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.

Reality Bites

Sometimes, people just don't want to hear the facts.

This week, I am standing in the office, looking at some blood work, when I notice SS getting A Look on her face. I pause and listen for a moment; sometimes this indicates a question that a doctor has to answer. But it appears that SS is discussing travel regulations. She is (quite patiently) repeating herself over and over, in a loop that goes something like this:

"Yes, sir. The Canadians will require a current rabies in order for you to enter Canada. They usually will not require a health certificate, but if you are passing back into the United States, you may be asked for one at that border. No, sir, we don't insist that you get the health certificate OR the rabies vaccine, but if you don't, you may be stopped at the border. No, sir, that rabies certificate is expired. Yes, the Canadians will require a valid and current rabies certificate at the border. No, the CANADIANS aren't the ones who will require the health certificate. That may be required in order for you to re-enter the United States. No, sir, WE don't require you to get the health certificate or the rabies vaccine. That will be the people at the border. Yes, sir, you DO need a current rabies vaccine....."

While I am wondering what is so difficult about this, SS is clearly wondering the same thing. Finally (after several minutes of this) she appears to have settled the question, and hangs up.

"Man, I'm glad I'm not that guy," she says. "I could hear his wife in the background the whole time, screaming about the rabies vaccine and how it's just a conspiracy to get their money. I don't envy him the chance to drive 3,000 miles with her harping at him all the way."

"Well, he doesn't have to get a rabies vaccine; he can take his chances," I say.

"So I told him," SS agrees.

I think nothing of this until a few minutes later, when KD comes back.

"Can you talk to this woman?" she asks SS. "She has all these questions about health certificates and rabies vaccines."

"I just talked to them," SS says, exasperated.

"Well, can you talk to them again? This lady is getting pretty nasty with me and I don't know what else to tell her," KD says.

"I'll take that call," I say. "What line is she on?"

This is one of those situations in which sometimes the client has to talk to the doctor. Although, having listened to SS, I know that she has accurately (and civilly, and with considerable restraint and patience) dispensed the correct information, sometimes clients will not believe it until the doctor tells them the same exact thing. In addition, certain people feel perfectly comfortable rudely abusing the staff, but will rein themselves in when talking to the doctor, so sometimes it is best that one of us just steps in and takes the call. I admit I take a small amount of lurking pleasure from this; I figure that if a caller has already been abusing my staff - particularly when I am aware that said staff has been more than professional and forbearant about it - the caller is then due a firm reality check, delivered calmly and with professional detachment, but without equivocation or ambiguity. This is in part to defend my staff, who work damn hard for me; partly to stave off future assaults on them by repeat attacks by the same client; partly because I personally feel that anyone who believes that the rules shouldn't apply to them has another think coming; and partly because I am, by being a doctor, engaged in a lifelong battle against ignorance and misinformation, and I love to slay those monsters.

I pick up the line and say, in a pleasant tone of voice (because after all I am not averse to slaying this particular dragon), "This is Dr. H. Did you have a question about rabies vaccine?"

"Yes," says the client. "I just want to know why rabies vaccine is better up here than in New Mexico."

"Better....?" I ask.

"Yeah, why is it only good for a year in New Mexico and it's good for three years in Alaska?"

"For one thing, that depends on the age of the dog; the first rabies is good for only a year in Alaska, too. It's only the adult boosters that are a three-year vaccine here," I tell her. "In addition, each individual state sets its own laws for the required frequency of rabies vaccine. This is dependant on the risk of exposure and what the public health officers of the individual states have determined to be appropriate in that environment."

This checks her for a moment.

"But you're saying I have to get another rabies vaccine because it says it's only good for a year in New Mexico, even though Alaska says the shot is good for three years," she protests. "We got the shots two years ago."

"If the certificate is expired, then it can't be used as proof of current rabies vaccine, no matter when the vaccine was given," I tell her.

"So you're telling me you're going to MAKE me get another vaccine," she says, waspishly.

"No," I tell her, "I'm not telling you that, the state and national officials who require the paperwork are telling you that that. If the state of issue will only honor the vaccine for a year, then the certificate is expired, and can't be used as proof of current vaccine."

"This is all scam just so you can get our money!" she accuses me.

Ah, yes. She's caught me. I personally invented this scam just so I could force her to pay me seventeen dollars (of which only a small percentage will actually go into my pocket). Yep, and highly worth it, too, for that princely sum. I resist the temptation to bang my head against the filing cabinet beside which I am standing, and settle instead for gazing out the window at a lovely view of the mountains, serene and peaceful under a crisp white mantle of fresh snow.

"No, Ma,am, it's not a scam so we can get your money," I tell her patiently. "WE don't set any of these laws, but we do comply with them."

"My brother is a - a biochemical - a biochemical physicist," she says, stumbling over the term (and leading me to speculate that he is no such thing.) "HE says that if you get one vaccine then you're immune for life." (Ah, yes. The well-known medical authority of the biochemical physicist. Whatever that is.)

"Well, ma'am, that's not actually true. A great deal depends on the health of the animal in question, not to mention their age, the agent being vaccinated against, the type, condition and quality of the vaccine, and the immunological status of the animal - in addition to which, if you want to have aggressive immunity sufficient to prevent infection and not just enough to hopefully stave off death, you do need to do boosters. Some animals will have longer immunity than others and some might even have lifelong immunity, but some animals are non-responders and will have no immunity at all. The only way to tell the difference and know which one your animal is, is to run titers."

There is a momentary silence.

"So what you're saying is that I have to get vaccines for my pets whether I want them or not," she says acidly.

"No, ma'am. I'm not saying that at all. We personally have no stake in whether or not your pets are current on vaccine. What I'm saying is that if you want proof of current rabies vaccine then, yes, you are going to have to have your dog boosted."

"What a crock of shit!" she spits. "This is all just a big conspiracy to get our money, isn't it?" (this last delivered in a tone of demand, as if she is insisting that I agree with her.)

"Ma'am, the state of issue has determined, for whatever reason, that in that environment it is appropriate for companion animals to be vaccinated yearly for rabies. Since rabies is a fatal disease of humans, in the interest of public health, they have set a protocol which they feel to be appropriate to protect human life and the public well-being. If you wanted to prove that your pets did NOT need rabies vaccines, you'd have to do titers, which run around $200 per animal. The state has determined that if you adhere to their rabies vaccination policy, they won't require you to do the much more expensive titer and will instead accept a rabies vaccination certificate as adequate proof that your pet does not pose a risk to the public health."

Now there is a pause. Since she can no longer return to the "this is a scam to make money" theme - given that the state could make a LOT more money if they insisted on titers - she takes up a new position.

"Well, it's a stupid law. All the states should be the same."

"Ma'am, not all states have the same risk of exposure. Moreover, it appears that your biggest obstacle right now is actually the Canadian border, and we in the United States do not have the right to set policy for another nation. They have the right to protect their citizens and animal populations from fatal infectious diseases in whatever way they see fit."

"Well, someone should make sure all the states do it the same way," she repeats, truculently.

"Perhaps so, in which case I suggest that you contact your local legislators about that when you reach your destination," I say.

"What I want to know is why you can't do something about this."

Sigh. That filing cabinet is looking better and better.

"Ma'am, this is not a legislative body," I tell her. "This is a private practice clinic. If you want to change the law, I recommend that you contact your legislators in whatever community you settle in at the end of your move."

"Oh, like that's going to help," she retorts sarcastically. "If 80% of the people didn't want a bailout and it went through anyway, it won't matter what I say, they won't listen to me. I think you guys should do something about it."

"Ma'am, I am not a legislator, I'm a private practice veterinarian," I say, increasingly baffled as to what this client wants from me, and unsure how government bailouts have anything to do with rabies vaccines.

"Yeah, but you'd have more pull than I would," she says.

"Ma'am, I have no pull whatsoever in New Mexico, as I do not live there and am not licenced in that state, nor do I practice there," I tell her.

"Oh, I'm not going back to New Mexico," she says. "That's just where I got the rabies shots the last time."

"Be that as it may, I can't affect any state law outside the state in which I live, and your beef isn't with the state of Alaska, it's with the state of New Mexico," I say.

"I still don't see why I have to get another rabies shot."

ARGH.

"You don't have to get one," I tell her. "It's up to you if you comply with state and federal law. We don't set those laws, we just comply with them."

"I DO have to get one," she contradicts. "You're telling me that I can't leave the state without another shot and a certificate."

Ah, I knew we could be back to square one eventually. I narrowly resist the temptation to say, "So, did you just want someone to listen to you bitch about this?" and say instead, "Did you just want someone to listen to your concerns about this, ma'am, or can I help you in some way medically?"

"Well, I just think it's a stupid law," she says, running out of steam. "I guess I'll call back about the shots."

"Okay, then," I say.

Shaking my head a little, I turn away from my window mountain view to hang up the phone. Unbeknownst to me, I have gathered a little audience. SS, KD, and Drs. S and G are all standing behind me in a little ring. SS and KD (having both already had the pleasure of chatting with these clients) are grinning appreciatively. Drs. S and G are looking at me with eyebrows raised.

"What was that all about?" asks Dr. G.

"Some people didn't want to get rabies vaccines. Said it was a scam to get their money," I tell him, going to take the next appointment and leaving him shaking his head.

I thought no more about it until the next day when I look up from a chart to see my receptionist B ushering Dr. G into a room. She whispers that it's "those rabies people" from yesterday. Oh, goodie. I am cravenly glad it is not me taking the appointment, and return to making call-backs.

Thirty minutes later Dr. G comes back out of the room. He has an expression of incredulity on his face.

"What?" I say.

"They came in for rabies vaccines for their dog and cat, but he asked me while I was there if I could look at these bumps on the dog. So I felt under the jaw where he said the bumps were and the dog has these huge lymph nodes. So I checked the other lymph nodes and they're all huge. So then I feel the dog's abdomen and he has a giant cranial abdominal mass. So I tell him all that and that I can't be sure where the mass is coming from but I suspect spleen or liver and I think the dog might have lymphoma," he says. I suspect the same thing; it's not a certainty, but it would absolutely be a big enough suspicion to take up the top three slots on my rule-out list.

"So what'd he say about treatment?" I ask; having gone the rounds with the wife yesterday, I figure the dog's hope of treatment isn't good. At the best of times, lymphoma in dogs is regarded as an incurable cancer. But curable or not, it can certainly be treated, prolonging good-quality time for the dog. Depending on the type of therapy, treatment can be relatively inexpensive (although the remissions achieved with minimal therapies are short). Longer remissions require more complex regimens and are correspondingly more expensive, and more taxing in the short run for the dog (although this is paid back by the greater duration of good-quality time on the other side of chemo.)

"He declined anything, even pred," Dr. G says. Pred is an inexpensive treatment for lymphoma, and while it doesn't provide a long remission, it at least provides good quality time while it lasts. Still, given the previous day's conversation, I'm not surprised to learn the owners won't consider it, and I'm not even all that surprised when Dr. G adds, "He says his wife has a bunch of herbals which will cure the dog." Well, or not; I'm not averse to alternative therapies, but if there were herbals out there that would cure lymphoma, we'd all be investigating them pretty eagerly.

"He says the cancer is there because of the Chinese poisoning the dog food with bugs," Dr. G continues.

"Bugs?" I repeat, not sure I'm hearing him right.

"Yes. The Chinese put bugs in the food to poison it, and the white cells attach to the bugs, which mutates them. Normally the liver filters out the bugs, but due to the mutation, the liver doesn't recognize the bugs. The second line of defense is the spleen, which sends a registry to the rest of the body."

"A registry?" I ask.

"A registry," Dr. G nods. "Then, because the bugs have mutated, the spleen misses it too and the registry isn't sent to the rest of the body and so the kidneys get cancer, which is how the poisoned Chinese food causes kidney failure. [Here I will point out that Dr. G told the client the dog had lymphatic cancer, not kidney disease.] But evidently it's all okay, because the owner's wife has herbals and grapefruit extract and these will obviously cure it, so I shouldn't worry about it."

I goggle at him for a moment.

"What did you say to him?" I ask.

"I was trying not to laugh about the mutating Chinese bugs," Dr. G says, "so I was mostly just biting my tongue. But I figured it was a lost cause anyway. I told him what I think going on there, and I even showed him the other lymph nodes were enlarged and that I didn't think grapefruit extract was going to do it. He doesn't want to listen to me. I don't figure he's going to, no matter how many more times I say it."

Well, he has a point. Some clients are so attached to their belief systems that no amount of logic, proof, persuasion or sweet reason will shake them loose from their delusions.

Reality: It's not for wimps.