Blocked Cats; My Cause and My Advice

A "blocked cat" in vetmed terms is a cat who cannot pass urine normally, or, at all. "Blocked" refers to urinary bladder blockage. A blocked cat is a medical emergency and should be treated as such.

Here is how I treat a blocked cat, and, why/how these cases often come to find me.

Stripes. Presented blocked and unhappy about it.

The typical scenario for a blocked cat presentation is this;

• Cat is in and out of the litter box, 
• Often crying, meowing, and/or, in distress 
• Little to no urine is being produced

Client and blocked cat show up at vet office or ER. Cat is examined and owner is asked to produce a $2,000 deposit for care. Most struggle to afford this. Many cannot. Therefore, they call me for help.

Here is a look at how I manage blocked cat cases with financial constraints at my veterinary practice.

Almost all cats can be diagnosed without diagnostics (outside of the above mentioned physical exam and history).  I DO NOT RUN DIAGNOSTICS IF IT WILL AFFECT A PATIENTS ABILITY TO RECEIVE TREATMENT. This is a practice that has become all too common place and the systemic practice of economic euthanasia to allow for diagnostics is unethical and warrants state board and AVMA scrutiny and policy changes.

KEY POINT; This should be provided in documentation after the examination is done. At each client documentation/signature request the client MUST get a copy, and, there MUST be current patient status listed. A client has the right to deny diagnostics and still receive life saving care. The egregious practice of turning away clients if they will not meet a practices proposed standard of care, and the corresponding costs associated with them, is also in need of AVMA and state board examination. We allow the euthanasia of patients because we reduce them to property status when it suits our prejudice and financial gain discretion. A blocked cat is typically young, otherwise healthy and free from any other medical conditions. They may present looking, and feeling, bad, but, they are treatable in almost 100% of these cases IF UNBLOCKED.

Urine, rally bloody, from a recently unblocked cat

I am going to describe the typical blocked cat cases that I see, and, how I manage them. Almost all of these are owned by people who have financial limitations. I am also providing challenges to the typical way an ER manages these cases to help highlight areas we can help allocate resources to as I call it, “get out alive.”

                First challenge; diagnostics are not needed to diagnose. Short of a very obese cat a competent physical exam AND thorough history will diagnose the majority of these cases. Why does everyone run diagnostics? Why, again, are we not talking about the client’s budget at the beginning of spending their money?

                Second challenge; diagnostics, regardless of their findings do not influence the care needed. ALL of these cats need to be unblocked immediately. In some very rare cases there are some patients who should not be treated, or, have a poor prognosis regardless of treatment. (i.e. geriatric cats with comorbidities, fractious, feral, unknown rabies history, cats we will not be able to safely manage fluids/urinary catheter on, loss neural function, etc). These patients/clients deserve to be notified before treatment, or estimates, are provided. Futility* medicine should be as ethically bound as economic euthanasia defaults, and over padded invoices that prohibit care ability because finances have been drained in the diagnostic phase.

I would like to provide users with a step by step approach to their cats care. Challenge the suggested treatment protocols to save clients from economic euthanasia

Next challenge; vets do not talk to clients about managing financial resources to allow for the expected stumbles in this disease process.

Challenge; talk about whole pet care, not point of care emergency. Who else talks to clients like I do? I say, once we start treating we are all committed to a positive outcome. This is NOT based on financial ability. It is based on needed patient care. Vet med withholds this until it is perceived that clients are dry and then we offer euthanasia as the only affordable option.

Challenge; these cats are typically young (under 3-4 years old) and otherwise very healthy. We are over-euthanizing young, previously perfectly healthy cats simply because we have priced them out of care. These cases have been around for decades. Decades where we treated them at minimal cost and saved the majority of these cats. Why are more cats dying now? We priced people out of care while better educating the public on this disease. That is unethical. This needs to be challenged.

Challenge; why do we run blood work on ALL of these cats? And then tell owners that ALL of these cats blood work looks bad, because, well simply they are sick, they are critical and they do look bad. What were we expecting the blood work to look like? We do it to make money, and, we do it to CYA, and we do it because someone made us believe it was a liability otherwise? It’s time to challenge pricing pets out of care while we CYA.

Challenge ALL of these cats in my experience go back to perfectly normal blood work indices after their obstruction is removed and they are given time to recover. They do not start out in kidney failure although all of them have blood work that looks like kidney failure while they are blocked and present for care. Vets use this to their advantage when discussing euthanasia, or repeating blood work. It is deceitful.

In cases of financial limitations (this is decided up front at the first visit/interaction) we have an ethical obligation to discuss what we expect, what we have seen to be true, and that this is not a one and done fix. We need to start with a whole cat case approach, not a singular point in time under emergency induced emotional duress and take clients for a one and done as much as we can get them for and to-hell-if the cat is euthanized along the way approach. We know better, even if our clients don’t.

Challenge; This ridiculous, archaic practice of not having vets discuss money (see equally ridiculous reasons here)

Challenge; most ER vets are unblocking without general anesthesia between cases. We can do it so quickly that the charge given to the owner is exorbitant. In many cases we can unblock a cat in the same time it can take to pass an i.v. catheter.

Challenge a line item list of how a cat is unblocked is not provided to the client.

Documentation on the procedure and the time necessary to unblock is not provided. This should be provided before treatments are given AND confirmed before invoice is given. 

Challenge; Removing a urinary catheter before 72 hours, or before the urine is running diluted and clear is setting the patient up to reblock. I would argue that we use time based estimates which are always egregiously too short thereby setting the patient up to reblock. Veterinarians should expect, and do, the cat to reblock within a very short period of time. We make more money with the cats failure. The ethics of this should be challenged. If clients cannot afford to keep a patient in the hospital they should be allowed to be transferred to a primary care facility, i.e. their normal veterinarian (even if they do not have 24 hour care), and/or allowed to go home with the intravenous catheter AND urinary catheter in place to be monitored at home. Challenge; I have never seen this happen. In all cases these are removed by the ER facility. These critical goods are paid for and owned by the client. Removing them without consent is a breach of consensual care and a done to the detriment of the patient.

We should all expect that a cat that has blocked once, will soon block again. How many times can the client pay for this? We should be addressing this at the first visit. We should be using the clients ability for the expected treatment course, and not the typical one time financial hit. We require a deposit for care, and that deposit is typically exhausted within the first 12-24 hours leaving cats to be discharged before they are ready, and setting the client up for a repeat obstruction within days to weeks. Where a small percentage of cats are treated on the first obstruction many are not on the second. Further the trauma of the blockage compounded by the passing of a urinary catheter causes excessive damage to the patient urethra. I would argue that the removal of a urinary catheter prematurely causes an increased chance of reblocking and therefore makes the veterinary team responsible for re-current obstructions that frequently occur within days. 

The inflammation from BOTH the blockage AND the urinary catheter always needs more than 12-24 hours to resolve.

Challenge; a client pays for the goods and services provided to the patient. Why then do vets insist on removing these? At least we should unblock and transfer elsewhere to provide these patients a longer fluid therapy plan. We need to be documenting and insisting these cats continue care elsewhere. Even if this at the owners home, if it cannot happen at a veterinary facility.

Although not ideal we keep cats in our vet hospital for 3-5 days even though there is no overnight care.

These cats need fluid therapy AND urinary catheterization for 3-5 days.

Unblocking a cat at my clinic; Client call to front desk with any of the above clinical signs is sent immediately to the Charge Tech. They immediately notify a veterinarian of the cat being blocked. If the cat is an existing patient we direct them to go to the ER immediately, or come to us. Upon arrival we immediately  examine to confirm bladder is large, painful and no urine will pass. Do not squeeze too hard. Bladder can rupture. This is always a surgical emergency, financially constrained clients will not be able to afford this.

Treatment tree looks like this; 

•  cold laser therapy of prepuce. Will reduce inflammation and allow some sediment to pass.  
• massage penis to remove calculi. May allow urine to pass, 
• attempt to place/pass a urinary catheter. Catheter selection matters, avoid tomcats and red rubbers, try Tom Tiddle, 3.5 french. Lots of lube! 
• Start i.v. fluids as fast as able. These cats die from dehydration causing cardiac fatality.
•  If unable to pass Ucath, try to relieve urethral obstruction with olive tipped syringe and 20 ml saline to retropulse obstruction back into the bladder. Lots of lube 
• If unable to olive tipped syringe decompress bladder with 22 gauge needle. Remove as much urine as able. I leave needle in bladder and switch out 20 ml syringes until bladder is soft. Warning, bladder rupture is possible.  
• Continue laser, massage and retropulsion with olive tipped. In almost all cases you can feel obstruction move as these are done. 
• Attempt to place Tom Tiddle and suture stopper to prepuce. If able;
• Flush bladder with sterile saline to remove as much debris, and blood as able. 
• Place collection back onto Ucath 
•  Start iv fluids. We use NaCl for ivf therapy 
• If a higher degree of difficulty in passing ucath take lateral caudal ab xray to look for bladder stones. This may indicate a cystotomy is needed.

Challenge; it is easier to unblock a cat then spay a large, fat dog. Why then is this done at 4 plus times the cost to the owner?

Why is it ethical to be charging so much just because this is an emergency? I would also challenge that these cats are easier to treat than a big aged dog spay, Which we do routinely and charge for at a fraction of the cost, because people can find this surgery at almost every veterinary facility. Where there is competition there is a lower price point. Further a spay is (typically) elective.

At home care after urine is clear; the following are my patients; 

• Teach owner how to palpate for the urinary bladder. 
• Place patient on a steroid to encourage drinking water and reduce inflammation. 
• Feed a wet food only urinary diet. Add water to each meal. The diet should be a urinary prescription formula and it should be used for the rest of the cats life. 
• Encourage water intake with a fountain,. 
• Encourage play. 
• Reduce stress in any and every way possible. 
• Monitor litter boxes lifelong. New litter options are being produced to help guide clients in detecting and monitoring for possible issues. 
• Use anti anxiety medications like gabapentin. 
• Or, long term medications like fluoxetine. 
• Use analgesics like transmucosal/dermal buprinex. Pain medications will help these patients quality of life. Reduce stress and reduce likelihood of recurrent stress induced cystitis, further reducing chances of reblocking. 
• Give sq fluids at home for days to weeks post op. Fluid kits are available on Chewy.com

We need to develop ways to allow in home care and supervision. Pawbly.com can help.  Start a savings account for the next urinary issue. If necessary discuss a PU surgery as the next treatment option. See VetBilling.com for pet savings plan options. 

PU surgery.

Here is a video from my YouTube channel on unblocking a patient of mine. More videos can be found there. Link here

How do I get these patients treated for about $1,000 (and, yes, even I admit this is too costly for many people), I invest in my clients AND patients care. We start with a goal. We talk about options. Every single option. They are all weighted equally to reinforce that we are in this together. From start to finish. If none of these seem acceptable to the client I ask, "what will it take for me to help your cat?"

We start there.

If you have a cat, particularly an adult (greater than 1 year of age), indoor, neutered, male on a dry food diet (particularly a grocery store brand) you need to ask your vet what would happen if your cat blocked? Would they refer you to an ER? If so. how much might this cost? Be prepared before this happens to you. Please follow my blog, my Jarrettsville Veterinary Center Facebook page, my YouTube channel for more on this, and other pet care issues. Please also stay tuned for a step by step guide to managing your cats emergencies, especially if you do not have an emergency pet care fund with at least $2,000 in it, as we are working on it now.

For more help you can ask our pet care professionals for free at Pawbly.com

References;

CareCredit. Hate Talking About Money? You Are Not Alone.

*Futility Medicine; 

UW Dept Of Bioethics discussion.

Medical Futility Is Commonly Encountered In Small Animal Medicine.