The Greatest Thank You
It was a typical busy Saturday at the hospital. Each appointment slot was filled, as was the parking lot when I got to work a half hour before the first scheduled appointment. I quickly did morning rounds, modified treatment orders, dictated several orders to a tech concerning meds to prepare, and made calls to clients requesting updates. I arranged patient release consultations and times. Repetitively, a very well meaning yet very annoying receptionist reminded me that the exam rooms were being filled and that one of the Saturday veterinary techs called in sick. “Thanks,” I jokingly said to the receptionist. Under my breath I sarcastically asked God if He could please make my day a little more hectic… and He did.
The first three appointments went well and were on schedule. Treatments were given, meds were made, and the patients attended to and discharged. We were into our hospital rhythm. It was a bit crazy, but it was a regularly expected crazy. Then Becky, the receptionist, broke into the exam room. When a receptionist enters an exam room after the day begins, it is never good news. Becky declared, “Mrs. Patterson has an emergency with her dog Spike. His face is swollen and it’s getting larger and larger.” Becky continued in a matter-of-fact tone, “Mrs. Patterson said he was bitten by a snake.” “How does she know?” I asked. Becky replied, “He was wearing the snake when they found him, according to Mrs. Patterson.” “Do they still have the snake?” I asked. “Are you kidding?” Becky replied. “Well, anyway, have her bring him in immediately,” I barked. “He is already here.” “Good,” I mumbled to myself, “we have time to prepare.” I asked Becky to quickly get Spike to the I.C.U., and then to inform the waiting clients that there would be delays, because of the emergency. I asked that Mrs. Patterson be taken to the consultation room. “Make sure she has a chair and something to drink, if she wishes, and let her know I will be in to speak to her when I have more information.”
I quickly ran to the I.C.U. Spike was on the exam table already being attended to by two vet techs. As I came into the room my first impression of the patient was that he looked more like a cartoon character than a real dog. His face and head were enlarged and greatly out of proportion with his usual compact and well muscled Jack Russell Terrier body. Oxygen therapy was initiated immediately. I was placing an intravenous catheter as I frantically directed the two veterinary techs. “Mary, try to keep Spike as calm as possible, this looks like a pit viper bite.” I yelled, “Shirley, ask the receptionist to check if Mrs. Patterson noticed if the snake had fangs, a small pit or opening between the nostrils and eyes or a triangular shape head.”
After starting intravenous fluids and assessing Spike’s heart and mentation, I turned my attention to his enlarged face. By this time his eyes were swollen almost shut. A small trickle of blood ran from Spike’s left muzzle. Following the flow of blood showed it originated from two small puncture wounds just above his lip. Shirley returned with no additional information, but the diagnosis was made. Spike decided to play with a pit viper. It could have been a rattlesnake or a water moccasin; both are prevalent in our area. Judging from the spread of the fang marks, the assailant was probably between three and three and a half feet long. Due to the rapid and aggressive show of signs the snake was probably in between meals and had an ample supply of stored venom. The fact that Spike was a typical excitable Jack Russell Terrier did not help. If the victim is active after the snakebite it results in a higher absorption rate of the venom.
Spike’s lips were very swollen and the inner surface was hemorrhaged. Pit viper venom is one of nature’s deadlier cocktails of damaging enzymes and non-enzymatic polypeptides. Enzymes like hyaluronidase and phospholipase cause local tissue damage and vasculitis. These bring about the “swelling.” At the same time other enzymes interfere with the body’s ability to clot blood. The non-enzymatic polypeptides affect the cardiovascular and respiratory systems.
My focus was now back to Spike. He seemed calm. Either we were doing well, or the venom, with its hypotensive affects, was nearing its deadly potential. A critical care monitor was now up and running. Good news… the ECG did not detect any arrhythmias. Bad news… the heart rate was declining. Usually at the start of a hypotensive assault the heart rate is elevated to compensate for the decreased blood pressure. A slower heart rate might mean that the body is giving out. Fluids were now running at a rapid rate.
“Shirley,” I yelled, “ask Mrs. Patterson for permission to start antivenin.” Shirley flew towards the consultation room. “Yes! Yes!” I heard from the opposite end of the clinic. “But she said she could only afford one vial.” Immediately a vial of antivenin was opened, mixed, and slowly administered intravenously. “Mary, watch Spike’s inner ear flaps for any redness and watch his chest and critical monitor for any changes in respiration.” If those signs occurred they could possibly indicate a potential allergic reaction to the antivenin. Unlike human medicine, in the veterinary world cost of treatment is a more real time concern. Antivenin costs $500.00 a vial to use; ethically we are bound to ask if the client wishes for it to be added to our treatment protocol.
A great effort was made to keep Spike as calm as possible. The heart rate soon stabilized, but the facial swelling continued. With the support therapy, in addition to fluid and antivenin in place we were now at the mercy of time and truly in the hands of God. I walked into the consultation room and was greeted by a tearful Mrs. Patterson. Then in a sudden barrage she asked, “Is Spike OK? Will he make it? Is he in pain?” I quickly explained that the snake Spike encountered was a pit viper. Mrs. Patterson excitingly added, “Yes,” she said. “That was a rattlesnake that got Spike. Unfortunately they are not uncommon in these parts, most especially at this time of year.”
Trying to console Mrs. Patterson, I told her we were doing everything we could do for Spike. I explained how the venom was attacking Spike’s body and what we were doing to counter its affects. “He is in some discomfort, but we are trying to minimize it,” I said. As I looked directly into the middle-class mother’s tear-filled eyes, I choked up as I answered her first question. “His condition is very guarded. We may not know if he will recover or not for a day or two.
It was a bright Sunday morning when I made rounds the next day. Previous communications with the I.C.U. nurse throughout the night revealed little improvement. Upon examination, it was found that Spike’s temperature and respiration were normal. Fluids and antibiotics were continued, but the swelling increased and the hemorrhage was worse. Spike was a fighter, but how long could he continue to fight? Most of my previous snakebite cases had more improvement by this time. My heart dropped. What was I going to tell Mrs. Patterson? I reluctantly asked the I.C.U. nurse to reach Mrs. Patterson on the phone. “Mrs. Patterson,” I requested, as I cleared my throat. “I just want to call you with an update on Spike. His vitals are stable, though I am concerned that the swelling and hemorrhage have continued to advance. His prognosis is still very guarded. If the next twenty-four hours does not bring more improvement, I fear his prognosis will fall to poor.” Mrs. Patterson said she understood. She thanked me for the update and said that she and her son Sam would be praying for Spike. I thanked her for her support and promised to give her an update the next morning.
It was a long second night for Spike. The intravenous catheter blew and another was started in his other front leg. As the night gave way to another day, a miracle occurred. The swelling started to recede and the hemorrhage started to disappear. As Spike’s deep brown eyes became more apparent through his swollen eyelids, so did his bright and exuberant attitude. Spike was being given back to us. That morning I had a great update to give Mrs. Patterson and Sam by phone. Although I was cautious, I predicted if Spike continued his recovery at the same rate, he possibly could go home by midweek.
On Wednesday afternoon we made arrangements to discharge Spike. His swelling was gone and his body proportions were normal. With the exception of two shaved legs where the catheters were, there was little evidence left of the ordeal he went through. It was announced that Mrs. Patterson and her son were waiting for me in exam room one. I instructed that Spike be reunited with his family and that I would be in soon to speak with them. After quickly completing another examination and ordering meds for another patient, I headed to exam room one. Before I could get there, Mrs. Patterson burst through the exam room door. She gave me a big hug. She was appreciative for the return of a living and healthy Spike. Mrs. Patterson repetitively thanked both the entire staff and myself; she seemed to elevate our status to sainthood.
Being thanked is a weird thing. While we try to deflect the appreciation they garnish on us, deep down we enjoy it. I told Mrs. Patterson we appreciated her kind words and that the staff and I were just doing our jobs. She exclaimed, “But Dr Z, you don’t completely understand!” “Understand what?” I inquired. Mrs. Patterson led me to the window in the exam room door. “Look, you have brought Spike back to Sam.” As I looked into the room I could see that Spike was smothering Sam with kisses. “Well, it is good to unite a boy with his dog,” I said. She did not answer as a tear appeared on her cheek.
I took another look into the room. Sam was now hugging Spike. It was the first time I really had a good look at him. He was a boy of maybe eight or nine years. His smile was wide and warm and his deep blue eyes represented a feeling of joy. His bright red baseball cap marked him as a Boston Red Socks fan. Yet, something was different about this boy. Sam had no sideburns, and no hair at all could be seen below his cap. His eyebrows were not light; they weren’t there at all.
At that moment Mrs. Patterson gave me another hug. “See Dr. Z, Sam has had a very hard road to travel. It was Spike who helped see him through his chemo. I do not know what would had happened if Sam had lost Spike.” Again and again Mrs. Patterson thanked the staff and myself. I suddenly felt the full weight of how all our lives were touched at that moment. I turned to Mrs. Patterson and hugged her, as I said, “No, it is us who thank you!”
The words, “Thank you,” are truly the greatest kindness that the human soul can express. I never grade one against another, but Mrs. Patterson’s thank you is one I will never forget.
Best of health to you and your pets,
Until we meet again,