Posted by: Adrianna | August 8, 2010

The end 8/7/10

First let me say thank you to everyone for your support.  I thought this blog would detail his diagnosis and successive battles, not a rocky road with a steep decline. Rocky as it was, so many of you have reached out to us every step of the way and I will aways remember and be grateful.

Elliott was still not eating, he didn’t want anything I brought.  When he saw me he tried to get up and he could only get his front legs up and I saw he’d peed on himself without bothering to move.  He was too anxious in the ICU so they’d put him back in cardio where he’d calmed down a little.

I had the choice to give Elspar (rescue chemo drug) +/- give more time & put a feeding tube the next day (he was so many days without eating now) +/-  add on another antibiotic … I just didn’t see hope.  If he rallied with the Elspar he had more chemo treatments ahead with harsher drugs that don’t work as well, and he’s been so sensitive to chemo in the past.  I was torn; I didn’t want to euthanize him for a crisis we might get past, but on the other hand he’d not enjoyed anything for days — not food (he was very into food his whole life), not walks (he was so weak), and even spending time with me only allowed him a little less anxiety so he could sleep. He was on pain meds, steroids, big-gun antibiotics, anti-emetics, GI protectants, anti-ulcer medications … we tried everything.

Then there was the twitching.  After I started thinking more about it, I realized that it must mean his cancer is in his brain.  I went over all the possible causes; it could have been something else (infectious disease) in his brain but even that, in an immuno-compromised dog, was a death sentence. He was twitching more frequently, mostly in his neck and shoulders and forelegs, but sometimes his whole body would jolt.

The internist spoke to me for a long time about all of this, and I decided to let him go.  When I thought of just trying something else, just waiting a little longer, my heart leapt because I didn’t want to lose him.  But he was so lethargic, sometimes whining, and he smelled like pee and hadn’t even taken a sip of water in days.

The internist got me a syringe of propofol (sedative) and left us in the dark in the cardio room.  I attached it to his IV extension, so as not to disturb him, and we lay in the dark together.  He laid on his side and tried to rest but his breathing was a little fast and, although I avoided sobbing (he gets so stressed when I’m upset), I think my grief was making him anxious.  He was twitching a lot too.  I gave him the propofol as we lay there and he fell asleep.  The internist came in and finished the euthanasia, and finally I could cry as hard as I needed to and cling to him and hug him tight.

He is a big dog and there was a perfect spot, just ahead of his shoulder blade on the side of his neck, where my head fit perfectly. I couldn’t lay there so much while he was alive because it would put pressure on his neck so it was reserved for brief hugs. Yesterday I rested my head there for a long time, holding his fur, and I can’t tell you how perfect it felt to hold him, and how much it hurts to know I will never feel that again.

For 12 years — for really my whole adult (post-college) life — he has been the center of my world and the guiding force in my life, even determining where I lived & what hours I kept.   I truly don’t know how to live life without him.  I think of it and I feel a shock and my stomach drops and flutters like it did when I was frightened as a child.  I woke up this morning with such a feeling of panic.  I didn’t know what to do with myself so I did what I have done every morning for 12 years, I put on some clothes and went for a walk.  But this time I was all alone and all the days stretched ahead look the same.

I love him so, so much.  I am in so much pain I can barely breathe.

I want to show you pictures, I want to tell you more but I can’t bear it.  Please look back here in a week or so to see him one last time, I want to know that people will see him and hear about him as a healthy dog.

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Posted by: Adrianna | August 7, 2010

Update

I’m off to the hospital with fresh cooked scrambled eggs, baby bell cheese, donut holes, turkey, roast beef, Beneful, and some mysterious can of chunks from Mighty Dog.  Fingers crossed.

Posted by: Adrianna | August 6, 2010

Still hospitalized, not eating

I don’t feel like writing this.

So he ate a little bit overnight and a little bit in the morning when I got back (I went home for a few hours to feed the piglets and shower).  Since then he has turned away from food for the most part.  His case has gotten complicated and is a long story so I’m going to cut to the chase … His collective symptoms including today are:

  1. poor appetite/anorexia
  2. hypersalivation (hyper-drooling) initially
  3. nausea
  4. problems eating (food falling out of mouth, food aversion)
  5. hind limb weakness
  6. lethargy
  7. dull mentation (perks up sometimes though)
  8. myoclonus (muscle twitching) in his face, legs, and shoulders. I first noticed this last night.

Blood work done when he was last hospitalized was unremarkable for him.  We have also considered (some results are pending):

  1. Ileus (too-slow GI tract)
  2. Addison’s disease
  3. Toxoplasmosis
  4. Cryptococcus
  5. Loss of remission (lymphoma)
  6. Pancreatitis
  7. Tick-borne disease
  8. Other stuff eliminated by physical exam

Nothing conclusive so far, so he is being hit with the kitchen sink of GI drugs, fluids, pain medication, and steroids.

No one has any idea why he is twitching.  He is twitching when he is at rest as if he’s asleep and dreaming, but he’s awake.  We are doing some infectious disease testing just in case something has taken advantage of his immuno-compromised state.  I would love it if we found something we could attack with drugs.

Today I decided to add on another chemistry to the blood we’d sent out for a PLI yesterday, just in case something had changed since we’d done a blood chemistry last weekend.  I got the results, and his liver values have doubled in the past few days.  Liver toxicity? Lymphoma resurgence in the liver? They are both bad; if it’s the first one, there is a chance that he’ll heal.  If it’s the latter, he’s up the creek because the life-extending chemo drugs are almost all liver-toxic so a damaged liver cannot withstand chemo.

We have started antibiotics in case this is a liver infection.  That is not terribly likely but it’s possible.  Basically there are no great therapies for the liver; it has to heal itself.  We are giving supportive care to see if this turns around, and I’m considering doing an aspirate of his liver or spleen to look for lymphoma.

I can’t really bear to think about this right now (I’m still at work with him).  I will say that I do not plan on hospitalizing him indefinitely, especially since he is mostly dull, uninterested in food, and intermittently anxious.  That is a reasonable price to pay for a dog that is going home to have good times; it is not a reasonable thing to continue if there is no real hope.

Posted by: Adrianna | August 5, 2010

Hospitalized 8/5/10

So we’re back in the hospital.  Last night I was considering bringing him in to see the orthopedist so he could examine Elliott’s mouth and jaw to see if there was an issue.  I got up at 4am this morning to take him out (he had Cytoxan yesterday and should urinate frequently to avoid cystitis) and he didn’t want his elevator treat.  Every time we ride in the elevator he gets a little cat treat and he always eats this treat even when he’s turning his nose up at everything else.  So that was unusual.

Then when I got up this morning I saw he was covered in drool and lip-smacking.  Drool-soaked chin, forelegs, lips, and actively dripping.  This is a sign of nausea in dogs (much more so than cats). Crap.  So I bundled him up, took lots of towels and got into a cab.  Thankfully he did not puke in the cab.  He looked pretty green around the gills but did not actually vomit.  When I got to work he was still drooling heavily and again looking weak and dull.  He just looked terrible, and I know he looked bad because my coworkers just got quiet and gave me sympathetic looks rather than the usual attempts to cheer me up.

The internist took over his case and did as full of a mouth exam as she could without sedation and there is a fractured tooth but it does not look fresh.  There was some uncertainty as to why he was drooling; he was drooling an awful lot for this to be just nausea, esp. since he hadn’t vomited at all, and with all the eating issues the past two days it was possible that there was something mechanically wrong in his mouth.  We would need to use full anesthesia to investigate that possibility. She suggested treating him for nausea for a few hours to see if it resolved the drooling; if not then he’d get knocked out, examined, x-rayed, and if that showed nothing they could use the endoscope to make sure nothing was wrong in his esophagus.

Luckily, Elliott stopped drooling after about 4 hours on a Reglan drip and after getting Anzemet and Pepcid. He ate a small amount this afternoon and we’ll try to give him more tonight.  We tested him for pancreatitis and Addison’s disease (results pending) and gave him a shot of steroid IV to see if it helped since all of this nausea business started after he was off his pred.

Man, he looked so sick this morning.  I kept changing the towel underneath his chin, he was soaking wet. And he was so dispirited, like he wasn’t even there.  It was terrible.

So why is he nauseous?  Why so much drool with no vomiting? Why won’t he eat even if he doesn’t seem nauseous?  Why the heck can’t he chew a slice of bread?  No idea.  None.  We are just treating his symptoms and waiting to see if the tests show anything or if this just mysteriously resolves with steroids, as some things do.  It’s frustrating not to know, but really right now what I want is for it to be fixed.  I want him to feel better, scarf his food, have some energy … if not as much as before the cancer, enough to let me know he is still enjoying himself.  I just want it fixed, and if steroids fix it, we’ll give steroids.  I just want him to come home and be himself.

We’re in the cardio room together now and he is resting but not asleep.  He doesn’t have a lot of pep but he is much brighter than before.  Tomorrow we shut off the drip, use only oral meds, and see how it goes.  This time he’s not coming home until he is doing well on his “at home” medication regimen.  Fingers crossed, good thoughts appreciated.

Posted by: Adrianna | August 4, 2010

Daily update 8/4

7:40am Walked pretty far U+++, his choice. No interest in eating/pill pockets when we got back. Just laid down.

Elliott checking his pee-mail

8:40am Interested in cat food when I prepared it for cat.  Got him eating pill pockets so he ate levothyroxine, gabapentin, and Cytoxan 50mg. Then ate 1 6 oz can cat food and a bit of another can of Felidae.  I don’t know why, he wants to be hand fed.  He doesn’t like the bowl?  The location? I don’t know.

11:30am Dogwalker U++

3:15pm Dogwalker U++

6:30pm Got home from work.  I offered him an entire slice of bread which he eagerly snatched but then he had problems eating it.  He chomped a few times and moved it around his mouth but ended up having it fall out, slobbered but uneaten.  He laid down on his bed and I took the piece of bread and gave it to him in tiny pieces which he gobbled.  What is going on here?

Then I made him some scrambled egg.  He was very interested in it and snapped it up when I handed it to him bit by bit. After 20+ small pieces, I put the rest in a little cat bowl and offered it.  He started to lap it up and then suddenly backed up and didn’t want it. ????  I offered him a little piece and he reached for it but didn’t eat it.

7pm Walk U+++ BM +++ (soft). Very tired, dragged his feet even though he wanted to go farther. Fed him the rest of the scrambled egg piece by piece, which he ate. Then I offered him one of the most treasured treats in dogdom — Ice Cream.  I put it on a spoon and he lapped at it but would not take the ‘chunk’ in his mouth and actually avoided doing so.  As it melted, he licked the liquid (inc. when it dripped on the floor).

9:30pm Ate some canned cat food when spoonfed, almost 6 oz.  Same thing as before: when I offered a bigger piece he took it then abruptly dropped it and didn’t want any more of that food.  He also begged for some of my sandwich and I gave him small pieces of crust which he ate happily.

10pm Made him another two scrambled eggs and fed him the eggs in small pieces.  He eagerly ate every bit of egg when fed by hand or if put on the floor in front of him. I took advantage of this “mood” and tossed him levothyroxine, gabapentin, and tramadol in pill pockets.

11pm Solicited a walk but just peed and didn’t want to go too far.  Dasuquin soft chew.

So I have been pulling my hair out over here worrying about his mouth and if he is having trouble eating.  I was fairly convinced of this and then did a little test, the Greenie test.  He loves Greenies, I guess because they have no nutritional value and are unreasonably expensive.  So I handed him the dental chew and .. drum roll ..

He freakin ate it up.  Just chomped and chomped until it was gone.  Now it did seem like he avoided the left side of his mouth somewhat but I did see a few bites go that way.  AAARGH.  Am I crazy?  Why is he dropping food and becoming averse to it unless he has a pain problem?  I did give him tramadol but it wasn’t that long ago.  I have no idea what to make of this. And to top it off, while he was chewing he started to lean back on his hind legs like they were becoming weak.  He almost involuntarily sat down on his rump but then pulled himself back up at the last minute.  What the heck was that? I wish I just hadn’t been looking.

I don’t know if I am over-observant, over-thinking things, deranged, or permanently brain-compromised due to stress and lack of sleep. Or all these worrysome things are real and just happen not to make too much sense.

Sigh.

11:30pm Here he goes with the panting again.  I bet he swallowed a ton of air when I was throwing the egg around. Gas-X and Reglan in pill pockets.  How I miss the days when he’d just burp and fart on his own if he swallowed air …

12:20pm Sound asleep.

Posted by: Adrianna | August 3, 2010

Daily update 8/3/10

7:30am I got up at five but he ws resting comfortably so I didn’t make him get up.  Right now he is resting on his bed and not inclined to get up either.

8am Walk U+++.  When we started, he was stiff for about half a block and then loosened up and trotted more comfortably.  He wanted to go an extra block so I let him.  He did get tired at the end but I think he had a good time sniffing and peeing (the male dog recreational sport). I broke the pill pockets into pieces and managed to get him to swallow gabapentin, levothyroxine, and 1/2 tab mirtazepine.

Fed one container Beneful plus 1/3 scoop EVO kibble.  I managed to hide a Beano capsule and 1/4 tab mirtazepine in the Beneful.  He ignored the kibble but ate the Beneful very quickly and seemed eager to eat more.  I gave him another container but he just ate a bite or two 😦  Still, better than nothing! I hope he’ll start to get stronger now that he’s eaten a bit.

I’m going to talk to the anesthesiologist I work with about his pain.  (She is also a pain mgmt specialist.) I watched him get up and move to another bed and he could barely take a few steps.  Once he gets going, he’s much more comfortable, so I think he is stiffening up when he’s lying down.  My other thought is that this is back pain; that’s why it hurts to change positions but not necessarily to walk (their spines are horizontal and don’t have the same pressure that ours do when we are upright).

10am He mosied over while I was eating breakfast and I gave him some pancake which he seemed to thorougly enjoy.

11am Walk U++ BM + (N!).  Again he wanted to walk farther, longer ! This is good!  Dasuquin soft chew. Ate a few more bites of Beneful when we got home 🙂

5pm Dogwalker U++ . She says he ate the rest of his breakfast and, although he still didn’t want to walk far, she felt he looked better today.  Yay!

10:20pm Walk U+++ (3600 steps today, not inc. dogwalker).  Levothyroxine, gabapentin, omeprazole, Cerenia (last day) in pill pockets. Zinpro biscuit.

Fed 1/3 cup EVO (put on the bottom of the bowl; I don’t expect him to eat it on purpose, just to swallow some kibbles caught up in the wet food), 1/2 can Whole Earth Farms (he has been turning his nose up at this, but I thought that if I mixed it …), 1 container Beneful. Gobbled up a few bites but left the rest. Aargh.

11:30pm Ate a little more dinner.

1:30am Walk U++ BM +++ (little soft).  Didn’t want to walk far.  Mirtazepine. Freeze dried chicken treat.

Posted by: Adrianna | August 2, 2010

Daily update 8/2/10

So today started out rather badly.  Elliott did not really want to go out for a walk, didn’t want to do the stairs, and didn’t have an appetite.  He ate two mouthfuls of Beneful (that is his ‘ambrosia’ food) but that was it.  He wouldn’t even eat any pill pockets so I couldn’t give him his morning meds.  He shuffled around the apartment, shuffled during his walk, and generally seemed to be a million years old and miles away even from the dog who chowed down in the hospital yesterday.

I went to work feeling terrible.  I wanted to speak to the internist but when I thought about how badly he looked his morning I felt like crying, and didn’t want to make a scene at work.  I spoke to his oncologist on the phone who stressed that his ultrasound was “clean” so she could not make a case for this being cancer-related.  The vincristine should be out of his system by now too.   Basically no one has any idea why he is feeling poorly.One suggestion was to put him on mirtazepine (appetite stimulant).

I got home from work and he was lying on one of his many beds.  He lifted his head but didn’t get up, and didn’t get up for a few minutes.  We shuffled outside where he peed a few times but again seemed exhausted.

Now we’re getting to a point here where merely the fact that he hasn’t eaten much in the past 5 days is also a factor in him feeling weak.  So I made it a mission for him to  eat tonight. I put some Beneful in a cat bowl, offering it first to the cats (to add to the allure, of course) and then, after spiking it with 1/2 dose mirtazepine, offered it to him.  He ate some on his own and I spoon-fed the rest. He also drank a lot of water which is good because I haven’t seen him drink much.

I made a sandwich for myself and, again using some subterfuge, got him to eat an entire slice of bread.  He was “in the zone” after that and I got him to eat the second half of the Beneful container.  Still way below his daily requirement but not a bad start.  I got him to eat Cerenia and omeprazole in pill pockets but when I tried the gabapentin, he chewed it and spat it out.  (Annoyingly, he recently decided to start chewing his pill pockets rather than swallowing them whole.) So I’m not sure what to do about that.

Right now he’s resting on the floor.

9pm Got him to eat some i/d by hand feeding.  Hid gabapentin inside 🙂

10pm Walk U+++ BM + (normal!).  No shuffling except at the end!  A bit of his usual spring in his step, went two blocks. Hand fed a little more i/d when we got back, plus Dasuquin soft chew.

Posted by: Adrianna | August 2, 2010

Late night update

He has been home since late afternoon now.  He seems very achy still, and he wanted his extra-special canned food, not any of his regular foods.   I’m very disappointed because he seemed so ravenous in the hospital, I thought he was coming home as his old self.  I feel like my hope/optimisim is so precarious, like if he’s not looking stellar it’s the end of the world.

It’s also frustrating that I can’t do much for his pain.  He can’t have NSAIDs because of his liver, and I’m not sure that tramadol isn’t part of the problem in terms of affecting his appetite.  I gave him tramadol as soon as we got home and his appetite didnt’ seem to be as good after that, and he seemed more lethargic.  NOthing is clear cut with animals since they can’t speak .. One of my many nightmares is that I am giving one of my animals something that makes them feel badly in some mild/moderate way but they can’t tell me and I keep giving it.  What if it makes him feel a little woozy, or queasy, or gives him a funny taste in his mouth, but not really nauseous (so no major symptoms)?   Aargh.  Maybe I over=think things, maybe I worry too much.  I dunno.

His treatment plan if he does NOT vomit any more is to give the cyclophosphamide (Cytoxan) tomorrow night and for the next two days, orally.  The onco doesn’t want to lose ground on his treatment by delaying it further.  BTW, this means that she is pretty sure it’s not a relapse or she’d abandon the cytoxan altogether.

I’ve just been so high-strung the past few days.  He, however, is snoozing soundly, I think he has the right idea.

Posted by: Adrianna | August 1, 2010

Home together

We got some good news this morning:  Elliott’s liver and spleen look better than at diagnosis, and the spleen looks better than two weeks ago (after starting chemo) and there are no enlarged lymph nodes in his abdomen.  These would all be hallmarks of relapse, so the internist and oncologist both feel that Elliott has had a bad chemo reaction and is NOT suffering a loss of remission.

Sleeping after ultrasound excitement

This is such great news, and I am so happy! When a friend took us in on Friday night, I was pretty sure it was going to be the end.  He looked just as miserable as he did at diagnosis. He looked a little better on Saturday morning, but not terribly so.  Then after I got back to the hospital that evening (after feeding the piggies kitties at home)  I thought he looked at lot better.  He was HUNGRY and wanted to walk around and be active.  He was — and still is — a little weak, and he’s definitely feeling some joint achiness.  This is probably due to cutting off his pred (used initially as part of his treatment, it is also great for arthritis) and some stiffness comes from lying around for the past three days.   I’ve found that now that he’s older, he really needs to walk a certain amount every day or he starts losing ground.

We slept on a bunch of comforters on the floor in the cardio room overnight (with him on his IV, of course) and were pretty comfortable.  Someone tinkled in his sleep on the comforter–my fault for not waking him up to go out when he was on such a high rate of fluids.  But otherwise it was great to hang out together.  This morning he was ravenous and had more energy.

Here he is on the car ride home:

Homeward bound

And yes in this pic you can note his “pred head” — muscle wasting on the skull around the occipital bone (the “crest” at the top of the head) and at the temples. This happens to dogs on steroids and also is a sign of cachexia (the loss of muscle associated with cancer and other severe diseases).

One unfortunate thing happened today, though.  He struggled towards the end of his ultrasound and I think he really hurt himself.  He has chronic low back pain and he has ended up achy on other occasions when he has been active or overexerted himself as he did today.  He seems to have gotten more sore throughout the day 😦  He is on pain meds and muscle relaxers tonight.

Posted by: Adrianna | July 31, 2010

In Hospital

I just had a shower, slept a few hours, and am going back for a visit.

So last night around 8pm Elliott vomited a bunch more times (this is with Anzemet on board) and started looking miserable.  I’d decided anyway to take him in today for an ultrasound but after all the vomiting then I was worried that he was getting dehydrated so I decided to take him in tonight.  Also he had been vomiting before, but didn’t seem nauseated all the time but now he looked miserable and exhausted.  For the previous two days I thought this was a poor reaction to vincristine; now when I looked at him I saw the same exact scenario as I did when he was diagnosed.

The difference between a bad rection to chemo and losing remission (after 2 weeks) is enormous in terms of prognosis.  If he has lost remission, how much farther should I go with this?  He is on the best protocol, the one associated with the longest symptom-free survival time.  If this intensive program can’t beat down his disease (advanced beyond the possibility of cure anyway) it’s just a bad sign.  Very bad.

The other related possibility was that his liver was shot.  Elliott has a history of chronic hepatitis and there were already issues of him perhaps not metabolizing his chemo drugs as well.  If his liver was done, we were done with what we could do.

I called a friend to see if she could drive us; after saying hello I froze up.  I couldn’t say anything for more than a minute.  I couldn’t ask her for a ride to take Elliott away to maybe never come back.  His last car ride, was this it? HIs last time in the apartment?  I’d return alone forever? I squeaked out a few words and she said she’d be right over for us.

He got up and was actually very excited to put his leash on.  He stayed “up” through the car ride and the arrival at the hospital.  Bloodwork showed no elevation in liver values (nothing above his normal elevation) and a slightly lower neutrophil count (appropriate for a dog on chemo).  We gave him some IV stomach protectants (Protonix, Pepcid), an anti-emetic (Cerenia) and a general-purpose antibiotic (ampicillin) and put him on fluids. This morning we started a Reglan CRI for nausea and to help move things along in his GI tract.

Friday night, not feeling well.

He slept like a rock most of the night.  (I set up a bunch of comforters on the floor of the cardio room and we stayed there, IV pole and all.) He didn’t want to get up to go to the bathroom but I dragged him out every 4 hours in case he actually did absorb some Cytoxan yesterday before vomiting and to keep him from peeing on himself.  He did pee a little on himself anyway.  Today before I left to come home he looked a lot brighter, though.

There was no internist today so no ultrasound.  I was very, very disappointed since that test holds the major part of the answer to our big questions.  So just supportive care till she comes in tomorrow.  The oncologist–who I’m counting on to look at all the results and tell me if we’re looking at remission/failure or an acute chemo reaction–spoke to the critical care specialist in charge of Elliott’s case.  I was too emotional to speak to her.  She says that vincristine can cause ileus and his symptoms are consistent with both this and a relapse, and we need to see how his ultrasound looks.  Even though his outer lymph nodes are not enlarged like they were at the time of diagnosis, if the lymphoma is pushing back it could first show this in the spleen.

(Ileus in this case is caused by a poisoning of the GI nerves by vincristine; the motion of the GI tract is slowed, nothing moves along and the result is a person/animal who feels miserable and vomits anything placed in the stomach since nothing is moving out.  This side effect resolves usually within 9 days of administration.  We’re on day 9 now, but if Elliott developed the ileus at day 6-7 he could still be feeling bad from it. Also, Elliott’s liver means he metabolizes drugs more slowly so that could also be a factor.)

So we’re back to waiting for the ultrasound.  I am trying very hard not to get my hopes up that he is going to get better and come home.  I can’t walk around thinking this is his last day on earth, though, so I’m trying not to think too much at all.   I plan to just go and  visit him, but it will be hard to leave him there.  It’s funny, all these days I’ve wished I could sleep a whole night and now I have the opportunity to do so but I’d rather sleep a few hours on the floor next to him.  I’ll keep this in mind the next time I get aggravated at having to wake up at the crack of dawn to take him out, if there is a next time.

Thank you to everyone for your good wishes.  I will try to keep you posted.

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