The First of Nine Lives

by Ken Poyner

In February 2018 we noticed one of our cats seemed to be losing weight. Sabbath, our youngest cat, was getting lethargic, and seemed to be hollowing out more than we would have expected. He was not as annoying as usual, and seemed to be getting a bit scarce.

Sabbath at the time had Greystar, Verakai and his half-brother Dralian as mischievous posse. The other three seemed still seaworthy, so off to the vet with Sabbath we went.

The veterinarian examined him, took X-rays, and came out to tell us that Sabbath, sadly, had lung cancer, and nothing could be done. She showed us the X-ray on her handheld laptop, cradling the device on her forearm with the pivot of the screen resting against the inside of the elbow.

I looked at it, examining as best I could with my layman’s knowledge the embattled lungs, and matter-of-factly said, “That is not cancer.” The vet awkwardly balancing the computer was taken aback, but otherwise reacted well. She agreed to test for infection.

Days later, the results of the infection test had not yet come back. She had prescribed three days of antibiotics, as a way to keep the wife and me happy, and perhaps to appear as doing something while everyone settled into the big wait. The next three days we gave him the pills on the listed schedule, and it seemed by the end of the period that he was getting better.

But still no results from the veterinarian. Somehow things were muddled.

So, we went to a second vet. A vet about as far away from the first vet as possible, staying within the city. The first veterinarian is on the North end of the city; the second is on the South end. Not done by design, but notable that it turned out that way. It was the type of trip for which you check your fuel level before you set out.

I am not a doctor, nor a veterinarian. My wife did work as a veterinarian’s assistant for 37 years, but she did not read radiological imagery. And I was the one who knew it was not lung cancer.

How would I know? In my first nine years working for the Navy, I was an information systems analyst for the Naval Medical Information Management Center. In those days, radiological images were still pinned to a light board and doctors came to stand pensively before the light board to read them. Sometimes they would be clustered like a small audience perplexed at some quizzical feat being performed in front of them. If you wanted an opinion from someone who was not in the local gaggle of doctors, you had to print the image, mail it, wait for the consulting doctor to get it and call you with his opinion.

This was particularly a problem for the military. Doctors in the civilian world are credentialed state by state. You can only practice medicine in the states where you are credentialed. There are issues with a doctor in Virginia getting a consulting opinion from a doctor in North Carolina or Utah. Not so in the military: you are credentialed by the installation where you are practicing, but can have consulting privileges across all military facilities. If the doctor at Portsmouth Naval Hospital wants to consult the Head of Radiology in San Diego, no issue. Except for the mail.

Computers back then were large, clunky things. The screens were CRTs and would by even cellphone standards today be considered low-resolution. Wouldn’t it be great if you could get a computer screen with adequate resolution to allow accurate diagnostic reading of digitized radiological images?

Seems several entities were thinking that, all about the same time. Getting the right mix of elements to make the technology of the day useful for diagnostic radiology, at that time, was for the military, for radiologist in general, for the technology companies, for professional medical associations, of major importance.

You might think the question was principally about building better screens. But added into the question was what type of image, how is the image digitized, are there issues with the image being transferred from where the image is taken to where the image is read, are there connect speed thresholds. These days, you can transfer the image to your smart phone, but back then, your huge CRT sat on your suitcase sized computer that had ten megabytes of storage, a five and a quarter inch floppy disk, and might connect to a network at a dizzying ten megabits per second (or perhaps five megabits with a coaxial cable).

Even credentialing had to be worked out.

A number of entities elected to cooperate, including the ‘purple’ military - the Army, Navy and Air Force medical departments working together, selecting one entity to represent them, called the Lead Agent. Also involved were the Bureau of Indian Affairs (bet you did not know they operate hospitals), Veteran’s Affairs, the Public Health Service, and multiple other entities, both government and private.

And the Navy, as Lead Agent, sent a technical representative to help refine the technology and all its little parts: me.

I was not involved in the medical decisions. My job was to tweak that, swap out this, redesign connections, and ask the doctors to take a look and tell me if it were clear enough yet. What types of pictures were we working with? Mostly, chest X-rays.

I know a little about medicine, though not a lot. But I do know what a chest full of cancer looks like. We used dozens of images. We tested several editions of equipment spat out by a plethora of vendors. This CRT with this CPU. Connect speeds of ten megabits or one hundred megabits. Different combinations, different speeds, different file formats. I flew to Albuquerque, went onto the hospital ship Comfort, went out to San Antonio, drove to Bethesda Naval Hospital.

A cat is not a human, and a cat’s lungs are different than a person’s, but I know what lung cancer looks like, its pattern. This new veterinarian took X-rays, stepped out of her office with a hand held tablet, showed me the image and said this cat has lung cancer. I said, I want a radiologist’s report.

We got the report that day and the radiologist said it almost surely was lung cancer. He did say, however, it could possibly be a fungal infection, but not likely. The vet said, well, it might be a form of tuberculosis. They were essentially making polite conversation.

In the end, however, as we were pushing for a diagnosis other than cancer, the vet came out and said, “I know it is cancer; but, to appease you, I will prescribe three weeks of antibiotics.”

Three thousand dollars lighter, we took our antibiotics and went with Sabbath home. We dosed him as instructed, and watched him improve. In three weeks, we went back to the new vet. She took an X-ray and came out of the room with the tablet in her hand, looking deeply into it, a blank expression sagging directionless on her face. As we were preparing to follow her back to her office, she came into the waiting area, finally looked up at me and said, “It’s a miracle. His lungs are 95% clear.”

We got another week’s worth of antibiotics, took him back for an examination at the end of that week, and his lungs were 100% clear.

Sabbath tonight is atop his furry tower, curled into a knot. His half brother Dralian has since passed, but is looking on from his urn across the room. Verakai is sleeping, or pretending to do so, on the scratchy rug by the front door. Greystar is somewhere around, probably stalking shadows.

What Sabbath had was a fungal infection. I could tell he did not have cancer because of the finely laid-out spirals of infection in his lung. Cancer does not spiral, particularly lung cancer. I did not know what he had, but I knew what he did not have.

The veterinarian who first examined Sabbath is still our vet. I do worry that two vets and one radiologist missed the diagnosis. I also worry that they did not originally want to treat him for infection. My advice is that, if you are 95% sure a patient has an incurable disease, and only 5% sure it is something treatable, treat that 5% likelihood with everything you have.

No one knows how long Sabbath, or any of us, have to continue writing the history of our lives. He was lucky this time that his human parents serendipitously had specialized knowledge, and the stormy insistence that one has to develop when working for twenty-seven years with sailors and Marines.

At the moment, Sabbath sleeps on his tower. Tonight, as every night, he will curl up at the foot of the bed where my wife’s feet would be if she were a foot taller, or wedge himself between us as some nights he likes to do. If he gets between us, early tomorrow morning he will have to fight with Verakai, for she thinks that early mornings that landing is her spot.