Retronym. I thought I had made it up but learned that the term was coined by a guy named Frank Mankiewicz in 1980. You know, those words we didn’t need back when all clocks were analog, all phones were land lines, and all documents were hard copy? Now although I love my computerized vaccination reminders and my cell phone, I still cling to a faux-leather, spiral-bound, paper appointment book where we scrawl our schedule in number two pencil. “10:00 Smith, K-9, Tunny, ADR. ” That’s “Ain’t Doin’ Right,” our catchall abbreviation for animals with nonspecific malaise.
This time of year, many ADRs turn out to be tick-borne diseases, so when Tunny, a middle-aged border collie cross, first arrived, that is what I expected. Until I checked his color. Not his coat color. The color of his gums. Unless pigmented black, these mucous membranes should be a healthy pink, but Tunny’s were pale, almost white. I glanced up, catching the eye of my assistant, Elise. She had seen it too and knew Tunny was in trouble.
“I just want to do a little test,” I explained, palpating Tunny’s tummy. Many things can cause pallor — but the most common in middle-aged dogs is a bleeding tumor of the spleen. I didn’t feel any unusual masses but could check quickly for internal bleeding by abdominocentesis, a five-second procedure tapping the belly with a needle and syringe. “No blood,” I reported, relieved, but still mightily concerned. It was time for further diagnostics.
Radiographs revealed an enlarged spleen but no obvious tumors. Blood tests showed severe anemia.When an animal is this anemic, there are three things that could be happening. He could be losing red blood cells through bleeding. Tunny had no visible source of blood loss — no nosebleeds, no bloody vomit or stool, no trauma. The abdominocentesis had not found blood in his abdomen, but I still couldn’t completely rule out a small tumor on the spleen, or even his heart, that didn’t show on x-ray. Referring Tunny for an ultrasound could help determine this.
The second possible cause for anemia is lack of red blood cell production. This happens with things like bone marrow cancer. The third is red blood cell destruction. When the body recognizes an abnormal blood cell, such as one infected with a blood parasite like Babesia, that cell is removed from circulation and broken down by the immune system. But red blood cell destruction can also happen spontaneously (and excessively) in a disease called autoimmune hemolytic anemia (AIHA).
AIHA occurs in dogs of both sexes and all ages, though some studies suggest middle-aged spayed females are at greatest risk. Breeds predisposed to the syndrome include cocker spaniels, springer spaniels, collies, miniature schnauzers, Dobermans, bichon frises, and Old English sheepdogs. Almost half of reported cases occur in the spring, especially May and June. Owners may notice progressive lethargy and weakness, poor appetite, vomiting, and discolored urine.
On physical exam, a veterinarian may find pale mucous membranes, elevated heart and respiratory rates, enlarged spleen or liver, heart murmur, and/or jaundice. Mortality rates can run as high as sixty percent.
Tunny’s family had difficult decisions to make. He needed an ultrasound to definitively rule out bleeding tumors. He needed further diagnostics to determine the precise cause of his anemia. He needed a blood transfusion while these tests were being pursued. Tunny’s situation was precarious. Hospitalization at a facility with ICU, specialists, blood bank, and round-the-clock care would optimize his chance of survival.
It is a particularly tough decision for Islanders, as this level of intervention requires a burdensome trip to the mainland. When I first came to the Vineyard, thirty years ago, few people opted to make that trek, and the standard of care for animals was far different. In those days we might make our best guess and send Tunny home with a handful of pills and a prayer. We might give Tunny a transfusion, using our own pet as a donor, without anything but the most rudimentary cross-matching to check compatibility. Sick animals often spent the night alone in unattended hospital cages. On the other hand, owners rarely ended up with huge veterinary bills.
Tunny’s owners lovingly opted to go to the specialists, but before leaving we had a heart-to-heart about prognosis and cost. “They won’t be able to tell if he is going to make it right away,” I said. ” They’ll probably advise several days of intensive care, maybe longer.” We discussed pragmatic options. The reality was that if Tunny was so sick that he needed more than one transfusion, his odds of recovery dropped dramatically, and the cost of more than a brief stay would be very high.
Over the next twenty-four hours Tunny was definitively diagnosed with AIHA. He was given a special transfusion of several units of packed red blood cells, kept in an oxygen cage, and started on an aggressive medical protocol. As anticipated, the specialists wanted him to remain hospitalized, but his owners were prepared. They had thought it through and made rational choices — emotional, medical, and financial. If Tunny was going to respond to the current protocol, we would know in a few days, whether he stayed hospitalized or not. Constant monitoring might give us more information, but wouldn’t necessarily change the outcome. And if he wasn’t responding well, his owners didn’t want heroic measures, nor did they want him spending his last days in a hospital cage, no matter how fancy.
Together we modified Tunny’s regimen to one we could manage here on Island as an outpatient. It’s a gift to have access to state-of-the-art medical care, but it is also both wise and compassionate to set limits. Maybe we need a retronym for the old-school, common-sense approach to veterinary medicine. Tunny received the initial benefits the specialists could provide, but now he needed to come home. Maybe that’s the retronym. Home care. Home, where he could be with the people who loved him, regardless of what lay ahead.