The other patient

The koi in its Nifurpirinol bath, Day 13

It could really use a name now, couldn't it? I am nearly certain it's a female, but not enough to commit to a name. Maybe I should call it George, as in George Eliot.

No. That stinks. I'll just refer to it has "he" and "him" until I have a better idea.

I need to put together a series of photos, from the first day I put him in quarantine and began salt and anti-bacterial/antibiotic treatments to the present, to see if he really has improved as we think he has. His eyes seem to be less protuberant, and there is a less marked difference between the scales of his body from those of his tail, which is also to say that the scales of his tale now seem to stick out a little, too, but the rest perhaps less.

I pour over pictures of different varieties of koi, looking to see if his scales appear normal now by some variety standards, and one very encouraging thing is that the enlarged blood vessels around his right eye that appeared just after I began treatment disappeared within a couple of days of treatment, and they have not returned. Another is that he appears no worse, if not necessarily certainly all better. He is lonely in his quarantine tub, but that is better than dead. Sometimes he comes out when I come to visit him. He also seems to accept my removing him when it is time to change his water, to which I add a Nifurpirinol tablet, in addition to the salt, to his water, and I am no longer doing the concentrated, brief Nifurpirinol baths.

I am not sure he is eating anything, but that's probably just as well for his system, and besides, hiding all day behind his rock and plants doesn't require a large amount of calories. If he continues to do as well, I will return him to the "bassin" in a week or two and see how it goes, but don't say anything to him; I haven't told him yet, and I don't want to get his hopes up.

It's time to leave to go see Baccarat for the afternoon. It's her last afternoon before open heart surgery, and I am doing things I don't recognize that I am to stay calm. I don't know what you call it, but it's a lot like that afternoon when I knew Audouin would come home with the lab results for my melanoma. I remember thinking, up on my ladder painting the Orange Room, "Soon, you could get news that will change your life forever. You could learn that you won't live much longer," and I looked out the window at the sunshine in the flowers, the dogs and Shadow sleeping on the lawn, and myself spoke to me, Just enjoy this afternoon, this moment. It's what you have, and I felt peaceful, happy.

Sometimes, that's enough.

This evening, Sam will call me when he finishes work, and we will meet up on the Champs-Elysées to go see Toy Story 3. Like he was just the right age for Harry Potter when it came, and made a reader of him, he was the right age for Toy Story, so that 11 years later, when Andy is going to college and leaving his childhood room, so is Sam. We'll spend time together and enjoy that, and tomorrow will bring what it will. Each moment until they have the result of the biopsy is a moment of the present, when Baccarat is still alive and there is hope.

Everyone knows that it is already almost a miracle that she is still alive with this mass taking up nearly all the space inside her right heart, reducing the blood flow to a trickle, her circulation to a a stream in the desert. Her heart could fail at any moment, her brain be destroyed, but say the name of one of her beloved people, and the head darts up, the tail starts.

"Baccarat! Guess who's coming to see you! Sam! Sam's coming to see you!" and the tail is going. Everyone laughs because I could tell her in the same tone of voice that we were going to force feed her some more of that protein-rich food, and she'd stare out past the legs of the chairs and people and sigh heavily. She is still there.

"C'est un bon signe," they tell me, "qu'elle se bat. Elle aurait pu se laisser aller, mais elle reste avec nous et elle s'intéresse; elle se bat." It's true. She could let herself go; she could let herself die, but she is interested in what is happening around her, and she is hanging on.

"L'hôpital va lui manquer," I laughed, "Parce qu'ici, l'où elle va, elle est accompagnée par tous ses amis, un petit groupe d'étudiants, d'internes et de résidents! C'est très agréable!"

And, this is true, too. She will miss the hospital and all her friends there because wherever she goes, she is accompanied by a small troupe of friends, students, interns and residents. It is very nice to be so cared for.

Tomorrow, the car will take her and two vets, including Dr. Gouni, to Montsouris. At noon, the perfusionist will attach her to the cardiopulmonary pump, and they will begin open heart surgery. She is one of the very few dogs ever to undergo this surgery, which would be out of the question in the United States. Even here, where the surgeons are donating their time in the interest of trying to save her and to learn more, it is going to cost more than my son's lycée, as much as one year of his school in Paris during collège.

"There is no price that can be put on her life, Mom," he tells me again and again.

"There is, Sam. For everyone, there is a limit, a moment when they cannot spend any more. They just can't. For us, we are willing to make this sacrifice because she is so young, and because we love her, you love her so much, but for others, for most people, it would be out of the question." It is hard for him to accept this.

"Il faut être un peu psychologue dans notre travail," said Dr. Gouni yesterday, as I filled out the papers and wrote a check to IMM Recherche. My fingers spelled the sum out easily. I didn't need to make a list of all the things I could live without to make it possible. Like my friend said, we can eat potatoes for a couple months. "La plupart des gens ne pourrait pas se permettre de payer une chirurgie et les soins. On le sait et on leur n'en parle pas." One must, she said, be a bit of a psychologist in our work because most people could not pay for this surgery and the medical bills. We know it, she said, and we don't even suggest it to them.

"Je pense au chien," I answered. "Il n'a que son amour à offrir à son maître. Il n'a pas d'argent pour payer quoique ce soit. Si son maître est en train de mourir d'un cancer, on ne lui demanderait jamais de payer ses soins, de lui sauver la vie, alors, pour lui, c'est normal qu'on lui offre ce qu'on a, l'amour et de l'accompagner dans le temps qu'il lui reste. C'est bien à ses yeux.""

I think, I told her, of the dog. He has no money to pay for his master's medical bills were he dying of cancer. He only has his love to offer, and he will give it until the last. So, for him, it is normal that we only offer him the same if it is all we have. It is good in his eyes.

I need to go now. I am late.
....

ENVA d'Alfort, Day 8, Thursday

Resting

The surgical team at the Institute Montsouris, or IMM Recherche - CERA, has been able to move Baccarat's surgery up to Thursday. Five days sooner.

The studies undertaken here are large animal veterinary, as I understand it, but it is part of the Institut Mutualiste Montsouris, which is a human medical center in Paris. We are assured that they have state of the art technology and techniques, that the team operating on Baccarat operates on human beings in cardiovascular surgery, and that medically, we have the best possible care available.

This, I do not doubt. I knew that the moment we were referred to the Ecole National Vétérinaire d'Alfort.

This evening, after Dr. Gouni came to find Baccarat and I and give me the estimate for surgery, I was sitting at the edge of Baccarat's cage and listening to the older couple who had come to see the dog in the cage next to hers, a dog that lies there on its inflatable pad and twitches. She has neurological problems, among other things, they told me. Her chart said that she is sweet, but you must get her attention before touching her. Baccarat's chart said, under temperament, "Gentille", but today it read "Très gentille". Their dog had been operated on and was still recovering. They were older than I am. Well dressed. They bent into the cage, rather than sitting on the edge, as I did. She was worried. He seemed pragmatic, concerned, self-possessed. He exuded knowledge and confidence.

"Vous êtes médecin?" I asked. I already knew the answer.

"Oui," he nodded. Of course.

"En quoi?"

"Rhumatologie," he replied. I noted his suit without tie, shoes. The red thread at the lapel button hole indicating his membership in the Légion d'honneur. Something my husband, who wears jeans and long-sleeved cotton t-shirts to the hospital, to protect his arms from the polyester mix of the "blouse blanche", would refuse. I wondered how he had earned it, thinking he was probably a professor of medicine. I noted his well-coiffed, somewhat long gray hair and nodded.

"Mon mari aussi. Il est obstétricien-gynécologue." He nodded and looked from me to Baccarat.

"Elle va être opérée," said his wife, looking over from her dog. "Elle a une tumeur dans le coeur."

Her husband knew. I had told him while she talked to her dog. 18 years old, they had found her in a forest when she was 2, 16 years ago. I thought of Wisp, also found in the woods, and who is becoming mentally unstable since Baccarat has been hospitalized. This morning, walking up the stairs to clean Sam's room -- I know, don't tell me; I am hoping to install better habits before he gets his own place --, I smelled a smell. It was only when I got in the bathtub to take my shower before leaving for Maisons-Alfort that I noticed the smell again, particularly strong in the bathroom, and saw the pile of cat poop deposited in the corner between the tub and the window.

Damn it, said myself. Now what are we going to do?

"Clean it up and hope Baccarat makes it, because if she doesn't, we've got a serious problem developing."

"Elle a beaucoup de personalité," said the rhumatologist, "ça se voit dans ses yeux." His wife looked around again into Baccarat's cage.

"Elle est si belle," she said. "Elle a des yeux si communicatifs."

"C'est exactement ça," I said, nodding, and looking back at Baccarat.

It was only after they left and the student who has been caring for her since she arrived came and knelt next to me, after having asked with a big smile if I had been told, Baccarat would be operated on on Thursday, reaching in to caress her head, and said, before getting up to leave, "Vous pouvez rester le temps que vous voulez," that I broke down again. I stroked her head, while she lie there, resting, her eyes closed. She glanced at me. I reached for the scarf in my bag from the motorcycle and buried my face in it, wiping my tears.

The veterinarian on rotation in medical hospitalization came in. She had come to find me outdoors earlier and introduce herself, and now she stood there smiling at me. They hold us up, too. They encourage us, and they tell us to bring our families; we have to prepare ourselves, see our beloved animal before the surgery because, if it is very bad, it will be kinder not to wake her up only to suffer the pain of recovery for nothing.

I knew what she was going to say; my husband had anticipated it, and Dr. Gouni had said it. I said it before she had to. She smiled at me, and I looked at her eyelashes. The length of them. Their color. The spacing between them and their curve. Her eyes. I looked at her lips as she spoke and smiled. I wondered if I would be able to recognize her again, seeing all of her face at once. I could only see pieces of her. Could she tell how I was seeing her? I could hear her.

"Si," Dr. Gouni had said, "c'est très, très méchant, il serait peut-être mieux de ne pas --"

"La réveiller," I finished. "Je sais. Mon mari me l'a dit. Je fais confiance à l'équipe médicale et chirurgicale." She nodded.

If it is a not so very bad, but malignant, they will remove it, close and let her live out the time she has.

We know it is decided already. Prayers no longer serve any purpose. They never did. It is what it is, benign or malignant. Love and support are what we need. Caring eyes and compassion.

Hope will help until the phone rings sometime around 4 pm Thursday, but we are told that we must prepare ourselves. The new vet and I looked at Baccarat, and my eyes filled with tears again.

"On se demande seulement comment, comment cette chienne si pleine de vie et si jeune aurait pu avoir cette tumeur."

"Elle est déjà une chienne spéciale. Ca se voit dans ses yeux si expressifs. Elle va vers les gens. C'est clair qu'elle est bien avec les gens, et elle se bat. Elle ne se laisse pas aller, et cest très important," she said. She is right. Baccarat is fighting to stay with us. She is not giving up, lying down to let herself go.

"Je vais la laisser dormir, se reposer," I said.

"Oui, et nous allons bientôt faire ses soins du soir," she said, smiling again.

"Je serai là demain, et après demain, et mon fils aussi," I told her, "Mon mari est de garde à l'hôpital mercredi. C'est bête. Peut-être il va pouvoir me joindre demain soir." She nodded, and left me to say good-bye to Baccarat.

I had to stand and shut the glass door on her cage. She watched me, her eyes never leaving mine. I smiled. I wanted her to know that it was alright. That I believed it was alright.

"Je reviens demain, ma Bacs. Je t'aime."

I walked down the corridor, and on down the stairs, out to my motorcycle, waiting in the sun on the wide sidewalk along the avenue.
....

ENVA d'Alfort, Day 4, a heart tumor

In the refuge of the shade of a plant

Baccarat has a diagnosis. After days of tests and results and more tests and more results that ruled out kidney and liver diseases, infections, deep intravascular coagulation, pulmonary embolisms, and thrombosis, Professeur Chetboul, who I have not met, spoke with the cardiac surgeon who would operate on Baccarat at the Institute Montsouris in Paris and called the veterinary cardiologist who has been following Baccarat with her and the chief of staff, Dr. Gouni, to tell her that according to the cardiac surgeon, if the clot is in the atrium and not moving, it is what they thought it might be, a clot formed over a tumor.

It is nothing else, and the course of treatment they have been pursuing will not be helpful, necessary as it might be to keep her stable until she can have surgery, which is the only option available to save her.

I listened to Dr. Gouni, the resident and student listening alongside, Baccarat on her green cotton tape lead at the student's feet, tired, while she explained that because Baccarat is so young, only having turned 4 last Saturday (she was born the day Zidane was given a red card for his head butt in Materazzi's chest and France lost to Italy, unfairly and undeservedly in 2006), there is a good enough chance that the tumor is benign to justify operating. Because of the size of the clot, they will have to use a cardiopulmonary bypass machine to reroute the flow of blood around the heart during the surgery. The hope had been able to give her the anti-coagulant Fraxiparine to prevent the clot from getting any bigger, while her body's natural process to degrade clots, or fibrinolysis, went to work to possibly make it small enough to operate by clamping a portion of the atrium, but the cardiac surgeon ruled that out owing to the tumor. We cannot know it's size.

Because the lump appears not to be connected to the heart wall, it is possible that it is relatively small still, or some kind of tumor my husband named that I cannot remember, but a tumor it is.

Dr. Gouni went on to explain that if Baccarat were 10 years old, they would not recommend surgery, since there would be as much as a 95% chance of the tumor being malignant.

They will be able to perform the biopsy on the tumor while Baccarat is on the table and have the reply immediately. If it is benign, they remove it and whatever part of the heart muscle they need to and close. She would then have a complete recovery, and little chance of a repeat occurrence.

If it is malignant, they will close.

"Dan ce cas, on peut discuter les options de traitement, chimio --" offered Dr. Gouni, a little reluctantly, it seemed to me, and I shook my head.

"On ne ferait pas ça." The intern smiled sympathetically and nodded her head. Dr. Gouni nodded, too.

"On pourrait lui laisser le temps qu'il lui restera à vivre -- " I nodded.

"Oui. Je lui laisserai le temps de vivre chez elle, et puis, on verra." There would always be time to have her put down if she began to suffer too much. They nodded.

The issue for now is that there is not a doctor specialized in operated the cardiopulmonary bypass machine, or "un pompiste", available until July 27. The surgeon wants to operate as soon as possible because Baccarat's condition is too fragile. They offered me to take her for a little walk outdoors again yesterday, and while she seemed stronger, choosing by herself to get up and move around more from time to time, she had diarrhea and vomited. These are signs that gave pause to Dr. Gouni. It indicates that she has low blood pressure, which they confirmed. Spots also appeared on her shaved belly during the afternoon that indicate internal bleeding. They ran platelet counts to determine whether she should still be on Fraxiparine and adjust the dosage. She will take no more walks. She can walk with me to the cardiology waiting room from her cage and sit there together.

I asked if the cardiac surgeon, who operates on people in a hospital for human beings, is not put-out to operate on animals.

"Oh, non!" said Dr. Gouni. "Il l'aime beaucoup. D'abord, c'est moins stressant que d'opérer sur un enfant" for example, her tone implied, "et puis il aime les chiens, surtout les Labradors. Il en a lui. Aussi, c'est dans le but de la recherche."

Baccarat's surgeon loves Labrador Retrievers. He is a Lab owner himself, and he is doing everything he can to move her surgery date up, and aside from being a surgeon, he is also involved in research. Baccarat's case adds to their bank of knowledge.

"Il donnera son temps," continued Dr. Gouni. "Ils ne factureront pas les chirurgiens, mais tout ce qu'on ne pourra plus utilser sera facturé." In other, words, the doctors will operate for free. We will pay the costs of materials that cannot be reused, and I don't think that amounts to very little in this case. She had guessed 2,000 euros, plus hospitalization and her current costs of diagnosis, treatment and hospitalization. It is somewhat staggering.

"You cannot," said Sam again last evening, when he called me, "put a price on life, Mom. We have to pay whatever it costs to save her."

I was getting on my motorcycle, getting ready to leave, when I happened to see rather than hear a call coming in on my cell phone, sitting on the bike. It said it was from Sam. I answered.

He was calling to tell me that he would not be going to Nanterre in the fall for law. He said it in a voice that sounded flat, possibly just an instant from being catastrophic.

But it's not possible not to be able to go to even Nanterre, myself said, our thoughts racing. They have to accept him!

"Hold on," I said to myself, "maybe it only means that he got into one of his other choices." I turned my attention back to Sam, "Sam, does that mean you are going to the Sorbonne?"

"No. I am not going to the Sorbonne."

"Oh, I'm sorry," I said, and I really was. That was his first choice, and he thought that with his English and his American culture, he'd have a chance, but these things can be somewhat haphazard, too.

Then what? asked myself, sounding panicky. Where can he be going? What's left? Can it be that he can't go anywhere?

"Descartes, Mom," interrupted Sam. "Paris 5. I got in."

I had to round up my stray thoughts, balanced there on my bike, feeling hot and vulnerable for a melanoma victim in the sun. It was lovely for a moment on an afternoon that had been sunny, then cloudy, windy. He seemed to sense that I was in need to being assisted in gathering my mind.

"I'll be in Malakoff, Mom, at Descartes."

"Are you happy? I mean, is that what you want?"

"It was my third choice, over Nanterre," he reminded me, sounding more patient with my slowness and failure to get into his head than usual. He has been feeling a little sorry for me, since he knows what it feels like to care about Bacs.

"Wait, third choice? What were your others, then?"

"The Sorbonne, Assas, and Descartes."

I had forgotten Assas. Or, rather, I had forgotten that he hadn't removed it from his choices, not that he'd need to; he had decided he didn't want to go there owing to its reputation for being cut-throat and competitive, not Sam's best learning environment, but he'd never get in, anyway. While all the public law schools, like all the public medical schools -- both of which are the best, anyway --, are supposed to be equal, Assas has a reputation for cronyism that cannot be denied in the professional world. Sam's got enough brains and personality to make up for that missed point of assistance. I am not worried about that.

"Are you sure you want to go there?"

"I can change later, if I want, and if I do well, maybe I can transfer to the Sorbonne, if I want. There is less information on Descartes' law program than on the others, but it is smaller, and I think that is better for me, and it was my first intuition to put it over Nanterre, so, here I go, I am about to click on "oui définitif". I'm clicking. There. It's done."

Can I possibly tell you how proud I am of him? He did this all by and for himself. Hours of research and reflection on himself and his options, and he made all his own choices, for the better or for the worse, but I can only believe that they will be for the better. He has this under control.

I only need to keep the currents warm under his wings.

"Do you want to come see Baccarat with me on Saturday morning?"

"What time?"

"Early, 9:30 am until noon."

"Alright." That's early for him, but he wants to see her. "Are they doing things for her to help the pain?" he asked.

"She isn't in pain, Sam. She is tired, and they are giving her all the attention, care and kindness we could hope for; they are making her comfortable and keeping her stable with everything they can do."

"There cannot be any question of money, Mom. This isn't about money. We have to help her."

I thought again of him saying that her life is far more worthwhile than all the "conneries" he could spend his money on, including the new used scooter he wants. I think now of a friend writing:

I'm with you--on every front. As a mother. The fact that Sam is moved by love for Baccarat to take a position: "Love, life--has more value than money" is both beautiful and a signal that your son has depth. What a fine man he will grow to be when this very special facet of his nature is nurtured.

And another saying:

[your husband] will pay for this for you and for Sam as you said, so don't question it. You do things for him, he does things for you, that's marriage. Have more faith!

And, finally, my sister weighing in:

I think if there is any type of decent chance that it might not be malignant and you can scrape together the money that you should do it. I know [my husband] is squarely in [your husband's] corner. He thinks it is unfair to the animal to put them through all that. I guess I would say the most humane thing is to do what is in Bac's best interest.

This morning, I told him that it is about money for many people, for nearly everyone. It unfortunately has to be because money is never unlimited, and it depends on each person or family's resources where they have to draw the line. We would have to draw a line somewhere, too. It's hard to know when, but it isn't now for us.

Baccarat will go to Montsouris, if nothing happens between now and then, whenever that will be, and she will have cardiopulmonary bypass surgery to remove a tumor, if it is benign.

I have to hope.


....