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.

Hmm.

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.

The Perils Of Pepper

So you may recall me mentioning Pepper, the dog of my BF, the dog who introduced me to Border collies (and thence induced me to fall in love with them), my step-dog. Pepper is, as they say, a classy bitch. She is a full-on, working-bred stock dog, serious and intent when it comes to work, disinclined to suffer fools gladly, yet always ready for a game or a cuddle. She is friendly enough to people in general, but has her favorites, and will quickly abandon even a good game with a stranger in order to spend ordinary time with one of those she likes best. She is kind to her sheep without letting them push her around, she is bold and willing to conquer new skills, she is tireless as a sidekick. There is in her amber-brown eyes an undeniable courage and intelligence, and behind the quick mind and strong will is a sweetness that is offered only to those she deems worthy of this regard.

I will say that in her youth Pepper's idea of cuddling was more of a casual affair; she liked the attention, all right, but should there be any hint that something more interesting was in the offing - say, a game or a trip in the truck or airplane, or a chance to go to the sheep - she would without hesitation abandon the petting and be off like a shot onto bigger adventures. She liked her cuddles for a few minutes, and then she was done and would go off and do something else, and sleeping on the foot of the bed was a "sometimes-only, and only if you don't move around too much and annoy me" kind of proposition.

Pepper is 13 now, though, and she's mellowed. She's still up for a game or a trip in the car or a go at the sheep (although encroaching deafness makes this less useful and more dangerous to her than it used to be), but she's become more judicious. Instead of following me everywhere, for instance, or racing up or down the stairs should I look like I'm even thinking of going that way, she positions herself strategically in the house so she can watch me go from room to room, and only gets up to follow if I call her or if I do, in fact, do something interesting. She's more inclined to sleep on the bed, and significantly more into the petting and cuddling than she used to be. Fools don't bother her as much as they used to - although she is still capable of expressing, at a glance, the most profound disgust imaginable, should some ill-mannered puppy or other time-waster cross her trail.

With age has come its rewards, of patience and restfulness and the pleasure in simple things. But age has its down sides as well.

Early in the year, while D was out of town (and hence Pepper was staying, as she does when he is gone, at my house), I happened to glance over at her, curled on the futon while I was working at the computer. Nothing amiss; she was sleeping, her feet tucked under her chest, cat-like, her head laid on a dog-pillow I had there for just that purpose. But I glanced back a second time and a third, wondering: What is it that's bothering me about this? And on that third glance I saw it: her left wrist had a small asymmetry to it.

Hmm. Pretty subtle. Am I making that up? I got up and disturbed Pepper's rest by stretching out her leg and having a look. No, I'm not making it up. There's a mass there, maybe 6 millimeters across, maybe 3 millimeters thick, adherent to the underside of the skin, but otherwise movable. Thin, but distinctly different from her other tissues.

Well, hell.

I emailed D in Hong Kong (or wherever he was at the time) immediately and received his prompt permission to do whatever I thought was best. So the next day I took Pepper to work and aspirated the mass. Under the microscope I found a number of cells, varying in shape, but all with some disturbing features. Some had a prominent chromatin pattern, some had two nuclei, some had multiple nucleoli (all of which, I assure you, are not normal-cell features, and all of which are disquieting.) But I am not a pathologist, so I sent a slide off to be read by one. The report came back as a mesenchymal cell tumor of some type undetermined... but definitely a malignancy.

Damn. Pepper, my darling, beloved step-dog, who I adore so much and to whom I owe what can never be repaid, has cancer. Pepper, D's only dog, his perfect sidekick for 13 years. He loves that dog.

So I gave the results to D and we talked over what to do. At my urging we talked to the surgical specialists in Anchorage, in case they had better options for her, and because I knew they would be able to be completely objective - a task I was not certain I could accomplish perfectly, given my emotional involvement with the dog. The good news about her tumor type is that it is one that is unlikely to spread to other body parts. The bad news is that it tends to send tendrils out from the main body of the mass, making it difficult to get clean margins, especially in that position: there is precious little tissue to spare on the wrist, a high-motion joint with relatively tight skin. I was uncertain that I could get clean margins (short of amputating her leg), and I wondered if the surgeons might have a better shot at that.

The surgeons were excellent, as I knew they would be, and advised D clearly, giving him his options without the blurring of the line that I feared my emotional involvement with Pepper might entail. Ultimately their advice was essentially identical to mine - although they were able to answer questions about skin grafting that were beyond my expertise - but I felt better knowing that I wasn't giving D options that included an emotional bias.

Ultimately, the decision had to rest with D - Pepper is his dog, after all - and he elected to have the surgery done at our clinic. He left it to me if I would do the surgery of have Dr. J do it; in the end I asked Dr. J to do it. He has 30 years' experience on me, and while I might have done as good a job, I didn't want to leave that to chance. I wanted Pepper to have the best shot we could give her.

So, accordingly, Dr. J excised a long oval from the medial aspect of Pepper's wrist, including the tumor and as much associated tissue as he could reasonably take without compromising the joint or the circulation to her foot. That meant that it was not possible to close the skin entirely; even if you could stretch it that tight, doing so would constrict the circulation and the foot would slough, so some of the incision had to be left open. That left a line of sutures above and below the open area, under some tension, and an open area about the size of a quarter over the highest-motion part of her wrist. I set a splint on the leg to keep the wrist strait, to avoid popping the sutures through excessive motion. The wonderful and artistic J looked at it critically and said, "Do you think D would object to hearts on Pepper's splint? It's February after all, and then it would be a Valentine's splint."

"D isn't sentimental about Valentine's day, but I think it would be adorable," I said, settling the matter for J. "But we'd better put an airplane on it, too, so it won't look too girly when D takes her to the hangar. I don't want all the other little dogs to laugh at her because her mother dresses her funny."

So J cut out Vetwrap hearts, and I made a Vetwrap airplane, and we applied them to her splint while Pepper was waking up from her anesthetic.

Pepper adapted with surprising speed to her splint, learning immediately that she could scoot it along the floor in a rapid shuffle instead of picking it up and clunking it down, for which reason she was as mobile post-op as she was pre-op. I sent her mass off to be checked for margins and a more concrete diagnosis, and Pepper went scooting about her days in good cheer (although she was not a giant fan of the plastic galosh that had to be applied when she went outdoors, in the interests of keeping the splint dry). The histopath report came back a few days later: big margins to the sides of the mass, narrow margins to the deep side - but clean. That's good news, much better in fact than I expected. That means there's a decent chance the surgery was curative.

Meanwhile, Pepper had a splint change (a different airplane this time) and then graduated down to a lighter wrap. This was a bit confusing for her; at first she walked on three legs, waving the now-un-splinted leg in the air as if uncertain if it was okay to use it without the splint. Once she began using the leg, she was lame for several days (as a consequence of being in the splint, which enforces different weight-bearing on the limb, over-flexion of the shoulder and under-flexion of the wrist). Having already had an underlying subtle and intermittent lameness of the shoulder on the operated leg, that was more pronounced than I had hoped, but she grew more and more sound as she went along in the lighter wrap. Now she is back to normal gaiting on that leg - and as for her surgical incision, you can see for yourself.

Yesterday, when we were hammered with snow, she spent the afternoon running around in it, biting snow, chasing my big Finn dog through the drifts and making him behave himself - no mean feat, I assure you. He's a big goofball. He can't help himself. Luckily Pepper is equal to the task of getting him lined out and making him act right. AND she wins the Queen-of-the-mountain competition every time.

Pepper likes to bite the snow.




Sometimes the snow bites back!

Ha, ha, you missed me!

I am Queen of the Mountain, neener neener boo boo! (The mountain in this case being a great huge snow berm from plowing runways on the lake.)

Not bad for thirteen, eh?