my technique? I didn't just catch that pig ear, I threw it, too, and I don't even have hands! I should get at least 8 points for the dismount, don't you think? I should probably get a ten, though, for creativity and style."

Naturally I laughed my sodden butt off, so he demonstrated the rules for me several more times. And, thus rewarded, Finn has persisted in the use of this particular Look. Which is in part how I knew, when he urinated all over me and my bed whilst fixing me with that expression, that something was Really Wrong.

I took him to the clinic and drew some blood. It was a Sunday; I was there alone. I waited for the bloods to come out, expecting signs of infection or possibly kidney disease. What I got was hypercalcemia. Very marked hypercalcemia. Enough to max out the capabilities of our blood analyst unit.

A peal of dread rolled through my chest when I looked at it. As a general rule, hypercalcemia in dogs means cancer until proven otherwise. And of the cancers that cause it, the most common one is lymphoma - which, in dogs, is incurable. The next most common are perianal cancer and bone cancer - and Finn had no such masses present.

Hell and God damn it. I love this dog. He's only eight. This can not be happening.

I admit I said a lot of really bad words while I thought. I went through my rule-out list of causes of hypercalcemia - the HARDONS list: Hyperparathyroidism, Addison's disease, Renal disease, vitamin D toxicosis, Osteomyelitis, Neoplasia, Spurious. My bloods had already ruled out Addison's disease, renal disease and osteomyelitis. There was no history of vitamin D toxicity (and I'd know, as this dog is with me pretty much 24/7, and when he's not under my eye he's in a run at the clinic.) That leaves me with hyperparathyroidism, spurious (lab error, essentially) - and cancer.

I drew more blood to be sent out to an outside lab to test inonized calcium levels and parathormone levels. The results would rule out lab error - confirmation or denial by an outside lab - and hyperparathyriodism. I also - while waiting for that test to come back - Xrayed Finn's chest. The commonest cause of hypercalcemia in dogs, as I said, is neoplasia - cancer. The commonest cancer to cause it is lymphoma, and the commonest form of lymphoma to cause it is a form called mediastinal lymphoma. The mediastimum is the structure in the center of the chest that contains the heart, the trachea and esophagus, the great vessels (aorta and vena cava) - and a cluster of lymph nodes just forward of the heart, at the branching of the mainstem bronchi. Lymphoma itself being a disease of the white blood cells, it forms most commonly in liver, spleen and lymph nodes, though it can go anywhere the bloodstream does.. Finn had no enlarged lymph nodes in the periphery of his body - the ones you can feel under a dog's jaw or armpits, in the junction of the shoulder, in the inguinal region or behind the knee. But the ones in the abdomen are harder to reach, and the ones in the chest, impossible. Those must be imaged.

The lateral view of Finn's chest looked okay - maybe a little hazy in front of the heart, but no visible mass. But the V/D view - one taken with him lying on his back - told a different story. There, in his mediastinum, right in front of his heart, is an unmistakable mass. Unmistakable.

More bad words, but I kept them to myself this time, both to avoid offending my co-workers, and as a way of whistling past the graveyard - pretending that I didn't know that death was stalking my household, its dark and roving eye fixed, for the moment, on Finn.

Meanwhile, there's one thing that cannot be ignored. Finn is still PU/PD - polyuric and polydipsic, which means he's peeing and drinking like a racehorse. The real problem here isn't the inconvenience; it's that, with calcium that high, you can induce kidney failure, and that, if left untreated, can potentially kill a dog faster than cancer. Something had to be done about this. There are there are choices: One is diuresis: simply running vast quantities of fluid into the dog to dilute the excess of calcium. It's a temporary fix, though, and may take days to produce the desired result. The second option is a calcium-wasting diuretic, one that excretes calcium preferenetially to other minerals. This isn't a bad option per se, but its capacity to drop the calcium is limited. And given the extreme numbers Finn was posting, I doubted it would help enough to make much of a dent.

That left option three: Steroids. Prednisone will dump excess calcium like a bad boyfriend. It's also cheap and well-tolerated, and tends to stimulate the appetite - which would be a good thing, since Finn - normally the most food-motivated of dogs - had started refusing food. There's really only one problem with it in a case like this: Pred induces MDR proteins.

MDR proteins are cell-membrane transport proteins that eject harmful substances from the cell. In the case of cancer, this is a bad thing: it means that medications that are meant to kill the bad cells are ejected before they can do the job. Normally, pred would have the additional drawback of destroying your ability to achieve a histopathological diagnosis (which means a diagnosis based on tissue samples examined by a pathoologist under a microscope)... but since I wasn't going to crack Finn's chest to biopsy lymph nodes this was not my main concern. My main concern was the MDR proteins. So there we are, Finn and I, between a rock and a hard place. If I use pred, I begin to induce MDR's, and the MDR proteins will close off any window I have for more-aggressive chemo that will earn me a longer remission. If I DON'T use pred, his kidneys will shut down and we'll lose much faster.

Still, you don't induce MDR's instantly, so I started Finn on pred on Sunday to dump his calcium; sparing his kidneys was the first obstacle, and I suspected the hypercalcemia was in part responsible for his poor appetite. I knew I didn't have long to decide what I would ultimately do. I'm in no way opposed to treating cancer - and have done it (sometimes with spectacular success) with any number of patients, not to mention four of my own dogs (Finn being the fifth such candidate). In animal medicine we aim for quality of life over length of life - after all, no dog is making it to sixty, and what matters to them is not how long they live. It's how WELL they live. And there's another factor: Of the chronic diseases, Cancer it the most curable one we have. We can't cure heart failure. We can't cure kidney failure. Past a certain point we can't cure liver failure, either. Treat them, yes. Cure them - short of a transplant, no. Cancer, we can cure. Not all cancers, of course, including the profoundly accursed lymphoma, and there's a cost - but as a group, cancer is the most curable of the chronic diseases.

This is all well and good, except for one big fat "however", being this: Lymphoma in dogs is a non-Hodgkin's form, and though medical science is always, always in pursuit of a means of curing it, that means has not yet come to hand. So based on the standards of medicine as they stand today, my best hope with aggressive therapy is a remission of some months' duration, and that may be hard-won... or possibly, unachievable. Not every dog will do a remission. And I have to consider the cost to the dog and the length of good time I propose to offer him in trade for the bad time I will cost him during treatment.

I thought about it from the minute I saw the high calcium levels, through the second blood draw and the Xray and while I was pending my other tests. Finn would do anything I asked of him - but he's a worrier. He hates procedures, and although he submits to them and tries to do as asked, he really really hates them. He is anxious and afraid, wonders what he's done wrong, is sad and uncertain for hours or even days afterwards. Can I in good faith put him through weekly procedures for this?

On the one hand: He's only eight (albeit, about to turn nine). On the other: It's not fair to torture them 'til they die. You have to strike a balance for the dog, do what's fair for them even if it's not the most time you can potentially gain for them. And ultimately, if you lose them now or lose them later, you're still going to grieve them. That won't change. All you can change is when. And with all that in mind - and Finn's temperament foremost - I decided that if it should be bad news, I'd stick with pred for as long as it would give me, and then, when it could give me no more, I'd do my best to help Finn die as gently and easily as it is in my power to make it.

A hard decision, but when I made it I knew it was the right one. It settled into my being with a little click, fitting in such a way that I knew, sad and grim as it was, it was the right choice for Finn.

Two days later the test came back: Hypercalcemia, and low parathyroid levels. So I've ruled out lab error, and I've ruled out hyperparathyroidism. That leaves me with one answer left: Hypercalcemia of malignancy, with a mediastinal mass telling me it's lymphoma.

I really expected this to just hammer me to my knees. I love this dog. Love him. He is charming and funny, sweet and willing, easy and kind - and so beautiful. Mainly that's his expression. My father once remarked that when Finn looks at you, you see his whole soul in his eyes. That's really kind of true. He is an honest dog, and a generous one as well. He gives you all he has, right off the bat, unreservedly. So what I expected was devastation, and I spent the entire day tensed, braced to stave off the well of pain and despairing of my dog lasting even 'til his 9th birthday, a week hence; he was that ill. But instead, once I was home and had a chance to drop my defenses, the fear fell away and what I had... was peace.

I found this confusing, and a little annoying. I knew what he had was bad. I'd already lost a dog - my beloved Buddy-dog - to lymphoma in the intestine. So how was this going to be okay? But I felt, somewhere unshakable, that it was going to be okay.  And after fighting that for a while, I gave up; I didn't understand why, but it was still there - that peace. Maybe it was just acceptance; we all die, sooner or later. Maybe it was just the understanding that whenever we part, Finn and I, it will hurt - and when is immaterial to that. The pain will still have to be endured, regardless of the date of its arrival.

Still: There's what must be done today.

Finn did well on his pred at the start. It is a medication that often causes excessive drinking and urination, of which he had plenty to begin with. But the pred did its job faithfully; Finn's calcium dropped like a rock. Within 36 hours he was actually less PU/PD than he was before we started the pred. He ate well for a few days - but then I noticed an alarming amount of weight coming off him, very fast. I upped his food, but he continued to drop weight and his appetite began to fade.

This is not just bad - it's really bad. Finn is very food-motivated, and in the past I've had trouble keeping weight off him, not keeping it on him. Things were moving alarmingly fast. The spines of his scapulae were like knife blades under his skin, the muscle on his shoulder blades gone. The vertical processes of his vertebrae stood up stark and clear, revealed by his atrophying back strap muscles. His arms and legs were thin and flaccid, his normal robust muscle tone gone, and his face looked hollow, the bones pressing against the skin from within, no longer clothed in normal flesh. Moreover he was weak and tired. This is a dog who had once had a leap so graceful and effortless that he seemed to float from the ground to the pickup bed, as if lifted there by magic. To see him climb laboriously, one foot at a time, into the cab of the truck - well. Not looking hopeful. I weighed him. He'd lost six pounds. That's 15% of his body weight, gone in less than 2 weeks.

The one thing about being backed against a wall like that is this: You have nothing to lose by punting. If you make a gamble and it doesn't pay off - well. You were losing anyway. So punt I did. I invented a protocol using a mitochondrial modifier. That went okay for a week, and then Finn started vomiting.

Well, crap. Okay, anti-emetics to control that, discontinue my invented protocol, taper the pred. Two days of that... and well, at least he has his appetite back; in nothing else, he'll at least eat well 'til I have to make the tough decision.

But then I noticed something. Finn stopped losing weight. In fact, he also seemed a little more cheerful. He'd eat anything I put in front of him, but now it seemed like it was actually putting some flesh on him.


Within a few more days, Finn was energetic enough to be really rather annoying - and there was great rejoicing. Mind you, it's a bit of a shock to be driving down the road, minding your own biz, and have something wet and warmly slimy suddenly thrust through your hair, smearing unidentified goo along your neck and then rolling down the front of you to land in your lap. This would, of course, be the drool-soaked Aflack duck (kindly provided by the Aflack dude, who gave me two because I told him Finn loves Aflack ducks). He does, too - he loves to bite them and make them say "Aflack... aflack... AAAAFFLLLAAACK!" Over and over and over again. Until your brain explodes. At any rate, the Aflack truck-duck is now mute, having been Aflack'd to death. Still, Finn keeps poking it over my shoulder so I can throw it into the back seat of the cab for him, because evidently driving is no longer interesting enough. We also have to have GAMES while we're on the road. (The Aflack house-duck has, unfortunately, kept its voice... which I know because I hear it every so often at FIVE IN THE MORNING, thank you very much, since Finn likes to get up and play with it while I'm trying to sleep. This can be ignored only so long. And "so long" is also a lot shorter if the spit-slimed duck is poked invitingly against your cheek several times, in repeating intervals of approximately 2 minutes, or else possibly dropped directly onto your forehead. Just sayin'.)

So: Hmm twice.

I'm inclined to be skeptical by nature, so I wasn't prepared to go all hog-wild about this. I took a "let's just wait a little and see" attitude, but I did feel that Finn was sturdy enough to go someplace with his sister Raven in the truck with us (something I'd stopped doing when he got sick, figuring he didn't need the stressor.) The first time I did this there was a clash of renewed sibling rivalry; even this was encouraging, since Finn had been so extremely passive when he first got sick. He'd defer to the back seat without even token resistance, leaving Raven the run of the front. But this time I had to banish him to the back, a correction he took with seemingly good grace.

Ahh. Peace. All is quiet on the western front. Until the Aflack truck-duck shoots forward and thumps against the dash hard enough to bounce back into my lap. So two things: one, Finn is maybe not as happy about the back seat as I thought, and two, maybe he should be pitching for the Yankees. Although I'm fairly certain he'd rather catch for them.

The upshot at this point is that Finn is, for the moment at least, well. It's unclear to me if this is a long-term remission - perhaps even a spontaneous remission, which does happen independent of treatment - or if it's just a lull, a temporary respite. It's too soon to tell. But in the short run I'm grateful for all I can get with him; he's very dear to me, and I'm not eager for a parting of the ways. And even if it means he's obnoxious and annoying and drops his spitty duck down my neck umpteen times a day, I'll take it. And I'll kick the soccer ball for him, and throw his Ceasar Milan designer squirrel frisbee until my arm falls off. I'm glad he feels well enough to be a pain in my behind, day and night. And i even admit that I don't really mind that much hearing "Aflack... Aflack AAAFFLLAAACK!" approximately one hundred and seventy-one times. In a row. Every few hours. Until my eyes bleed. The main thing is: the dog feels good.

But I am kind of considering some kind of de-voicing surgery on the Aflack house-duck.

Monday, June 20, 2011

Farewell Sunny Knik

This is why I love Alaska.

I have some friends who (for privacy reasons) I will pseudonym here as the Resk family (which stands for "really excellent super-keen", just so you know.) The Resks are everything you could want in friends: They're smart, funny, generous, warm, good-hearted, hospitable people, and man can they cook. Which, if you're friends with them, is vastly to your advantage, since there's every chance they'll feed you at some point along the way. I say this in complete confidence, since every time I show up at their house, food magically appears. And it's GOOD food. And if they offer you a drink? Try it. You'll like it.

When I first met them, it was as clients. Mr. Resk (who will henceforth be called Mac, which stands for "manly and capable") mostly came in with the dogs at first, since his lovely wife Tara ("talented and really adorable"), a nurse, was working a 3-on, 3-off schedule far far away in Bethel. I can't really remember what it was that got us started, but Mac and I made each other laugh really a lot. Somehow we'd always manage to get a physical exam and treatment lined out, even so, but it was a near thing sometimes.

It turns out that Tara was making beaver mitts as a fund-raiser for Iditarod one year. I thought: I want some beaver mitts! So (following instructions) I traced my hand twice on a piece of paper: Once with fingers together, once with fingers apart. My rings made odd little bumps appear on my tracings, so I carefully labelled these, with arrows pointing to them: "This is not a deformity. This is my ring." The thumbs ended up looking a little weird, so I labelled them, too: "This actually IS a deformity. Oh, wait, it's my thumb."

Evidently Tara thought that was pretty funny, but despite my deformity - er, my thumbs - she made me an absolutely gorgeous pair of beaver mitts. It's not possible for your hands to get cold in them. Trust me, I've tried. Ain't gonna happen.

At any rate, I've enjoyed a friendship with the Resk family for many years. Lately it's been even more interesting, what with the addition of their children, Extremely Adorable #1 and Extremely Adorable #2. These are charming boys, sturdy and bright and SO cute that no one alive can look at them and not go: "Awww!" I tried it once. I almost had a seizure trying to hold it in. It's better to just give in right away. Trust me on this.

One day, a few months ago, I happened to hear that the Resks were planning to sell their house. I must digress here for a moment and tell you: I love their house. It's cozy and snug, sitting up on a hill amongst big old aspen trees. It's a log home with a fieldstone fireplace in the living room and a long deck across the front of the building. There are outbuildings and a couple of nice, level areas for dogs, a fenced yard for kids and a wide, flat space where barbecues can be held. Plenty of space for horseshoes or a volleyball net or a game of giant-inflatable-soccer ball soccer. A congenial space, in the Knik Historic District, with access to the trail system. It's not far from the Musher's Hall of Fame, the Kink Bar (where Hobo Jim has put on many a rollicking pre-race concert) and Kink lake. There's access to the Iditarod trail right off the property.

Iditarod trail access.... Hmmm. My tech Julie should hear about this. She runs dogs. She likes log homes. This would be PERFECT.

So, quick like a little bunny, the minute I returned to work I told Julie she should call the Resks. She did. They're all like "Wha...? We told ONE person we were planning to list our house and already we have a potential buyer? Before it's even been listed? We don't even have a real estate agent! Um... eh?"

Alaska. It's a big state, but it's a small town. Word gets around.

So, fast forward a few weeks, and: Ta-da! Julie and her husband bought the the Resk house. What do you know. It is perfect. Or, at any rate, perfect enough. Me, I'm pretty happy that it's going to someone I know and like. It's a lovely space, and if I can't have it, well then, someone dang good should.

The upshot, naturally, is that I went to yet another perfectly fabulous barbecue at the house. It's not a housewarming party; that's when you move in, and this was thrown by the Resks the day before they moved out. So what do you call that? It's kind of the opposite of a housewarming. But somehow "house-cooling party" doesn't sound right. House-switching party? Tag-team house-handoff party? Hm. Well, anyway: A party.

I did mention the Resks know how to cook, right...?

Halibut, onion and pepper shishkebabs. Reindeer bratwurst. Scallops wrapped in bacon. Tenderized pork on a skewer, basted in something yummy. Marinated prawns. And of course, for the faint of heart traditionalists, hamburgers and hot dogs. Luckily for me, the ranks of the Resk friends can, by and large, cook as well: Smoked salmon. Potato salad. Home-made salsa. Spring rolls. Mmmm.

I might also mention that there was Sangria, Sunny Knik Margaritas, and Alaskan Summer Ale on tap. Hm. I have to try ALL of those.

Jeez. Where to begin? So many choices, so little space in the average human stomach.

Well, it was a gorgeous (and I mean gorgeous) day, and the fire was crackling cheerfully, basting the air with the scent of fire. Clearly where I must start is with a nice cold ale, whilst standing near enough the fire to get the smell of smoke thoroughly permeating my hair. Oh, and as a by the way, that's where the good conversations got started, so obviously I picked the perfect spot to begin. So there I am, basking in the warmth of a sunny Alaskan day, chit-chatting with friends while the rich, warm taste of my cold ale limbers my tongue, and watching a bald eagle fly low to check us out. And hmm... the grill is starting to smell mighty good, perhaps I should get a plate...? But first a hunk of this smoked salmon and - damn that's good, nice work, man! What, there's plenty? Don't mind if I do, then... nothing like a nice hunk of smoked salmon with a bacon-and-scallop chaser.... (pause to enjoy random dog cuteness) What? You're right, my plate is empty! How did that happen...? Oh, another couple of shrimp and some pig-on-a-stick? Sure, why not? Nobody minds if I eat like three of these spring rolls in a row, do they? (short intermission for more random dog cuteness) Oh, look, Extremely Adorable #2 is doing something extremely adorable! And Extremely adorable #1 is passing out bubbles to the other kids - who, strangely (not!), are also extremely adorable. Wow, better move back, here comes Mac with an entire sled full of wood to throw on the fire all at once. I think I'll just stand back here for a few minutes.... Oooh, another Margarita? Sure! What, giant marshmallows for roasting? Wow, dudette, that is a champion s'more you just made there! (and, yet more random dog cuteness).

Well, it went on like this for several hours. Five and a half, to be exact. If not for the fact that I had dogs waiting to be fed, I'd probably still be there. Fortunately I'd not eaten lunch - it being a busy day at the clinic, as usual for a Saturday - so I felt more than justified in eating two days' worth of calories in one afternoon. Why not? We're celebrating here, man! It's the house-hand-off.. er.. whatchamacallithousewhateveritis party!

Overall it's a bittersweet occasion - sad to see the last of the Resk BBQs, happy for their new adventures; Happy for my friends Julie and her husband, sad Julie could not make it to the party. Still, there's no denying the pleasure of the day, the enjoyment of good friends and good food and good weather. The Resk family isn't leaving the state, or I might have been too sad to go to the party. As it is, there will be other parties, and maybe they'll come to Wildwood for one event or another. Maybe Julie will throw her own BBQs, and we'll all meet there. The possibilities are endless.

One thing is for sure though: There's something about standing under the wide open sky, the heat of the sun on my head and the heat of the fire on my legs, the scent of wood smoke and grilling meat pierced by the happy squeals of children and the murmur of conversation.

It feels like summer now.