Sunday, May 15, 2016

Feeding tube in a feline. Why being aggressive saves you one of those 9 lives.

This is Minnie. Her story is a testament to how unfair life can seem, and why you have to believe in miracles..
Minnie and her surgical set up

Perhaps there is some deeply seeded catholic benediction my foreparents bestowed upon me that moves me to do the things I do? In too many cases I find myself inexplicably emotionally invested in my patients care. When the case is a cat with a poor prognosis and a back story fitting for the Hallmark channel I also find myself barging into them. 

For all of my intrusive Dr House desire I have grown increasingly impatient for owners to make up their minds when it comes to their pets direly needed treatments. Finding the way to promote being proactive without scaring them into more treatment paralysis takes conviction, dogged determination, and willingness to participate in the responsibility of every possible outcome.

Seems most clients need more prodding than I do to jump in and change the course it so obvious their cat is headed in. Call it my veterinary ability to forecast medical futures and having seen too many unhappy endings, but living with regret for cases that could have ended differently should time have been on our side, I have become more resolved to not let a patient fail if at all possible. A decade of experience in foretelling the future has reaffirmed that people wait too long to make treatment choices, most especially when it comes to their cats. Parents need to be motivated by death looming at the door. Not the tiny chimes of angelic bells on the horizon, No, people wait until cats are taking their last breath. Waiting in too many cases is letting biology keep its course toward death. DON'T WAIT FOR FATE TO DECIDE! If Mother Nature were to decide for us I would have to find another profession. Medicine and Mother Nature are polar opponents within science.

Cats are special critters. They may have nine lives but they need aggressive care when it comes to the following;

1. Warmth. Young and old cats need to be kept warm. Warmth is attainable only when they have dry fur and adequate muscle mass. Debilitated, diseased, skinny (cachexic) elderly and young cats need help. They need shelter and warmth. If they are unable to stand or walk you must monitor their temperature with a thermometer. They get very cod very fast and when you put them on a heating pad (wrapped in a towel always or it will burn them!) they warm up too fast. They need to be between 100 - 102 Fahrenheit. 

2. Parasite free. Fleas and intestinal worms are small lethal killers when found in great numbers. This idea of knowing that your cat "doesn't have intestinal worms" is not based on any shred of intellect. Unless your vet looks at the feces under the microscope ASSUME they DO have parasites. And, just because I ask you to assume this, please (pleeeease) don't go buy some toxic stuff at the corner store and throw it down your cats gullet without checking with your vet.. that stuff is toxic.. yes, terribly toxic... bleck!

3. Eating. Regardless of the cause (and it is SUPER important to identify the cause) you have to get a cat eating. Any cat not eating for over 48 hours is at great risk of hepatic lipidosis. I don't wait longer than 48 hours to decide what to do about an anorexic cat, I get aggressive, I put in a feeding tube. Kittens (anyone under 4 months old), need to eat every 4-6 hours. If they aren't they need to be seen by a vet immediately. Products like NutriCal, Karosyrup on the gums, or syringe feeding might buy you a few hours,, might,, and hours, not days.

This is Minnie, a middle aged petite all black domestic short hair feline. She had just been adopted by her new family a week ago. When she came to the clinic I was spying on her exam work up. The clinic has 5 supremely wonderful vets. We are an eclectic bunch with our own areas of expertise, strengths, diverse experience and most wonderful sense of camaraderie. We share each others successes, failures, frustration, and hard cases. But, when it comes to cats I always volunteer for the hardest and most bleak cases. Worse of all I want the sickest kittens and the broken bodies. They are my favorite cases to fight for. When I heard her story I was determined to get her case in my hands.. (bet you never knew that the vets arm wrestle over cases?).

Minnie was considered "unadoptable" at the shelter. A label that pretty much assures that only crazy people or rubber neckers will glance at you. Being at a shelter is hard enough for any pet, being labeled "not worthy" is unimaginable. Pity is a powerful motivator. I was enamored with her story, her little fragile broken spirit and two people who could cast aside her Scarlett Letter and love her in spite of the professional warnings.

Minnie had waited 2 years to get adopted and within 1 week she was falling apart. Poetic country song justice was being served. The first appointments of Minnie's new life had cost her family over $500. They were looking at and accepting taking the writing on the wall and giving up... until I stepped in (even if it more closely approximated a 'barging in'). 

Minnie presented to JVC with significant diarrhea. The kind that looks like brown water dripping out the anus. Hard to manage for all involved. Medications were sent home. They had minimal effect.

She returned shortly after for more help. Blood work and x-rays then lead to a diagnosis of a mass in her chest.. typically evidence of cancer. All of the vets converged on her case. It was a caucus of opinions, emotional outbursts, "what-if's?", worst case scenarios, suggestions on how to pitch the findings without costing Minnie her second chance, and managing liability, and expectations. Not to mention the heated debate about what treatment options to actually recommend. The negotiations of what to say, what to do, how to help your patient without condemning the unknown future that lies ahead is some of the most stressful moments of every vets life.

I did not want her new parents to be convinced that she wasn't worth another chance of trying..

In reality we guess waaay more than we should. In the obligation of providing advice we GUESS! Without a lung biopsy that white blob on the radiograph is an unknown. No one knows Minnie's past, there are no x-rays to compare, and further that bleb may not have anything to do with her parents presenting complaint. We saw it because we went looking. Differentiating between "incidental findings" and "life threatening"is something left to more invasive diagnostics that most clients do not pursue.

Vets are supremely confident guessers. Handing down a death sentence is a burden vets take too lightly. In an effort to cover all of our bases and be thorough, and cover our asses we throw around words like "cancer," "expensive diagnostics" and "poor prognosis." In the human field it takes weeks to months and massive numbers of tests before you get a diagnosis. Human medicine is elusive and mysterious and often frustrating becuase people are desperate for answers that are not provided UNTIL the discovery process is complete. It is as it should be. Maintaining pursed lips until we have a definitive answer saves lives. Prognosis? Well, that is only for the brave and the well armed. 

Within another few days she was losing weight and not eating. 

"Great," I thought. "I was so hopeful that maybe her chest mass wasn't something bad? And now she has to prove me wrong?" Ugh!

And still I thought,,, "How could everything unravel like this? How is it statistically possible that she is fine for two years in a shelter and within 1 week she is dying from cancer? Stress can explain the diarrhea. The not eating was the congestion, runny, nose, and sneezing like every other cat from a rescue gets." She fit that scenario much better than the 1 week collapse and cancer affliction.

And so it was settled,, I was going with the more plausible scenario, jumping in, and willing Minnie into finally having her 'happily ever after'.

So I did what I wanted to do. I asked her family to let me try? They wanted a happy ending as much as I did. The financial investment was getting concerning. I see it so often. The bill gets bigger, the answers get shadier, and the prognosis for "full recovery" is more and more in question. I get it. I also get that many vets don't want to make assumptions that certainly could be wrong, and we don't want to scare our clients into giving up. So, our answer? We make a deal. Barter for service. 

"What if I do the feeding tube placement for free?"


"What if you only pay me if the treatment in successful?" 

Deals, and discounts.. and you and I both put some skin in the game to influence the outcome.

Sometimes sheer will power can make miracles happen.

So Minnie got her feeding tube placed by the Good Samaritan Fund. She also got four days in the hospital to try a whole new set of medications. Me, well, I got to try. The longer I practice the more I am seeking the challenges, the battles between biology and faith. The more I realize that the beauty lies in the struggle. Happy endings take work and effort, they are not supposed to be quick and easy.

Now I am not a surgeon, nor an expert of any species of any kind of veterinary anything, BUT, I do place feeding tubes way before anyone else around me contemplates doing it. Being proactive saves lives. It is why we use preventatives, advocate for yearly examinations, and promote vaccines, examinations, and excellent animal husbandry.

Feeding tubes save lives. They are cheap (tube $5, anesthesia $100, and suture $5, skill about $40).. I also take a radiograph with barium (contrast) to show that I have the tube where I want it to be. When I have the bill in my own hands I take liberties other vets have to scrutinize. Minnie was my case to do as I thought best. I did everything I thought she needed. If your clinic doesn't have an in-house slush fund I urge you to consider why not?

There is the always resistance when I mention  or suggest a feeding tube. We humans relate to medical treatment options as if we are the patient. Your cat is not a human. There are many treatment options that pets seem to tolerate far better than we do. Broken bones, spay/neuter, illness, cancer, you can almost name anything. They often bounce back very quickly and never feel sorry for themselves. Minnie was losing weight and getting sicker, she needed help to maintain her body weight, deliver the medications she needed and have a chance. She needed a feeding tube. She needed it now.

Helpful Real-Life Vet Tip; Don't hesitate to put a feeding tube in a cat. EVER! (OK, I should never say never, or ever,, But I do mostly mean it here).

The myths behind feeding tubes;

1. They are invasive. Not hard to place not difficult to do. A few photos in a training manual and basic surgery skills.

2. They are extra-ordinary life saving measures. Not any more so than an iv catheter and we do this daily.

3. They are hard to manage. They aren't. A few simple instructions and they are a satisfyingly simple life savers..

4. They are cumbersome and bothersome to our patients. of all that I have placed not one cat has seemed to even notice them.

Here are some things to remember about feeding tubes;

1. They are transient short term lifesavers.

2. They permit for adequate food and medication delivery quickly and efficiently.

3. Cats can (and do) eat around them. We let Minnie decide when she was ready to have it removed.

After a few days of hospitalization she started eating very well. We sent her home with a few basic instructions on monitoring the tubes placement site to make sure it wasn't moving, looking infected, or had food caked around it. Feeding requires liquefying one of the many prescription foods and allocating the daily allowance over the 4-8 feedings prescribed. After each meal the tube is cleared by flushing a small amount of water. The tube is capped and tucked away in the neck bandage.

Food and water is offered and kept available at all times.

Most of these cases are given concurrent;

1. Probiotics (after all we are adding a lot of water to liquify the food and lots of water leaves likely diarrhea).

2. Appetite stimulant. I like mirtazapine. The point of Minnie's plan was to get her eating. Use all tricks, tips and tools available.

3. Address and correct Minnie's underlying issues. Feeding tubes buy you a little bit of time but they don't cure. Like all medical procedures we buy bits of time, we continue to search, 

Minnie went home for a few days to acclimate (again),  feeding tube in place. Her parents had a daily list of medications to give, and instructions on how to monitor her feeding tube. The biggest fear I had was pulling her feeding tube too soon. She had to be well enough that she was maintaining her weight, could stay on her prescribed medications, and be comfortable in her new home.

Things that indicate a problem;

1. Cat isn't eating or looking interested in food. A feeding tube can't stay in forever. Start an appetite stimulant, look for additional underlying issues, and don't forget to address behavioral components (a stressed or unhappy cat will not eat).

2. The feeding tube is vomited up, or coughed up and coming  out of the mouth. These cats will chew off the end of the tube and we don't want the tube to be swallowed. 

3. The entry site of the tube needs to be checked daily. We change the bandage that covers it daily. Infection is dealt with aggressively and immediately. 

4. Using a feeding tube takes practice and calculated amounts of the correct prescription food. Your vet needs to help you so that enough calories are given, enough water is used to move the food into the stomach, and a flush of water as a chaser is given after the food is delivered so that the tube doesn't clog.

Minnie has a new second (maybe we are on our third?) chance at life. She is being monitored closely. Given her own spot to acclimate to her new home, and get used to life after the shelter.

And me, well, I've got your back Minnie, and all of us at Jarrettsville Vet are rooting for you!

One week post op.

Many thanks to all of the friends of Jarrettsville Vet who help us provide second chances to those in need. The Good Samaritan Fund is available at the discretion of the staff of Jarrettsville Vet to our clients. If you would like to contribute please contact us here. The veterinarians who utilize the fund are not paid out of it. The vets donate their time if they elect to use the Fund. Everyone (we mean everyone) puts some skin in the game and is personally invested in the case.

If you have questions about anorexia, feeding tubes, hospital care, and how sheer will and determination can shape health and destiny, please find us on It is free to use and open to all who care about animals.

You can also find me on Twitter @FreePetAdvice.

And if you have a cat who needs a friend find me at Jarrettsville Vet. I am always looking for a case to champion and a cat who hasn't exhausted their 9 lives.


  1. Have you seen these? I like them for feeding tubes....

    1. Hello Brandy,
      yes, I have seen them (although it has been quite a long time)! I forgot to include them in the blog! Thank you soo very much for reminding me and adding the link. The video is actually super helpful for owners to review and learn about all of the little tips we provide but may get lost with the massive amount if information we load upon them.
      Many Thanks!
      I look forward to seeing your additions, and I would love to have your help on We hope to build a credible place for everyone to add their knowledge and advice to others regardless of socio-economic status or access to vets, and your advice is both desperately needed and very much appreciated!
      Many thanks again!

  2. You have a great blog. Thank you so much for sharing, and warm greetings from Montreal, Canada.

    1. Thank You Linda!
      Warm greetings back from stormy, gloomy Maryland

  3. Did Minnie pull through?

  4. I found this when I was searching online for information about oesophagostomy feeding tubes, my cat had one put in a couple of days ago when he stopped eating following surgery (bilateral ventral bulla osteotomy), he had a flare-up of a URI probably due to the stress of surgery and I think his throat was a bit uncomfortable.

    I did have some trepidation, but knew it was the best (if not only!) thing to agree to for the wellbeing of my cat.

    It is going pretty well, he is happy and has plenty of energy, he is eating a little by himself so I am confident that once the stitches are out and the slight URI clears up, he will soon recover and be back to normal.

    I just want to say to anyone who finds this page, if your vet recommends a feeding tube do not hesitate - my cat tolerates it really well and is completely normal and very happy.

  5. My cat has a feeding tube & is doing OK EXCEPT has developed an occasional deep cough. Is this normal or should I have it checked out?

  6. Cat (15 yo, M) hasn't eaten for two weeks. he's lost a ton of weight. Still drinking water, still grooming (as much as he ever has), still seeking affection.

    Vitals normal
    CBC normal
    Comp Metabolic normal, except for elevated BUN

    They gave him entyce (an appetite stimulant), and I was eventually able to get him to lick some tuna water off the top of the can. He's a bit more active today, but he still isn't eating. Solid food, soft food, warm food, we've tried everything.

    Based on diagnostics, the vet wants to wait three days to see if he picks up before moving forward with treatment.

    Now, it is quite likely that I'm being overzealous, and I'll be the first to admit that my capacity for objective valuation is suspect in this instance -- However, based on the severe weight loss we've seen over this last month, I think the time for a feeding tube came a week ago, and hasn't passed yet.

    Can you help me understand what the vet sees that I'm missing?

    1. I understand that you aren't able to respond. All of these threads seem to trail off after the first post or two. It seems that either the cat gets better and posters are no longer in need of advice, or the cat dies and the posters are no longer in need of advice. I'm keeping the thread going because the next person to find themself in this situation will be along before long.

      4 of the last 5 nights spent at the vet. it took until the 4th to convince them to place a nasoesophageal tube.

      As I mentioned, the entyce didn't work -- and it's supposed to be the wonder drug. Call me simpleminded, but all I care about is feeding my cat. I know they want a rock solid diagnosis before they'll go forward with letting me feed my cat.

      So I open a line of credit and get the X ray. They spot a mass pushing organs out of the way. They want to do the ultrasound, but they don't have ultrasound operators on staff after dark. keeping him in overnight is going to run me $1800. That gets me out the door with -- Maybe -- a diagnosis. And no resources to treat whatever they find.

      Don't get me wrong, I love my cat. but I have a family to take care of, and I'm not the sort of independently wealthy person who can dump $1800 at a whim. If that got me out the door treated, I'd have done it.

      I did some research (based on information provided by my vet) into common causes of masses in that location. Possibly lymphoma, possibly something worse... but we just can't know without an ultrasound -- and I can't get a day off from the hospital to take care of it.

      Day 3. We put the cat on prednisolone, which has helped breathing. But still no eating.

      Day 4. I finally made a more direct request: Let's put in a feeding tube and see what happens. If the cat is sturdier in a few weeks we can explore our options. If nutrition isn't sufficient to perk him up, I'll quit chasing the veterinary dragon.

      We've been feeding about 30ml, four times per day for 2 days. I expect it will take about a week to see any major uptick, but the cat is already more stable -- compared to before when he was so weak that I wasn't terribly confident he would survive the night.

      He's sleeping a lot, which I ascribe largely to the prednisone, and also to being sick. We've been letting him rest as much as possible. He isn't purring for the last day now. I suspect that's he's a bit grumpy because of the invasive nature of feeding and the SubQ fluids.

      I have a very realistic outlook on my cat's prognosis.
      At the maximum degree of blue sky optimism I can muster, I know that Oscar's story will draw to conclusion within six months. I can't rule out that it will end tomorrow.

      I'm comfortable with the possibility that I've bought a week to say goodbye - and hopeful for the possibility that he might recover enough strength to eat on his own and enjoy some sort of happiness again, for a time.

      They say the tube is good for about 30 days.

      Once his condition takes a dive, despite the feeding, I'll know it is time.

    2. The feeding tube did its job, though not in the way I had hoped.

      It was a strange dichotomy. The good parts of Mr. Snausage Kitty's (Oscar if you're a glutton for formality) day did get better. And yet, the bad parts never stopped getting worse. He had more energy, he was moving around more. But his breathing was getting worse. In the end, it seemed like we were making him strong enough to endure his pain.

      My special little guy has been with us for 16 years, but it was only about 5 years ago that he decided I was his person. It was right after my previous cat died. They never got along - Oscar was never the alpha cat, and was always on the losing end of feline disputes - but Bently's death moved Oscar. He mourned with me, and this bonded us together. It was almost like he could tell I needed a friend. I became the center of that cat's world.

      Tonight, during his feeding, we were unable to push any food. Something brown pushed its way back into the syringe. I was getting ready for bed when I heard the noises my cat was making. Coughing, gagging, and some sort of pitiful squeal I'd never heard from him before.

      It was time.

      So I get dressed again and take him to the vet. They gave his belly a squeeze and he shot liquid feces across the room. His mass had gotten bigger, even in the last week. It was blocking his ability to pass his food through his intestines.

      I want to be clear about this: I regret nothing. When my guy went under for the last time, I knew I had done everything I could do without jeopardizing my family, and without putting my cat under undue stress without cause.

      I wanted to feed my cat, to see if it would make him better. So I fed him, and he got better. and he got worse. Both at the same time. This morning I really thought I had another week. He was chasing around the house with us. Jumping up and down from the bed. We gave him the nutrition he was lacking. And in so doing we identified the problem of throughput.

      We made him strong enough to be certain it was time to let go.

      This isn't the ending we hope for, but I got what I needed from this: I bought my week to say goodbye. And I bought the certainty of knowing that I didn't give up too soon, or without a fight. I know that I gave my special guy the best shot I could give him, while still being sensitive to his pain.

      There are no promises in this game. But if you don't play, you can't win. Don't let my outcome dissuade you from feeding your cat, should the time come to do so.

      Act sooner, rather than later.

      Best of luck to you, and your cat.

  7. Thank you so much for this post. My 11 year old cat has an infection in his gallbladder and liver, as well as pancreatitis. He was in the hospital for a few days being treated with antibiotics, fluids, appetite stimulants and nausea medicine via IV. He came home but refuses to eat on his own. Liver values have been decreasing, vitals are stable, he seems to be more comfortable and less lethargic but he just won’t eat! The emergency vet has been pushing a feeding tube but I’ve been so scared about making the decision. When I talked to my mom about it, she made it sound like this horrible thing and if my cat needs a feeding tube, I should just put him down and spare him the suffering. After reading your post, I feel at ease and confident the feeding tube will help him eat on his own again. Thank you!