CDC leader’s response matches the level of concern

CDC FriedenIn a New York Times article by Don McNeil, CDC Director Dr. Thomas Frieden reacts to yet another high-level breech in operations that could have led to serious consequences.

“These events revealed totally unacceptable behavior,” Dr. Frieden said. “They should never have happened. I’m upset, I’m angry, I’ve lost sleep over this, and I’m working on it until the issue is resolved.”

Frieden’s response seems harsh. For people inside the agency might think they’ve been thrown under the proverbial bus. But Frieden is responsible for the safety of research involving lethal biological agents. The whole world trusts his agency. It’s not a time to be wishy-washy.

Response by leadership has to convey that errors are being taken seriously without creating unnecessary alarm. Frieden is a savvy communicator. His strongly worded message says he’s taking this personally and he expects improvements.

And, by the way, don’t fire him because he’s the guy who can fix this problem.

Let’s hope the people with direct responsibility for safety are taking this as seriously as the director, because communications only reflects what’s going on inside an organization, it doesn’t change it.  

 

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Build a better mouse catcher

If I’m lucky, there’s a mouse trap downstairs, in the pantry, that’s done its job successfully.

But I don’t want to go down there.

Catching mice has never been this complicated before.

Was it the trip to Disney?

Is it because the other morning Ella found the trap, empty, and threw it away because, she said, she heard on TV that mice are good?

Why would I rather catch the mouse alive and make it our pet?

Is it the vivarium I went into last week at work?

We’ve had mice in the pantry before. It’s a big walk-in job, with plenty of shelves for the little critter to scurry around on. But they never seem to eat much. There are no holes chewed in the corners of cereal boxes, no rice strewn along the floor. They only appear in winter, when it’s cold and wet outside. This one has been the trickiest to catch. The past two two nights it’s eating the peanut butter without tripping the trap.

Oy. Here I go.

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Bones

After a lot of debate, and advise from my good friend Nancy, I decided to have Duke cremated. Trish sat this decision out. I had my last dog, Paco, cremated, and the tin canister that holds his ashes, that sits on the shelf in the closet of our home office, still creeps her out a little.

But, Trish did agree with me that talking with Ella about cremation would be too difficult to explain to Ella. We didn’t want to scare her. And we didn’t know how in the world to do it.

So I was surprised when Ella asked me as I tucked her into bed the night Duke died when she said, “Dad, you know your old dog? What was his name?

“Paco?”

“Yes, Paco. You know Paco? Can I see his bones?”

There are occasions when I suspect Trish has said something when she really hasn’t, and I walk through a door Ella has opened into a conversation I could have avoided. So I probed a little bit.

“Paco’s ashes? What do you mean?”

“Mom said you have his ashes, that he was crematated.”

“Cremated?”

“Cremated. Can I see his ashes?”

Thanks, Trish.

Ella has this way of finding out information with a sideways into a line of questioning, like drawing a triangle — establish a baseline, ask a related question about 90 degrees in a different direction (that’s the set up), then asking a final question, the answer of which, she has already concluded, must return to the base. It’s a skill that I acquired only after I began reporting. By asking about Paco’s ashes she knew she was gaining information about Duke.

Trish later told me that Ella had interrogated her about Duke, post-death, for two days, and finally she caved. Trish supplied a mixed-metaphorical explanation, something about dinosaur bones, to explain what a skeleton is, or what bones are, and the ashes she and Ella have smudged on their foreheads on Ash Wednesday, to explain, I guess, ashes. It confuses me still.

Now I was hearing questions like “why will we keep his ashes?” and “how do they burn the body?”

I did the best I could. On the burning issue, I was as honest. I told her I didn’t really think about that much how it was done. I tried to explain that when we die, our body stops working — our lungs stop breathing, our hearts stop pumping — and we stop feeling pain. But our spirits live in memories. Whatever happens to our bodies doesn’t cause pain (I hope!). Duke was a great dog, and I saved his ashes, which were more like coarse sand with chips of broken coral, so he would always be with us, and what I liked to think about most are the memories we would have of Duke and the photos that helped us remember him, and that would keep him alive in our hearts.

The day I took Duke to the vet Ella was, I’m sure, confused. Her dog was alive, but he was soon going  to be dead, and I was taking him to the vet to make that happen. I picked up Duke, who had lost so much weight his thick, soft fur felt like a loose bag around his bones, and placed him in the back of my 4-Runner. Trish said goodbye, and I wanted Ella to say bye, but she resisted. But I insisted, and I’m glad I did. She went from angry and confused to a child simply saying hugging and kissing one of her friends. I knew, from experience, that she eventually might regret not saying goodbye and expressing her love.

Ella’s bedtime curiosity was, for the time being, satisfied. Over the next several days, though, she wanted to talk about Duke, about his being dead. She was still trying to connect, I think, his physical absence with our emotional connection.

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Duke’s last day

Duke, summer '08

Duke, summer '08

I sat beside Duke, leaning against the exam room wall, as he lay on a blanket the vet provided, ready to give up. He rested his head on my leg and I stroked the downy soft fur behind his head, his silky ears. His eyes weeped drainage, almost like tears, for the first time in weeks.

I placed my hand on his chest so I could feel his heart beat, and I held it there until it stopped.

Duke was the second dog I’ve had put to sleep. I was determined he would have a good death, that I would spare him as much suffering as possible. I think I did that. Since Saturday, three days ago, his tail stopped wagging. On Sunday he seemed disoriented, and too tired to even lie down. He just stood, mostly, on sprawled legs like a new calf, as if he were feeling his legs for the first time. In fact, he was, for the first time since a newborn, feeling unsteady on legs that used to zoom circles around other dogs. All these strange things as the end of his life grew closer.

We called the vet this morning and told her it was time. We made an appointment for 3:30. I knew the time my dog would die. It was both surreal and, because I’ve had almost five weeks since his diagnosis to come to grips with his death, reassuring. I knew the moment my dog would no longer suffer.

I’ve heard that people waste away when they’re sick with cancer. I saw it in Duke. I could feel his spine and his hips when I petted him. He labored to breathe, and, these past few days, he wobbled when tried walking down the steps of our porch. Duke was the most vibrant, alert, healthy dog I’d ever known. he was fast, curious, aware, but not obnoxious. He did tend to raise his snout in most people’s crotch, which usually made me smile.

Duke loved being in motion so much he couldn’t stand still while he pooped. He’d poop a little, then waddle forward and keep going until he was finished, which made picking up after him on walks a little annoying. When he wasn’t pooping he was peeing. How he held so much urine in his bladder always amazed me. No matter how many mailboxes we passed he had a little left over to mark his stop. This drove Trish nuts. she’d hit a good stride and Duke would stop to pee. She’d get going again, with the other two dogs in the lead, and Duke would pause to piss. There often was a small trail of urine across the sidewalk where she’d have to drag Duke away from someone’s flowers, and he’d still be peeing.

Duke chased birds. Not little flocks that would land in the yard, but big hawks and crows. He’d catch a shadow of a bird and chase it from one end of the yard to the other.

Duke had the best ears — one up, one down. One night, not long after Trish and I married and we blended her dog with my two boys, we were in the living room visiting with a friend when we heard a loud yelp. Our friend let Duke in the house and said, “he’s bleedging.” His up-ear had been, well, dog-eared. There was a nice little notch taken right out of the tip, about an inch and a half wide.

We never found the ear tip, but we suspected that the dogs had been wrestling playfully — they got along great together — and one of them held onto Duke’s ear while he jerked it away.

I asked him today, his head in my hands, who did it. He still wouldn’t say. I asked him if the guilty party would finally fess up. Nobody has, yet.

Duke was the bad boy, which means he wasn’t always trying to climb in someone’s lap, like Tiger, or begging to come inside, like Abby. He did his own thing, mostly. He was less tolerant of Ella’s pawing. He didn’t like the suggestion of being ridden, and he hated being led around the backyard on a leesh fashioned from one of my belts.

This made Ella love him more than the others. And that makes me worry that she’s going to either be attracted to the bad boy image or play the bad girl role, pulling some hapless boy around, making him bend to her will.

One of Duke’s favorite past times, shared with many dogs, was riding in the back of my 4-Runner. I’d crack the rear window a little and he’d stand there with his nose sniffing the air as we drove around Nashville, or he would crane his neck forward and look through the windows intently, as if waiting to see something familiar. We did that less often after Abby joined the brood, because she always whined loudly and jumped into the front seat.

Today Duke didn’t perk up much when I told him we were going for a ride. I lifted him into the back and he stood there a little shaky, unsure even in one of his favorite posts. I drove slowly around our small town roads and kept glancing back to see if he were enjoying himself. Finally, after several miles, he made his way to the corner of the window, stuck out his snout and took a loud whiff.

I think Duke died OK. I mean, if he had lingered beyond today he surely would have been miserable. I think the timing was right — for him, never for me. But Duke was never mine, and as I held him during his last breaths I thought about spirits, and how strong the desire can be to keep a the spirit of someone alive. I understand why people want to believe in reincarnation, why cultures believe a spirit is manifest in another living thing. I wanted to draw Duke’s spirit out, take it as he exhaled those last few times, and keep it alive, put it in one of those powerful birds that circles above our house, casting it shadow in our yard. In some ways, I think I can. I think I will do that.

I’ll miss you, Duke. You were the best.

Duke and Ella, summer '08

Duke and Ella, summer '08

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Duke’s death, cont.

There’s a lot going on in this story. At the risk of confounding you more, I’ll dive in a little deeper. It’s now Aug. 25, a week after I wrote the first post about Duke.

First, an update. Duke still lacks the energy he used to have. He can trot out the door and across the street, but if he doesn’t get farther than a house or two away before he gives up and comes home, seeking the refuge of our air conditioning and the cool wood floors. But he’s been playful lately. Last night he lay on his back and wriggled with his feet in the air like he was wrestling and imaginary friend. Last week he patiently let Ella dress him in an old pair of her underpants and a t-shirt, necklaces and pink ribbons around his feet.

But I’m not finished with the vets. Our local vets were both evasive and defensive about Duke’s diagnosis. One wanted to assure me that she had examined him on Monday and didn’t see any problems, so this cancer came on quickly. But on Thursday, when I asked her to run his bloodwork (she still had a blood sample), it was clear that he was declining then. She either hadn’t examined him — hadn’t read his pale gums — or she completely missed what was obvious to the Wednesday vet. The Wednesday vet tried to sugar-coat a diagnosis. His blood count’s a little low, he’s a little sick, you need to take him to a critical care clinic where there are bigger brains. The Monday vet wasn’t much better. “One thing we start to think about is cancer.”

Please. It took the recent vet school graduates 10 minutes to tell me my dog has cancer.

Let me talk about those young doctors.

I wanted to go to the vet school. I knew they had more resources than anyone else in the area, including more brain power among the faculty. And, I thought they would be less expensive.

The internist came into the waiting room to get me and led me back to the exam room. She had kind, empathetic eyes. She explained what was happening with Duke and listened to my questions. She spoke calmly and quietly. I sat in a chair and she squatted on the floor against the wall opposite me and said we would be informal. A student trailed her into the room and sat on the floor. And, she brought the oncologist into the room, who explained a course of chemo that might extend his life. Media life expectancy — she patiently explained the word “median” — was nine weeks, and with chemo, an 11-week course, Duke might live 18 weeks. Together they explained what diagnostic procedures they could offer — bone marrow aspiration, ultrasound, CT, more blood work, careful observation in the ICU. They could perform radiation therapy in conjunction with the chemo. Then they left the room to let me think things over.

After 20 minutes or more I asked for the internist to come back into the room. Again, she was calm and listened, until I said that I did not want Duke to go through chemotherapy. I wanted him home, and I wanted him to die on our terms.

He demeanor changed from understanding to mild disbelief. She excused herself and returned a few minutes later with the oncologist, and when the two re-entered the room I felt double-teamed, like I was about to get the good-cop, bad-cop treatment. The room became a holding cell — bright lights, cold hard floor, stainless steel furniture, windowless. They were there to rescue me from my bad decisions, and my dog’s care would be better left to them.

The oncologist was in some ways the antithesis of the internist. The internist was in scrubs and sneakers, her hair in a pony tail. She looked like a doc who planned to be awake at 2 a.m. caring for patients. What she lacked in physical poise she made up for in apparent dedication.

The oncologist, however, was smartly dressed in black pants and the cuffs of her black turtle neck peeked out from the sleeves of her white coat –sure, it was August in North Carolina, but I thought she probably dressed to ward off the frigid AC. Maybe she was cold-natured. Before, when she ran through the rote response about leukemia, she stood erect, her head held back. Confident. That’s good. She was smart. This time, she came into the room and sat in the chair next to me, leaned back and put both hands on her knees. She started, “I became on oncologist because I wanted to offer …” I could tell she was preaching from her experience, but I stopped hearing her. You’re not an oncologist, I wanted to say. You’re a resident, an oncologist in training, and you’ve just crossed the line from healer to harper.

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Duke’s death

Duke is dying.

But he’s dying a good death, best as I can tell. He eats well, and he’s perky, even happy. He wags his tail and wolfs down dinner.

But inside his body leukemia is choking out healthy red blood cells, pushing platelets out of production. According to the vet he might have six weeks left. It’s hard to tell, though. Her estimate was based on her few years as a student and oncology resident. She also figured a course of chemotherapy that would last 11 weeks.

My estimate, however, of a “good death” is based on experience with a very poor death, one that was lonely, painful, confused and sad. And, preventable. Paco, my dog before Duke, was gripped by a sudden illness that left his esophagus slack, unable to swallow. An inexperienced vet puzzled over him. I remember seeing her one day walking out of a church service, and she said she was going to go home and read her text books to see if she could find the answer. By the time she had an inkling, Paco was declining fast, and by the time I got him to Auburn University’s vet school, he had bacterial pneumonia. I had planned to bring him home to be put to sleep, but he died before I could.

I can’t say my experience with Duke’s vets was better than with Paco’s.

One Sunday afternoon Duke came up to me outside and his eyes were swollen; the right eye was completely shut, the left one was open a sliver, but this third eyelid, that milky-white membrane that looks like a Venetian blind that pulls up from the bottom, covered it. I instinctively yelled for my wife, a nurse of 25 years. Neither one of us knew what could have been wrong with Duke, but we knew it wasn’t good.

Monday, the vet said Duke’s eyes were too swollen to examine. She prescribed steroid drops and a follow-up in a few days.

Wednesday morning I showed up, hoping to get answers. A different vet would be in that day. I left Duke and took our daughter to pre-school. Later that day the second vet, the Wednesday vet, called. She still didn’t know what was wrong with Duke’s eyes, but she was more concerned that his blood counts were low. How low, I asked. Pretty low. How low is that? Around 18 percent. And what’s normal? Normally around 40.

This was the first sign that something was wrong not only with Duke, but with our experience with vets. The Wednesday vet was very experienced, skilled, knowledgeable and well liked by her customers. But she hemmed and hawed. Eighteen percent is pretty low. I said, he’s pretty sick. Yeah, well he’s not doing too good. And his gums are pale.

The Monday vet said nothing about pale gums or poor blood results, although she had drawn blood, and, the Wednesday vet assured me, his gums had looked fine on Monday.

The Wednesday vet said we should try to get Duke into the North Carolina State University vet school hospital, where they have “bigger brains” and more resources to know what’s wrong.

All this from swollen eyes. After reflecting on it a while I thought Duke got sand in his eye from lying in Ella’s sandbox. Trish thought he might have scratched his cornea among the tomato plants. Maybe it was a bee sting. But none of those instances were likely to result in both eyes being swollen. Now Duke had low blood — which, Wednesday vet and Trish explained meant that he wasn’t getting oxygen.

The NC State vet hospital was full — no room in the kennel for a very sick dog. They suggested I try a couple of private animal hospitals, staffed by intensivists. That sounded fine, but it also seemed expensive. NC State, I thought, would be more reasonably priced. And I like the concept of academic medicine. So I decided to wait. I was instructed to return to my primary vet the next morning for more blood work.

The Monday vet was back at work on Thursday. She drew more blood; his counts were still low. That morning he had bled a little, and had apparently shaken his head and splattered drops across the floor of Ella’s bathroom. I mentioned this off-handed to the vet. She called me later, sounding anxious, and told me they knew where Duke was bleeding, from his nose. Swollen eyes, bloody nose, low blood count. I couldn’t add it all up. But the vet could, and probably did, she just hadn’t told me yet.

I adopted Duke from a shelter a little over a year after Paco died, and about four months after my divorce from my first wife (how many marriages end after a pet dies?). I was writing a story for the newspaper about the kennel late one Friday afternoon, and decided to take a look at the pups. I thought the timing might be right. I was living alone, lonely, and needed something to do in my free time. About four or five columns of cages with lack-luster pups, here was one with a bright black-and-white coat, sparkling eyes and cockeyed ears — one down, one up, his very own flag. He was about six weeks old and had a thick coat of medium-length hair, and a curly fluffy tail, so he was listed as a border collie-huskey mix. His name was Falco. I have a friend whose last name is Falco, but at the time I thought it was the worst name for a dog I’d ever heard.

I decided to sleep on the decision. It was late Friday, and the shelter was closing. But by Saturday morning I had already scheduled the vet visit and was the first one through the shelter’s doors, there to claim my new pup. I read books about dog training, and I walked Duke three times a day. He was the model dog and a quick study. That first day home he went right to the door and pawed it, telling me he needed to go outside. He never needed housebreaking, he was training me!

Thursday’s vet still seemed puzzled. She assured me that Duke’s gums were not pale on Monday. Yet I wondered how long his blood levels had been low. They drew blood on Monday, did they test it then? No. So could she test it now? Sure, and a few minutes later came back to say his levels were already at 18 on Monday. His gums had to have been pale. I knew the vet was starting to feel guilty, and I didn’t press her. Finally she told me that his bloodwork and symptoms were pointing to a diagnosis of cancer. If I still wanted, she could make some calls and get me into the vet school.

It was 5 o’clock before I got Duke to the hospital, and by then the attending vets were leaving.

A vet called me back to an exam room so we could talk — I noticed we didn’t stop in the corridor as some of the other families had. She was joined by an oncologist and they spelled it out for me. Duke had leukemia. The oncologist explained the disease’s course, and my dog’s prognosis. She offered ultrasound, bone marrow aspiration, radiation therapy, eleven weeks of chemo … to extend his life by a few weeks at best. If he responded to the drugs. If the treatments didn’t kill him first.

The young vets seemed surprised, and a little disappointed, in my decision not to pursue chemo. The oncologist left, but when I pressed the internist about not wanting chemo, she left and returned with the young cancer specialist, who began by telling me she had become an oncologist so she could save animals. She was sure I wanted my dog to spend quality time with my family. She offered to give him one dose of a drug that would carry him through the night.

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Something says I’m supposed to be writing again.

It’s been six months.

Ella turns 4 in two weeks.

She’s grown so much

This was written in October 2008, published August 2009

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