The Keys of Death
“The Most Wonderful Time of the Year”
Michaela gripped the patient’s lower leg and pushed it down, bending the knee enough for her to insert a suction tube into the joint space. With a squelch, blood and fluid disappeared, revealing glistening cartilage and ligaments.
Dr. Brightman, standing next to Michaela, peered into the knee joint. “You were right,” he said. “The meniscus is torn. Good call.”
She nodded. It was a good call, if she said so herself. After slipping on the ice at Thanksgiving, this patient could hardly walk. When he came to see Michaela, the X-rays revealed plenty of abnormal fluid in the knee joint, but even under sedation, with his leg muscles fully relaxed, she had been unable to demonstrate instability in the joint. His response to pain meds was only so-so. It sounded like the cruciate ligament was only partially torn, at worst, but the level of pain pointed to a torn meniscus, the cushioning tissue deep within the knee joint.
Michaela was good at diagnosing, but when it came to surgery, David Brightman could do these things in his sleep. She watched him work. He was amazingly fast. His hands were in constant motion as he removed the damaged portions of the meniscus, flushed the joint, and drilled the anchor holes for the stabilization suture.
At fifty-eight he showed no signs of slowing down—he was too much of an overachiever for that just yet. He was an internationally recognized surgery professor at the University of Illinois vet school, originally from London’s Royal Veterinary College. And yet here he was, in Michaela’s little animal hospital, doing a simple exploratory and stabilization surgery on a dog’s knee. It was a nice way to end the day. Michaela had no more appointments and would close the animal hospital for the evening when this surgery was over.
A radio on the windowsill played Christmas music, and David hummed along. He moved his hands aside slightly. “Suction, please.”
She inserted the suction tube once again and cleared the joint of blood and fluid.
David went back to work on the knee joint. “Terry out with the crew today?”
“Better him than me, in this weather,” David quipped, although they both knew that Terry loved it out there. Michaela’s husband Terry was also a clinical professor at the vet school, but in a much more down to earth capacity than David. Terry went out every day with senior vet students on the Ambulatory and Farm Services rotation. The dirtier and muckier it got, the more he seemed to enjoy it.
Michaela repositioned the knee to provide a bit more exposure, and David worked in silence for a moment. Then he spoke up. “You’re awfully quiet.”
She smiled. “You know me. I’m always quiet.”
David snorted. After a moment, he continued. “You’re irked.”
“How do you know?”
He just looked at her, and Michaela could tell that beneath his surgical mask he wore his characteristic smirk.
“All right, you win,” she said. “I’m irked.”
Michaela sighed. “Why is it that every year around Christmas, people are filling my schedule with put-to-sleep appointments?”
“Ah,” said David, comprehending.
“It’s almost eerie,” she continued. “Without fail, you can gauge how close Christmas is by the number of dog and cat euthanasias.”
“I know what you mean.” He finished tightening the stabilization suture around the joint. “The annual yuletide parade of death. The ancient Irish Setter’s incontinence is barely tolerable by the immediate family, but now they’re having visitors for Christmas. Or, the seventeen-year-old cat’s daily vomiting is bound to cause some bother if she upchucks all over the carpet in the guest bedroom.”
She nodded, and despite the grim subject matter, she couldn’t help smiling, enjoying her old professor’s acerbic British humor.
“Then of course,” he said, “after the holidays it’s the ones who forgot to die. Really should have been put down months ago, but they just wanted to give blind, arthritic Toby one more year to aimlessly circle the Christmas tree.”
Michaela laughed, then sobered immediately. “If it didn’t involve the death of a living creature, I suppose it would be amusing,” she said.
David cocked his head, a touch of concern in his eyes. “How many have you done today?”
“That’s enough death for anybody.” He shook his head. “Why do you think I got out of private practice? I hardly ever have to deal with that anymore.”
“One of them was yours, actually, David.”
“A little Welsh Terrier, ten years old. You did an experimental heart procedure on him when he was a puppy.”
David raised his eyebrows and nodded.
“For the past few months he’s been in kidney failure, and he just stopped responding to the treatment. The poor guy got sicker and sicker…” Michaela shrugged.
“And it was time,” David concluded.
She nodded. “He was a sweet little dog.”
David began closing the joint capsule. After that he would stitch up the subcutaneous tissue, then the skin. “Just keep reminding yourself why you got into this in the first place, Michaela. You have to find your own reason for getting up in the morning.”
Before she could respond, the voice of Abby, the hospital receptionist, came from the intercom on the wall. “Dr. Collins, there’s an emergency in room two.” The intercom went silent for a moment, then they heard Abby’s voice again: “Better bring the crash cart.”
David and Michaela exchanged a glance.
“Off you go,” he said.
Michaela exited the surgery suite, pulled off her gloves, cap and mask, untied the surgical gown, and slipped off the surgical shoe coverings. She grabbed her lab coat and put it on over her scrubs.
Finally, a chance to save a life instead of ending one.
A few steps down the hallway brought her to the treatment area, the bustling nerve center of the animal hospital. A bank of cages lined one wall, in the middle of the room there were work centers and procedure tables, and on the wall opposite the cages were five exam room doors—far too many exam rooms for a one-doctor practice, but Michaela had insisted that the architect leave plenty of room for the practice to grow. Someday she would have enough veterinarians working for her to make full use of all the rooms.
She lifted the animal’s medical file out of the rack mounted to the door of exam room two and flipped it open. New client. Local address. Two-year-old female spayed Labrador retriever named Rosie. Reason for visit: Put out of misery.
Michaela raised her eyebrow at that.
She knocked on the door and pushed it open. Two women stood by the exam table, trying to hold down a large yellow-haired dog as it struggled.
“Easy, girl,” one of the women said.
The dog writhed on its right side, trying to get up, whining, its left eye darting. Red-tinged foam spilled from the mouth. Blood smeared the dog’s tawny fur and the stainless steel table.
Michaela stepped forward and lifted the dog’s upper lip. The gums were bluish pink and tacky to the touch. She pressed the gums with her finger, released it, and watched the white area left behind to see how long it took for the color to return. Three and a half seconds. Not good.
She looked up. “What happened?”
The two women looked at each other. One was tall, with fair skin and freckles. The other was shorter, Hispanic, with long, dark hair.
The Hispanic woman spoke. “She was hit by a car,” she said. Her voice shook. “The wheel went right over her. The driver just took off.”
Michaela shook her head. It made her sick that someone could run over an animal and just keep going.
She continued her examination. When she lifted the dog’s head, she felt the sickening sensation of bone grinding on bone beneath the skin—the bone around the right eye was fractured and blood oozed from the eye socket.
The Hispanic woman spoke again. “She’s in a lot of pain. Can’t you just put her down?”
Michaela lifted her eyes and took a good look at the women. Both were in their twenties. The Hispanic woman, who had done all the talking so far, was heavyset. The tall woman was slender, with short red hair sticking out from under a navy blue Fighting Illini ski cap. Each woman wore snow boots and a heavy winter coat.
The dog was struggling to breathe. Her mucus membranes were taking on a sickly blue cast—cyanosis. Michaela stepped back to the sink and washed the blood off her hands. “This is bad,” she said, “but I think I can help her. I’ll have to hurry though, get an IV going, treat her for shock—”
“No!” the Hispanic woman said, sharply. She looked up at the other woman, and they exchanged a frightened look. “I’m sorry,” the woman said, “but she’s in too much pain. Can’t you just put her down? We don’t want to see her suffer any more.”
Michaela took a deep breath and quickly ran through a mental list of the most serious likely injuries. All of them were extensive, life-threatening, and painful: hemothorax, diaphragmatic hernia, flail chest, pneumothorax, ruptured spleen and liver, broken spine and pelvis. Treatable, but only at great cost. Perhaps that was a factor for these women. The initial diagnostics and critical care alone would rack up a bill of several thousand dollars. If any major bones were broken there would be costly orthopedic surgery on top of that.
The dog had stopped trying to get up and was now lying rigid, exerting incredible effort just to breathe.
She stroked the dog’s head. They were right. It was the owners’ choice to accept or decline her medical recommendations. Every veterinarian took an oath promising to ease animal suffering, and this dog was suffering terribly. The medical file was in order. One of them had signed the Euthanasia Consent Form. Method of payment: cash.
She looked up at the two women. “I’ll be right back.”
Michaela left the room and went to the controlled drug cabinet in the treatment area. She unlocked it, took out a bottle of sodium pentobarbital and drew up eight ccs into a syringe.
Two veterinary technicians passed nearby, carrying the knee surgery dog toward the treatment area. David was right behind them, pulling his mask off and removing his surgical cap. He took note of what Michaela was doing, but offered no commentary.
She returned to the exam room with the syringe and a tourniquet. “You’re welcome to stay, but you don’t have to,” she said. Not everyone was comfortable witnessing the death of an animal, and Michaela always gave people the option of stepping outside for this part.
Again, the Hispanic woman spoke for the two of them, and her voice quavered. “We’ll stay.”
“Have you ever seen an animal put to sleep before?” Michaela asked.
“Yes,” they said, together.
She slipped the tourniquet around the dog’s left forelimb and tightened it just above the elbow. Then she paused and put her hand on the dog’s head. She stroked her ear. The dog looked up at her, but remained motionless. “It’s okay, girl. It’ll all be over in a minute.”
Michaela uncapped the needle, grasped the dog’s paw in her left hand and held the syringe in her right. She pumped the paw and watched the cephalic vein rise beneath the skin.
She inserted the needle into the vein, then pulled back on the plunger of the syringe until a plume of purple blood flowed into the barrel. She loosened the tourniquet and depressed the plunger. The euthanasia solution flowed into the vein.
“Good girl,” Michaela murmured. “Easy now.”
The Hispanic woman stroked the dog’s head. “It’s okay, Rosie,” she whispered. “It’s all over now, sweetie.”
In a few seconds, the syringe was empty and the dog was still. The agonized breathing had ceased. Her eyes stared straight ahead, pupils wide open. Michaela withdrew the syringe from the vein and placed it on the counter behind her. She took her stethoscope from around her neck, fitted the earpieces into her ears, and placed the bell against the dog’s chest.
“Is she gone?” the Hispanic woman asked.
Michaela looked up and was not surprised to see tears running down the woman’s face. She took a box of tissues from the countertop and placed it on the exam table. She touched her finger to the dog’s cornea: no response. “Yes. She’s gone.”
Both women took a tissue from the box and wiped their eyes.
The taller woman spoke for the first time. “Doctor, are you absolutely sure she’s dead?”
Michaela heard a note of intensity, an urgency that she’d never heard before in this situation.
“I’m sure, yes.”
“Can you make absolutely sure?” the Hispanic woman said.
“What do you mean?”
“Can you get an EEG tracing?”
Michaela blinked. An electroencephalogram was an advanced piece of equipment. Most general veterinary practices didn’t even own one.
“A heart monitor, at least,” the tall woman said.
“A heart monitor? Honestly, it’s not necessary. There’s no heartbeat, no corneal reflex, no respirations.”
“We would really appreciate it,” the Hispanic woman said, with a glance at her taller companion.
Michaela left the exam room, trying to shake off a wave of irritation. But it was late and she didn’t feel like arguing.
She went into the surgery room and retrieved the cart with the anesthetic monitoring equipment: pulse oximeter, respiration monitor, and ECG machine. She unplugged the equipment and wheeled the cart to the exam room door.
Rising up onto her toes, she looked through the peephole. Normally she didn’t use the peephole to spy on her clients—only to see whether a room was occupied or not without having to barge in. But this time, she looked through and watched the women for a moment. They were conducting an examination of their own. The taller woman pressed her fingers into the groove in the inside of the rear leg, feeling for a pulse. The Hispanic woman was checking the left eye with a penlight.
Michaela’s husband Terry came around the corner, wearing his winter coat. He was red-faced from the cold. “Hi, hon,” he said. “What’s going on?”
She shook her head, a gesture that said, “Don’t ask.” She pushed open the door and wheeled the cart in, deliberately taking no notice as the Hispanic woman hastily put away the penlight.
Michaela plugged in the ECG machine, unwound the leads and attached them to the dog’s limbs, one just above each elbow, the third just above the left knee.
She switched on the ECG. A green, horizontal line appeared on the monitor. She let it run for thirty seconds. “She’s gone,” she said. “I’m sorry for your loss.”
The Hispanic woman stroked the dog’s head gently. “Good bye, Rosie,” she said, her voice catching and tears filling her eyes. Again, she exchanged a glance with her companion. Then she turned to Michaela and extended her hand. “Thank you very much, Doctor. Merry Christmas.”
“Merry Christmas,” Michaela said.
The taller woman also shook her hand and wished her Merry Christmas, then they left the exam room. Since they had already paid, they headed straight across the empty waiting room and out the front door.
Abby, the receptionist, piped up from behind the front desk. “That must have been a tough call.”
Michaela nodded. It never felt right, putting an animal down when she knew what was wrong and how to fix it. Terry worked with livestock farmers all day, who routinely made life and death decisions based on money and practicality. He was used to it, but she hated it when economics came to her door.
She watched through the front window as the two women got into a maroon Subaru wagon. Michaela walked over to the desk and handed Abby the file. “Did they seem odd to you?”
Abby shrugged. “They were upset. Freaked out. People usually are with a hit-and-run.” She dropped the file into a wire basket on her desk. “They requested ashes back.”
It was not common, due to costs, for people to request “ashes back” on their pets. Most pet owners chose group cremation, which was inexpensive. “Ashes back” meant private or semi-private cremation and the return of the pet’s ashes in a special sealed container. A certain percentage of pet owners were willing to pay extra for this added service, since it gave them a tangible keepsake of their pet.
“Go ahead and lock up, Abby,” she said. “I’ll get Terry to help me bag this one.”
Michaela met David and Terry back in the treatment area.
The surgical patient was bandaged and recovering from anesthesia. David had changed into his street clothes and was preparing to leave. “Right. I must be off. Back to the veterinary college to be stimulated by young minds who don’t know a cat’s anus from their own.” He looked at Michaela. “Any better?”
David looked at Terry. “I think you need to take her home for a healthy dose of Christmas cheer.”
Michaela felt her cheeks flush. “I’ll be fine, David.”
“If you say so.” He shook Terry’s hand and gave Michaela a gallant kiss on the cheek. “Good night, you two. Happy Christmas.” Then he donned his wool overcoat and swept impressively from the room.
Terry looked puzzled. “What’d I miss?”
“I’ll tell you later. Could you do me a favor and help me bag the dog in room two?”
Michaela went back to the exam room. The dog lay on the table, surrounded by congealing blood. Its fur stood up in red spikes. She put her hand on the dog’s head and stroked its left ear, thinking. Something wasn’t right about this case.
“Rosie,” she murmured. The skin on the inside of the earflap was soft and pink.
Then it hit her. While obviously the victim of a serious trauma, Rosie lacked one of the telltale signs of being struck by a vehicle. Usually, hit-by-car victims had dirt on them. Abrasions embedded with gravel. Leaves and sticks in their fur, and in the winter, snow and slush—evidence of having been thrown violently to the pavement, possibly dragged across it, and then ejected onto the side of the road. Rosie was covered in her own blood, but otherwise clean.
Terry came into the room with a bright blue carcass bag.
“Can you help me flip her over?” Michaela asked.
They turned Rosie over onto her other side.
“Whoa,” Terry said.
Michaela looked at him. “I guess she wasn’t hit by a car.”
Like her left side, Rosie’s right side showed no signs of vehicle trauma: no dirt, no road rash. But on the ribcage were two distinct, circular holes, each oozing with fresh blood.
copyright 2016 Clare T. Walker
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