The Hope Center Blog

Case Reflection – Emergency

Sign from an Angel

April 27th, 2015. The alarm painfully sounded at 4:30 a.m. I hit the snooze button for the third time with a sleepy uncoordinated fist. “Why did I agree to work this extra shift?” I stumbled out of bed and then stumbled into work that morning, black coffee in my veins losing the battle against the villain of exhaustion. My left eyelid started twitching, a supposed sign of foreboding, according to my superstitious mother. I felt my body sigh. I have never been a morning person, but I have found ways to cope. I knew what my mind needed: I walked towards a cage in the ICU and was immediately revived by the gracious meow of a large grey cat. I offered my hand and he returned the favor by vigorously pressing the side of his face deeply into my palm as I scratched behind his ear. Better than a venti triple shot from Starbucks. I was now ready for the day.

The shift started as any other, and I was seeing the usual variety of emergency cases in the hospital: a dog with fetid burgundy diarrhea, an overweight blocked cat, and a playful kitten with a URI. Then, Angel* came in. Angel was a beautiful 13 year old FS brindle Shih Tzu Bichon Mix that presented for mild dyspnea. An initial physical exam revealed a heart murmur and fine crackles. I immediately placed her in an oxygen cage and we locked eyes through the plexiglass. She breathed more comfortably in oxygen and “smiled” at me while panting, excited to get any attention. The techs and I stopped for a minute to adore Angel’s kind-hearted demeanor and the striking lashes that fluttered above her dark gleaming eyes. Ms. Stenton*was the proud owner that I met in the exam room. She was a mature woman with peppered grey hair and a kind, warmhearted face. Her gentle personality revealed some concern for Angel, but there was tranquility about her that I admired. I felt easily connected to her. We shared stories of our former pets, and she enlightened me on Angel’s story. “The breeder called her the ugly one, and so I picked her.” I discussed my plan: oxygen, lasix, and echocardiogram. Ms. Stenton glanced down at her watch, “You know, I’m the type of person that believes in signs and that divine force is inevitable. Things happen for a reason.” She held out her wrist and pointed, “My watch stopped last night at 5:55 p.m., and I feel it’s a sign. I don’t want to lose Angel, but I have a feeling I will today.”

I answered her, “Interestingly, my eye has been twitching today and my mother would say that’s a sign.” I tried to allay her fears, “But I don’t believe in signs and I’m hopeful for Angel. Her prognosis is dependent on a diagnosis, but she really seems stable at this time with only mild dyspnea.” To prove my point, I escorted her to show Angel’s improved comfort in oxygen.

On the way out, Ms. Stenton chuckled, “She does look better. But just in case, I’m going to pick up a new watch battery on the way home.”

To my dismay, Angel’s clinical status declined. And it declined quickly. Within 3 hours, we had a diagnosis of severe pulmonary hypertension and despite treatment, Angel progressed to severe dyspnea. She became recumbent and her mucous membranes turned to a dark muddy pink. I called Ms. Stenton, “We are doing everything we can but Angel is having much more difficulty breathing. I want you to have the opportunity to visit with her in case she declines further.” She rushed back to the Hope Center.

I met Ms. Stenton at the front door, her eyes red and brows furrowed with worry. Amazingly, Angel, who had been recumbent, conserving her energy for respiration, recognized Ms. Stenton even through the plexiglass. She instantly sat up, and panted showing that familiar “smile.” With flow by oxygen, Angel sat in Ms. Stenton’s arms and enthusiastically licked her face with pure delight despite the marked respiratory distress. It was an emotional moment between pet and guardian, and the love and devotion was heartbreaking. I recognized the sorrow flowing from her eyes. I, too, have personally experienced those exact tears — they overflow with the beauty of love but are tormented by despair. Ms. Stenton said with resolve, “I know she is suffering. It’s time to let her go. We’ve said goodbye.” We let Angel rest back in the oxygen cage as I escorted Ms. Stenton to our Comfort Room and set up an oxygen line.

I could not take her pain and sadness away; however, I needed to let her know, “Ms. Stenton, thank you for loving her and giving her a wonderful life. You’re making the right decision.” She sobbed harder, unable to speak, but smiled and squeezed my hand.

I took twenty purposeful steps back to the ICU, and cleared my head with a long, deep breath. I looked inside the oxygen cage and found Angel agonal, barely conscious. I remember this moment too clearly. These are the memories I would like to forget. My memory here quickly turns to black and white. The room around me seemed to dim and sound faded into low echos. My heart sank as I quickly picked up her limp body and raced her to the comfort room. With each running step, I repeatedly whispered, “No, no, no.” Twenty steps felt like an extended nightmare. But then, solace. When I opened the door to the comfort room, color returned. I vividly recall Ms. Stenton’s red blouse, the orange couch in the comfort room, and a warm golden lighting. Angel took her last breath just as I gently placed her on Ms. Stenton’s lap. She caressed her head as we both wept hand in hand. Breaking the silence, Ms. Stenton uttered a few broken words, “Look at the time.” Through blurry tears, my eyes drifted up to see the clock. 5:55 p.m. I gasped. On this day I was not supposed to work and woke with my eye twitching, at this very minute, exactly 24 hours after a loving owner’s watch stopped is the minute an Angel took her last breath. It is a day and a minute I will never forget. I did not believe in signs, but I cannot deny this extraordinary moment. I am so saddened by the loss of that lovely little Angel, but blessed to have met this wonderful woman who showed me that maybe, signs do exist. As a veterinarian, we are often immersed in science, convinced by evidence, programmed by facts. 5:55 p.m. will now forever remind me that I need to take the time to notice and appreciate the marvels that occur outside of logic. Rest in Peace, sweet Angel.


*True Story. Names have been changed to maintain confidentiality.

Pulmonary hypertension (PH) is one of the most frustrating conditions, in my opinion. As an ER doc, there are many times I have treated a case of presumed heart failure to find out that the lasix I gave was merely dehydrating my patient that had PH. The condition occurs with an elevated pulmonary artery pressure and can be due to many causes, including association with heart disease, hence my frustration with misdiagnosis. Other causes include interstitial lung disease, chronic upper airway obstruction, heart worm disease, idiopathic (primary), and pulmonary thromboembolism which is what we suspect occurred in Angel Stenton* due to the quick progression of signs. Pulmonary thromboembolism also can be evasive on radiographs. PH is a result of either increased left atrial pressure or increased pulmonary vascular resistance. Radiographs can show tortuous pulmonary vasculature, right ventricular enlargement, pulmonary artery enlargement, and left atrial enlargement. An underlying cause of pulmonary disease may be seen concurrently. However, I have never been able to definitively diagnose PH with radiographs alone. Confirmation of the condition is achieved by echocardiography. In addition, echocardiography allows us to measure the severity of the disease. Treatment of PH includes medication to reduce pulmonary arterial pressure, oxygen, and treatment of an underlying condition if present.

References available upon request.


Karena Joung, VMD

After graduating pre-med from The Johns Hopkins University, Dr. Joung knew her passion for medicine combined with a deep affection for animals would suit a veterinary career. She received her veterinary doctorate from the University of Pennsylvania in 2003. Her interest in Emergency Medicine was cultivated during her internship at Michigan State University where she received recognition as Intern of the Year.

After spending 10 happy years at Hope Advanced Veterinary Center in Vienna, Virginia, she is excited to serve in Rockville as Chief of Staff. A native of the DC area, and graduate of Quince Orchard High School, Dr. Joung spends spare time with her husband (a football fanatic), their 2 dogs, and 2 cats.

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