When Nature Calls: Care Of The Critically Ill Orangutan. A Case Report

Channeling my best Robert Malone, I decided to do a variation of his "Friday Funnies", except this one I will call "Monday Madness"... except in my version, I am the cartoon.

A good friend of mine was searching for an old email in her inbox when she came across one from me from years ago where I related a story that had just happened to me. She re-read the email and laughed so hard she cried.. again. She immediately called me and demanded me to do a Substack post about it because, “It. Is. My. Favorite. Story. Ever.”

Even though I am the butt of this joke of an episode in my life, it’s a welcome change from my usual drum-banging around Covid corruption and medical system insanity. I trust it will bring a smile and even a few laugh-tears to my dear subscribers. We sure could use one in light of the fact we are about to lose all sovereignty to Tedros and the WHO. See, I couldn’t even let up for even one post. Yeesh am I tiresome.

Anyway, here goes. Please note all names and places have been changed to preserve anonymity.

I was once in charge of the ICU of a large hospital as well as one of the leaders of a training program for doctors wanting to learn the specialty of Pulmonary and Critical Care Medicine. At one point, I was working closely with a medical device representative as I was trying to build a custom insertion kit to help my critical care fellows and medicine residents to place central venous catheters in as sterile and efficient a way as possible. Placing such catheters is one of the foundational procedures that a critical care physician must master, and maintaining a sterile field during an ongoing resuscitation of crashing patients is paramount to avoid blood stream infections. This isn’t what this post is about though.

One Sunday morning, I received a call from the device rep. I was pretty shocked because device reps usually don’t call ICU Directors… on a Sunday morning (I was not working that day either).

He started by apologizing for bothering me on a Sunday, but we were pretty friendly, so I asked him, “what's up, how can I help you?” He then started telling me about how his wife is one of the operational leads at the local zoo. I wasn't really sure where this was going, but then he began to explain that the zoo needed my help.

The zoo had a very sick teenage orangutan named Winaka who was suffering paralysis, and the veterinarian team thought she was sick with tetanus. They needed to get nutrition as well as medicines into Winaka because she could no longer raise her arms to feed herself or even hold herself up. He said the veterinarian team requested an expert at putting in a central venous catheter and wondered if I would be able to help because the veterinarians never place them in their practice.

As tired as I was on that morning, I immediately jumped up, as the opportunity to be involved with caring for a critically ill orangutan was beyond exciting to me. Let alone the fact my Hippocratic oath dictated that I help anyone in medical need when asked (not sure if the Hippocratic oath mentioned orangutans but you get it).

So I said “absolutely, I'll go over there right now, let me just pick up my equipment from the hospital.” He laughed and explained it could not be today because they needed to get a whole bunch of stuff in place. Apparently you can’t just walk into a cage with an orangutan and ask them to lay quietly while you insert a central line into their femoral vein. In fact, no human ever enters their cage because they can snap your arm off when scared or excited, except perhaps in cases like you see on TV where they know you from birth etc.

He explained that in the morning they would first sedate Winaka, bring her into the treatment room at the zoo, then an Anesthesia team from the hospital would be there to intubate her and attach her to a ventilator so that we could place the central venous catheter. He put me in touch with the veterinarian, we discussed the case at length (I probably asked a hundred questions as I was endlessly fascinated by this case). I became quite intrigued, not only with the medical history but with the history of this orangutan.

Winaka was apparently a very smart, and very suspicious orangutan. They had never been able to secret pills or medicines in any food, not even yogurt or ice cream because she would NEVER touch anything they messed with. This was their standard approach to administering needed medicines to all their animals but Winaka never fell for it. Other weird stuff in her history was that she once had a baby, but didn't like the baby and was mistreating it so they had to take the baby away. Apparently this happens sometimes with young teenage mother orangutans. Also, orangutans apparently spend the first 8? months of their life draped on the chest of their mother.

Problem: they had to take the baby away from Winaka. So what did they do? They hired staff who worked in shifts, holding the baby orangutan on their chest, wearing like a fur vest, and they bottle fed her that way. When I met one of the “surrogate orangutan mom’s”, they told me that the shifts were hard because they had to hold their pee for hours because if they went to pee it required peeling the baby orangutan off their warm chest and this was very distressing to the baby orangutan. The team was very proud of their efforts, especially the ending where they ended up bringing the baby to a zoo across the country where a mother orangutan had recently lost their child (I think) and when they presented the baby orangutan to the adopted mom, apparently it was a match made in heaven and they have lived closely and happily together ever since.

Let's get back to the story at hand. As soon as I got off the phone with the rep, I sent a group text to all my fellows (senior physician trainees in critical care medicine), when they immediately started to blow up my phone, all begging to be chosen to come with me to the zoo. My favorite was one of my fellows, who was on vacation across the country at the time stated that “he was getting on a plane right now.” Anyway I selected two of my fellows and we all made plans to go down there in the morning with our ultrasound machine and equipment.

Fast forward to the next day, the team of anesthesiologists were already there, as well as a neurology team (they were there to do a spinal tap, also something not commonly done by veterinarians). The anesthesiologists were already working on inserting a peripheral IV to administer medicine to perform the intubation.

I will just leave you pictures of that day and then we'll get to the meat of the story.

Picture #1: An anesthesiologist is looking for a vein to insert a peripheral IV

Photo #2. The anesthesiologist is “pre-oxygenating” Winaka in preparation for insertion of an endotracheal tube

Photo #3. Anesthesiologist is opening the jaw in preparation for insertion of the laryngoscope

Photo #4. The anesthesiologist begins to open the jaw with the laryngoscope in order to visualize the vocal cords for placement of the endotracheal tube.

Photo #5. We splay open Winaka’s legs to prepare the field for insertion of the central venous catheter in the right femoral vein (in the right groin)

Photo #6. My fellow placing the central venous catheter. Winaka is chilling out under Anesthesia.

Photo #7. The neurologist is performing a lumbar puncture (spinal tap) to obtain cerebrospinal fluid for analysis.

I will say that all procedures were successful, Winaka was immediately administered critical antibiotics with other medicines as well as nutrition. All teams were quite proud of our work.

I got consulted multiple other times on various aspects of Winaka’streatment, none more memorable than when they called to tell me Winaka’s right leg was double the size her left. Ugh. Deep venous thrombosis (DVT). I again went down there with my ultrasound machine, diagnosed the DVT and we started her on blood thinners. I also had to counsel the veterinarian team on what to do if Winaka “threw the clot to her lung." This is called a pulmonary embolus and can cause a medical emergency or even cardiac arrest. We arranged to get some clot busting medication to have on hand in the event it were to happen. Another day in the life of a critical care orangutan doctor.

Now, please realize, we are not at the funny part yet. What happened next is that my team (which included a partner of mine) wanted to write up the case and publish it as a “case report” for an upcoming national conference we were all going to. We thought it interesting to discuss the application of ultrasound in the diagnosis and treatment of a critically ill orangutan. Plus the pictures were cool :). Anyway, we asked the veterinarians to co-author with us, they were excited to write it up as well, however they told us we needed to get permission from the zoo first. This is what happened next (note I have changed or redacted all names and emails).

From: Dr. Smith
Sent: Thursday, October XX, YYYY
To: Deputy Zoo Director
Cc: Pierre Kory ; Dr. Jones
Subject: Abstract Request

Dear Deputy Zoo Director,

We are part of the ICU Medical team that evaluated and helped treat your orangutan, Winaka, several weeks ago for her quadriparesis and deep vein thrombosis. We were thrilled to have the chance to interact with Winaka and hope we were able to contribute to her wonderful recovery. 

Use of ultrasound is increasing amongst ICU physicians but remains underutilized, particularly for identification of deep vein thromboses. We hoped to submit an abstract describing Winaka’s case at one of our pulmonary and critical care meetings (American Thoracic Society) with the hopes of increasing excitement and use of bedside ultrasound. The fact that she is an orangutan will undoubtedly increase interest and we hope will stimulate improved uptake of ultrasound technology. I have attached the abstract, which we hope to submit October 29, for your review to ensure it maintains confidentiality of the Zoo and accuracy of the case. We have already had it reviewed by the veterinarian team doctors.  

Thank you for your consideration. We would love to assist with any future cases if we can be of service.

Drs. Smith, Jones, and Kory

On Oct 17, , at 5:54 PM, Deputy Director of the Zoo wrote:

Dr. Smith, 

The entire Zoo is grateful for the support and expertise shared from the local medical community during our time of need and uncertainty. It goes without saying, the intent of everyone’s focus was to improve Winaka’s quality of life. And as a result, a community of likeminded professionals and talents came together for one common goal. There is still a lot we don’t know, and a lot we still need to discover. Over the next several months the zoo’s leadership team will be working closely with the Orangutan Species Survival Plan (SSP) and the Association and Zoos and Aquariums (AZA) steering committees. Our zoo’s Executive Director, who leads one of these committees, will establish message points and timelines for how information regarding Winaka’s case gets released, and for what purposes.

At this time we cannot approve this abstract for submittal. This is not to say future considerations won’t be accepted, but for the moment we’ll need to put this on pause.  

As the Zoo establishes best practices in medical care for our collection, we are also putting together a comprehensive plan of how to communicate, educate, and teach these practices. We hope you understand our decision at this time; furthermore, know that the success of Winaka’s recovery, and all of our zoo’s collection, relay heavily on our community’s continued support.

Respectfully, 

Deputy Zoo Director

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Here is where.. I fucked up. I ended up “replying all” when I meant to just send to my two colleagues. It ended up landing in the inbox of the Deputy Zoo Director. Whoops.

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From: Pierre Kory <> 
Sent: Thursday, October 17, 8:21 PM
To: Deputy Zoo Director
Cc: Dr. Smith, Dr. Jones
Subject: Re: Abstract Request

That reads as if it was written by a professional spokesperson/press agent/lawyer. And I think it’s crap because at the end of the day a little abstract at a medical Society meeting is not a big deal. They fucked up, they forgot to give Winaka her tetanus shots and now they look stupid. At least that’s my take on it :) 

Hilary, let’s write an email to this guy every month just to see him twist and turn in his replies. It will keep us entertained while we wait to publish Winaka’s case report. :) -P

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Ouch. Not good. I actually realized I had sent a reply all by accident… like within minutes. I immediately called my colleagues asking for help in trying to claw back/delete/rescind an already sent email. They were of little help, in fact, one colleagues husband was like an IT guru and he quickly explained to me that it is very rare and very difficult to be able to prevent an email from reaching it’s destination once you click “send.” Ugh. I was so embarrassed and began dreading the reply. It came late the next morning.

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From: Deputy Zoo Director
Date: Friday, October 18, at 11:30 AM
To: Pierre Kory <>,
Subject: RE: Abstract Request

Dear Dr. Kory, Dr. Jones and Dr. Smith:

The intent behind this email response is twofold: the Zoo wants to be clear on our position regarding your abstract request, titled, “When Nature Calls: Care of the Critically-Ill Orangutan,” and to share with you my displeasure regarding the email response from Dr. Kory.

As stated in my email of October 17, the Zoo does not approve the submittal of the above mentioned abstract at this time. If future considerations are made for publication, or variations of it, please feel free to contact me so that we can consider them. If approved, the the zoo will draft a formal letter stating it has authorized publication. I have copied our legal counsel in my response to answer any questions you may have about our decision or the approval process. 

As stated above, I was shocked and disappointed with Dr. Kory’s unprofessional and crude response to my email. During my career, I have worked to ensure all animals under my supervision including the animals at the Zoo have the best care possible. This sometimes requires the help of community professionals with the expertise and technology to aid in this care. My professional agenda has always held only one purpose: improving animal welfare. 

You can imagine my surprise when I received Dr. Kory’s email which explicitly describes an effort designed to intimidate me for entertainment. I do not understand how a professional email exchange between two individuals could devolve into the aggressive, crass and expletive filled email response that Dr. Kory sent.  In order to preserve the mutually beneficial relationship between our organizations, I ask that greater care be taken in your communications.  

Moving forward, and keeping animal welfare at the forefront of this message, we appreciate all the help and support that was received involving this animal’s case, and would like to ensure professional conduct is maintained at the highest level.

Respectfully,

Deputy Zoo Director

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I was so ashamed. I immediately wrote back with the below.

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From: Pierre Kory <>
Date: Friday, October 18, at 11:38 AM
To: "Deputy Zoo Director” “Dr. Smith”, Dr. Jones”
Subject: Re: Abstract Request

Dear Deputy Zoo Director,

I completely agree with your assessment of my email as crass with expletives and I recognize what an unfortunate choice of words I used but please know my suggestion that we entertain ourselves was a poorly worded joke, there was no absolutely no serious intent behind it. Either way, this was, I hope, a new low in regards to my attempts at humor/expression and hopefully will never be repeated. I am truly ashamed of any hurt/offense I have caused. Respectfully and apologetically yours, Pierre Kory

The saddest part of this whole story.. is my career as a critical care orangutan doctor came to a crashing halt. Forever.

P.S. Winaka ended up making a full recovery! It was fascinating and incredibly satisfying to watch the daily videos of her recovery sent to me by the veterinarian team. She never threw a pulmonary embolus either despite the fact she never took her blood thinners once she went back into her cage (every time they put it in any food, she wouldn’t touch it).

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I just want to say how much I appreciate all the subscribers to my substack, and especially the paid ones. Your support is so greatly appreciated.

P.S I am getting professional help (hah!) to write a book about what I have personally witnessed and learned during the Pandemic war on ivermectin. Pre-order here for: