Another Dog, Same Breed, As Soon as Possible

“Hark to Beaumont. Softly, Beaumont, mon amy. Oyez à Beaumont the valiant. Swef, le douce Beaumont, swef, swef.” Beaumont licked his hand but could not wag his tail.”  T.H. White, “The Once and Future King”.
               For the past couple of years, my life has been pretty easy.  I spent last summer putting in a vegetable garden, and making improvements in the landscaping around my home.  In September I went back to work after a somewhat abbreviated bout of retirement, but just part time covering other radiation oncologists’ practices.  My two Scottish Deerhound sisters, Queen and Quicksilver were then approaching 7 years old, and were long past the destructive behavior so characteristic of the giant breeds in their youth. My little mixed breed rescue Yoda had never been a problem.
             On December 19, 2015 I upended my quiet comfortable life by getting a new puppy, a ten week old borzoi named Pibb.  Two weeks later, I compounded the chaos by acquiring a “brother” for him to play with, an eighteen week old Scottish deerhound puppy named Cole.  Despite a few misgivings and knowing full well what I was getting myself into, I went ahead with what I knew deep in my heart was a preemptive strike. Queen had been limping off and on, and despite my denial I knew that the proverbial “other shoe” had dropped.  Her chronic lameness worsened suddenly a few weeks ago and like her dam before her, she was diagnosed with osteosarcoma, a bone cancer common in her breed.
                  As a radiation oncologist for adults with cancer, my day to day ethical challenges are few. I do my very best to be sure that my patients understand their diseases, and the side effects, risks and benefits of treatment. As a devastated dog owner, the decision making process is not so simple. The tell tale X-rays resulted in a consultation with a board certified veterinary oncologist, where my husband and I sat and listened to our options. Amputation and chemotherapy, the standard of care, would give Queen a median survival of 9 months.  Untreated the disease progresses rapidly, often times resulting in a pathologic fracture. Pain control is also a problem, and pain can often be ameliorated by radiation therapy–my own specialty. Except in the rarest of cases, the disease is incurable because metastases are present, whether they can be detected or not.  All treatment is palliative.
               As we sat with the veterinary oncologist two weeks ago, contemplating our options, I remembered my friend and vet oncologist Dr. Greg Ogilvie saying, “The dog doesn’t look in the mirror and say, ‘Oh, I only have three legs.’ The dog only knows that the pain is gone.”  And we were told that dogs tolerate chemotherapy exceptionally well, much better than human beings.  So we sat and nodded and thought that perhaps our initial instinct, which was to provide comfort care only, might be wrong.  Who knows better than a cancer doctor how important it is to provide and maintain hope?  And so we wavered.
                 In her incomparable essay “Oyez a Beaumont”, Vicki Hearne describes what it was like to lose her Airedale Gunner when he fractured his pelvis from prostate cancer.  As a dog trainer, her advice to clients has never wavered:  ”Another dog, same breed, as soon as possible.”  And then she admits to us, that it was ten years between the death of Gunner and the purchase of a new Airedale pup.  She says, with feigned indifference as our hearts break, “That was as soon as I could get to it,what with one thing or another.”  I got to it a little sooner.
               Deerhounds are homebodies, and our Queen particularly so.  Carsick since puppyhood, trips are stressful for her, and the risk of fracture even getting such a large dog in and out of the car is significant. Outside the veterinary specialty hospital, in the cold light of day, we lifted her into the car and she fell immediately into a sound sleep because she knew she was going home-home to her sister, her humans, and even those pesky puppies. We knew then that home is where she will be for what remains of her life.  We love her and this, more than anything, is what we owe her.

The Face Of Hope

With special thanks to Dr. Dingle Spence.

Thirty three years ago my husband and I went to Jamaica for a belated honeymoon.  We got married on the last weekend of my internship year, and immediately flew back to Boston for me to start my second year of internal medicine training.  Seven months later in the dead of winter, we flew to Jamaica to a lux resort in Ocho Rios where I spent a blissful week drinking sweet rum laced drinks and sleeping them off on a white sandy beach where the water was warm and turquoise, a far cry from the sodden gray snow banks of Massachusetts. We managed to get into the town once, long enough for me to buy a wood carving of two lovers kissing, made from Lignum Vitae, the national tree of Jamaica.  The sculpture still sits in the window by my front door.

Two weeks ago I finally had a chance to go back to Jamaica, as the invited guest of Dr. Dingle Spence, radiation oncologist and palliative care/oncology specialist at the Hope Institute, a small cancer hospital run by the Jamaican Ministry of Health.  I was there for two working days, spending the first at the large urban Kingston Public Hospital, a 500 bed hospital which houses the only government funded radiation oncology unit on that side of the island.  In the morning we did teaching rounds with the ear, nose and throat surgical team, along with the residents and medical students.  Patients and their families waited outside our conference area and were brought in one at a time, to be examined and questioned by the team such that each had our full attention. Several patients had advanced disease, and I learned that one major problem is that the pathology department is overwhelmed with cases from all over the Caribbean, and that oftentimes it takes two to three months to get a pathologic diagnosis.  By that time, many cases have progressed so far as to be incurable with the resources at hand.  Still, the dedication of the team, and in particular that of the head surgeon Dr. Natalie Whylie was very apparent and heartfelt.

That afternoon, I had the opportunity to see several patients with Dr. Spence—all with various forms of advanced lung cancer requiring radiation to palliate symptoms of shortness of breath, and hemoptysis—coughing up blood. Simulation at Kingston Public Hospital is done the old fashioned way—by taking an X-Ray with markers on the skin in the approximate area of the tumor, then shifting the “field” to match the tumor accurately. On that day, all of the X-ray machines in Radiology were in disrepair, and non- functional.  We escorted the patients to the Emergency Ward, where the radiology tech told us that the ER was too busy, and that we would have to come back later.  All three men, quite ill from their cancers, took a seat in the waiting room without food, water or complaint.  Three hours later, when we were called back to do the simulations, they were still there.  We simulated each in turn, then escorted them back to the radiation department, where they waited some more until it was their turn to be treated on the Cobalt machine later in the evening.  The therapists work 12 hour days on that machine, and we left before those patients had their turn.  After a short visit to the private radiation oncology facility in Kingston, where cash paying patients can be treated on a linear accelerator, we returned to Dr. Spence’s home high up on Jacks Hill.

The second day was spent at the Hope Institute.  Founded in 1963 by the Jamaica Cancer Society, the hospital has grown to 45 beds, for patients receiving chemotherapy and radiation and for end-of-life hospice care.  Since patients frequently travel long distances for cancer care in Jamaica, beds are often used to house patients for prolonged courses of treatment.  The wards had clean crisp linens, and the smells of fresh cooked meals in the large recently modernized kitchen wafted through the rooms.  The nurses had an air of easy familiarity with their charges and the atmosphere was upbeat, despite the fact that many of the patients were gravely ill.  I was asked to lecture on several subjects, and given an air conditioned auditorium and three hours which I doubted seriously that I could fill.  As it turned out, the nurses, therapists, residents and students who attended felt comfortable enough to ask questions, and a home cooked midday meal helped pass the time quickly.  My old Resident’s Manual, given to me at Massachusetts General Hospital in 1982 and carried with me for over thirty years as a souvenir, was a major source of interest, because it contained information pertinent to the treatment of patients with the equipment that is available to cancer patients in the public sector of Jamaica, equipment that has long been abandoned or replaced in our own country.

The thing that struck me the most about my experience in Kingston was the fact that despite the human suffering that I saw, in a country short on both technology and morphine, the patients remained hopeful and even cheerful in the face of extreme adversity.  I asked my host, Dr. Spence, how this could be, coming from the land of complainers, myself chief amongst them. She replied, “Most people in Jamaica have a deep faith.  They truly feel that they are in God’s hands, and what will be, will be and only God knows best.”  As I watched her move from bed to bed, giving comfort to the dying with only her soft voice and her cool touch upon their feverish foreheads, I realized something that sometimes I have forgotten in my excitement over the technology that I have available every day, without even thinking about it.  In the end it’s not about the technology at all.  For the most desperate among us, it’s about faith, and about love and human kindness.  For this reminder, I will be forever grateful.