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 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.

....

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.


....

Any port

Wisp, in Rapide's neck

This is where she normally seeks comfort, only in Baccarat's neck. Any port, as they say, in a storm. Her dog has disappeared, and Rapide is wondering when it will be her turn to suddenly leave and not come home again. She is as nervous and jumpy as a cat on a hot tin roof. All I have to do is touch her when she can't see my hand coming, and she tenses and leaps into the air. I have to remember to announce my intention to reach out, from where she can see my hand, and then touch her.

What a lot of anxiety and loneliness one dog's illness and being hospitalized can create.

This morning, my husband tried to draw the vial of Rapide's blood necessary to serve as a control for Baccarat's D-dimer results. We are in the "jamais vu" in veterinary medicine. A D-dimer blood test is used to rule out a pulmonary embolism, deep venous thrombosis or disseminated intravascular coagulation (DIC), or, in other words, the presence of other blood clots (thrombi) in the vascular system. Basically, they are looking to see how much D-dimer is in the bloodstream.

This is not a veterinary blood test, as the incidence is non-existent in dogs, being more common in cats, but possibly still statistically small, and so the test has had to be done in a lab for human blood testing. Happily, the lab with which my husband works the most does test animal blood for our local veterinary clinic, and they agreed to perform the D-dimer, charging us for one test, instead of the two needed. However, the results indicate normal and elevated levels for human beings, and we cannot be certain of normal in canines.

This rather amazed my husband, but you also have to consider that the D-dimer test was first described, according to Wikipedia, in the 1970s and its clinical application discovered only in the 1990s. That it hasn't been established for non-existent cases in veterinary medicine is not, then, wondrous. Rapide and Baccarat would offer some information to veterinary cardiovascular science should Baccarat's levels differ significantly from Rapide's, and their comparison to human D-dimer levels would be interesting.

D-dimer is a fibrin degradation product, or a small protein, that is present in the blood after a blood clot is degraded by fibrinolysis. If there is a lot of D-dimer, chances are good that the body has been busy degrading blood clots, meaning that there is the possibility of a thrombosis, or an illness tending to produce blood clots. If Baccarat's blood sample indicates a higher than supposed normal level of D-dimer, we can suppose that there is another clot, or more, elsewhere in her body, that she has suffered a pulmonary embolism, or that she is suffering from DIC. It is nearly certain that if she is, it is not a severe case yet because there is not the bleeding that accompanies severe DIC. If it is mild DIC, the possible causes are several, with only some being likely or possible in Baccarat's case:

• Cancers of lung, pancreas, prostate and stomach, as well as acute myeloid leukemia (particularly APML)
• Obstetric: abruptio placentae, pre-eclampsia, amniotic fluid embolism
• Massive tissue injury: Trauma, burns, extensive surgery
• Infections: Gram-negative sepsis, Neisseria meningitidis, Streptococcus pneumoniae, malaria, histoplasmosis, aspergillosis, Rocky mountain spotted fever
• Miscellaneous: Liver disease, snake bite, giant hemangioma, shock, heat stroke, vasculitis, aortic aneurysm, Serotonin syndrome^[9]
• Viral: Arenaviruses causing Argentine hemorrhagic fever or Bolivian Hemorrhagic Fever

A cancer has been ruled out, at present, and Baccarat has been spayed, so obstetric causes are not in consideration; nor has there been any trauma. There are no indications of infection, either, and the hepatic results show a normal liver. There are no lesions to indicate vasculitis, which is common in dogs and horses, and Serotonin syndrome can be ruled out, as well, because it is an adverse drug reaction, and Baccarat has not been on any medications. An aortic aneurysm has not been mentioned, since there does not appear to be anything abnormal with the thoracic aorta, and I believe they have looked at the abdominal aorta in the abdominal sonograms performed. As far as snake bite is concerned, we cannot be certain that there was no poisonous snake bite, but she has demonstrated no pain, we have seen no swelling or oozing blood-like liquid from a snake bite site, and there have been no neurological indications.

This tends toward what the veterinary cardiologist has been suspecting, should the D-dimer level indicate DIC, which is that Baccarat possibly suffered heat stroke.

We are obviously hoping that the D-dimer level matches Rapide's and tends to correspond to normal levels in humans.

Last evening, after the finish of the 10th stage of the Tour de France, which we watched collapsed on our respective sofas, the healthy animals draped over furniture, cushions and each other in similar repose, we took Rapide for our old walk, down on the path along the edge of the fields where they end at the bank of the Seine. We went as far as the little stone-covered beach under the willows and other trees I cannot identify, or haven't bothered to, and Rapide waded in the cool water, while my husband sat up on a bench and rested his back. It has been hurting again. I watched Rapide, and I remembered all the walks we took there, moments spent watching them play in the shimmering river, back before Baccarat tried to bring back one too many stinky, foul dead things she'd scarcely fail to find, or, worse, to roll in, like her mother.

I thought about how precious moments are, and how even if we know it at the time just how precious they are, one day they will be unrecoverable, memories only, and they will sear the throat and heart, and the greater the joy and beauty, the greater the pain.

I thought about taking Baccarat and Rapide to walk along the Seine from the vet's, past Sam's lycée, and on a little farther toward the bridge to Limay Monday morning, and how I could see the Ile aux Dames, where the tennis club where Sam used to play is, and how I used to bring the dogs to walk in the park and wait for Sam's lesson to be finished. I had wanted to get there, to sit with them in that park again, but Baccarat could go no farther than halfway up the stair to the bridge, and then she found a damp spot in the shade and let her front legs slide until her belly touched the stone and she did not get up until I had to try to get her back to the vet for care.

We sat there and I looked at where the club would be, on the other side of the bridge, and I thought about how those moments are unretrievable, part of another part of my life as a mother, and how Sam has joined me as an adult, ready to care for our dog with all the love he has learned he has for her. I wanted to run to that parking lot and sit there again in my car, see him walk up the gravel path between the courts, his racket over his shoulder, his curling hair long over his brow and down his neck, a can of coke in his hand, won because he beat everyone, ready to tell me again how they are lousy, anyway, but he started too late to be one of the chosen players. I looked at Baccarat, and I thought about how that Sam is gone, just like she might soon be gone, a memory, photos, the stories we can tell, and I felt almost desperate against the nostalgia you have to fight.

Go on, only on. Love and let the future take care of the past and the pain.

Rapide came to my side and looked at me. It was time to join my husband up on the bench. I told him, my voice so tight the words could barely come out. I looked at the opposite bank, the water flowing by. He touched a tear that hung from my lower lashes and threatened to betray me by being followed by another, running down my cheek.

"Je pense," I told him, "que ce n'est pas pareil pour toi qui passes ta vie à l'hôpital, où les jours sont les mêmes sur toutes ces années qui filent, mais nous, les mères qui peuvent, qui sont avec leurs enfants, même si on travaille, qui les amènent à leurs activités, qui s'en occupent tous les jours, on vie ces périodes, ces phases, on doit les laisser passer pour vivre la prochaine et un jour la voir passer aussi. On a tant de petits deuils à faire, et on doit se battre contre la nostaglie tout le temps ou couler."

He considered a moment. I glanced at him and saw him looking out over the Seine, as well. Once, my husband told me that he couldn't imagine not living by water. Twice this week, I had sat and watched the river flow by along with my memories and thoughts.

"Tu as peut-être raison," he finally said, "mais je vie des moments de nostalgie aussi, seulement, je les repousse."

"Moi non plus, je ne me laisse pas rester dans la nostalgie. Je serais trop malheureuse pour rien faire. Ce n'est juste que la coincidence entre ce moment quand on risque de perdre Baccarat et je vois Sam devient un adult, son enfance dans le passé, c'est trop fort, mais je n'y reste pas." He put his arm around my waist, and we headed back to the path along the Seine and home, to our bottom gate.

The coincidence, the terrible synchronicity in perhaps losing Baccarat at the very moment that Sam's childhood ends, is too much, but I won't let myself get lost in that. Baccarat needs me to do what I can for her, and Sam will need me in different ways, with new things to live. Ends are never so neat as that, thank heavens. They just seem that way when we are fragile.

It's time to leave for Maisons-Alfort. I'll take my motorcycle today, since Baccarat won't be coming home yet.
....

Tout bébé, notre Baccarat arrive à la maison

Puppy butt, 9 weeks
September 13, 2006

It's time to pull out her baby photos and share them again. She hasn't changed, only gotten bigger. At least, given the number of hours I have spent staring at her and photographing her, I can see Baccarat today in the little thing she was when she first came home with her mother.



I dreamed this morning, as the rain fell on Bastille Day and I slept late, that I saw her running and playing again. I didn't want to wake up.

Get well, ma Bacs. Vite. Tu nous manques si fort.
....

ENVA d'Alfort, Day 2

Look at that face -
Just look at it,
Look at that fabulous face of yours.
I knew first look I took at it,
This was the face that the world adores.

Look at those eyes -
As wise and as deep as the sea.
Look at that nose -
It shows what a nose should be.

As for your smile, it's lyrical -
Friendly and warm as a summer's day -
That face is just a miracle.
Where could I ever find words to say

The way that it makes me happy
Whatever the time or place?
I'll find in no book
What I find when I look
At that face.

Look at that face -
Just look at it.
Look at that funny old face of yours.
I knew first look I took at it
You've got a face like a kitchen door's.

Look at those eyes -
As close as the closest of friends.
Look at that nose -
It starts where a good nose ends.

As for your smile - spectacular!
One grin would frighten the birds away.
You've got a face like Dracula!
And I mean that in the nicest way!

To say that there's no one like you
Would not even state the case.
No wonder I shook
When I first took a look
At that face.

Today, they asked me if would like to take her for a walk when I arrived for visiting hours shortly after 2 pm, regretting the 20 minutes I had missed owing to a late start and a long drive. She was in her impeccably clean cage, with a bowl of water, another of food, sort of touched, and a length of green cotton tape tied around her neck. A makeshift hospital leash. They told me that she had already been out for a little walk and had peed. We were so proud of her!

Really, I am not being sarcastic. Even the smallest of things doesn't seem so small when someone is so very sick.

We took the elevator down to the ground floor, Baccarat stopping to relieve herself just outside the waiting room, which no one minded in the least, and down a corridor that seemed as long as the QE II at Baccarat's new pace. Just past the door was a little wood, with a path along which some interns and students hurried with small dogs in their arms, or others strolled in small groups, with a dog on its green tape. We past a bench, rounded a corner and came upon a red plastic bowl filled with water and drowned insects.

"Bacs, tu veux boire un peu?"

She answered by way of making a slow bee-line for the bowl, lowering her muzzle to drink and then letting her forelegs splay and her body sink slowly to the ground, like a mechanic's lift leaking hydraulic fluid. Her forepaws remained on either side of the bowl, her head just above it, for convenience. I got out Daniel Deronda and read, but mostly watched her watch the strong summer breeze in the leaves of the trees around us where we sat in our patch of shadow beneath an Acer campestre, so named by Linné, or Lineaus, the tag told me. A Field Maple. I thought about how the trees were planted with scientific discovery and learning in mind and contemplated making a garden for them.

Too much work for them, said myself, who had been fairly quiet of late.

That's what being preoccupied with real worries will do.

And then I noticed that some of the people walking near us were walking right up to me. It was Dr. Begue, a young vet in her last two years of specialty training in internal medicine, and Dr. Gouni, the cardiologist. I felt as though I should apologize for making them have to come find me, but they were smiling. They knew where I was, and it was alright. They do this. They had come to tell me about Baccarat's progress and what they knew. I had seen Dr. Begue already when I arrived, but not Dr. Gouni.

What they knew for now, with some pieces of lab work not yet available, is that Baccarat's liver is fine, that she is not in kidney failure, that her kidneys seem to be alright, but they still do not know why she lost so much blood protein. That loss of albumin and the protein that is responsible for anti-coagulation probably explain the formation of the clot.

They asked if I could find a lab for human blood work that would be willing to test dog blood because they need to perform a test usually done on humans to see if there is thrombosis, in other words, a thrombus somewhere in her body (in addition to the clot in the right atrium) that they haven't seen; a lot of Baccarat's diagnostic work and care involves people medicine, and will possibly involve people cardiac surgeons. We are going to have to take blood from Rapide, too, so that the lab has a comparison with a healthy dog, since the indicators for humans don't necessarily correspond to dogs. This thrills my husband, since Rapide, after nearly 4 years of cohabitation, still hasn't come around to him.

It's looking like I will have to ask our vet out here to draw the blood or never get it done. Sigh.

This brought us up to what they had in mind. The thinking is that if her physical condition improves, and if the cause of the clot can be identified and is not chronic in nature, and if we feel we can afford the cost, they will organize surgery for Baccarat in a hospital in Paris in an OR for humans.

I haven't told my husband about this. Not yet.

They hope that with the return of blood proteins to a normal level, which seems to be the case, and the anti-coagulating drug Fraxiparine (at 16 euros a day) that the clot will not continue to increase in size and her body can do its natural work to dissolve the clot. Another echocardiogram today seemed to show it ever so slightly, possibly smaller. If it decreases in size, then they can consider operating on the heart without a bypass. It it doesn't, at its monstrous 5 cm proportions, then they would have to do bypass surgery to open the atrium and remove the clot. It is unlikely, given its size, that it can go completely away, and they cannot give dogs the drugs they give people to shrink a clot. They are almost always lethal for dogs.

And, here is another piece of information. A clot tends, I am told by Dr. Gouni, to form on an area that is "moche", or "ugly", meaning "not smooth", but "bumpy", "irregular". It can be from the formation of a tumor that attracts clotting around it, or it could be from an irregularity on the inside surface, in this case, of the heart muscle. What they remove would be biopsied. If it is a tumor, it is certain to be malignant. If is it merely an irregularity in the surface of the muscle, then it is corrected. Sam has offered his earnings. He says it is more worthwhile than any other "connerie" on which he would otherwise have spent them, like a new used, higher cylinder scooter for the fall, on which he had his heart set.

My husband will want to know that this offers her a longterm positive outcome and quality of life. They have the same objective and say it is too early to tell, but they wanted just to know if we would want to do this if they felt it could be worthwhile because many people would not be able to, owing to the cost.

"Si j'avais un chien qui en avait besoin," she said to me, "je sais que je ne pourrais pas le faire."

I looked at the sunlight in the trees and the blue sky and down at Baccarat at our feet. I thought of all the things I don't want as much as I want her to live. I thought about Sam and how much he has come to love this dog he didn't want. I thought about what it means to be part of one another and about from where the money would come. I felt happy thinking about it.

Happy? That meant one thing: I wanted to do it for her, if it would mean that she could run in the Moraine again in the snow.

I was happy later, when with Mappy maps in hand showing the locations of some 16 pharmacies in Créteil, I sat down on a parking barrier in the courtyard to call as many pharmacies as it took to get a week's worth of Fraxiparine. I picked the cluster the closest to the boulevard to the veterinary hospital and started calling, rounding up doses of Fraxiparine and noting it on the maps. After 5 calls, I had what I needed. I jumped into the car and headed off to collect it all. It took three pharmacies for a week's supply at about 120 euros.

I was doing something to help her. I was happy to be the gopher, to get anything they needed, to give them the name of a lab that would help, to make their work possible and easier.

"Vous faites un beau métier," I told Dr. Gouni yesterday.

"Mais, savez, ce n'est pas toujours beau," she replied.

"Non, que le résultat ne soit pas bien n'enlève rien de la beauté du métier." She nodded, accepting that.

It was going on 7 pm when I returned to the hospital, emptied down to the bare bones staff and emergencies, and rang the bell. A young intern came to let me in, and took the little plastic bag full of other smaller plastic bags of Fraxiparine. She told me everyone was gone, but she would deliver them to the service for me. I turned to leave, and remembered I had left something for me in the bags and took the stairs up to ask if it could be retrieved. There were two students, or interns, at the emergency desk. Embarrassed, I explained.

"Elle était petite, en vert, les cheveux bruns?" the young woman asked.

"Oui, c'est bien elle."

"Attendez, je vais aller la trouver," she said, without looking put upon in the least.

"Si vous mettez plus que deux minutes," I told her, "laissez tomber. Ce n'est rien d'important --"

She was already gone and back with the petite young woman in green with brown hair, who went off with a smile to get my sunscreen and returned to tell me that if I could possibly wait, Dr. Begue hoped to speak with me. Glancing at my watch and thinking I was going to miss any chance to get groceries before the stores possibly closed tomorrow for Bastille Day, I nodded.

"Bien sur je peux la voir." After all, these people were practically dedicating themselves to caring for my dog and trying to save her.

Dr. Begue appeared, hoping that I could wait for the blood to take to the lab and the syringes and tubes for Rapide's, and as soon as she was gone to do that, Dr. Gouni rounded the corner, practically straight into me, smiled, and took another chunk of her day to bring me up to date.

When we had said good-bye, Dr. Begue returned and talked about the hospital, about dog food, about anything. They work hard, but with so many hands to make light work of it, they have time for what Dr. Gouni said is also part of their work: the people who bring their sick animals to them, because, as Dr. Begue said, if we bring them there, then we are truly dedicated pet owners.

"Une dernière chose, si je peux m'abuser encore de votre temps," I said. She smiled, waiting. "Aurait-il un supermarché dans le coin?" She nodded. There was a Casino. She gave me detailed directions, as helpful as she had been with the Mappy maps of Créteil with the pharmacy locations circled in red pen and a print-out of their names and telephone numbers.

"Il est encore ouvert à cette heure-ci?" I asked, a little worried. Out here, everything closes by 8 pm.

"Oui, ça ferme à 21 h. N'oubliez pas de mettre l'échantillon de sang au congelateur," she reminded me with another smile as we parted, and I headed off to do my grocery shopping, Baccarat in her clean glass-fronted cage with her green cotton tape around her neck, perhaps sleeping, only several doors away.

It was alright. Dr. Begue and the students would be with her. I'll be back Thursday.


....

la Maladie du maître médecin, Baccarat at the ENVA d'Alfort

l'Ecole Vétérinaire Nationale d'Alfort
Maisons-Alfort, France

Baccarat is here. She spent the night in intensive care, and I have not been so exhausted in a very long time. There is the exhaustion that sleep helps, and there is the exhaustion that remains when sleep is done. I have not told this story in more than fragments in an email here, a text message there, a post on Facebook, or a message. Our Baccarat is very sick. I will tell the story, but she needs me now, and so the story will have to wait.

She has a 5 cm mass in her heart that was initially believed to be in the right ventricle, but is in the right atrium. It appears likely that it is subsequent to a renal issue, but we are waiting for the results from the tests that were performed last evening and this morning, and I am on my way to go spend the afternoon with her, perhaps bring her home. Tomorrow is Bastille Day, and if there is any chance that she is better off there, that is where she will remain because she could not be in better or kinder care. The ENVA at Maisons-Alfort is the reference in veterinary education, training and care in France, and she has had the chief of cardiology consult on her case.

They say hers is a rare case. They have decided to call it "la Maladie du maître médecin" because the only other one they have seen was in a dog whose master was a doctor, too.

We watched her grow weaker as the afternoon passed, but after her long series of cardiac and abdominal sonography, in quiet, darkened rooms with hands holding and stroking her head, paws, tummy, she had a better moment and looked out the windows before lying down, still looking more like her old self than I had seen in days.

That's what touch and love can do. That is what they are unafraid to offer at the CHUVA (Centre hospitalier universitaire vétérinaire).

She is an amazing, wonderful, distinct person. Once you meet Baccarat, there is no mistaking any other Labrador for her. She is imperfect, and she is beautiful. She is loving, and she is funny. She lives with us and makes her place, a very large place I have not always seen a loved animal inhabit so completely. She is present and ready, and to see her hardly able to fill her own paws and respond is terrible for us. Friends who love dogs tell me she is strong and we have to help her fight.

I need to go see her now.
....