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Life and Death Decisions Part III: Mojo's Story


Chris Longenecker, a Certified Veterinary Technician in Reading, PA, contributed to this article.Mojo, a 14-year old cat, presented to the surgery consultation with a history of poor appetite and weight loss for 2 weeks. A physical exam was performed. Mojo was on the thin side but otherwise healthy. Because he was thin, a mass, likely attached to the intestine, was felt. Blood work showed no significant findings.

Radiographs confirmed that a mass was present in the belly. Since cancer had to be suspected, the next step was to take chest X-rays, to make sure it had not spread to the lungs. Chest X-rays did not show any sign of obvious spreading, but it did reveal a single lung mass. Again, based on statistics, it was mostly likely cancer.

Mojo’s owners, devastated, wanted to know more and decided to do an ultrasound. The ultrasound confirmed a mass in the intestine, with enlarged lymph nodes.

Based on this information, what would you do if you were the owner of this 14 year old cat, with a suspicion of cancer in the chest and the belly?

I suspect that most owners would take Mojo home, give him a big comfy bed to sleep in, feed him anything he would want to eat and plenty of catnip toys to play with.

But Mojo’s owners did not choose that option. They elected surgery to remove both masses.

Now, here is where my ethical dilemma as a surgeon comes up. Even though I’m the first one to say that "age is not a disease", is it fair to do surgery on a 14 year old cat who is sick and is likely to have cancer in the chest and the belly? Is it humane to put a cat through a double, invasive surgery?

Since I knew we could provide safe anesthesia and excellent pain management, we decided to proceed with surgery.

We first performed open chest surgery and found a single mass in a lung lobe, which was removed. We then performed abdominal surgery and discovered a large mass involving the last part of the small intestine, the appendix, and the beginning of the large intestine. In addition, local lymph nodes were enlarged. Because of the possibly drastic consequences of this surgery (including ongoing diarrhea) I decided to call the owner in the midst of surgery to have a heart to heart. Despite the risk of diarrhea, they encouraged me to remove the mass - which we did successfully.

The end of the small intestine was sutured to the beginning of the large intestine. What was striking is that the mass was blocking 99% of the diameter of the intestine. No wonder Mojo wouldn’t eat or defecate!

We sent the biopsies out to the lab. Mojo recovered nicely after surgery and went home only two days after surgery.

About a week later, the biopsies confirmed two different types of cancer in the lung (broncho-alveolar carcinoma) and the intestine (adenocarcinoma). The mesenteric lymph node showed metastatic adenocarcinoma.

Mojo's owners were compassionate and realistic at the same time. They wanted to improve Mojo’s quality of life, even if it was for a short period of time. Based on a long conversation with them, and convinced that we could keep Mojo comfortable before, during and after surgery, we agreed to do the double operation.

The amazing part of this story is that Mojo was a cancer survivor for 14 months - without the benefit of chemotherapy - which is an extremely long time based on his (double) diagnosis.

When Mojo’s quality of life started to decrease significantly, his owners chose euthanasia to allow him to pass away with dignity. They were extremely grateful for the extra quality time they were able to spend with their beloved cat.

If you have any questions or concerns, you should always visit or call your veterinarian – they are your best resource to ensure the health and well-being of your pets.


Cleopatra

Cleopatra VII ruled ancient Egypt as co-regent (first with her father, then with her two younger brothers and finally with her son) for almost three decades. She was part of a dynasty of Macedonian rulers founded by Ptolemy, who served as general under Alexander the Great during his conquest of Egypt in 332 B.C. Well-educated and clever, Cleopatra could speak various languages and served as the dominant ruler in all three of her co-regencies. Her romantic liaisons and military alliances with the Roman leaders Julius Caesar and Mark Antony, as well as her supposed exotic beauty and powers of seduction, earned her an enduring place in history and popular myth.


Early Life and the Battle of Monmouth

Pitcher was born circa October 13, 1754, near Trenton, New Jersey. In 1768, she moved to Carlisle, Pennsylvania, where she met Hays, a local barber. They married on July 24, 1769.

During the American Revolutionary War, Hays enlisted as a gunner in the Continental Army. As it was common at the time for wives to be near their husbands in battle and help as needed, Pitcher followed Hays back to New Jersey during the war's Philadelphia Campaign (1777-78).

Hays fought in the Battle of Monmouth in Freehold, New Jersey, on June 28, 1778, a brutally hot day. His wife was present as well, and she made countless trips to a nearby spring to fill pitchers of cold water for soldiers to drink and to pour over their cannons to cool them down.

As legend has it, the soldiers nicknamed her Molly Pitcher for her tireless efforts. But the legend only began with her new name. According to accounts, Pitcher witnessed her husband collapse at his cannon, unable to continue with the fight. She immediately dropped her water pitcher and took his place at the cannon, manning the weapon throughout the remainder of the battle until the colonists achieved victory. According to the National Archives, a witness documented her heroic acts, reporting that a cannon passed through her legs on the battlefield, leaving her unscathed:

"While in the act of reaching a cartridge . . . a cannon shot from the enemy passed directly between her legs without doing any other damage than carrying away all the lower part of her petticoat . . . She observed that it was lucky it did not pass a little higher . . . and continued her occupation."

With her actions on that day, Pitcher became one of the most popular and enduring symbols of the women who contributed to the American Revolution.


Shy and Inexperienced, George Becomes King

In 1760, George's grandfather suddenly died, and the 22-year-old became king. A year later, he married Charlotte Sophia of Mecklenburg-Strelitz. Though wed on the day they met, the couple enjoyed a 50-year marriage and had 15 children together.

But in addition to the crown, George inherited an ongoing world war, religious strife and changing social issues. Since 1754, Britain and France had been engaged in a border skirmish along the frontier in North America that began when a British colonial militia, let by Lieutenant George Washington, attacked French Fort Duquesne. During the resulting Seven Years' War, George III was closely advised by his prime minister Lord Bute, who kept the young, inexperienced monarch isolated from key members of Parliament. However, due to his Scottish background and belief in King George III's divine right to rule, Bute was maligned by other members of Parliament and eventually forced to resign due to strong criticism from the press and his purported involvement in a sex scandal involving George’s mother.

In 1763, George Grenville succeeded Bute as King George’s prime minister. With the Empire deeply in debt at the end of the Seven Years' War, Grenville looked to the American colonies as a source of revenue. He reasoned that since the colonies had benefited from the outcome of the war and British troops were needed in North America to protect them, they should pay for it. King George agreed with the reasoning and supported the Sugar Act of 1764 and the Stamp Act in 1765. But in the colonies, the Stamp Act was met with outrage, contempt and, for some tax collectors, violence. Claims of “no taxation without representation!” rang out in Boston, Massachusetts, and eventually other colonial cities.


The Challenge Of ICU Coronavirus Care Grows When Life And Death Decisions Can’t Be Made Face To Face

Photo courtesy of Peter Stubenauch Dr. Peter Stubenrauch, Critical Care Pulmonologist, National Jewish

Dr. Peter Stubenrauch starts the day at 7:30 a.m. on the COVID-19 unit at the St. Joseph Hospital ICU.

All the patients here are on ventilators, unusual even for the ICU, but unusual is the new normal as Stubenrauch and his colleagues try to care for patients who have a disease no one has figured out.

Stubenrauch, a critical care pulmonologist with National Jewish Health compares notes with his colleague, Dr. Mana Amir, who specializes in pulmonary medicine with Kaiser Permanente. They talk about what makes this work so hard right now. For one thing, all medical staff have to wear so many protective layers, it makes it difficult to connect to patients.

This story is part of a project that follows a day in the life of Colorado on Thursday, April 16, 2020

And that’s especially difficult because the patients can’t see family or friends since St. Joe, like all hospitals, doesn’t allow visitors due to COVID-19.

“I think the fact that they are not able to have their loved ones nearby, even when some of them are, you know, more restless and needing comfort care,” Amir said. “I can’t even imagine how terrifying that must be for them.”

Starting at 8 a.m., Stubenrauch reviews his nine patients and considers the next steps. The most pressing challenge is managing the effects of long-term ventilator use. For instance, those who are on high levels of oxygen usually are placed on their stomach to ease pressure on the lungs. But that leaves patients vulnerable to skin damage as their body rests on the tubes and equipment.

“Unfortunately, it comes down to an intellectual discussion between how sick are their lungs and how worried are you about the skin,” Stubenrauch said. “But ultimately the skin wounds should, should recover (and) we need people oxygenating well enough that they'll hopefully recover from this from a lung standpoint too.”

Then there’s the question of what treatments to try. The medical guidance on the coronavirus is evolving quickly. Stubenrauch said doctors have the “tried and true” approaches to respiratory illness, and a variety of experimental treatments being developed for the virus.

“I do find it fascinating though, how two weeks ago we were reading about ‘you’ve got to do it this way’ and a week ago, ‘no, that's wrong. You got to do it that way,’” Stubenrauch said. “So that's, that's been interesting to see how things evolve.”

For one of his patients, he recommended she be added to a drug study he thinks is promising. He hopes that if she is accepted she would get the actual drug, instead of the placebo some patients in the study must receive.

Explore More Colorado COVID Diaries

Just before 1 p.m. Stubenrauch took a quick break in a quiet room with a peanut butter and jelly sandwich, his lunch staple for years.

“I just bring my own food, although I have to admit they’ve been bringing some pretty good food around from restaurants that have been donating food to the healthcare workers,” Stubenrauch said.

The afternoon included consultations with families. All by phone. It’s another challenge of pandemic care, discussing life and death matters without being face to face, with family members who can’t consult — and can’t even — see their loved one. And the uncertainty about COVID-19 means always preparing families for the worst.

“You by no means have any interest in giving up on a patient, particularly someone who came into the intensive care unit relatively recently, but also set the expectation that we're observing a lot of patients who remain on mechanical ventilation for prolonged periods of time and can quite suddenly take turns for the worse and pass away,” Stubenrauch said.

By the end of his shift at 7, Stubenrauch saw hopeful signs. One or two patients might be ready to get off the ventilator the next day. No new patients came in. With another doctor taking over his patients for the night, he can try to leave work behind.

When he gets home he performs what’s become the ritual after a day at ICU. He takes off his clothes in the garage and showers before settling in with his wife and two teenagers. He jokes his teenage daughter is a pro at social distancing from her parents, but he admits he still hugs his wife and son.

It’s hard to keep his guard up all the time.

This story is part of a statewide reporting project with more than 20 newsrooms led by the Colorado News Collaborative to document a day in the life of Colorado on Thursday, April 16.


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