[My beloved Rupert, a big cat in a small world, patiently squishing himself into his scratching post bed. He got cold very easily and loved his assortment of sweaters and coats in the harsh Northern winter.]
You can’t save them all. How many times have we as veterinary professionals or even we as clients heard that phrase? It becomes a mantra at work during the bad days, a way to compartmentalize away the deaths and euthanasias that happen on your watch, the terminal diagnoses, the weeping owners, the pets who don’t know they live under a death sentence. My record of saves is good, maybe a little above average, but every now and then a pet comes along that reminds me — I can’t save them all, no matter how hard I try.
His name was Rupert.
We called him Rupee, Rupes, Lord Rupert, Poopert, and frequently, medical mystery. Rupert flew (literally!) into my life one freezing February night, a transfer from a Vancouver Island shelter. I had seen his photos and stories online and fallen in love with his huge, handsome face, his dignified bearing, his calm eye. He was having a hard time finding the right person to be a permanent foster as he had insulin-dependent diabetes which they were having difficulty controlling. I thought it was a match made in heaven; I could use and abuse my clinic discount to help regulate his diabetes and in return I could welcome another cat into my life after the sudden loss of my previous cat, Newton.
Right from the beginning, I knew it would be hard to regulate him — but I was confident we could do it. He was on a special diet, had his insulin at exactly the same times morning and night, only ate high-protein treats such as freeze-dried shrimp or liver, had his blood glucose checked twice daily regularly and had a glucose curve (a test where the blood sugar is checked every hour for 12-24 hours) done every two weeks. But even after a month of this rigorous treatment plan, he wasn’t responding.
My vet and I were stumped. His blood sugar was routinely incredibly high, often three to four times higher than it should have been, and nothing really seemed to bring it down. We tried increasing his insulin; it seemed effective for a short time but never really brought it down to normal levels. We tried decreasing his insulin, wondering about something called a Somogyi effect where the body overcompensates for low sugar levels by increasing them drastically, but that didn’t help at all. We removed questionable teeth that we worried were causing infection and damage to his endocrine system. We tried different forms of insulin. We tried different diets. We ran bloodwork multiple times looking for anything we could think of that might make him insulin-resistant. But nothing seemed to make a difference.
Rupert bore all of this with his usual dignified bearing, only chastising me with a rasping meow if I had to poke him too many times in one day. He had learned quickly that the beep of the blood glucose monitor meant he got a treat and would sit perfectly still, almost quivering with anticipation, until the monitor chimed. Then he would leap for my hand, almost devouring my fingers in a quest for his shrimp. But I knew this couldn’t be easy for him either. The chronically high sugar was almost certainly making him feel strange and uncomfortable; he was incredibly thirsty all the time and passed vast amounts of syrup-sticky urine. He was ravenous always, wolfing down his meals in minutes and always questing for more that he could eat. He was skinny and frequently cold; I invested heavily in cat sweaters which he thoroughly enjoyed, often pawing at me if he wanted one on. But that was just papering over the cracks, something, I knew, was deeply wrong inside of him — but what?
It was a veterinary friend of mine who gave me the answer without realizing it. She’d never even met him but as I was venting to her about our struggle and how much I wanted to help him to feel better, she brought up something I’d never even heard of: acromegaly. Acromegaly is the disease process caused by a tumor that sits on the pituitary gland and constantly secretes growth hormone, causing (among other things) severely insulin-resistant diabetes.
I ran through the symptoms in my head. A classic feature of acromegaly in cats is an abnormally large head and paws, both of which Rupert had. The tongue and soft palate can enlarge causing noise when the animal breathes; Rupert snored loudly and frequently had a rasp to his breathing. During his dental his radiographs had shown that his jaw looked strange, now I wondered if it was from late-in-life growth. It was with a gnawing fear in my stomach that I pulled blood from him and sent off for a growth hormone test, hoping against hope it would come back normal but also knowing, in the corner of my mind, what it would say.
His growth hormone levels were extremely high. Rupert had a tumor. I frantically researched treatment options but the only real options were radiation therapy which we didn’t have access to and could take years to effectively shrink the tumor, and surgery which could only be performed by extremely specialized veterinary surgeons which again, we didn’t have access to. The only solution seemed to be to try to manage his diabetes with frequent extremely high doses of insulin and hope for the best.
I was crushed. I had previously had animals with poor prognoses which had pulled through after intensive care and previously had animals specifically with me for palliative care, but this was different than either of them. I had taken Rupert to fix him and instead, he was going to die. Sooner or later I didn’t know, but he was going to die from a medical condition I knew about and couldn’t fix. It ate at me at night as he shuffled up his ramp to my bed and curled up to snore into my ear. It ate at me at work, helping owners with their diabetic animals and feeling irrationally jealous as they came under control and even went into remission. And it ate at me when I went on my six-week trip to Botswana, a trip I had planned before I had gotten Rupert but had assumed would be fine to go on as he would have been stable and my vet looked after him while I was gone.
When I came back from the trip and looked at Rupert with fresh eyes, I was surprised to see how old he looked. His jaw looked bigger even than when I’d left, thick new bone pushing at the confines of his skin, and his pawprint was wider. He was thinner. He drank and urinated more than ever but seemed less hungry, something I tried to see as a good sign but couldn’t be sure of. He’d been pampered and spoiled the whole time I was gone by my coworkers and friends but now he just seemed…tired. I resolved to do some more bloodwork in a couple of weeks and see what we could do to help him.
On May 10th, 2017, sixteen days after I came home from Africa, I gave Rupert his morning meal and insulin, kissed him, told him I loved him, checked his blood glucose (high as usual but not as bad as some mornings), slipped him a couple of shrimp, and went to work. The day was busy and I ended up getting home about an hour late. Coming in through my front door I was surprised to see that he wasn’t there to greet me but when I went into my living room, I saw him asleep on his bed, curled up with a little kitty smile on his face. The room was warm with mid-afternoon sun and I almost felt bad about waking him when I crossed the room and went to stroke him, hand gliding over his chest.
But he didn’t move, and under my suddenly still fingers I could feel no heartbeat beneath the warm fur.
The rest of the night passed in a blur of tears and notifying people. I called the rescue, weeping almost too hard to get the words out. I called one of my close friends and coworkers, a vet, and she met me at the clinic to help with his last rites. Together we rolled out the clay and pressed his huge paw into it. I remember sitting on the floor in the darkened clinic while she tactfully went elsewhere, holding him and crying into his still-warm fur. He must have passed just moments before I walked in the door, the vet told me. Perhaps he was waiting. Perhaps that hour of overtime was too much for him to wait to say goodbye or perhaps he wanted it to be that way, waiting until I stepped in to let himself cross over. I don’t know. I didn’t want to know. I just wanted him back.
You can’t save them all, my vet told me, hugging me tightly. You gave him everything. You tried everything. Later, after his post-mortem showed a heart so enlarged it was a miracle it had been able to pump blood at all and a scarred, half-dead pancreas, she said it again. You can’t save them all. Nothing could have saved him. No one could have done anything. But I still wish I had. That’s my struggle in this job, that I do want to save everything. I take it personally when something under my care dies and I don’t think it had to happen. I take it personally when I take on an animal with a poor prognosis and they pass away, or need to be euthanized. I take it personally because I worry that the day I accept it is the day I stop trying.
But I know it’s true, the great cosmic frustration of our profession. You can’t save them all.
11 comments
Hello Rose,
This is my second reading of You Can’t Save Them All, and I still have tears hanging on my glasses!!
Thanks so much for sharing your journey with Rupert as he came to the end of his life. It is comforting to know that someone, who may have your pet in their care, will feel so connected and concerned.
Dorothy
Hi Dorothy!
Thank you so much for your kind words. I feel a deep connection with all of my patients and it is so good to be able to to share that with others.
Cheers,
Rose
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