Dog Dylan’s story continued with us riding on the hard rails of her roller coaster, headed directly and most surely for her first brush with death. Anxiety and uncertainty reigned in my head and followed a night without sleep with all kinds of thoughts racing thorough my head. Life with a very sick dog, life without Dylan, could I make a tough decision, did I have the energy for this? What could “I” do, what did I need to do, did I have any clue of what I was doing? I am one of the fortunate ones who maybe did have a few clues. I am certain it impacted the choices I made.
I definitely had experience with prednisone and its use in people fighting autoimmune diseases and inflammation in general and also some of the many antibiotics and immunosuppressants that had been used over the years. There were new drugs too and this attack on Dylan was not at all like what I had dealt with in the past. The consequences of failure for her were certain death and in Dylan’s case, like so many, the attack was immediate and she was going downhill fast. One of my biggest concerns as Dylan aged had been a question of her early aggression returning and would it takeover her. And would that then make it impossible to care for her? This was a real concern given her original history, wild and abused before she came to my home and she always used fear to scare away the people around her she perceived as the cause of her problems.
Earlier in the week I had made contact on Facebook with a Dog Agility acquaintance from Merritt BC. This turned out to be rather fortuitous and life saving for that matter. When I posted Dylan’s condition on Facebook, she immediately replied and began helping me. Thank-you Maureen Sanderson I am so happy for you and Mercedes for making it though this and for being my inspiration.
Not only did she provide a long list of helpful advice, like getting stomach protection started (Pepcid AC/famotidine) and Milk Thistle to provide help for her liver thanks to the toxic load of prednisone (and for others using additional meds); Pet Tinic, a Vitamin B/B12 and Iron supplement for helping make blood (and how to get it on the Internet, as it is not available in Canada), but she also put me in touch with a great group of caring dog people who all understood what was I going though and what I was about to go through.
There is no way I could have made it alone and whether it is/was support, advice, AIHA knowledge, or discussion; the VetNet AIHA/IMHA Discussion Forum 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. The fight against AIHA starts with knowing your dog and a great veterinarian, but so much more is required to endure the challenges and 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 waves of 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 feet. There had 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 started putting Jimmi and Joey in their crates before I started dinner preparation. I could not afford to have a fight over food. 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 any more attitude between them and Dylan.
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 it can even be under attack by the immune system as well. So this was a valid concern for sure.
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 most people and generally 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 because I wanted to see evidence that the prednisone she was taking was working, it became essential, even critical to me to be able to know the difference if I could. 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 of prednisone that paralleled the aggression and it was a complete reversion to her early aggressive behavior. From the reaction I was seeing, I began to become concerned about the dosage of prednisone and I wanted to discuss this with my veterinarian. That would have to wait until Monday, unfortunately. The aggression, constant and truly excessive drinking and peeing, and extreme drive for food continued over 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 even greater 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 me emotionally 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.
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. At that time 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 thank my friends enough.
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 their 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 potentially treatment too. As it was, and thank goodness, prednisone was kicking ass and that fact combined with my minimal stress philosophy along with the fact that getting Dylan drug free, the ultimate goal, would be much easier without any other drugs for prednisone 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 only present in some veterinarians 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, but it was getting worse.
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 roller coaster hill.
Monday night I started to become more concerned and was completely unsure of what was happening. Since I thought she had improved during the day, I became very concerned by her evening weakness. 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 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, a breathing pattern once told me I was going to lose my dog Jagger. In her case we could not stop the bleeding from a tumor in her chest and the blood building up in her pericardium was making it hard to pump blood and therefore get oxygen to her body. I knew from 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, during this battle for Dylan, Jagger was with me helping me decide what was going on in Dylan.
Although Dylan’s 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, their lack of coordination and ability to drink easily is an obvious sign.
That night was my first conversation with Dylan 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 what was necessary. Thankfully, although she appeared to walk in a drunken manner, she still was not going anywhere.
I guess I was still blinded by her strength earlier in the day and the 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 Staffordshire 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. Of course now the purpose of watching Dylan breathe was serious and to make better decisions about saving her life.
Many who have come to the VetNet list since, have 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, but it can be entertaining as they dream. It may 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 to be gained on this one day. Either way, again it led to hope. This time I had reservations built into my 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 inability to do what she needed. I knew then I needed help and I began calling for some. I called my friend Bill to get me some ice cream since Dylan had begun refusing food 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 from his freezer 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 or 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 a little like 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 that I could not get her outside and her state was certainly frightening.
Suggestions of a transfusion appeared on the VetNet forum in response to my concerns 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. I thought too that 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. I wanted so badly for her to stay, but I could not make that request of her.
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 situation either. 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. The events of that night are still very painful to think of, seeing her unable to do any basic thing which we all take for granted.
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. I had no choice but to be there for her.
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 the 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 had come!
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 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 like she was drunk and then she could not stand, are all signs of increasing severity of anemia. Her inability to drink and operate her tongue were also signs of severe 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 only turned to the right. It seems the muscles on her left in her rib area and maybe further back, did 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 would d0 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 really 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, I was not and I don’t believe it was fully possible. All you can do is do your best. The emotions are intense and the feeling of helplessness is strong. What was most important throughout this trauma was that I show her my love for her and be as reassuring as possible. 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.
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. I have seen many cases since that have ended without a fight at all simply because the attack was too fast and treatment not in time. It is not just AIHA that needs to be acted upon quickly, there is a long list of conditions unknown to us as pet owners that we need to be on alert for and may need to act upon once day.
I want everyone who faces this disease in their dogs 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. Everyone I meet who faces this disease goes through the same unknown, but must become knowledgeable in order to save their dogs. Fortunately they have lots of help. Once you have been through it, you feel compelled to help others.
It was also 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 are 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 us make what are very difficult choices. I also want my vets to listen to me, as I needed reassurance too. I expected 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 and it helped me find strength to fight for Dylan. 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. 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.”