Creature Comfort

Tales from the other University of Minnesota hospital

As Kayla is led away for a biopsy, Mark Farmer is left sitting on an orange plastic couch picking black hairs off his London Fog. It's his first visit to the University of Minnesota's Veterinary Teaching Hospital in St. Paul, and he concedes he's a little overwhelmed. For the last half-hour, his elderly black Lab has panted her way through some serious prodding and poking, while he tried to absorb a textbook's worth of information on different kinds of tumors and the treatments employed to try to keep them at bay. "I'm surprised and impressed about the lengths these people would go to to save an old dog," he says. "I mean, chemotherapy for dogs--who'd a thunk it?"

Nine years ago, Farmer and his brother found Kayla wandering across a frozen lake hunting for ice-fishermen's leavings. (Farmer requested that both his and the dog's names be changed for this article.) She was friendly and well-trained, and Farmer couldn't fathom how anyone could have abandoned her. His three daughters adore her; not even the arrival of a new Lab puppy last year pushed Kayla from her pampered niche in the household. Farmer used to take the big dog hunting every fall. He supposes her first owner did, too, since she needed no prompting to retrieve ducks.

But as both man and beast have gotten older, they've slowed down. One consequence is that the dog doesn't get a lot of exercise. So four months ago, for the first time in Kayla's life, Farmer needed to cut her nails. After he clipped them, the dog started limping. For a few weeks, he thought he'd done a sloppy job and nipped her in the quick. Then he noticed a big lump on one of her toes. Kayla's regular vet ruled out any connection with the nail clipping and referred Farmer to a specialist at the vet hospital.

Michael Dvorak

Dr. Jenny Urbanz immediately suggested what Kayla's vet had been hesitant to declare definitively: The lump looked like an osteosarcoma, or tumor of the bone. Kayla was hustled off for an X-ray. The film revealed a mass that looked like it was chewing away her toe. Urbanz needed to draw some fluid from the tumor to be sure, but a diagnosis of cancer would leave them with several options.

If the disease had already invaded Kayla's lungs, there would be little doctors could do. If it hadn't, and the Farmers opted for further treatment, Kayla's toe--or more likely her whole right front leg--would have to be amputated. After that, she would need chemotherapy. The cost would run more than $3,000--unless Kayla qualified for an osteosarcoma trial being conducted by one of the hospital's oncologists.

As he awaits Kayla's return on the orange couch, Farmer doesn't know where to even start thinking about the situation. He loves his dog and doesn't want Kayla to be in pain, but everything he's heard described sounds like a potential ordeal for the whole family. "When I was a kid, I lived on a farm," he says. "We had animals running around all over the place, and none of them lived to be very old. When they got too sick, people would shoot them."

What the Farmers are facing isn't so different from the dilemmas contemplated by doctors and families at human hospitals, says Dr. Jeffrey Kahn, head of the university's Center for Bioethics. "We didn't have to worry about when to discontinue life support before we had life support," he says. "We didn't have to worry about defining death before we were able to talk about removing a beating heart for transplant." When it comes to pets, he adds, choices are made a little easier by the fact that people are used to determine their animal companions' lives--and a little harder by the fact that no one else is picking up the bill.

What's more, adds Jeff Klausner, interim dean of the UM's College of Veterinary Medicine, a growing number of people consider Fluffy a full-fledged member of the family, and thus demand ever more sophisticated veterinary medicine. "The bond between people and their animals seems to be increasing as life becomes more complicated. It's the unconditional love that they get from their animals that they may not get anywhere else," he says. "And people's expectations of care in this country are pretty high and they tend to transfer them to their pets: 'If I can get this for Grandma, why can't I get it for my cat?'"

 

More than half a century old and known worldwide for its pioneering research, the veterinary hospital is housed in a low-slung, 1970s-style beige brick building near the cow barns and greenhouses that reflect the UM's legacy as a farm school. The facility specializes in cases that require in-depth diagnostic evaluations, advanced treatment methods, or specialized surgical procedures. Four of every five vets now practicing in Minnesota graduated from the college and worked at the hospital; new vets from across the country vie for residencies that will help them to develop a specialty. The more than 40 full-time veterinarians on the staff spay and neuter and vaccinate, but they also implant pacemakers, perform delicate eye surgery, and replace atrophied joints.

Many of the patients seen here travel hundreds of miles in the hope of finding a diagnosis or treatment that was beyond the capabilities of their neighborhood vet clinic. The hospital's computer record-keeping system contains codes for hundreds of species. The archive can identify marmosets, aardvarks, and lemurs, as well as esoteric dog breeds with names made up mostly of consonants.

In addition to tens of thousands of family pets and farm animals, doctors here have treated polar bears and red pandas. A Como Zoo flamingo is currently undergoing radiation therapy. The Great Plains Zoo (of Sioux Falls, S.D.) recently had one of its monkeys treated here on the same day that a pair of hedgehogs visited the staff dermatologist because of a skin condition.

The hospital has equipment many Third World hospitals can only dream of, plus cement corridors designed especially for nervous bladders and patients used to leaving dung pretty much wherever. There are anesthesia masks and muzzles to fit ferrets and Brahma bulls. The large-animal clinic has more hooks and rings hanging from the ceiling than an S&M dungeon: A patient weighing 2,000 pounds can be tilted slowly onto her side and winched from the X-ray room to the surgical bay to a padded recovery chamber.

On a recent afternoon, the surgical recovery area held two unusually complicated sterilization cases: One of the patients was a terrier with incurable bone growths that prevent it from opening its mouth more than a quarter of an inch--barely enough to let the dog's tongue scoop up a single nub of kibble at a time. The dog's usual vet couldn't get the jaws open far enough to insert an anesthesia line, so the university vets made an opening in the animal's throat.

Waking up next to the terrier was a hermaphrodite cocker spaniel. It had two complete sets of external genitalia, but doctors weren't sure which internal reproductive organs they'd find. In surgery, they discovered nearly complete sets of both, and so spayed and neutered the dog. They also removed its testicles; on hermaphrodites these often sit inside the abdomen and are prone to developing cancer. (Just as in humans, hermaphroditism is rare in dogs; hospital staffers say the few cases they've seen have been in various kinds of spaniels.)

The teaching hospital may be at the forefront of veterinary medicine, but it's hardly the only place now offering high-tech care for animals. In their last year of veterinary school, UM students work at the hospital. Many also spend their first year after graduation in an internship there, and some take an additional four years to complete a residency. As the new vets go into practice, they take the hospital's increasingly sophisticated techniques with them.

And once new diagnostic procedures and treatments appear on the consumer market, there are plenty of pet owners willing to pay for them. Though pet ownership has remained fairly stable for the past decade, spending on pet care and supplies has fueled growth in what is now a $21-billion-a-year industry in the U.S. Pet trends barely lag behind those among humans: Organic dog and cat food is available at local co-ops, and last year, a gourmet bakery for dogs opened in Minneapolis's Linden Hills neighborhood.

"The number of pets is expected to show a steady increase because of rising incomes and education and the movement of baby boomers into the 34-to-59-year age group, in which pet ownership has been highest," reports the American Veterinary Medical Association in literature aimed at budding vets. "Seemingly, pet owners may be willing to pay more for elective and intensive care than they have in the past." More than 750,000 people nationwide have purchased health coverage from a company called Veterinary Pet Insurance at a cost of $8 to $21 a month. The highest demand for new vets these days comes from specialty clinics where veterinary ophthalmologists, internists, orthopedic surgeons, and others see difficult cases referred by general practitioners; holistic care is also growing in popularity.

Ed Kosciolek, administrator of the university hospitals, says the veterinary facility's appointment logs clearly demonstrate that demand for specialty services is skyrocketing. Between July 1997 and June 1998, he estimates 10,000 patients made 25,700 visits to the hospital--a 27 percent increase over the fiscal year before that. Judging from the numbers so far, fiscal 1998-99 should bring another 21 percent jump.

While the hospital doesn't track the numbers of individual species seen, Kosciolek says it's safe to assume that 80 percent of small-animal patients are dogs. Cats, which account for half of household pets nationwide, tend to be more resilient, in part because most live indoors. So-called exotics--ferrets, iguanas, and the like--comprise a mere fraction of the hospital's caseload, though the number of llamas being seen at the large-animal clinic is growing.

A dozen years ago, Kosciolek says, about 80 percent of the hospital's budget came from funds the state provides to the university, with the remainder made up of revenue earned from services. But in the current fiscal year, only 15 percent of the hospital's $7.3-million budget came from the state. In 1998/99, the budget is slated to top $9 million.

In June 1997, the facility added two emergency vets to meet demand for evening, weekend, and holiday critical care. Construction of a new intensive-care unit is under way, with half its $800,000 cost donated by clients. During the last year, consumer demand has forced the hiring of new specialists in neurology and oncology, as well as a second ophthalmologist. This year may bring construction of a special suite for eye surgery, as well as a more hoof-friendly floor for the large-animal wing.

Administrators say there's no one type of person more likely to use the hospital's expensive services: Lots of people who joke about designer doggie doctors feel different when their own pet is suffering. Kyle and Roberta Peterson were aghast when Kyle's sister spent $1,600 to have her dog's congenital hip deformity surgically corrected four years ago. "At the time, we thought my sister should just put the dog to sleep," admits Kyle.

Now they're here with Jake and Joey, two Lab-mix puppies they adopted at the Lake Superior Humane Society near their home in Duluth. Both dogs are halfway through having the same operation on each hip, for a total of $6,000.

Kyle is a heating repairman, and every time they bring Jake and Joey to the hospital, he has to take an unpaid day off. Roberta has been using vacation time from her clerical job. On a recent visit, they were hoping to negotiate putting off the dogs' second operations; they're still scraping together the money to pay for the first ones. Even after watching Kyle's sister cope with a canine invalid and a used-car-sized bill, adds Roberta, "we didn't know what we were getting ourselves into" when they started the process of fixing the pups' hips.

And then there's Leroy Kramer, who drives a van that transports troubled teens back and forth to school in Minnetonka. His 9-year-old black Lab, Sam, recently tore the anterior cruciate ligaments in both knees--the same injury that sidelines many football players. Doctors have already built Sam one new ligament. He's scheduled to have the other one done in six months. When Kramer's buddies learned that the procedures cost $900 per knee, they subjected him to quite a ribbing: "They said for what I paid for this operation, I could buy two full-blood Labs. I said, 'Yeah, but I couldn't buy another Sam.'"

Bioethicist Kahn says many owners will stretch their finances to pay for expensive vet care--up to a point. "Most people probably don't decide how far to extend care based on money. They love their animals," he says. "But someone facing a $5,000 bill for a kidney transplant for a cat? They may well decide that's too much. There's sort of a parallel between what's best for Rover and what's best for Mother. It's kind of the same thing--until you're looking at spending $100,000. And then, in the case of Mother, you probably find a way."

 

Auggie Doggie is that rare specimen who's actually thrilled to be at the doctor's office. According to his owner, Judy Hurt of Eau Claire, Wis., he starts whining when she turns her Ford Explorer east off Highway 280 onto Larpenteur Avenue. By the time they've driven through the fields on the outskirts of the UM agricultural campus, Auggie is so excited he tows Hurt into the vet hospital building.

Now inside an exam room, the 4-year-old boxer is surrounded by humans--orthopedic surgeon Larry Wallace, two surgical residents, a veterinary technician, and two visitors. He prances from one to the next, taking in their scents and scoping their willingness to rub his creaky rump.

There are three shallow, sickle-shaped ridges in the short fur on the dog's haunches, souvenirs from earlier trips to see Wallace. The first two are from operations to tighten up each hip. Auggie suffers from hip dysplasia, a bone disorder common in large dogs. The third scar outlines his back left knee, which Wallace opened up two years ago to repair a torn ligament.

Like many large dogs, Auggie probably inherited his dysplasia as the result of generations of poor breeding. The disease prevents his hip joints from coming together properly. As dogs age, the condition inevitably worsens, causing arthritis. Sufferers become progressively more lame until they can barely walk. In the past, many dogs were put to sleep at that point.

Two years ago, Wallace repositioned Auggie's hip joints. He made three cuts, separating the major bones of the pelvis, allowing the hip socket to be rotated over the ball of the joint. Fixed in place with a plate and screws, the joint became more stable. A gray-haired veteran of nearly four decades in surgery, Wallace has been doing this particular procedure for more than 30 years.

A few months after Wallace realigned Auggie's hips, he fixed the boxer's left rear knee, or stifle. The anterior cruciate ligament, which runs inside the knee and helps hold it together, had torn. The injury often comes when a dog or cat--frequently one that's overweight or out of shape--overexerts itself. Wallace painstakingly rebuilt Auggie's ligament using a little piece of tissue borrowed from elsewhere in the leg. This piece of handiwork runs in the neighborhood of $900, depending on what surgeons find when they get the joint open.

But Auggie's owner insists he's still limping, so today Wallace is examining whether the dog may have reinjured his ACL. He takes out the same kind of hard rubber hammer used to test reflexes by people-doctors and, mindful of Auggie's massive jaws and dislike of surprises, lets the dog smell it. Making sure his hand crosses Auggie's field of vision, he lowers the hammer to the leg and starts tapping.

Auggie just slobbers. Wallace and Hurt, however, are launched on some gentle verbal jousting. The surgeon insists the dog is suffering from garden-variety arthritis in both the knee and in the toes on that foot. The last time Hurt made the trek up from Eau Claire, Wallace diagnosed arthritis and prescribed Rimadyl, an anti-inflammatory drug. But Hurt says the pills didn't help, adding that Auggie's limp is much worse at home. Nylon jogging pants crinkling audibly, she slides down to the floor and the dog immediately backs up and leans against her. "See, he's taking the weight off that leg," Hurt says.

Wallace stifles a giggle. "I don't doubt that it hurts," he replies. "I just think it's arthritis."

The two examine a lump on one of Auggie's toes (run over in an accident several months earlier) and then agree to have it X-rayed at a cost of $70. Auggie bounds off toward the radiology department without any sign of a limp.

When the films show nothing except arthritis, Hurt questions Wallace about what else might be causing the limp. Really the only other possibility, he says, would be a tear in the meniscus, the cartilage in the center of the knee that cushions the bones. He could diagnose that via an arthrogram, a kind of X-ray in which dye is injected into the joint. Wallace again says he suspects arthritis and recommends drugs. Perhaps something else would work better for Auggie than the Rimadyl.

Hurt listens, but opts to spend the $200 for the arthrogram anyhow.

Again, the only thing visible in the images is arthritis--persistent and painful after a workout, but nothing Wallace can fix with a scalpel.

As the field has become more sophisticated, people's expectations have skyrocketed, says Wallace. Like Auggie Doggie's doting human, his two-legged clients are adamant about definitive resolutions for their animals' ailments. "Take my back patients," he says. "Say a disk ruptures and they're down and they can't walk. I do surgery and explain to their folks that it's going to take a while before the dog feels better. After a couple of weeks, they call saying they don't understand why the animal isn't up and around--while a human would still be in a wheelchair or on crutches."

When Hurt returns to pick up Auggie Doggie, Wallace is immersed in an emergency. A technician wanders back to the surgical wing where the vet is preparing to repair a cocker spaniel's pelvis, crushed the night before by a car. "Auggie's owner has a lot of questions," the technician says. "She's wondering if you have time to talk to her."

Wallace shakes his head. "You tell her for me that she doesn't have to do what I say," he tells the tech. "You tell her that's what I said." The tech is back a few minutes later, asking for another Rimadyl prescription.

Like most students, Wallace started vet school thinking he'd like to own a small-animal clinic. He was inspired to become a surgeon by a Michigan State University professor who is considered one of the fathers of veterinary orthopedics. When Wallace graduated in 1962, the first surgical procedure to correct hip dysplasia in dogs had just been developed. Aspiring surgeons didn't have many choices.

Outside academia, some of the best opportunities for veterinary specialists back then were in human medical research. Companies that manufacture products like sutures or bone cement often hire vets to conduct tests on research animals. Years later, after the product in question becomes commonplace in human medicine and its cost falls, it often trickles back down to the veterinary market. Wallace himself spent seven years consulting on the pacemaker, which was refined by testing in dogs even after it went into use in humans. Today, the vet hospital implants pacemakers in pets.

After graduating from veterinary school, Wallace studied human medicine to learn more about orthopedic conditions that affect both humans and animals. But veterinary orthopedics--with its then-limited job opportunities--kept tugging at him. One of his first veterinary achievements was to perfect the second surgical treatment for hip dysplasia.

The procedure doesn't correct the arthritis that accompanies the disorder, explains Wallace, but does give dogs an extra five to seven pain-free years. At a cost of about $500, it's still used by vets in private practice when a pet owner can't afford the superior, but much more complicated, triple pelvic osteotomy. The hospital staff know of only two private practices in Minnesota that routinely perform the latter procedure, which Wallace has been teaching at the UM since he arrived in 1972.

The number is one indication of the complex financial picture facing new vets. Most students leave school deep in debt and can't afford to spend four years completing a residency--even though developing a specialty is one way budding vets can assure themselves of a decent income after graduation. In her last year of vet school, Jen Roberts has her postgraduation finances worked out down to the last nickel: An out-of-state student, she anticipates leaving school with about $90,000 in debt, or loan payments just under $1,000 a month. (Even at $17,000 a year for nonresidents, tuition in the UM's veterinary program is a relative bargain for a school ranked in the top 10 nationally: At Tufts University, for instance, the bill hovers near $25,000 a year.) Veterinary medicine "has become a luxury degree," she opines.

"If I can get away with $500 a month for rent plus no car expenses, I could get away with earning in the low 40s," Roberts says, explaining that this automatically rules out any possibility she could work, for example, with horses: Salaries for equine vets start in the mid-20s. Agribusiness pays $40,000 or more for cow and pig vets, but she's not interested in working with "food animals," as they're sometimes referred to here. Nor, with an average starting salary of $36,000 a year, is the prototypical neighborhood small-animal clinic an option. (The financial picture is even dimmer for veterinary technicians: Their two years of school cost anywhere from $6,500 to $20,000, while salaries start at just $7.50 an hour.)

There are workshops, Web sites, and software packages designed just to help future animal-health professionals figure all of this out. Roberts has run the numbers repeatedly, applied formulas that adjust the numbers by geographic region and specialty, and concluded that the best compromise between her passions and her pocketbook lies in the emerging specialty of critical and emergency care. After graduation, she hopes to land an internship with one of the animal emergency rooms springing up nationwide. The internship would last only one year--not four, like the residencies needed for many specialties, such as surgery. Roberts figures she can put off her payments for that long.

Despite the dismal numbers, veterinary medicine consistently attracts top students. Almost 1,200 people applied for admission to the UM's veterinary college in the fall of 1998. Just 76 were accepted, 61 of them residents of Minnesota, the Dakotas, or Manitoba. Most pulled straight A's as undergrads.

Vet college dean Klausner says about 40 percent of the program's graduates go to work for a private small-animal clinic. Another 30 percent treat both small and large animals, while 20 percent of graduates end up working only with large animals. The remainder go on for some kind of specialized training. Only a few pursue careers in research, agribusiness, or industry, says Klausner--even though that's where the highest entry-level salaries are.

Even those who can afford to pursue a hot specialty are light-years from even dreaming about the prestige and wealth enjoyed by, say, a human cardiologist or neurosurgeon. One of the surgeons here, Dr. Tom Bowersox, slogged his way through a residency and then opened a specialty clinic in a Twin Cities suburb. He sent out a letter announcing he was accepting referrals of ACL cases and other sophisticated operations. He had four-legged patients lined up from day one and figures that in 10 years he did 2,500 ACL repairs. He ended up giving up the business, however, when it became too big to handle by himself.

As a surgeon at the UM, he's in about the same financial spot he was running the clinic. "When I get my Porsche, the license plate's gonna read ACL," he quips. The other surgeons within earshot crack up: "That's that Matchbox Porsche you're been dreaming about, right?"

 

At one end of the hospital's treatment room--the place where most nonsurgical procedures are carried out--someone has laid a small orange cat on a stainless steel table. At first glance, there doesn't appear to be anything unusual about the motionless form. Many of the animals awaiting attention here are similarly still under the influence of narcotics or anesthesia. Veterinarians and technicians stroke the tabby as they pass, some stopping long enough to scratch behind a limp ear.

It isn't until one of the technicians attending the cat lays a plastic bag on the stainless steel table that it becomes clear this animal is dead. A cancer in its bladder had gone too far, the tech explains, and spots had begun to show up on its lungs. No one needed to mention this when the animal was brought into the big room; when a patient doesn't make it here, word gets around with lightning speed.

Euthanasia is possibly the most grueling of the tasks faced by the hospital staff, says Klausner. "This is a hard practice. It isn't like most, with happy, healthy puppies and kittens and shots. We're the end of the line. Even if there are specialty practices out there, we're still going to be the court of last resort."

All UM veterinary students take an ethics class to learn how to deal with the dilemmas of high-tech care. "We teach our students to think in terms of options. People choose different options, maybe because of finances, maybe because of their bond with their animal." And at every stage of every encounter, he says, pet owners want to know whether their animal will suffer. "If the answer is yes, they're going to say, 'No, I don't want that for my cat or dog.'"

When a family decides to have its pet put to sleep here, doctors will ask them if they want to be present. If they do, the procedure is carried out in a special area where people can spend as much time as they want without worrying about making room for the next appointment. Owners are given information about support groups and literature on grief, as well as a choice between mass cremation and getting their pet's remains back in a mortuary urn.

The procedure is made as comfortable as possible for the animal, too. Technicians insert an IV catheter into a front leg so they won't cause discomfort by searching for a vein. Syringes are then used to inject two drugs into the catheter. The first literally puts the pet to sleep. The second contains a powerful narcotic which stops its heart.

A vet walks up and presses a stethoscope to the orange cat's rib cage. She can still hear the occasional fibrillation from the heart--leftover electrical activity that might or might not indicate that the euthanasia isn't quite finished. When the sounds stop a few minutes later, a tech carefully cuts away the surgical tape holding the IV line.

No one can explain why, but the company that cremates animals for the hospital wants the bodies stripped of all foreign matter. The tech discards the tape and the miniature catheter into a special trash barrel destined for a medical-waste incinerator. The cat will be reduced to ash separately.

Everyone here stops to pet everything lying on these gurneys, animate or not. The staff spends a lot of time helping pet owners let go, but they're no more sure than anyone else what happens at the moment of death. Brain activity may have ceased for the orange cat. But you just don't know when the soul slips away, the techs say.

When "end-of-life" decisions are made about human beings, the first thing usually considered is the patient's wishes, says Kahn, the bioethicist. But there are cases when a patient can't speak for him- or herself. When that happens--in both human and animal medicine--care providers suggest family members consider the degree of suffering and the prognosis. "If the answer is that someone's not ever going to get better and they are suffering, then it's pretty easy to say, 'Yes, let's stop life support.'"

Predictably, that equation isn't always so clear. When the biopsy results came back on Kayla, Mark Farmer's geriatric black Lab, they were inconclusive: The dog didn't have the osteosarcoma originally suspected, but another form of cancer. The suggested course of treatment remained the same--amputation, followed by chemotherapy.

Back home, Farmer told his wife everything he had learned at the veterinary hospital. If Kayla were younger, they agreed, they'd be more likely to take advantage of the cutting-edge care. But between her age and the fact that the tumor was just the latest in a long string of ills, they couldn't see opting for chemotherapy. Urbanz suggested amputating the cancerous toe, but even that was too much for the Farmers. The cost of the treatment didn't even enter into the discussion, he explained later. It simply seemed best to keep Kayla at home until she visibly suffers, at which point she'll be euthanized.

A few days later, Urbanz called to find out what the couple wanted to do. Farmer says the only concern she voiced after hearing that they didn't want further treatment was making sure they kept Kayla comfortable. Nonetheless, Farmer says he feels a little guilty. He's pretty sure the kids would want to try anything that might keep the dog with them longer.

"In the past, we didn't have so many options or choices. And we wouldn't have given so much second thought to putting this animal to sleep. We've done more for this dog than we would have in the past." Partly, he says, that's because unlike the animals on the farm where he grew up, Kayla lives in the house and interacts with the family all day long.

"You want to try to save the pet," he says. "That's something that tugs at you, too. Especially with my kids. If they thought I wasn't going to do something that would help or fix the dog..."

He lets the thought trail off, adding after a brief pause, "I'm not going to have that discussion with them. We thought a lot about what we're going to tell the kids, and we're just going to tell them that Kayla got old and died."

 

Intern Miki Mosman contributed to this story.

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