Rest, Baccarat. Rest, Good Dog

The empty bench

You have to imagine Sam and I sitting here, eating our tortilla wraps (and he his roast beef sandwich on industrial baguette) the other evening. He came after work, taking the RER from Nanterre to the Gare de Lyon, and another to Alfortville, after a long day at work. Dr. Gouni waited for us. She said she had work to do, anyway, but she's like my husband. I know what that means. She thought it was important for Sam to see Baccarat again before the surgery because we cannot know how it will turn out.

Earlier, I told Baccarat that Sam was coming to see her, "Sam! Ton Sam va venir!", and her eyebrows jumped up her forehead, her tail starting to brush the flooring in cardiology with all the enthusiasm her heart can manage. Everyone laughed. She knew exactly what I was talking about. I know you are thinking, "It was the tone of voice she heard, not what you said."

No, you are not thinking that. You know, just like I do, that they understand that much.

It was like the day when my husband came to see her, arriving after Sam and I had. It was the first morning of her hospitalization at our veterinary clinic, and she was collapsed on the floor after a very brief walk, but when she saw him walk around the standing display of flea products and dog pheromones, "for a happy dog", her head shot up and her tail started cleaning that darker gray flooring.

"C'était seulement qu'elle pensait que j'allais la ramener à la maison, puisque vous ne l'avez pas fait," he joked. He knew that she was just happy to see him, too.

It was just past 7 pm when I went to pick him up on his way up the Avenue Générale de Gaulle on my motorcycle. He had walked enough for the day, and Dr. Gouni was already so kind to wait. She took us up to Baccarat's cage and left us with her.

We were tired and hungry, our heads aching, by the time we thanked Dr. Gouni for letting him come as late as he had to to be able to see her and emerged on the sidewalk.

"There's the Casino over there," I looked up the avenue, past the post office and towards the traffic circle, beyond which the A4 leads to the Péripherique and the A13 home. "We could get something to tide us over until dinner, maybe some sandwiches, and I need some things for dinner. Oh. There's not much room in the top case. I forgot."

"I have my backpack, Mom. We can put some stuff in there," he offered, still standing there on the same spot on the sidewalk. We weren't deciding anything very fast. The sidewalk is where we decompress.

"What do you say? Should we go get something, or just head home? My head is killing me." I had barely eaten anything since my scrambled eggs long ago that day.

"Alright."

"Okay, then, let's go." We stood there another second. He had joined me in my state of suspension.

We got sandwiches from the display at the entrance to the store, looked at the soda. Found a sandwich the color of the salami of which was too gray to be considered consumable and gave it to the guy at the "welcome" desk.

"I know just how he feels," said Sam, "when someone finds a sandwich that's gone off, someone's going to make a complaint. You try to get them before anyone else does." His job this summer has been refilling vending machines for his uncle at one of their biggest clients in Suresnes. He knows about sandwiches and standards of freshness, margins of profit on soda and coffee. "There's a Coke Lite left, Mom," he added.

He stuck his hand in the water vapor over the fresh vegetables.

"What's that?"

"Water to keep them fresh." We looked for the string beans, if there were any, and picked up some organic bananas. "I'd better get a small bunch, for the backpack, but you'll eat one, maybe?"

"Yeah. I'll eat a banana," he said. We still hadn't found any green beans and made another trip around the vegetables.

"My hand doesn't get wet when I put it in the gas," said Sam.

"It's not a gas; it's a vapor," I replied.

"Vapor is a gas, Mom," he said. He was right. We wandered off, looking at the meat, looking for jambon de pays for the melon I had picked up and put back down, thinking of space. I remembered and left the jambon de pays. We walked through cheeses, and Sam picked up a package of prewrapped cheese slices for Croque Monsieur sandwiches.

"Now this is what I am going to need," said Sam, with a new energy we had been lacking.

"But, I buy those already. Usually the cheddar ones for your cheeseburgers," I said. I thought he had seen these a million times, in our fridge, but certainly at my husband's parents' home, where it is staple to feed the army of grandchildren a light supper.

"Oh. It's just the cheese," said Sam, disappointed. "I thought it was the sandwiches."

"Sam, it's really easy to make the sandwiches from the cheese slices."

"I am going to buy lots of pre-made sandwiches, all ready to heat."

"You're going to need much more than that, if you are going to survive law school." He looked back toward the soda and headed off, returning to tell me the last Coke Lite was gone and he had decided against a Coke for himself. He seemed disappointed for me. I rarely drink Coke Lite. It was considerate of him, anyway. "Where are the smoothies," he asked. "I am in one of my healthful foods phases," he added. "The other day, in the Marais, I got an oxygen water. Twice the oxygen of normal water."

"They're right here." I pointed to the juices, just next to where we happened to be standing, still looking toward the display of Coke and Coke Zero, back across the tables of fruits and vegetables, appearing fresh under their streams of gas.

"I want mango and passion fruit."

He compared the Tropicana and the Innocent ones and found the Innocent less expensive. It looked like more, but it was the same size as the Tropicana. A lesson in packaging, but he already knew that. He knows how to look for the price by weight or volume, and read a label.

We headed past frozen foods, and along to the end of the store, scanning the shelves. I didn't know what I wanted. I couldn't concentrate. He was patient, or the same as I was. We had cheese, bananas, dates, sandwiches, fruit smoothie. We negotiated the self-check and headed to sit on the bench, eat our sandwiches and watch the students and residents leave the school and the hospital to enjoy the regular lives on a warm July evening. I watched the vet in her last year of residency who took care of Baccarat last week cross the street, thinking their lives go on; it's normal.

Yesterday, Baccarat and I lay on the ground under a chestnut tree on her last afternoon before surgery. It was cool, and there was wind. It would rain later. I gazed up at the undersides of the chestnut leaves and watched the students walk the dogs who could run and chase sticks. Baccarat watched, too. She knows she can't.

They had found the mass in her heart quite changed, and they were inside meeting about her case, while we rested together outdoors, I on my back on my big cotton scarf, the one I bought in Petit Andelys last summer. The mass had gotten smaller, from a peek of 7 cm in one direction, to 5 cm, and it had moved further into the ventricle from the atrium. Some dark spots in the area where it was thought to be connected to the heart wall had appeared.

"Ce sont des petits endroits de liquide, comme dans son abdomen," said Dr. Gouni. "C'est normal qu'on les trouve là si elle a de la liquide dans le ventre. Mais, on voit que ce n'est attaché que par des filaments, ce que donne l'impression de quelque chose moins tumorale, et plus de thrombose." There were little areas of liquid visible where the mass attached to the heart wall, which is normal, since there is liquid in her belly, and it appeared now that the mass was attached by filaments, and not to a tumor. This, she said, does give the impression that it is a clot, and less a tumor.

"Mais les filaments peuvent être cancereux," I asked. She nodded. They could be cancerous, too.

It was also much darker in appearance, indicating that her body was doing what it is supposed to and working to degrade the clot part by lysis, which confirms it's appearing to be smaller. New clot formation shows as white areas, and when Dr. Gouni showed me the images later, I could see that it was no longer white, only white in small areas.

She pointed to the valve in the right heart, visibly opening and closing with the beats of her heart, but there was no valve visible on the left side. The mass is keeping it open, all the time. She thought she could see a bit of it, and I could see a white bit, similar to those of the valve on the right, held close to the wall of the left heart. She explained that this can damage the valve, and that they have a valve ready for Baccarat, in order to replace hers if it is determined necessary.

"On préfère ne pas le faire," she told me, "si on peut l'éviter. C'est déjà une intevention très --"

"Lourde," I finished, trying to be helpful. She nodded.

"Oui, très lourde. Si on peut éviter de faire plus, on l'évitera pour elle, mais je pense que la valve doit être bien abîmée."

"On peut avoir l'impression d'être chez le garagiste, avec le remplacement des valves," I joked, weakly. She smiled and explained that the valves are given to the research center by the laboratories. They use them to do research. This valve had been given to them; it is worth 6,000 euros, but we would not pay for it, and it was, she explained to me, already prepared for another dog, who was to have been operated on at the beginning of the month. The owner never showed, and never called. They could not reach her. She and her dog disappeared.

"Le chien," she told me, "fut un Labrador." I already knew that.

But, Baccarat will never need that valve. The phone rang some minutes ago, too early. Too early for good news. Baccarat had a hemangiosarcoma, possibly a rhabdomysarcoma (embryonal) and it was bad. They had removed the tumor, and they could wake her, but it would come back, maybe as soon as in only two weeks.

I understood. It was time to make the decision. I knew what my husband thought, and I knew in my heart that he was right. Even if a dog's threshold of pain is much higher than ours, we would put her through recovery only to see another tumor replace this one in less than a month, only to have to let her die later, when she could go now, knowing nothing more than what she has been through already, after our afternoon yesterday, when I had told myself to live each minute, see the colors, feel the warmth of her body against my legs, the weight of her head on my arm, watch her eyes and her expressions to never forget them.

I handed him the phone.

She is gone now. We will pick her up later. They asked if they could keep her heart. It doesn't happen often that 4-year-old dogs are diagnosed with hemangiosarcomas or rhabdomyosarcomas, much less that they are operated on. Her heart will give them information, and perhaps her case will one day help another dog, another family. Perhaps the University of Colorado and the University of Pennsylvania's veterinary clinical studies will yield hope for preventing or curing hemangiosarcoma before anyone else has to watch their beloved animal go so quickly.

We will take her ashes to la Moraine, and leave them under the peaks of l'Aiguille Verte and Les Grandes Jorasses, where we walk under the boughs of the giant firs and feel the sky like a ceiling just above our heads. I am tempted to lie down on the earth there, as though it has a special power to bring peace and safety. It was her favorite place to run and play, in the snow, pushing her head and cheek into it like a snowplow, rolling, running, jumping in the deeper snow until I thought her heart would burst. Let her lay down there to become part of the mountain, the firs.

The mountains offer another form of peace, the rest of eternity. While I walk through the forest at their feet and feel the urge to lie down on that cold earth that beckons kindly, watched over and protected by the eternal peeks and soaring trees, promising to cradle me gently under the night sky, others climb the rock faces and the glaciers and find their rest and safety below the cold ground and snow.
-- "Rest", The Sisyphus Journals, February 24, 2009,

She will always be there, waiting for us, Sam and I.
....

ENVA d'Alfort, Day 6, An education I don't want

Sam joins me

Today was harder. Baccarat seemed a little sadder, but maybe that is only because I might be. Perhaps she was the same. They always ask me how I find her each time I visit with her; some days (I can say that now; it has been a week that she has been hospitalized), she seems more perky; some days, she seems deflated, resigned, sad.

Or, that is I who feels that way.

It's the wait now that is hard. I can see that now. In the early part of the week, we were busy. We were busy with the first echocardiograms and sonograms, blood tests and x-rays. Then, I was busy calling pharmacies looking for Fraxiparine (a form of Heparin) and going to get it. Then, I was busy getting Rapide's blood drawn and taking it to the lab out here for the D-dimer test. And, finally, I was busy waiting for the results of all the tests, busy being with Baccarat when I could, or driving to and from the CHUVA at the Ecole Nationale Vétérinaire d'Alfort (l'ENVA d'Alfort).

Yesterday, we learned that there is certainly a tumor under the 5 cm blood clot clearly visible in the right atrium, or l'oreillette droite, of her heart.


At its size, it fills the chamber, and it protrudes through the tricuspid valve into the right ventricle, as well as nearly covering the valve of the vena cava, from which blood returns to the heart to be pumped to the lungs for oxygenation before being returned to the left heart to be pumped into the body. Watching the images on the echocardiogram machine, you can see that there is still blood flow, but it is severely restricted through the tricuspid valve, with some blood backing into the vena cava when the tumor shifts toward the valve. Baccarat is fatigued from a lack of oxygenation, and this is why she cannot walk very far at any time, and shouldn't. Calm and rest are the best thing for her, as well as staying cool, so that the demands on her heart are kept to a minimum. It looks like depression.

Now I think of all those days before she stopped eating, when I called to my husband or Sam to come see how cute she was, appearing to deal with the terrible heat with grace, when she was actually suffering from a tumor of the heart. It wasn't cute at all. It was the earliest signs of what could be a hemangiosarcoma, the least cute thing imaginable for a dog. Since there is no question that there is a tumor, the best we can hope for is a hemangioma, the non-malignant form. If it is an hemangiosarcoma, they will close without removing the tumor because it is an highly aggressive, high-grade soft tissue sarcoma that metastasizes very rapidly throughout the body, attacking the blood vessels. According to the Canine Cancer Awareness Organization:

Hemangiosarcoma is insidious, as it attempts to build it's own blood vessel network, making blood blister like formations which disrupts normal organ function. It is commonly in the advanced stage before detection, making it virtually a silent killer.

It's once you know your dog has a heart tumor that you know the signs that would have helped you help your dog much sooner had you known them, but you must forgive yourself because it is rare. It is especially rare in 4-year-old Labrador Retrievers, although their cousins the Golden Retrievers and German Shepherds are the two breeds most likely to develop this kind of cancer.

I asked before Sam and I left today if I had understood correctly that if the biopsy shows the tumor to be malignant that they simply close, leaving it in place. The young student, who is usually as quiet as Sam can be, spoke. He told me that it is the case because it metastasizes so rapidly and is not considered treatable. They can try chemotherapy, but in most cases, it will not save the dog.

"Et, ça, cette forme de cancer, elle s'appelle comment encore?" He answered me, but I couldn't retain the word. I was embarrassed. It happens when I don't actually want to be having to hear something. A friend who is a breast cancer specialist tells me this is typical; they know that as soon as they say "cancer", the patient can hear only 1 of 5 words. She modulates the way she speaks to help the patient hear and retain more. I had to ask again and force myself to pay attention to the reply, begging my brain to remember.

"Hémangiosarcome, si c'est malign. Hémangiosarcome. C'est rare."

I only remembered that it began with "h" and ended in "sarcome" by the time we were out on the street. It was alright. I had understood enough, I have a doctor at home to ask, and Google. I could find it again, now that I knew what to look for, and it turned out to be an education I wish I never needed.

According to the information on the Canine Cancer Awareness Organization's site, which cites current clinical studies at The Animal Cancer Center at Colorado State University and The University of Pennsylvania, Department of Clinical Studies, there are three types of hemangiosarcomas, dermal, hypodermal and visceral, with the type where tumors form in the heart or on the spleen being visceral, or the most lethal form of hemangiosarcoma. Again, from the CCAO site:

Visceral Hemangiosarcoma accounts for 2% of all reported malignancies and up to 5% of all noncutaneous tumors in dogs. Although these numbers seem small, they have a significant impact on dogs, since this form of cancer kills. The spleen and the right atrium of the heart are the most common sites of occurrence of visceral Hemangiosarcoma. Dogs may have nonspecific signs such as lethargy, loss of appetite, weight loss or more specific signs such as difficulty breathing, pallor, or abdominal fluid. Regardless of the site of origin, visceral Hemangiosarcoma is locally invasive and highly metastatic. Up to 25% of dogs with splenic Hemangiosarcoma have cardiac Hemangiosarcoma and up to 63% of dogs with atrial Hemangiosarcoma have metastatic disease. Metastases commonly affect the lower mesentery, lungs, and brain.

This was terrifying to read. Baccarat's tumor is in the right atrium, although the spleen, or la rate, is normal without any sign of metastases at present. She had all of the nonspecific signs of a hemangiosarcoma except the pallor. When she was first seen at our nearby clinic, the vet found her pale, but by Monday, the vets at the CHUVA did not, and they still do not, although they check her gums regularly. Her lungs also do not show signs of metastases. Her brain has not been scanned. She could, nonetheless, not yet have developed metastatic disease. I turned to my husband, who was stretched out on the sofa, his back in an analgesic position, watching the Tour de France.

"C'est difficile à penser que la tumeur ne soit pas maligne quand tu lis sur le hémangiosarcome," I said.

"Ca n'a pas l'aire bon," he replied. I nodded and looked back at the computer screen, scanning the words for something that said "bénign". There was nothing. I Googled benign heart tumors, and I found information on myocardial tumors on PetMD.com:

Myocardial tumors refer to tumors that specifically affect the heart. These types of tumors are rare, and when they do occur, they tend to occur in older dogs. Benign tumors are masses of tissue that do not metastasize, whereas malignant tumors metastasize throughout the body. Abnormal tissue growth arising from the blood vessels in the heart can be malignant, as with hemangiosarcomas — rare, rapidly reproducing tissue growths; or they may be benign, as is the case with hemangiomas — harmless growths consisting mainly of newly formed blood or lymph vessels.

"Il y a aussi des hémangiomes," I said to my husband. "C'est la forme bénign, et ce sont des masses faites des vaisseaux sanguins ou lymphatiques récemment formés, mais dans l'atrium, c'est peut-être plutôt un myxome à ce moment-là. Ca existe aussi, et les symptoms sont pareils."

"Même l'amaigrissement?"

"Oui, car il y a aussi un manque d'apétit." I returned to reading the first site. "En plus, il y a plusieurs signes qu'elle n'en a pas. Avec un hémangiosarcome, l'ascite à la même apparence que le sang, et la liquide dans son ventre c'est du sérum, plutôt taché du sang. En suite, c'est souvent accompagné par un coagulation dissimulée intravasculaire, ou CDI, ce qu'on vient d'apprendre qu'elle n'a pas avec le D-dimer. Aussi, son sang coagule normalement tandis que le sang dans le cas d'un hémangiosarcome ne coagule pas. Elle ne sagne pas visiblement non plus, comme du nez, par exemple. C'est peut-être bénign après tout, et elle est si jeune," I added, hopefully.

"Peut-être," he said, before drifting off to sleep, while I continued to read, trying to convince myself that her chances were as good that it was benign as that it was malignant from all the things she doesn't have, such as liquid in her abdomen that looks like blood, a blood disorder called disseminated intravascular coagulation (DIC), which did not show up from her D-dimer results, blood that does not coagulate (they found her coagulation rate normal last evening), and no visible bleeding, such as nosebleeds. And she is young for a malignant cancer, they say.

Before I left her with the two students, who were preparing to take blood again, the young woman told me again that they are doing everything they can to move up her surgery date from the 27th to next week. It all depends on being able to get the person who runs the cardiopulmonary bypass machine, which are "pumps are operated by allied health professionals known as perfusionists in association with surgeons who connect the pump to the patient's body." See Wikipedia, http://en.wikipedia.org/wiki/Cardiopulmonary_bypass. Here in France, a perfusionist is called a "pompiste", and there are few of them to begin with, but particularly few available in the vacation months of July and August, with the first availability being July 27th.

I suppose the only way they can move the date up is to beg someone to make him or herself available when they are already fully booked, which I hope the surgeon and the veterinary cardiologists can succeed at doing. It is especially hard when they cannot charge for their time. They are doing this for the glory of clinical science and from their humanity.

Baccarat needs them now, but she will wait patiently, if she must. But, she is getting depressed, as kind as and attentive as everyone treating her is, and as much as we go to spend visiting hours with her every day they have them. It's hard to be in the hospital, away from everything and everyone you know.

Hang in there Baccarat. Nous t'aimons si fort.

When we left, Sam was hungry. I was, too. If Baccarat didn't want her "very appetizing pâté", we wanted something.

"I think there are some brasseries that way," I said to Sam, pointing across the avenue Générale de Gaulle, towards the grocery store, where I had done my shopping the other evening. Sam looked off down the avenue.

"There's one there," he said. "But, there are probably nicer places in Paris." I thought about getting back on the bike and heading into the city for lunch, which would be nice, and then I thought about Audouin, waiting for us at home. "Wait, we're where? On the southeast side of Paris?" He shook his head. "There's not really anything there."

We crossed the avenue and passed an animal supply store and the post office, turning in to where the grocery store is.

"There's the Casino."

"Do you want sandwiches or something there?" I asked, not trying to sound enthusiastic and glancing around for signs of the village center and a place to sit down for lunch.

"Not really."

I turned left onto a road that branches off the traffic circle at the entry to Maisons-Alfort, and we walked along, past a fruit and vegetable stall, a boulangerie all in pink, with tables on the sidewalk, and on under the train overpass, past some sort of restaurant, Japanese I think, closing for renovations, and on a bit farther, scanning the storefronts and awnings, the street signs, looking for signs of something promising.

"Mom," said Sam, interrupting my search. "Where are we going?"

"I don't know, Sam. We're looking for where the shops and cafés are. There must be some." I looked across the street, and there was a wine bar ahead, and some tables set up on the sidewalk, the storefronts set back from the sidewalk. "Like that, there's something there. What is it?"

We saw the word "bagels" at the same time, and Sam grinned.

"We'll go there?"

He was already crossing the street, toward bagel, ham and cream cheese sandwiches, Vitamin Water, milk shakes and cousins of Frappucinos.

"Who'd have thought a place like this would be here, in Alfortville?" he mused, reading the chalkboard menu on the wall.

"See, Sam," I said, "sometimes you don't know where you are going, and then you find what you would have been looking for, I mean, if you knew it were there."

"What's pastrami?" he asked. I realized we'd been away from New York for a long time and explained. He listened and decided on the ham and cream cheese.

We sat, alone, up in the mezzanine at the rear of the shop, Sam still feeling chilled from the ride in, and probably the emotion, the unseasonable temperatures in the 70s, a breeze, and maybe from being hungry.

"I haven't had cream cheese since we went to London," he said, chewing his sandwich.

London. That was a little more than 2 years ago. I nodded, trying to remember where he'd had cream cheese, but he interrupted my effort to remember, saying, "Maybe I'll go to New York after my license, Mom. I can eat food like this, get to know the art world there, and work on my photography full-time, get a job at Element. If it doesn't work out, I'll do my law degree."

"Don't you eat that stuff when you go to that American restaurant -- what's it called? And aren't there bagel and cream cheese places all over near your old school?" Of course there are, but they aren't on every street corner, everywhere you look, whenever you happen to want one. "And, you know, they have bagels in the Marais, the authentic Jewish bagels."

"Yeah, but they're braided and have poppy seeds." His attention was back from NYC.

"They probably have plain ones, too. Or at least just with sesame seeds."

Bagels.

He's still a New Yorker somewhere in his soul, and bagels are always in NYC, where they are everywhere, anytime you want one, with whatever you want on it, where they were when he was a child. Anywhere else, well, they're a reminder, a symbol for what they are: part of an unretrievable past. And when we understand that the past is unretrievable, we may chose to understand that the only thing left it to greet the future and live today.

....