Aug 062011

Dog Dylan’s story began March 18, 2011.  She was diagnosed with Autoimmune Hemolytic Anemia (AIHA)/Immune Mediated Hemolytic Anemia (IMHA) , on March 19th, 2011; when my quest to save her and her second life as an AIHA survivor began.

This version of the story is my first draft version, written in detail for those currently fighting the disease and maybe those who have fought this disease for the life of their dogs.  It contains drug use and dosage used in Dylan’s treatment and also specific timeline  information important to some, but not most people.  And, really, I hope most people never have to know this detail.

Life for us all here changed that Friday morning when I noticed that Dylan hesitated to eat her breakfast.  This was an alarm to me for sure, the anxiety I felt was immediate, since she had not done so ever that I could recall. I knew something was wrong and that I needed to pay closer attention to her. This is my default response to any unexpected behavior.  When I got home after a lunch time meeting, around 2:00 PM, Dylan had thrown up her dinner in her kennel.  So as soon as I could, I took it outside to clean it and while doing so, Dylan went for a pee.   This might seem unimportant, but I later regretted not seeing this.  At the time, I had to clean a kennel before I could let the other dogs out.  While I was cleaning it, I ended up taking  a phone call from a customer who was heading out of own and needed some help before leaving.  I told Hew during that conversation that I felt something ominous was wrong.  I just had the feeling!

Sure enough, when Dylan went out in the evening, around 7:00 pm, she went to take a pee and  I must say, something startled me.  I could clearly see her, but something was drastically wrong, my anxiety immediately jumped to  a new level and I could feel my heart beating rapidly.  The color of her pee was not at all yellow, nor was it clear.  It was a dark red and looked like blood. Well if the alarm bells were not clanging before, they sure as hell were now.  And I do mean “hell.”  I don’t use this term lightly either.

At that moment, I had to decide what to do and it was an important decision.  I had to decide whether to take her to he emergency clinic where I had taken Jagger 2 years earlier, or wait until my vet clinic in North Vancouver opened in the morning.  Some might think that is a no brainer decision, but no decisions from then on would be easy.  I knew the kind of care she would get at the animal emergency hospital and I knew the costs would mount quickly.  I was concerned I might be making decisions based on financial restrictions and that recommended procedures were not always the same as what my own veterinarian would do.  In the end I decided to watch her very closely and decide to go to emergency if the problem worsened and required an immediate decision.  That night I watched her closely for any signs of more trouble.  My experience with Jagger had taught me that bad can things happen quickly.

Despite what I know now in hind site, I still think that was a good decision, although Dylan’s anemia over the next few days did become critical and very much touch and go.  The emergency clinic may not have diagnosed the problem until morning and delayed giving medication until they had test results.  If this was true, then there was nothing to be gained at the emergency clinic the night before.  They could not get test results immediately anyways.  Secondly, a transfusion may have been offered as a solution and although it might be a good choice in some cases, it would never be my first choice.

Saturday morning, Dylan was noticeably weaker, but no other overt signs and so I called Mosquito Creek Veterinary Clinic first thing at 9:00 AM when they opened.  They were fully booked, as I expected, but once I described the red pee, and along with the anxiety and concern in my voice, that got their attention. Dr. Janice Crook, Dylan’s Veterinarian, had me quickly check her eyes and gums.  Her gums were pale with brown patches and she had brown patches in the whites of her eyes.  Janice immediately knew the likely problem was AIHA and had us come in immediately.  Although I knew they would take us in that day, like they had for previous issues, I would never have accepted waiting until Monday from any vet that cares for my dogs. This is a requirement! I knew I had to move quickly now.  I knew this was serious.  My responsibility was clear.

I am grateful for the care I get from all the veterinarian’s at Mosquito Creek and how they understand what our dog’s mean to us.  Janice did a quick exam and took a blood sample.  I had brought in a collected sample of her pee, which I got just prior to her going into the clinic.  Dylan was put on very high dose prednisone immediately to suppress her immune system quickly.  Her immune system was attacking her Red Blood Cells and if it was not stopped, it would soon kill her.  Janice prescribed 2 mg/pound split in 2 doses per day.  We rounded up a tiny bit so I could give Dylan one 50 mg pill with each meal.

We discussed other treatment options such as azathioprine and cyclosporine, but decided against them initially.  Dylan’s attack was very acute in nature and it was certainly unlikely that azathioprine would have anything to do with saving her as it takes 2 – 3 weeks to act.  Cyclosporine may have helped, as it does act faster, but it is still considered a better tool for assisting in getting off prednisone. It also may not have worked and my experience with immunosuppressants in Crohn’s disease always left a bad taste in my mouth, because they often did not work.

Another factor in the decision was from what I call a minimalist perspective.  I believe chemical stress is an important factor and that by adding multiple substances we were going to make it much harder on Dylan’s liver and other organs.  Also, the eventual outcome, as I discussed with Janice, was to attempt to remove prednisone as the treatment went along if we were lucky (this depends a lot on the nature of the trigger and the attack itself).  Removing prednisone and other drugs too gets more complicated since there are interactions and multiple substances to be reduced.

So we decided go with the initial treatment with prednisone alone.

That afternoon and evening were tough.  The anxiety of knowing what she was up against was immense.  I immediately started researching the disease and what I learned was not great.  There was no sleeping that night it seemed, as I watched Dylan breathe.  Trying to stay unafraid and calm was not possible it seemed.  I put a lot of effort into doing things, but I remember beginning to go around in circles emotionally.  Calm and determined, then fearful and anxious. I certainly can say I never felt confident in anything at the time.

The next day, the blood test came back and in particular showed a lowered pcv and a histology profile indicative of AIHA, including spherocytes.  The report stated that the damage was intra-vascular (inside the blood vessels).  Her reticulocytes were low although still 3%, so it was initially classified as “poorly regenerative,” but this was not true, thankfully.  The fact that the damage was so new and had not spread everywhere was likely why reticulocyte generation had not ramped up yet.  We know that later it did and that she was fully regenerative.

Poorly regenerative, or non-regenerative would have been worse.  I have learned since, that the autoimmune attack can occur at different stages of blood cell development.  Destruction to mature red blood cells can occur and is what was occurred in Dylan.  The physiological machinery necessary to build red blood cells was not under attack and we now know was functioning fully.  Her cells were being attacked after they matured, so she was “Regenerative” (generating replacement red blood cells, reticulocytes).

The immune system can also attack at the building phase and in fact at any stage of the blood cell building phase and can in fact attack the precursor cells and impact development of platelets and/or white blood cells as well.  This non-regenerative anemia means the body is not able to build replacement red blood cells with low reticulocyte numbers and that the attack must be stopped in order to start building cells.  This will result in a longer delay to get mature Red Blood Cell numbers up.  Transfusions are used in this case to provide mature cells until the body machinery can begin replacing them as this process does take time.

In Dylan’s case, the red blood cell numbers (RBC), hematocrit (Packed Cell Volume, or PCV), and hemoglobin were low:  RBC=2.9, (low end reverence is 5.5), Hematocrit=.21 (21 %, low end reference of .39/39%) and Hemoglobin=74 (low end reference is 138).  Her platelet count was also low at 103 (low end reference of 170).    She had definite signs of destruction of red blood cells too.

Earlier in the week I had made contact on Facebook with a Dog Agility acquaintance who I had previously had a few conversations with over the last year,or so.  She has very nice Poodles and trains people and their dogs in dog agility and other dog activities.  This turned out to be rather fortuitous and life saving even.  When I posted Dylan’s condition on Facebook, she immediately replied and began helping me.  Thank-you Maureen Sanderson of Merritt BC :-)

Not only did she provide helpful advice on getting stomach protection going (Pepcid AC – Famotidine) and liver help (I used Milk Thistle only), Pet Tinic, a Vitamin B/B12 and Iron (with Copper) supplement for helping make blood (and how to get it on the www, as it is not available in Canada), but she also put me in touch with a great group of dog saving people.

There is no way I could have made it alone and whether it is/was support, advice, AIHA knowledge, or discussion; this place is a very special place with special people helping save every dog they can from this insidious disease.

Another valuable resource in the beginning for me was the Meisha’s Hope site where, in addition to success stories, there are a number of informative pages on AIHA/IMHA (Immune Mediated Hemolytic Anemia) and the treatment of this disease.

It is amazing how a support system can grow so quickly.  Everything starts with knowing your dog and a great veterinarian, but so much more is required to endure the swings of emotion one feels in fighting AIHA.  Even the simplest of cases, if there is such a thing, is an emotional ride as your beloved companion becomes weakened and incapacitated by the disease and its treatment.

The ride for Dylan and I had only just begun.  The next few days were followed by heart wrenching optimism and the heart wrenching fear of losing her.  I could see right away the effects of prednisone were strong.  Behavioral signs were almost immediate.  She began excessively drinking and I kept two large bowels full of water for her.  Of course this meant a constant need to pee and constant diligence on my part to recognize her requests and deliver what she needed – day and night.  She was no longer on her usual “sleep all night” schedule, that is for sure and since I was a tad anxious to say the least, sleeping on my part took on new meaning for the next 2 months.

She also showed increased aggression immediately, along with an increase in her already voracious appetite. She began her food snatching routine, which clearly indicated I could no longer feed myself or them as I had before.  I could no longer carry food about my house without being harassed and she would howl or grab for food.  I could not eat dinner with her around and my old habit of preparing their meals with everyone hanging about in the kitchen was no longer safe.  Now I had Dylan, the dog who would aggressively move to attack any food, or anyone who went for that food and not just at her feat.  There have been no issues preparing meals with multiple dogs in the past and no reason to believe the change was not completely due to prednisone.

My dogs normally eat in their crates and the youngsters, Jimmi and Joey, have done so since they were weaned and introduced to crates. So with Dylan’s new tendency, the first of many changes to their environment began and I immediately began putting Jimmi and Joey in their crates before I started dinner preparation.  I could not afford to have a fight over food, as is always the case when I prepare food of any kind.  I am a very strong believer in the immediate imprinting of extremely intense behavior, so even one incident is too many in my books.  I have had the odd sparring over food between Dylan and Stevie Ray on very limited occasions for very specific reasons, so I know even dogs who can be friends and live well together are not immune to disagreement.  Never had I had any such case with Jimmi, or Joey and I did not want them to get any new ideas, or an attitude between them and Dylan, which did already exist, to worsen.  I prefer and expect behavior to get better, not worse over time due to the effort I put into it.

Dylan’s aggressive behavior was evident elsewhere as well. I immediately began evaluating the cause of the aggression I was seeing in addition to the anemia, caused by AIHA.  When I mentioned it on the AIHA VetNet discussion group, the first  concern was her thyroid gland function and potential hypothyroidism.  As I have learned since, AIHA is more common and often associated with poor thyroid function and can even be under attack by the immune system as well. So this was a valid concern for sure.

All along the way in Dylan’s story, there is a repeating theme.  One that I hope you all take very seriously with your own dogs and other pets.  Observing Dylan’s behavior and knowing her behavior really mattered.  It saved her life, there is no question of that.  It is possible she could have been saved without such keen observation and understanding, but this is highly unlikely.  Firstly, the initial diagnosis could not have been delayed.  If it had been, there is no way she could have made it.  As you will find out later, the outcome of her story is completely dependent on my knowing her eating habits and watching for further symptoms as a result of a change I observed.

As I explained on the AIHA discussion forum, Dylan had been a rescue and had exhibited extreme fear aggression when I got her.  Years of desensitization and working on her fears had taken us to where she only used it when there was real stress present.

She had learned behaviors that included barring her teeth and growling, and snapping near the person (or dog) she perceived was the cause of her fear, likely before being set free to run wild as a pup and possibly why she was set free from her initial home. I know from experience, how and why these behaviors would develop and they are not from loving care and most likely result from abuse.  She would duck anytime you raised your arms, or stepped toward her suddenly. She would cower and freeze when she felt totally threatened, often over nothing when she first arrived.

While on the street she also learned that barring, growling and snapping kept well meaning strangers away. It is clear from how she treats people who lean over her, that leaning over her to capture her was a very big concern for her when she arrived in my home.  After years of positive experiences with other knowledgeable dog owners and trainers she has become good with all people and loves them – they dole out food easily :-)

So the changes in her condition reflected these initial behaviors like they were growing in strength.  She was very fit and stable before the AIHA attack so there was no reason to believe she had a hypothyroid condition prior to AIHA.  Since I was considering two potential causes for her increased aggression and also I wanted to see evidence that the prednisone she was taking was working, it  became essential and even critical to me to be able to know the difference, or at least be able to make a good guess.  Often in AIHA, you are very lucky to be able to make a good guess and with the aggressiveness of the disease, it is wise to treat it aggressively and not casually or average in any way.

My conclusion with her aggression was that it was a result of the prednisone she was ingesting.  She had other symptoms that paralleled the aggression and it was a complete reversion.  From the reaction I was seeing, I began to become concerned about the dosage of prednisone and since we had rounded it up for convenience to 50 mg instead of 45 mg, I wanted to discuss this with my veterinarian. That would have to wait until Monday, unfortunately. The aggression, and truly excessive constant drinking and peeing, and extreme drive for food continued over the Sunday and into Monday.  Throughout this time  I remained convinced the aggression was from prednisone and not hypothyroidism.

Another trend in her behavior started to become obvious and caused me concern.  Although she had been strong Sunday morning, her strength dissipated at night. She became obviously weaker despite having appeared stronger during the day.  I learned quickly that optimism was going to hurt and that sinking feeling was going to become common.  For those who have fought for their dogs lives in such a way, these swings of emotion take on new meaning.  This 24 hour cycle concerned me and became a high priority on my list of questions.  Throughout this period of time within the first 3 days of her first symptom, there was a constant stream of questions that needed to be answered.  Many helpful suggestions came from Maureen and the VetNet group.

Stomach protection in particular were critical since the drugs used to treat it are very hard on the stomach.  At the very least Pepcid AC (Famotidine) and other stomach coating substances like Sucralfate are recommended. In addition, the liver in particular was being overworked by processing the products of the RBC breakdown and converting prednisone, but also pancreas and gall bladder and other organs are all under duress.  So Milk Thistle and other products are recommended, but this is where your choice of veterinarian will matter too.

The fact that I live on my own now could have been a big problem, as I certainly felt I could not leave her side.  I felt the critical nature of the fight we had undertaken.  I began speaking to friends and telling them of my situation and asking for help.  Friends like Lisa Koncsik and her husband John.  And my Friend Bill Kulsky. Friends ran critical errands for me and gathered the stuff I would need to care for Dylan so I could care directly for her.  She was in critical condition and absolutely needed to be monitored at all times. I can’t thanks my friends enough. (If I forget anyone, please remind me, it is certainly not intentional).

After talking to Janice Monday morning about my many concerns, we decided from my descriptions of Dylan’s behavior to lower her prednisone dose to 40 mg twice a day.  We also discussed the possibilities for stomach protection.  Since Dylan was only on prednisone and I did intend from the beginning to get her off prednisone as soon as was feasible, I decided to go with famotidine only. I felt that I could monitor her closely and catch early signs that might require a change from this plan.  Again, my ability to observe closely, was a key to this choice. We also decided on Milk Thistle only.

One of my key beliefs that I am completely compatible with my veterinarian and her belief’s is that both physical and chemical stress matter a great deal when treating any disease.  These two types of stress will always subtract from effect and recovery and therefore there consideration in dosage and treatment is important. Most vets do not even consider this nor mention it.  Years of doing science in pharmacology had taught me otherwise, along with all of my observations in other chronic human disease conditions. All stress matters.  Minimizing it in all possible ways is important.

In my discussions on the VetNet forum, of course the immunosuppressant drugs kept coming up.  In particular Azathioprine and Cyclosporine.  My choices here were slightly complicated and I discussed this again with Janice.  As I was already aware, Azathioprine took a couple of weeks to act and would not save Dylan.  If she did not react to the prednisone, she would die!  Yes, if there was time and her condition was slow to progress, or we chose other potential options in the future, this might change and I was always aware that I could add it at any time.

Cyclosporine was another matter.  Janice knew I could not bear unlimited financial costs.  If I could, it would have further impacted discussions and treatment.  As it was, and thank goodness, prednisone was kicking ass and that fact combined with my minimal stress philosophy and also the fact that reducing prednisone and getting Dylan drug free, the ultimate goal, would be much easier without any other drugs to interact with, meant ultimately choosing to stick with prednisone alone.  As I have have said previously, I would know reducing prednisone meant all subsequent changes were a result of the decreasing prednisone.  This would mean all I needed to do was to be able to tell if anemia was better or worse after a reduction (and other potential effects of AIHA).  From the other effects I was seeing with prednisone, I was hopeful and even confident I would see it stop the AIHA attack.  Unfortunately, that fact would have to wait a few more days.

We discussed other options and decided to continue our current path and wait it out.  During this discussion, we discussed transfusions and what would be needed.  I started to look into what it would entail. So many things to consider and so many things to do.  During this 24 hour period, I had learned a ton, but still knew so very little.  This is the scariest part of this disease.  It is so overwhelming in complexity and danger. So many things can come up so fast.  This is is where the presence of the VetNet Discussion group was so essential. An experienced veterinarian and possibly an internal medicine specialist are also likely required.  The willingness to listen to me and to listen to suggestions of others and potentially seek help from other experts is a special trait in these caretakers and is another I would suggest you seek.

Not everyone on The VetNet forum can answer difficult questions, but many have seen the possibilities and help by providing reassurance and support and answering the first questions that get asked and should be dealt with when not asked.  Simple things that when going through such a traumatic and intense experience mean so much.  Standing tall and fighting like a soldier, appearing to your dog as though you are in charge and have everything under control as always, when simply you are a complete wreck, devoid of confidence.  Not so simple and yet just a little support from those who have been there helps so much to get you up once again and help you fight as hard as you can.  There is no other way with AIHA.  There is no easy path.  there is no easy pill to simply fix it.

Once again that Monday, Dylan began to get weaker after a strong morning.  I initially just attributed this to fatigue after a tough day, having mistakenly assumed the strength I saw in her earlier in the day was maybe the turning point.  She was beginning to walk like a drunk and I could see she did not have much strength to pull her feet forward and land properly on her pads.  Her eyes and ears were very low on her head and she simply appeared tired.  This was expected from anemia, however.

This was actually just the roller coaster ride that is AIHA.  Optimistic moments followed by moments of being crushed by reality.  Up that big first hill we continued with a bit of twisting and turning and what turned out to be minor ups and downs compared to what was coming in our near future.  Although they did not feel minor at the time, we were yet to fall off that first hill.

Monday night I started to become more concerned again and was completely unsure of what was happening.  Since I thought she had improved during the day, I became very concerned once again.  This time, I just kept it to myself and tried my damnedest to keep it inside.  I watched her breathing that night so closely.  She did not get up as much and at one point chose to lie beside me at where I work on my computer.  She just laid there and she had never really just laid right beside me like that before.  I noticed and became a little concerned once again.

So I stopped my incessant research and laid down beside her to hold her.  I obsessively watched her breathe.  I had already been watching her breathe on a regular basis by now and would get up every few minutes, or every hour or so to check and make sure her breathing was okay.  Once again I was carefully analyzing her behavior.  It is amazing what breathing patterns can tell you.  Unfortunately in the past, they had once told me that we could not stop the bleeding from a tumor in my first dog Jagger and that the blood crushing her heart was going to kill her.  I knew for her breathing she was beginning to suffer and I had to take steps to put her at peace, which I sadly did.  Once again though, Jagger was with me, helping me decide what was going on in Dylan.

Although her breathing was not as deep as it had been, it continued to slow during deep sleep and get more shallow and then speed up and get deeper during REM sleep.  This made me somewhat comfortable that she was not completely critical, although I was also not necessarily aware of how anemic she was becoming. I had also noticed her tongue was much more pale.  Vets say the gums are better than the tongue for checking anemia and they are (press and release to see the blood return).  But as it turns out, when the tongue is pale, the anemia is severe and is likely more accurate than the gums, as blood is very slow to return and the gums stay pale.  They also lose the ability to curl the end of the tongue, making drinking water much harder.  They may also choke occasionally.  This is a very coordinated muscular event and in severe anemia, it is an obvious sign.

That night was my first conversation with her about her letting go.  I had just enough doubt about her future that I wanted to let her know how I felt.  While hugging her and reassuring her on my floor that night, I calmly and quietly told her it was okay if she had to let go; that if it was too difficult she did not need to stay for me.  I told her she would be with me forever either way and that I loved her.  I told her I preferred her to stay, I but was prepared to accept her choice. Thankfully, although she appeared to walk in a drunken manner, she still was not obviously going anywhere.

I guess I was still blinded by her strength earlier in the day and hope that prednisone was working and she would turn the corner soon.  Although I was watching Dylan with intensity, I have always watched my dogs breathe.  During rest and during play.  It is critical with my Staffy Bull Terriers to recognize overheating and panting that can become a dangerous cycle from normal panting to overheating and death, as they produce more heat panting than they can dissipate.  This was true of Jagger too, as she was big muscular dog.  Of course now the purpose of watching Dylan breathe was in order to make better decisions about saving her life.

Everyone who has come to the VetNet list since, has asked a question about breathing.  Like all things about your dog, I strongly suggest you watch them sleep and breath on occasion; not only is it relaxing and it can be entertaining as they dream, but it also will serve you well in caring for them in the future when they are sick, or critically ill.

So Tuesday morning, Dylan was once again stronger.  I tried that morning to get some answers about her cycles, but this was not well understood.  Some circadian rhythm in her metabolism, or immune system, but no one could really say for sure at the time.  Maybe there is still insight on this one day.  I do hope so.  Either way, again it led to hope.  This time I had reservations built into this hope and my brain began trying to suppress my emotions to prevent the big swings I was taking.  Later in the day, I could not prevent them.

That afternoon, Dylan surprised me at about 5:00 PM, when she tried to get up for a pee and some water and could not. Suddenly she became panicked and very aggressive when I tried to help.  I was not able to help her, as every time I got near her , she completely freaked out.  After I realized she was dazed and startled; not only by my behavior, which she probably did not even recognize, but even more so by her own behavior. I knew then I needed help and I began calling for some.  I called my friend Bill to get ice cream.  Dylan was refusing food now and I had to get  her evening prednisone dose in her.  Bill brought a tub of ice cream, like I had asked for, and a tub of pasta he had made that later saved me.  I am very grateful to Bill for recognizing my sense of urgency and stepping in immediately to help.  Little things go a long, long way when under such duress.

I asked about her standing problem and panic on VetNet and no one really had an answer right away.  This time I was somewhat alone and felt as such.  I am quite sure every one who fights this disease for their dog will also feel this way at some point.  Again, the uncertainty, the lack of a clear path with clear decisions and never really knowing what is going on in them and what you can do to help them.  It is truly a difficult time.  I continued to check VetNet all night in hope someone would respond with an answer soon.

Although Dylan did eventually drag herself to her water bowl, she did not have the strength to lift herself up and would not let me help her and would not stop in her panic.  It appeared like maybe a stroke and later I found out this might be true as well.  At this point I simply tried to keep her still.  At the suggestion of my good friend and Sheltie breeder, Renee Hughes, I used a syringe to get water in her, which thankfully worked.  I still struggled with how to get her outside for a pee and did not have a solution before she needed to do so. Fortunately, I could just deal with it I guess.  Wipe it up and clean her up and it was gone.  At this point that was an easy one, but I was still very concerned I could not get her outside.

Suggestions of a transfusion appeared and I do have to agree, it was the only thing that could be done for her, but at the time , she was so weak and so afraid when I moved here, that  I was certain it was too late for that option.  I felt moving her would cause enough stress to push her over the edge and kill her.  Then I thought, just being on the table in a emergency hospital that way would be the last straw of physical stress in her completely weakened state and I knew I could not bear to have her die on some table in a vet emergency hospital.  I had been there before and knew how I would be treated .  She would die without seeing me and without my reassurance and comfort and I felt, just like I did with Jagger, I could not have her die that way, period!

If she were to die, it would be here on my floor, where Jagger died.  I spoke to her again about letting go.

Later that night she tried to go on out her own and as I had woken up from a short, but deep sleep in a stupor, I probably mistakenly let her out.  I guess I was amazed she was on her feet, but she was not at all stable.  Like a falling down drunk now.  And of course, once she got on my uneven ground, she did fall down and came very close to hurting herself on a concrete cinder block.  My place was not at all prepared for this.  I was also realizing my vehicle was also not at all prepared for this.  Where would I put her now that she could not walk or get into and out of a kennel?  My van did not have a big flat space to use for an ambulance.  So much to do, but I would have to deal with that later though.

In her trip out, she had a bowel movement and it was so hard for me, as she was not able to do it on her own.  Once again she became panicked after she fell.  This time I realized she was dazed and confused and needed time to adjust to me.  This was often true in a normal situation that made her afraid, like as a result of injury, or even a poo hanging from a hair.  But this was so much more difficult.  This time, I held her and calmed her for a bit and then carefully lifted her back into the house and on to the bed I had made for her. This time she let me help her, thankfully.  She really had no choice at the time.

As it turned out, Dylan’s trip out may have been the turning point. It did not feel like it at the time and in fact did the opposite to me.  Once I had her cleaned up, I had to hide in the bathroom.  I was a complete and utter basket case.  I was crying intensely as I thought for sure I would lose her that morning.  I was so afraid.  I had truly fallen off that first roller coaster hill and was at the lowest point possible, short of certain death.  Eventually I gathered my strength up again.

Once again, for the third morning in a row, I HAD to call my veterinarian.  The thought she would tire of me crossed my mind, but never slowed me down.  I had to know!  Janice was never bothered by my calls and always spoke to me right away.  She always listened to my descriptions of the events very carefully.  I am so grateful for how she handled the situation and how she treated me.  Once again, she calmed me.  She suggested it was a result of anemia and he only thing other than a transfusion we could do was wait. I knew it was too late for a transfusion and Janice agreed that it was very risky in her current state.

I had another conversation with Dylan that morning.  again I told her it was okay to let go.  I would be with her and she would be with me forever.  I wanted her to stay, but only if she could.

And she did!  My Miracle!

Again she started to show signs of improvement that Wednesday morning.  I was very grateful when she was able to get up and get water and actually ate breakfast. That was a relief for sure.  I was once again dreading the afternoon, however, and had prepared my vehicle for emergency transportation, removing the other back seat and rearranging kennels. Unlike the previous day, however, she did not get worse in the afternoon and in fact seemed to gain strength.  She  was back to being the drunken sailor, but was no longer the falling down drunk dog she had been.

By now though, I was extremely skeptical and it wasn’t until she was fully mobile the next day and all day that I finally felt I could take her out of the emergency ward, so to speak.  She was no longer critical.  Upgraded to serious, but stable condition.  What a relief that was for sure. As it turned out, her ability to get up that early morning, despite her fall, was the start of her recovery.  The depth to which her anemia took her was not measured by a CBC blood test, but I do have behavioral evidence of the severity.  During her deepest state I estimate her PCV was less than 10, maybe as low as 8.  Not only was she so weak she could not lift her head, nor coordinate her muscles to stand, there were other behavioral signs all along; she certainly could not pull her feat forward and lift them far enough to get the bottom of her feat on the ground and would step on the top part of the foot.  Her drunken walk, stumbling and then falling down drunk and then she could not stand, are all signs of increasing severity of anemia.

She also suffered brain damage from ischemia (cell death due to lack of oxygen) that resulted either directly from the anemia (most likely), or possibly a stroke which occurred during her critically weak state (during her panic attacks) .  I cannot be sure of which it was, but the result of that damage was obvious in her subsequent behavior.  Now she was always bent to he right and turned to  the right.  It seems the muscles on her left in her rib area and maybe further back, do not contract as they did before.  This has left her with an obvious bend to the right and has clearly impacted her ability to turn left.  Following the anemia, she always  does a 270 degree turn to go left. In the next few days it would become somewhat less obvious and I started working on getting her to turn left with food as soon as she was back on her feet.  I personally am not concerned about it and was not at the time either.  It is just another something I have to work on during her rehab and it  is not the only aspect of her trauma that has required work in rehab.

There was also much more to be concerned about, since  I could not be sure for a while yet that she would not relapse.  So much doubt enters your mind after you have been up and down such hard emotional swings.  You try not to get excited and you try not to get disappointed in order to prevent them and protect your dog from them, but that is not possible.  Suppressing it just lets it explode later.  I certainly suggest finding a way to have controlled releases.  Although I always wanted to keep this from Dylan and remain strong and determined in her presence, as well as loving and absolutely reassuring, but again, I don’t believe it is fully possible.  All you can do is do your best.  This is the same for every aspect of this disease, including how I treat any new person with a dog  in trouble from AIHA/IMHA.

Video: Dog Dylan and Autoimmune Hemolytic Anemia: Early in her second life.

Video: Dog Dylan Before Autoimmune Hemolytic Anemia – February 2011

I want everyone to know that there are no absolute answers.  There are only best guesses.  You try to use every piece of information you can.  All you can do is your best with what limited information you have.  I also want it to be clear that saving Dylan required my expertise on her behavior and it required I work hard to learn what I could to help save her.  It was critical that our veterinarian be willing to listen to me as I know they were guessing too.  There are no facts, other than a few numbers on a piece of paper and some symptoms.  No answers spelled out.  I prefer a veterinarian who knows this and how tough this fight can be and is willing to use all important and relevant information to help me make what are very difficult choices.  I also want them to listen to me, as I needed reassurance too. I expect them to want to hear my detailed descriptions of what is going on with Dylan to provide her the best possible care and all the veterinarians at Mosquito Creek in North Vancouver BC were great at discussing the situation with me and helping me make decisions.  Dylan and I are very lucky to  have had such veterinarians helping, because getting through the first 5 days would not have  been possible without it.  Each day after talking to them, I felt much more relaxed than I did when it began.   Each day began with panic from the day and night before.  Even Sunday I spoke to my vet when I got the results for her blood test Saturday.

But the story does not end here.  That was just the first battle.  The roller coaster was on the way up again and if you are familiar with roller coasters, you will know that second hill is a a tough one too, dropping you off and spinning you upside down and around once again.

Her behavior during anemia was very specific and very important to know.  Once again, knowing her behavior and knowing what anemia looked like would become absolutely critical in helping her later.

I would later use this knowledge to save her once again, in “The Battle of Prednisone.”

Richard Ford, M. Sc.


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