Friday, November 21, 2014

Custard's (Almost) Last Stand. The Blocked Cat Meets Tailio

The cases I fear the most  arrive as quiet still patients who are oblivious to the fact that they are in the vets office. The cat who lies in their moms arm barely able to lift a head to face the barks and bustling of a busy veterinary clinic. Such was the case for Custard. He appeared to be sleeping soundly in a carrier on his moms lap. A cat never sleeps in a carrier when they arrive at the clinic.

With every pass I make through the waiting room I am always scanning for the still beast in the box, the swaddled pup in the blanket, or the sobbing person waiting. There are intuitive glances, postures, and the abnormal sounds of experience that I am always keeping my subconscious listening and looking for. You see I know that there should always be a look of concern, curiosity, some element indicating engagement in this is foreign place. We are a veterinary clinic a land of odd smells, unfamiliar noises, and a sixth sense of wonder and reservation. For the pets who arrive without this I worry and I jump in without pause.

I went to Custard immediately. I gave a very quick "hello" to his mom and without permission opened his carrier. He gave no response, and with that I told his mom I needed to take him to the treatment area right  away. In the second of her glance I knew that she was realizing her worries were just solidified.
A lifeless barely conscious Custard.
I am removing as much urine as possible before we
try to pass a urinary catheter to relieve the obstruction.
Custard barely responded to being taken out of the carrier, carried away and had no movement as he was placed on the exam table. I was certain that when my hand found his belly I would discover a large hard bladder.

Custard was what we call a "blocked cat." He was unable to urinate to empty his bladder. He was also very close to death and his chances of survival without immediate care were nil. I immediately removed as much urine as I could, about 100 mls of dark urine, while my associate started to prep to place a urinary catheter.

With this diagnosis time is your nemesis. You do not have a second to waste and everything in the building is put on hold until the bladder is patent. Unblocking a cat is about returning them to a place of homeostasis. This includes the ability to thermoregulate, free from infection, blood loss, build up of toxic levels of potassium (toxic to the heart), and puts a significant (although usually temporary) insult on the kidneys.

There are a few instances where veterinarians will act quickly and directly, a perceived blocked is one of them.

Here are the signs you should be aware of that might indicate your cat has a urinary blockage;
  1. Repeated trips to the litter box
  2. Crying or vocalizing in the litter box
  3. Only producing small amounts of urine
  4. Straining or posturing to urinate
  5. Lethargy, acting tired, or painful, or weak, or even vomiting.
A blocked cat is an emergency. They can die if they wait for help. Custards mom was not surprised when I returned to tell her that Custard was blocked. She had lost another cat to this a few years ago, and Custard was acting just like the other one had. She brought him in to see us as soon as she realized this.

With the diagnosis comes the treatment plan. To treat a blocked cat requires about three (or more) days of hospitalization and care. The estimate we gave her was about $800, if everything went without any obstacles. 

Custards chance of lifesaving care depended on our ability to meet a very tight budget. We didn't have resources to do blood work, or any diagnostics of any kind. 

This is Custards urine collection bag,
his urine is significantly hematuric, (very bloody).
Custard arrived at about 5 pm. He was lifeless, cold, and barely clinging to life.

By 8 pm (closing time) we had gotten Custard warmed up but he was still very poorly responsive. I secretly hate these moments; when a pet is dying in front of  you and your back is to the wall. Our clinic closes at 8. There is no overnight staff, and we still had Custard bundled up unconscious and barley alive. I was stressed, worried and knew that he needed to be closely monitored, kept on fluids, and I couldn't walk out the door, turn off the lights and sleep tonight. I still take these cases to heart, I still can't convince myself that someone else's financial struggles, declining to transfer to the ER and a cat on the brink are not my problem.

I swaddled him up in blankets and placed him in a cat carrier to take him home with me for the night. I wasn't going to be able to sleep anyway, so I figured that I might as well give him the best chance that I could. And if he tried to die I wouldn't have to live with regret that he suffered by himself. The husband at home, 4 other cats, and 2 dogs wouldn't be surprised or upset with me arriving with an unannounced overnight guest.

At 9 pm I was still shielding myself from being too hopeful that Custard would survive. He wasn't looking like he was improving and he had arrived in such terrible shape.

By 1 am he could lift his head and open his eyes. I was so elated and relieved! With these guys better is significant. If they can get to better they can walk out of the hospital,,

IF they have enough time and monitoring. Here are the important monitoring points;
  1. Fluid therapy is vital. Intravenous fluids keep the bladder flushing. Whatever caused the blockage needs time and fluids to flush it out, crystals, red or white blood cells, crud,, whatever.
  2. Pain management. These patients strain, lick and posture because it hurts to hold urine.
  3. Antibiotics. Even if the cause of the blockage isn't caused by infection shoving a plastic tube up the urethra can introduce infection, never mind still having to deal with fecal output happening in very close proximity to the urinary genitalia.
  4. These guys benefit significantly from 24 hour supervision. There is an iv catheter going into one foot and a urinary catheter from the penis. They can, and do, get tangled. Also, the urine is still so bloody or infected that the urinary catheter can become occluded and they become blocked again.
  5. Warmth, feeding, adequate oversight to monitor for changes is also vital. For instance, Custard was on three different antibiotics, a bladder muscle medication, and was montiored for fever, and bladder tone every few hours. Then he decided to stop eating, (don't quite know why), so we had to start force feeding as we started to guess why he was no longer interested in food. He also had terrible diarrhea to complicate the treatment.
It took about 4 days of iv fluids, urinary catheter flushing, and TLC to get Custard back to being able to urinate a normal amount of clear urine. He needed antibiotics, pain medications, constant i.v. fluids, and even force feeding for a week. He was one very sick kitty. But Custards incredible story doesn't end there.

You see Custard came to us as an unneutered cat from a colony of cats that lived in a barn. He was the first (and so far only) unneutered cat that I have ever unblocked. His caretaker provided the funds and permission to let us treat him. (For those of you who know me I have a very difficult time NOT trying to treat a treatable pet, I wasn't going to accept a "no" easily). There are very few people who care for a feral colony with this much love and dedication.

After a 5 days of treatment Custard was still spiking a fever (evidence of residual infection) and was reluctant to eat. In an effort to get him well enough to leave the hospital we offer what we call "the endless cat food bar." I sent a tech to the grocery store to buy him some unusual options.
Here are some of my recommendations for picky cats;
  1. Baby food. Try the meat flavors. Super stinky to get the nose thinking.
  2. Canned tuna. The traditional feline favorite.
  3. Cooked chicken.
  4. Junk food cat food. The only time I recommend buying those cartoon caricatured, day-glo colored cat foods that you find at the low end of the price range.
  5. Kitten food wet and dry.
  6. Cat snacks from the normally forbidden grocery store cat food section.

How is that for options? We label the many samples in the hopes of finding one he might take a liking to.
Signs that we still have an angry bladder. A tiny spot of urine is produced.
Another sign of a urinary condition, licking at the genitals.
A cat licks what hurts.
After a week Custard was healthy enough to start his vaccines, be neutered and begin a life as a loved kitty. Can't you see the love and gratitude in  his eyes?

Custard came back to visit a few weeks later to finish his kitten vaccines. He has earned himself a spot inside with a family and remains a very calm, confident, sweet boy.

Many would have dismissed Custard as a difficult case. He had no vaccine history, a litany of complicating factors, and a list a mile long with reasons to not try to save him, but he also was a cat with a person who cares and wanted to give him a chance, and it wasn't just me this time.

Here are my take home points when it comes to blocked cats;
  1. They can be expensive. Our estimate is about $800. They usually require about 3-5 days of hospitalization.
  2. They are usually treatable.
  3. They need immediate medical intervention.
  4. They can be treated affordably and reasonably. Ask for an option that is affordable. If nothing more unblock them and take it day by day. It is not advisable, but we started treating without any vaccines or any diagnostics. I know the blood work and urine are going to look awful when I start treating a blocked cat, it isn't going to change what he needed immediately. FeLV/FIV status is relevant to the discussion of long term care.
  5. If they block once, there is a very good chance that they will block again. You need to change what you are doing to help avoid recurrence. The food is almost always the culprit..

This common ailment has early detection signs, like frequent trips to the litter box, frequent straining, producing only small amounts of urine, and excessive pawing at the litter once inside the box. There is a new tool to help pet parents identify when these are occurring. The ingenious tech device is called Tailio. Tailio works by collecting information from the litter box and it can then be used to understand subtle changes in your cats behavior. They like to describe it as a tool to help pet parents evolve from "Reactive to Proactive to Predictive." In essence they can put more knowledge and subsequently more power in your own hands,, They are in their first round of raising funds, visit them and pitch a nickel on KickStarter here.

And for the rest of you pet loving people, please visit me on Pawbly is a place dedicated to helping people and their pets by providing a free unbiased platform for the open exchange of information. You can ask a question, share a story, or even just be a beacon of hope and compassion for others.

You can also find me on Twitter @FreePetAdvice, the clinic Jarrettsville Vet in Harford County Maryland.

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