The adorable Cavalier King Charles mix puppy is acting very unpuppy-like: He is lethargic and doesn't have an appetite.

Veterinary technician Carlene Ternes holds the tiny, white-and-ginger puppy up into the air and gazes at his fuzzy, teddy-bear face.

Hes not eating, but his tail works, she reports, grinning.

Logan is just one of the many patients spending Friday night at the Red River Animal Emergency Hospital and Referral Center. The 24/7 emergency veterinary hospital the only one in North Dakota or western Minnesota treated somewhere between 18,000 and 20,000 patients last year, according to Dr. Andy Carver, the hospital's director and the first board-certified specialist in emergency and critical care in North Dakota.

In fact, the 11,000-square-foot hospital is so busy that plans are underway to add a $6 million, 17,000-square-foot addition to the building at 4491 23rd Ave. S., Fargo. The hospital will also add 20 staff, including specialists in internal medicine, oncology and surgery as well as critical care veterinary technicians, says Bill Walker, hospital administrator. A groundbreaking to commemorate the new construction will be held at 1 p.m., Thursday at the hospital.

As a pet owner who has brought my own dogs into the ER several times, I've often wondered what goes on behind closed doors at an emergency veterinary hospital. Now, thanks to access granted by Carver and Bill Walker, the hospital administrator for the RRAEHCC, I know.

Within four hours there, I was exhausted. In that time, I saw dozens of animals, including a ferret named Bandit who ingested an Advil, a green conure with fluid build-up in its abdomen and a very large dog named Elvis who jumped out of a moving car.

I also saw a bunch of hard-working vets and supporting staff who impressed me with their professionalism, teamwork and stamina.

Veterinary staff Alex Wong (left) and Amanda Fish remove the oxygen tube from a Basset hound's nose as they prepare him to go home. / By Tammy Swift

I can't stop comparing the facility to a human hospital.

There's a posh waiting room, a big reception desk and a slew of exam rooms.

The waiting room of the Red River Animal Emergency Hospital was empty most of last year when COVID-19 made it impossible for owners to wait for their pets as they were treated. As in many other veterinary clinics, owners needed to wait in their cars until their pets could go home. / By Tammy Swift

In the back, there's a glass-enclosed recovery unit and ICU units outfitted with oxygen and temperature control. There's a triage area, a blood bank, operating rooms, an x-ray room and a room that contains a human-grade CT scanner. RRAEHCC even has a mechanical ventilator.

The hospital has several pieces of human-grade medical equipment, including this CT scanner. Tammy Swift / The Forum

Carlene Ternes was instrumental in setting up the hospital's blood bank, which is now regularly restocked by more than 30 dogs and 15 cats. The pets receive treats and toys for their life-giving gift. / By Tammy Swift

Vet techs like Ternes marvel over how much the hospital has grown in her nine years here. When she started, the clinic was in a single suite on Oak Manor Drive South. In the early days, only one or two vet techs would work each night and there would be evenings when no patients were admitted.

In 2018, the hospital moved into the site of the former Golden Corral. Their new space can accommodate up to 38 animals at once and it frequently does. So much so that they have had to initiate a priority system. Once the hospital reaches Level 3 capacity, they will only accept the most critical cases. Owners whose animals have a less-serious ailment, such as an ear infection, are encouraged to monitor their pets closely and get them to their primary providers as soon as possible.

Vet tech Kailley Martinson holds a cat still while Molly Moritz draws a blood sample from its jugular vein, a commonly used venipuncture site for felines. / By Tammy Swift

Talk to staff and they share many theories as to the hospital's popularity. Carver attributes it to a growing regional awareness that the facility exists. Walker attributes it to the RRAEHRC's excellent reputation. Still others link it to the metro area's vigorous growth.

Another factor: People nowadays are more willing to pamper their pets. "More people are willing to spend money. They're family members now," Ternes says.

Carver says he hates turning owners away, as he knows how upsetting it is when one's pet suddenly gets sick. Even so, it has become necessary in a facility with limited room and staff. "I think its tough for people to realize the whole art and science behind needing to triage things and prioritize care," he says. "Everyone who comes there truly feels its an emergency. They see a quiet parking lot or lobby and get frustrated. I wish they understood ... priority has to be on caring for the sickest ones. We're not just being lazy and hanging around behind closed doors."

Just as I arrive, Carver emerges from surgery. Hes just operated on a 7-pound Yorkie to remove foreign objects from the puppys stomach.

The dogs owner brought him in after noticing the little guy was shaky and uncomfortable.

Carver soon found the problem. Or, actually, a whole wad of problems. The dog had ingested enough hair ties to outfit a drill team.

Carver removed a wad as big as a newborn's fist, along with another oddity a single jalapeo.

Any veterinary surgeon worth their scalpel has found a grab bag of goodies in the digestive systems of pets, from rocks, pantyhose and socks to children's toys, pacifiers, tinsel and pencil erasers.

While a "dog eat sock" world might sometime be caused by a nutritional deficiency or anxiety, Carver says most cases stem from pets being playful and inquisitive. "They're curious about things and they may like the mouth-feel and, without thinking about it, they may wind up swallowing it," he says.

Carver moves on to perform an ultrasound on a small dog.

The source of the dogs pain is soon apparent. A healthy pancreas is less than one centimeter thick and is hard to find on an ultrasound, Carver says. But this dogs pancreas is a billowy mass, filling the upper one-fourth of the ultrasound screen.

Dr. Andy Carver (left) performs an ultrasound on a dog with pancreatitis, while Dr. Anna Stansbery assists.

The little guy has a taste for eating trash, which explains the pancreatitis, Carver says. The pancreas produces enzymes to assist in food digestion and hormones to regulate blood sugar or glucose metabolism. When it isn't working right, it activates those enzymes prematurely, so they actually start digesting the pancreas itself.

Some bouts of pancreatitis are mild and can be treated at home. But some cases are severe and life-threatening; those animals may wind up in ICU, hooked up to feeding tubes and treated for multiple related problems.

Carver says this dog's pancreatitis is in the "moderate severity" range. The dog will make it, but his garbage-foraging days are over.

The ultrasound has helped RRAEHRC staff diagnose problems with greater efficiency and accuracy, Carver says. Before they had the machine, they relied on a patients bloodwork, which would have shown elevated liver enzymes. It could have easily been misdiagnosed as liver disease. This way, the pup will be on the road to recovery much more quickly and his owners will not have to spend more time and money trying to get to the real problem.

When people are looking for highly specialized medical care, many will travel to Mayo Clinic in Rochester, Minn. But when Mayo physicians and Minneapolis-area pet owners seek highly specialized care for their pets, many will travel to Fargo.

Dr. Ashlyn Kuklock performs emergency surgery on a canine patient while Kailley Martinson (center) and Rachel Manning assist. / By Tammy Swift

As the RRAEHRC has the only dialysis machine for animals between Seattle and Chicago, the University of Minnesota Veterinary Hospital routinely refers dogs and cats with failing kidneys here.

A recent example: After a referral from the University of Minnesota, Carver and Dr. Sam Wigglesworth, the second criticalist to join the RRAEHCC staff, performed a therapeutic plasma exchange on a golden doodle, who had managed to eat an entire bottle of ibuprofen.

The animal was in acute kidney failure, so the two vets performed a therapeutic plasma exchange, a process in which they used dialysis to separate the cells from the liquid part of the blood, then discarded the liquid part, which contained the toxins. They then replaced that fluid with donor fluids.

"The dog did great and went home with no symptoms," Carver says.

In another case, a Mayo doctor's dog, Ezra, was on dialysis at the Fargo hospital for weeks, Walker says. A little later, the hospital again received a call asking if they could keep Ezra for 10 days. Staffers were alarmed: Was Ezra sick again? Oh no, the doctor responded. He planned to go on vacation and didn't trust anyone else to watch his dog.

One of the more serious cases of the day involved a farm dog hit by a car. Tex's owner had driven two-and-a-half hours from Devils Lake to bring him here. She heard this is the best place, says Dr. Anna Stansbery, who is overseeing his case.

Veterinary technician Shelby Feickert comforts Tex, a cattle dog who suffered a severe compound fracture after being hit by a vehicle. / By Tammy Swift

Tex is a handsome Australian shepherd with long, russet hair. His snout is enclosed in a muzzle and his breathing is shallow and fast. His amber eyes are wide open, but dont seem to focus on anything. He is pretty shocky, a vet tech remarks.

Upon seeing his injury, its easy to see why. Tex's left front leg is broken so badly that splinters of bone peek through the skin. The limb bends at an unsettling angle.

Pain relief is first priority. While several techs stroke to calm him, Stansbery calls for a shot of methadone a quick, effective painkiller for animals.

With Tex's pain managed, Stansbery analyzes the best way to proceed. The owner could take the dog to the University of Minnesota Veterinary Medical Center, where they could perform a complex surgery in attempts to reconstruct the leg. But it would cost at least $5,000 and contain no guarantee that the leg would work.

Tex is 12 years old. Most dogs adapt well to three-legged life, especially smart, athletic herding dogs, Stansbery explains. At the same time, the loss of a front limb is harder, as the front legs bear more weight than the hind legs.

She discusses the options with the owner, who decides it is best to amputate.

When Tex awakes, he will be a three-legged dog. But, as Stansbery points out, our pets don't wrestle with the same pangs of self-pity that we do.

"They don't wake up and say, 'Poor me,'" Stansbery says. "It's more like, 'What can I pee on and what's for dinner?'"

Even in this adrenaline-charged atmosphere, I spot many little acts of compassion.

Sarah DeCrans and her French bulldog, Nigel, provide a morale-boosting visit to vet tech Chris Knutson. / By Tammy Swift

One chihuahua has been crying most of the night. A veterinary assistant walks over and strokes its tiny nose, which immediately calms the dog. Later, I see another vet assistant cuddle a tiny calico kitten simply because "he's so darned cute."

A veterinary assistant reaches into the kennel of an ailing Chihuahua to comfort her by stroking her nose. Tammy Swift / The Forum

This tiny calico kitten looks particularly tiny and vulnerable in his kennel, but is comforted by piles of blankets and the snuggles of veterinary staff. / By Tammy Swift

Out in the triage area, another puppy is having a bad day. Freia is a baby black lab who had a run-in with a lawn mower. Its one of the trials of puppyhood: Learning how to co-exist amid all the shiny, cleverly-hidden dangers in the human world.

Dr. Ashlyn Kuklock carefully examines the afflicted foot to make sure Freia only has soft-tissue damage. But first, she caves to the pup's sweet charm, cradling the little Lab's head in her hands to plant a masked kiss to Freias soft, furry forehead. The puppys tail whips back and forth hopefully.

Experienced vet tech Carlene Ternes knows one of the perks of the job is the ability to snuggle and comfort adorable pets like Logan, a puppy admitted for lethargy and poor appetite. / By Tammy Swift

Its a testimony to puppy optimism that even when they hurt, most still find a reason to wag their tails.

In a quiet area on the south end of the treatment area, a lone veterinary technician works over a gray cat. I'm about to ask what he's in for before realizing he has been euthanized. She is cutting off the bandage that secured his IV; theres no need for that now. Black ink prints of his paws have been made on white cards and rest by his body. He lies atop a cuddly fleece blanket. For some reason, I am glad for the blanket, this last offering of comfort before he crossed the rainbow bridge.

Emergency pet hospitals often must perform euthanizations when an animal becomes gravely ill or critically injured outside of their regular veterinarian's office hours. Grieving owners are able to say goodbye to their pets and grieve in the privacy of a special "comfort room," which features overstuffed furniture and displays this comforting passage from "The Rainbow Bridge." Tammy Swift / The Forum

It is a sad, quiet moment.

Its a question I ask several people who work there. How can these animal-loving professionals handle the euthanizations? Their answers reflect a combination of professional reserve and compassion. They tell me that it is easier for them to remain objective than it is for a grief-stricken owner. They also talk of mercy, how they see this as a way to relieve an animal whose body is racked by pain, severe illness or the ravages of old age.

But after saying all this, a couple of vet techs admit it is the least favorite part of their job.

This tiny calico kitten looks particularly tiny and vulnerable in his kennel, but is comforted by piles of blankets and the snuggles of veterinary staff. / By Tammy Swift

Walker says the team likes to focus on the the triumphs the dog that beat life-threatening sickness, the kitten saved by dialysis. "Compassion fatigue is very real in the veterinary business," he says. "So it's the good things, the ones that survive and beat the odds, that keep everyone going."

All of the veterinary staff are pet lovers, as illustrated by veterinary assistant Rachel Manning's "cat-too" of her two cats. / By Tammy Swift

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From broken legs to a punky pancreas, here's what a night in Fargo's animal ER is like - INFORUM