What Every Parent Hears on the Summer Road Trip. I Gotta GO!

Plodding through a mostly piddly-wet day there are a few cases that are blog worthy to share.

It was a typical busy (but not crazy) Monday. We had our token half dozen urgent phone calls before 9 am, and I went into work with half dry hair.

Magpie reminds me that all work and no play,,,

 

There was one blocked cat to see at 9. I used to get all in a tizzy over the dreaded "blocked cat call." But I have learned that about 50% of the time it is a cystitis, or urinary tract infection and not the life-threatening half dead fully comatose cats of every vet students nightmares. For those of you out there that do not understand the gravity of having a blocked cat think of how terrible you would feel if you had to pee and were unable to. As much as this sounds like psychological torture it is made even worse for your kidneys and heart. If your bladder is unable to remove the urine the bladder will expand and expand until it either ruptures (a very very bad thing to happen, and also equally life-threatening) or your heart will eventually stop beating due to the toxic accumulation of potassium in your body.

SO, important take home message to everyone out there: If your cat seems to be visiting the litter box frequently, and/or is only able to produce a small amount of urine, or if you ever see your pet urinate and it isn't a light yellow color (really any other color is bad, not red, not pink, not orange, not brown), or if your pet is vocalizing (indicates they are in pain) in the litter box (or any other place your pet is eliminating), then go to the vet immediately! If there is any way you can bring a urine sample (ideally a free catch from the source urine sample) then bring that too.

When vets say "free catch" we are speaking about you catching a urine sample as your pet is urinating. The best sample is a mid-stream catch. I know it sounds silly, and virtually impossible but it can be done. I think it works best of someone takes the pet out on a leash

My favorite story of urinary tract infection is the year that we had our first snowfall in late October. The next two days after that fluke 12 inch snow fall I saw 6 clients who all came in telling me that "they were outside with their dog and when they peed they noticed that the snow was pink." ( I guess we need to start telling kids to not eat the yellow or pink snow?). Those pets all probably had infections for months and no one ever noticed until the snow fell.

I know it sounds gross and silly but we all really need to pay attention to what is coming out of our pets. I will ask you to describe every item that comes out of every orifice. If they vomit I need you to describe how it happened, (i.e. did their stomach contract? did it look like the food just fell out of their mouths? what did everything look like, your pet, the product?) This is all very important information. Your pet's treatment plan and long term prognosis is based to a great extent on the information you give us.

The 9 am blocked cat turned out to be a diabetic. I knew as soon as I saw the medical chart that this was probably not a blocked cat.


OK, let's review diabetes. Diabetes happens when the pancreas gets overwhelmed by trying to digest all of the sugar in the body. (This is the very very simple version). For cats we see this in obese, overweight cats being fed a dry food. It is an acquired disease. These cats show up at the clinic as having one of a  few complaints; 1. drinking excessively 2. and/or urinating inappropriately, 3. unexplained weight loss, 4. loss of vision. In all cases a diabetic cat drinks excessively and because of this urinates excessively. It is therefore, almost impossible for a diabetic cat to have a urinary blockage. they are the most flushed pets on the planet. BUT, what diabetics do get is chronic infections. The diabetes is an immunosuppressive disease. These guys are far more likely to get concurrent infections that the normal healthy adult cat. So, right off the bat I suspected we had a cat going to the litter box excessively and only producing small amounts of urine because there was a urinary tract infection.

A blood glucose test (459, waaaay high), and an un-palpable bladder, (it was too small to find), suggested my hunch was correct.

Just rescued after being hit by a car

I focus a lot on cats. They are the underdogs (pun intended) of my community and profession. People spend far less time and money on taking care of their cats than their dogs. Cats are also much better at hiding a problem, so those problems are often magnified by the time we see them.

Please follow me and please see the many other blogs I have on blocked cats, or FUO, feline urinary obstructions.

If you are passionate about cats, access to affordable veterinary care and want to help please join us at Pawbly.com and the Pet Good Samaritan Fund

Leave No Patient Behind

George is a 9 year old indoor domestic short haired cat who visited us about a month ago for straining to urinate in the litter box, and producing only small amounts of urine. 

He presented again to us yesterday; unable to urinate. George is now a "blocked cat" or, UO cat (for urinary obstructed) cat. 

He found us, like they all do, with a little bit of luck, and a parent with limited resources. 

When he arrived on Saturday morning at the vet clinic we suspected that he was blocked. We also hoped that his parents had a rainy day account of immediately accessible funds so we could send him where he needed to be; the ER. The ER these days require a $4,000 deposit for this. It is beyond my comprehension what they do with that $4k, but it seems ubiquitous enough amongst the lot of them so it must be accountable in some list of line items. 

Within 20 minutes of Georges arrival at my clinic my phone rang.

"Sorry to bother you, (I was away for the Thanksgiving holiday), but, we have a blocked cat here." 

"Is anyone there willing to unblock him?" I asked.

"Yes."

"Ok, then we will figure out how to pay for it later. Have the owner go through our emergency sheet. Have someone else in the room with them to serve as a witness. And, make sure she is ok with us sharing the story and photos. Call me if you need anything."

"Ok. What would happen if we didn't help these cats?"

"They would die at home a miserable death, or be euthanized. Just like all of the rest of the cats. You know that." I replied.

My office manager agreed to go over everything with George's mom. She was working from home, on her day off because that's what George needed from us. George is a perfect example of who we are. He is deserves to be cared for. He is why I went into veterinary school. He is my WHY as much as any of the regularly paying customers are. Maybe more so.

George, the morning he arrived at JVC.

Here is the Facebook post we put up that morning; Georges first FB post here

"This is George.  He has found himself in a hopeless situation today.  He is blocked, and his mom only has $400 available to help him.  At our practice unblocking runs $800 - $1,000.  Despite the lack of funds we’ve agreed to help him, because we know without help George will die.  George and his mom could use some help financially with the cost of his care and treatment over the next couple of days.  Donations can be called in or made in person directly to George’s account.   Donations can also be sent via PayPal to jarrettsvillevet@gmail.com, please note that your donation is for George.

A big thank you to our kind hearted Dr. Ahrens who agreed to stay late to help George today.  ❤️"

A few hours later we posted an update;

Waking up from surgery.

"George is out of surgery and resting!  Thank you to all who have donated.  Please know any funds raised in excess of what is needed for George will be used to help another pet in a predicament like George. 

We truly couldn’t do this without the kindness and generosity of those who support us in our mission to help pets like George."

Two hours after the first post was put up we had raised $1900 for George. 

I posted a video on his story. Find it here; Inspire an army to save lives video here.

George update

One day post op. Looking good George

He is feeling SO much better with the help of our rockstar Saturday staff. He is getting his sq fluids currently (he is awesome at it) & taking his meds like a good boy.

So, George is a miracle, right? I mean its an incredible thing to be able to be given the treatment you need at a price your client can afford? Why doesn't every veterinarian do what we do? 

Well, because they think they can't. I hope to set an example of how this can be done. And remind everyone how good it feels to help save these lives.

We take a can-do approach to these cases. We take a leap of faith that we can save these pets first of all. We only offer payment plans, pro bono, take a risk on non-payment for cases that we think will survive and have a good return to a quality of life. We do not offer this to patients used for breeding purposes, people who are abusive, unkind to the staff, and who we do not believe will continue to provide routine preventative future care. For all of the cases we do not offer pro bono, or potentially not pay us back, we do offer to have the pet parents the option of signing over their pets to us. We will find a home for them, or keep them as our own for the rest of their lives. While this might sound cruel or unkind there are situations where pet parents realize they cannot provide the care their pets need, and they put this above all else. These are the people we want to over extend ourselves for. Sadly, almost everyone would rather their pet suffer, remain without treatment, and ultimately die than give them up. There was a case of a 4 year old dog who swallowed a corn cob who died recently after the owners declined the offer to give lifesaving surgical intervention. They watched her die over 4 days while they tried to raise the $3500 the ER required as a deposit versus signing her over to the rescue who offered to take her and get her the surgery she needed. 

Here is the document we use for these cases. We ask the pet parent to initial each line and then give them a copy for their records. If people would come to me and say "I love my pet so much that I would rather have her treated and alive with someone else than dead with me." I would do everything to save them. I don't think I am alone with this. 

For more information on this please see our website; Jarrettsvillevet.com see the tabs for Financial Assistance and Immediate Help.

All clients who cannot afford the estimate for needed care at Jarrettsville Vet must agree to and sign the following;

___ I understand this is an emergency.

___ I understand my pet would be best served at an ER, ICU, referral center.

___ The only reason that I am NOT at the ER/referral center/ICU is that I cannot afford it.

____ I understand that my pets current condition is (we fill in our differential diagnosis here).

____ I understand that I may not fully understand the extent and severity of this condition without a referral or additional financial resources

____ I have been given an estimate for care;

I can   ______        or    _____       cannot afford this estimate.

____ I understand that the estimate may change as my pets status changes. We will offer a payment plan if we go over your estimate.

If I cannot pay the estimated deposit for care I will;

1.       Sign a letter of collateral. If the invoice is not paid in 90 days the collateral will be transferred to JVC at my cost and the item will be sold for payment. Collateral item is; ______________

2.       Allow my case to be shared on any social media platform of JVC’s choosing to try to raise funds for my pet and awareness for their condition. This will help pay knowledge forward and maybe spare another pet from this condition.

3.       Follow all suggestions to include full story write up, starting a Go-Fund Me, sharing the fundraising efforts of JVC, and assisting with future fund raising projects at JVC

4.       Volunteer at other non-profits to pay it forward.

____ I allow JVC to share photos, videos and pertinent patient info for an indefinite period of time at their choosing.

____ I allow JVC, Dr Magnifico have full access and rights to my pets story. Past, present, future,

___ I will provide updates as asked and allow JVC, Dr Magnifico, the GSF, TPGSF, to share my pets story.

___ I understand that JVC has offered to help me care for my pet as an extension of compassion, kindness and shared goals to help end suffering and provide care regardless of financial constraints. It is with this in mind that I will be kind, compassionate, and generous with the actions and comments about my pets care.

___ We reserve the right to refer care back to an ER/ICU/specialist at any time.

 

Our Immediate Need Policy and Expectations for Non Clients are as follows: 

· We strive to offer affordable options for pet owners.

We usually require a full deposit at the time of intake for any emergency services. Our team will go over an estimate for your pet’s care once your pet is assessed. 

Please visit our website for additional resources to help with paying the balance. 

CareCredit may be utilized. You can apply for CareCredit via their website - https://www.carecredit.com/applyo Payment plans will be offered only to existing clients who have applied for or exhausted CareCredit. Payment plans are provided via Vet Billing

· Any financial concerns must be discussed at the time of receiving an estimate. 

· If you cannot afford the exam fee, the estimate for diagnostics and the treatment plan we will ask what is feasible for you financially, emotionally and physically to care for your pet long term. You are asking us to put your pet above the cost of running a veterinary facility, paying our staff and the emotional burden we take on with these cases.  

You will receive a copy of our Client Rights and Responsibilities and be expected to abide by it. We will not tolerate abrasive behavior directed to our staff. We are here to help you and your pet and expect to be treated with kindness. 

We will work together as part of a team for what is in the best interest of your pet. 

In working within the confines of financial concerns we may discuss with you waiving some diagnostics to keep the estimate within your budget. 

If it is determined that it not feasible for you to care for your pet long term, or if you pet is in need of immediate emergency care and we can not come up with a reasonable financial plan we may discuss surrendering your pet to one of the rescues we work with so that may receive the lifesaving care they need. 

· Jarrettsville Vet is a small animal general practice, we do not have staff in the building overnight. In most cases you will be expected to pick your pet up before we close. 

· We are working your pet in as an emergency. This means that the veterinarian may defer update calls to the support staff. Please rest assured that if your pet’s condition worsens you will receive a call. 

· It is our policy that if your pet is in need of emergency surgery and is intact, they will be spayed or neutered at the time of surgery. This is non-negotiable, if you are not agreeable to this clause please seek services elsewhere. All patients will also be vaccinated for rabies and given a microchip with Jarrettsville Vet listed as the contact for the life of this pet.

· You will allow us to share your pet’s story on Pawbly.com and social media at the discretion of the veterinarian. 

· If you receive funds from our Good Samaritan Fund you will participate in JVC or Good Samaritan Fund fundraising or volunteering and agree to the terms and conditions of our Good Samaritan Fund Recipient Policy. By signing below, you are indicating that you have read and understand our Emergency Services Policy.

The Blocked Cat. The Approach To Get Out Alive. Part Two

Cats with a urinary blockage always need to be addressed as an emergency. Unless you have experience with this condition before almost all of these patients arrive at the clinic as an emergency. Most commonly they have been blocked for some period of time and this leads to a higher likelihood of either bladder rupture or toxic changes to the heart. 

Beau. Blocked three times. $8,000 for two ER trips, 
then he found us. Third block and a PU surgery; $1500 on a payment plan.

I have to recommend that you go immediately to a vet if you suspect that your cat has a urinary blockage. I also have to caution that most clinics either refer to the local ER, or, charge a hefty price to treat this. 

Please go back to the first blog in this series now (go here) if you haven't read it already. The first chapter will define what a urinary obstructed cat looks like. 

The singular goal of this is to get your cat out alive. If you are like most of us you live in financial constraints and your cat is a vital, beloved member of your family. The profession knows this, and the profession has profited greatly because of it. We know you love your cat, and we know your cat is going to die from this, soon, if you don't cough up the admission fee for us to treat it. It's the culture of the American way. Make as much money as you can from wherever you can. Ask yourself how you are a part of the problem and then ask yourself what you are doing about it. Sure, I am disappointed in my profession for killing so many treatable pets, but, this is the world we all decided to emulate. Every rich person has profited from the misfortune of another. Medicine should be the neutral, sacred territory. It isn't. 

Here is my professional advice, as a veterinarian of 20 years, on getting your cat out alive when they have a urinary obstruction (aka a blocked cat). 

Tips; 

• be nice
• be honest
• be insistent
• be ready to challenge every interaction
• never lose hope
• never walk away without knowing that the only advocate in your pets life is you
• be willing to surrender your cat if it means it might save their life. 
• ask for help from everyone. Build an Army around your cause and then help pay it forward. If you find a way to get out alive pay that forward to someone else. The current practice of blocked cats in almost every ER setting is so expensive it is forcing most of these cats to either suffer or be euthanized. There are only these two options. Why is it that we allow these cats to go home and die a horrific death of suffering? or shame you into paying for something that has such an incredible mark up we lose the ability to heal? 

If your cat is demonstrating any of the clinical signs listed in the first blog on this (see here) then you must bring them to a veterinarian. 

Start with the exam. Blocked Y/N if YES, then ask for a written copy of the exam findings. Immediately. If the staff or vet declines, ask them to give a verbal description using the form provided below. Do not leave your cat without this. You should always have a copy, or have documented a detailed list of what has been done for your cat and what you have consented to. This is very important to help manage your cAts care and the expense associated with it. A blocked cat should be diagnosed by physical examination alone. The cat will often have a painful bladder that is hard, large and unable to be expressed (able to produce urine). If you sign anything ask for a copy of it immediately.

From the initial examination an estimate is given for the expected, or recommended, treatment plan. Here is the first place that negotiations should begin. Here is the first place where I recommend that clients challenge the options being presented. 

Next; 

Is the estimate is affordable? IF YES, (your cat is blocked) and the estimate/deposit required is affordable walk away. Sign paperwork, get a copy, and walk away. Your cat is in good hands, and the safest place they can be. The veterinary clinics are set up to provide top tier medicine and provide appropriate treatments for the worst case scenario. The problem is that most people cannot afford this, and, in almost all cases you are charged for worst case scenario treatment even though most cases do not require them to be successful. The veterinary clinic benefits greatly by being prepared to treat your cat as the worst case scenario outlier even though most are not. No client should have to pay for Gold Standard care if the case does not need it. Further, if you cannot afford the first estimate you should be permitted to be given the treatment plan tailored to your cats needs at a price you can afford to get the best possible outcome. THIS IS NOT BASED ON THE AMOUNT OF TIME YOU CAN AFFORD, BUT THE CARE YOUR CAT NEEDS. I recommend that your cat stay on iv fluids and with a urinary catheter in place for a minimum of 3 days. Your cat should stay in their care until urine runs clear. Your cat decides the length of stay,, not the hospital. They should do the following; full blood work. ECG, abdominal radiographs, do ultrasound, do urine culture and sensitivity. Provide analgesics, appropriate urinary diet, appetite stimulant, stress free housing. The cost of this at a specialty hospital with ER has been reported as $6,000 up. Reminder; your cat has a chance of re-blocking. I.e. you and your cat may be back here again, soon. Budget accordingly. 

IF NO;

If the estimate is not affordable; No? Everything from here is based on budget and time. The house decides your cats prognosis based on your budget. The smaller the budget the less ideal the care. Why do they get to decide that?

 

If blocked and you cannot afford the estimate; ask for all of the diagnostics to be declined before cutting the in hospital time. If the hospital will not do this ask to see the manager. Ask for the reason in writing. Do not leave with out this. There is this incorrect notion that vetcare is a one way street. We tell you what to do, and how much it is going to cost and you either pay or you hit the road. It is not the case. Veterinarians can decline to treat, but they are expected to give you a place to go for care. You can decline line items. You can ask for written prescriptions to fill elsewhere, and NO they cannot charge you for this. You can decline all diagnostics and ask for your cat to be unblocked. You can even decline pain medications, although I strongly disagree with this. Unblocking your cat, providing fluids (even in the case of a fluids kit you bring home to provide SQ fluids at home) is an option. Taking your cat home after they have placed an iv catheter and a urinary catheter is your right. In cases where the cost of care is so high I recommend that you tell the vet that you are transferring your cat to another clinic and they they be transferred with BOTH the urinary and i.v. catheter in place. I know of many (in fact I know of only 1 case where this was provided). In all other cases the specialty practice pulled BOTH catheters and then sent the cat to me. I had to replace both and this was detrimental to both the patient and the client. IF you paid for these you own them. Remind the practice this after you pay. (See form below).

If you cannot afford anything ask for a cystocentesis to remove as much urine as possible, go home find a general practitioner who will help. Call every rescue, shelter, veterinarian, put out a social media plea. Start a fund raising campaign. Offer to surrender your cat. Any person who refuses to surrender their cat appears more interested in ownership then compassion and the life of their pet. 

<$500; exam, comatose cats can be catheterized without sedation or analgesia. Take a video of how your cat presents to the ER. Ask if sedation is needed? If not it should be removed from your invoice. place urinary catheter ask if you can go home with sq fluids kit and urinary catheter in place. The act of placing a catheter is traumatic to the urethra that is already not functional. Placing and then removing before the tissue has healed is problematic, if not further worsening the cats prognosis.

Decision Tree;

blocked -> Yes, AND I can afford the suggested treatment plan., sign forms, get copy, go home. See you in a few days. (Warning patients can re-block in days to weeks).

Blocked-> Yes, BUT I cannot afford first treatment option provided; I would like to decline all diagnostics to have a urinary catheter and iv catheter placed, and at least 3 days of both with in hospital care.

Blocked-> Yes, not enough money for multiple days iv fluids and urinary catheter treatment, then place both and take home. Find a vet who will help at an affordable price. Give this directive in writing. If your vet pulls the catheters after providing written or verbal directive see your State Veterinary Board and file a complaint. 

Blocked-> Yes, cannot afford urinary catheter or iv catheter, decompress bladder (place a needle in the bladder and remove as much urine as possible. This will buy you a few hours to find a vet who can help. (Find me in Jarrettsville Maryland, or Denton County Animal ER in Denton Texas).

Pet Parent Consent For Care Form here.

If you know of someone who provides affordable, transparent care for blocked cats I want to hear about it. Email me at krista@pawbly.com

The Cost Of Hope

 Hope. When there is everything, and nothing, there is still hope.

Hope, for me in vetmed, is all of those blocked cats who never see a chance at help
because we may it too expensive.

A long time ago there was a girl who was afraid. Of all of the things she was this one thing dominated. It was what propelled her, crippled her, and reminded her. It was the beast she lay victim to for all of the days. It was the affliction her mother had and her mother before her. It was everything and nothing. It was, and it was what she let it be. 

It was like this for a very long time. A lifetime, and then, a lifetime more. 

Mom in her barn for her first antique sale.
She was beamingly happy, can't you tell?

It took a long time to recognize the part of her she didn’t have to be. She knew that there had to be more to this journey. The one she woke up to everyday to repeat the whole pattern again. But when you carry a beast so big, and so heavy, for so long, it is hard to raise your eyes above it. Maybe fear is the antidote to hope? she thought. And, maybe hope was the cure for her fear? And with that it began; the daily ritual of pulling her bootstraps up and raising her chin above the horizon, just to see if maybe out there somewhere there was another option to her fear. Maybe there was a place she could leave it? Just to rest its weary head for a while. Maybe, it was as tired of her as she was of it? Maybe, they could exist without each other? The shell without the cortex. The cure without the disease. Maybe, if she could grow big enough and strong enough, she could outgrow its need for her, and with all things that persist long enough, her need for it? Maybe? Just maybe?

What happens is that time works its magic on you and you grow comfortable with even the most horrible. You get used to each other to a degree that makes it hard to coexist without each other, even when the other half is a cancer stealing you from yourself. A bad marriage arranged on the most horrific of terms. Life is like that. It will kill you if you let it. Leach you to anemia just to see what the reserve tank has in it. Medicine, the art of molecular life in the grips of another life, the host with its many moving parts all required to work in tandem even when they have opposing agendas, is just like this. A dance, a tango set to a music you cannot always chose. You try to lead but you know the tempo might change and there may be feet stepped on as you tip-toe across the floor. 

Isn’t life like this for all of us? The calculations of actions you make silently within to try to make it through life with as little turmoil, pain, and scarring as possible. At what point do we learn that if you don’t have one side of the coin its impossible to know the other. Maybe with age there is wisdom and the ability to excise the fear so you can live with just the hope?

Outer Banks. Duck

Today is Mother’s Day. The day that we all celebrate the origin of our existence on the double X chromosome in our own DNA. For me, 5/14 is the day my mother died. On this day at 4:14 pm in a little stone house not too far from my own, my mom took her last breath. I say this as it marks a date, impermeable, and in-excisable. The pivot point to which the calendar resets, and a life without another starts. I say this because that day changed so much within me. There is a book to write about her, and her impact upon me. A book that sits waiting for the time and the distance to write it without it eating me up. Consuming me like the fear that swallowed her and kept her trapped within.

Today I remind myself that there is life after another life passes on. I cannot call her gone. She is never gone. She is here all around me reminding me to always have hope. To always see the beauty and the joy in the life that exists even if you have a difficult time seeing through the tears. Today I talk about hope.

Today I opened my eyes before the sun came up. The sky crept from black to the darkest of blue. A grey-washed out kind of blue. Smeared in its blurry shadows. Quiet, heavy, and slumbered with a fog that keeps all of the earth’s tiny souls safe in their beds. The first rays of sunshine wake up the world and to this awakening the first chirp can be heard. It is my time to be alone and feel as if the world will remind me that I am never really solitary. One little chirp. Just a call in the almost-darkness to awaken the rest. I turn on my Merlin app, and start to record. I now know that this tiny rooster call is an American Robin. Maybe being afraid, and trying to replace it with hope is about seeing the bravery in the darkest of places and still singing?

The potting shed. Mom and Diedra's boys

I made a video the other week about all of the clients I see who come to me having to lay their pet to rest after disease, and age, and all of the many afflictions that life can wear you down from. They always ask me the same thing, without fail; they ask, “this must be the hardest thing that you have to do as a veterinarian?” And I always reply the same way… “No. You loved your pet so much that you made them a part of your family. They were loved every moment of their lives. How lucky they are for that, and I know they are so grateful to have been yours.” That is the hope in the face of fear. That is the beauty in the face of death. Maybe losing someone you love is about remembering the hope they brought you every day you were together?

With hope springs gratitude eternal. Is there anything we wouldn’t give for that?

Happy Mother’s Day to you all. (regardless of what your chromosomes or current children roster looks like)..

The first icy drink of Summer. A mojito from our mint patch.
Diedra, mom and me.

And P.S. go out and foster, adopt, and live life with someone else… pets count as kids these days,, so we are all moms here. Maybe there is life outside of the one you are living right now where hope springs eternal? And, maybe its time to go look for it? Let’s all look for hope in the love that reminds us we are all mothers. 

P.S. I write about all of the issues that being me brings. I know that I am not alone and I hope (there's that word again), that others hear me and know that they aren't alone either.

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.

 

Get Out Alive Blocked Cat Episode.

The cases that move me are not the easy quick ones.

Life works that way. Your greatest rewards often lie in the trenches during the greatest conflicts. It is our version of the battlefield stories that bond us in our darkest hours.

Yesterday was one of those days. (I seem to live in these days these days).

We get a call that goes something like this; (I only heard one side of the conversation. My receptionists side).

"I'm sorry to hear about your cat. You say that you found a clinic that would give your cat a free examination, (clearly a corporate marketing tool to drum up new clients I thought?), and, they say your cat is blocked? (A blocked cat is a cat who cannot pee and this is ALWAYS an emergency!)." long pause.. "I'm sorry did you say that you have seven (7????) dollars?" Her voice took a tragic upturn on the dollar sign part.

...short pause.....

"Ok, well,,, umm,,   (pause)      ummm,,, (deep swallow),,, let me get your information and I will call you right back." My receptionists are seasoned pros. They hardly get flustered. But, then again, who calls with $7?

At this point everyone within ear shot was huddling around her desk with muffled giggling. This is the giggle of the great battles. The first shot has been fired, the troops are gathering and a plan is about to be hatched. These are the stories of the place Jarrettsville Vet has become. These are the stories other vets get, most sarcastically laugh at and dismiss, disregard, or decide to just be bitter about. I was/am/try very hard NOT to be this person. I pay for electricity, wages (waaay above minimum btw) and blah, blah, blah, (excuses to not care), but it doesn't change the fact that there is still this guy, AND, there is still this cat.... so we listen to the stories. We gather the troops, and we devise a plan. The plan is always a conversation, a compromise and a quest. The goal however is always mutually consistent in the most critical component: We have to act fast AND we feel compelled to get help. We place phone calls. We are a place that listens and lives by our motto 24/7/365.

After a round table discussion we formulated a preliminary plan. The first phone call was back to the cats dad. We have a team dedicated to returning these phone calls. We have a shield for them in our first line of defense, our receptionists, then the team takes over. No one should be the single troop in a militia. The first test is in assessing the pet parents intention and integrity. He has to be able to compromise. Turns out he also has to be one other thing.. completely dedicated to his pet and follow through with our advice so we don't perpetuate another terrible predicament. Vitally important to the success of these cases is that he has to participate in this cats treatment, recovery and long term care. Thankfully we discover that he loves his cat and he is willing to do whatever he needs to keep him healthy. I can do just about anything as long as we start here. Everyone has to invest in CARING. Nothing of merit lives outside of caring.

Next step in the plan of attack;

We called our friends at the rescue. Circle the wagons, build momentum by uniting the troops. They have the ability to manage this cats care after we get him unblocked. They can manage the nursing care for the next few days while he gets his bladder and kidneys diuresed. It is nothing more than a medically induced flushing of his urinary system. "The solution to pollution is dilution."

They offered to pay for his after care. We would get him unblocked. Two phone calls and we are on our way to saving this cats life. Go Team GO!

An hour later we met Socks.. As always (ok,, truly always), the ones who need you the most are the ones who are the sweetest souls. This cat was pure love. Young, adorable, and desperate to pee. He purred the entire time we squeezed his rock hard massively overfilled bladder.

Here is his story in synoptic detail, video style.

There are articles and discussions of this condition listed below. While I am not here to argue that there are absolute benefits to maintaining ideal standards of care I firmly beleive that the biggest failure we provide is not offering assistance regardless of clients financial abilities. When we as a profession decide collectively to support our patients first I will with hold posting prices and offering cost saving options. Get Out Alive series is coming. Blocked Cats is first on my list. Next, pyometras.

The typical cost of a blocked cat at my clinic is;
Exam; $50 to $75
Radiograph $100 *
Intravenous catheter $40
Intravenous fluids $40
Intravenous fluid pump $40
Anesthesia $100
Urinary catheter placement $75
Hospitalization care about $100 per day. Usually stays for 3-5 days.
Bloodwork $150 *
Urinalysis $50 *

* optional if client cannot afford it.

For more information please see these articles;

Urinary Obstruction in Male Cats, ACVS article. One of the best on this condition. Please read this one!

Feline Urethral Obstruction: Diagnosis and Management. By Today's Veterinary Practice. A very thorough description of how, why and what happens to these cats along with detailed description of treatment options. I recommend taking this article and discussing each step with your veterinarian as they provide an estimate for the cost of care. Know how much each step costs, know where your cat falls within the spectrum of the disease process and know that one size does not fit all! You may be able to cut some costs with the use of this step by step guide. Get everything in writing and GET OUT ALIVE!

A protocol for managing urethral obstruction in male cats without urethral catheterization. Cats were treated in a hospital but not catheterized (which I feel is the most important part of the treatment plan). Read carefully and understand this protocol cannot, and should not, be  accomplished at home.

Controversies in the management of feline urethral obstruction. Journal of veterinary emergency medicine. 2015, PubMed. Please read the prognosis section; "Feline urethral obstruction is associated with 90-95% survival, with reported recurrence rates of 15-40%." How many people cannot afford to treat their cat when the survival rate is this high? I would guess that there is not a single other emergency condition that pets get that has this high of a survival rate when compared to the number of economic euthanasia's due to cost. What is the rate of economic euthanasia for this condition? At my clinic it is zero. What is it elsewhere? (Good question? Anyone want to share their numbers? Speculative numbers?)?

Can these cases be managed at home? Without a veterinarians intervention or assistance? I would strongly discourage this. I feel the prognosis is far better with a urinary catheter placed and intravenous fluid therapy to flush the bladder, kidneys and remove the toxins and systemic imbalances, but here is a widely cited article on managing these cases at home. Which is better than nothing (although I would still argue it isn't enough!).

If you have questions about your cats care, the cost associated with this diagnosis and most importantly ever feel pressured to euthanize based on economics please ask/beg/insist on options and please seek a second, third, or even fourth opinion so that your treatable cat can GET OUT ALIVE!.

I am here for you. Find me on Pawbly.com and remember "never go quietly into the night."

Free pet advice is available on Pawbly.com.

Parting thoughts;
1. Get Out Alive. Ask about options. Insist on care. Document everything. There is help available even if you have to be insistent on it. This is an emergency condition and your cats life depends on your actions. Be kind. Always be kind. You can't ask someone to be someone you are not.
2. If you do not have any  financial constraints almost every vet and emergency facility can care for your cat with this condition.
3. If you do have financial constraints ask for a written estimate. Go over each line item. Ask which is most imperative at the immediate time. Ask the vet to rank these. Start at number one. Stay at the clinic as each line item is addressed. Once your cat can be transferred to your vet it might be more affordable to get their care with them.
4. Ask about the incidence of recurrence for this condition? Ask how you might be able to avoid this? My advice is a diet and lifestyle change. Less dry food, less poor quality dry food, more exercise, less stress. (Ask about cat stressors? Often clients cannot, and do not see the world the way their cats do).
5. Ask about a PU surgery. Start planning and saving for it. The second, and definitely the third time a cat blocks we put this surgery on the table. This is about GETTING OUT ALIVE! remember. PU surgery info here. Perineal Urethostomy by Michigan Animal Hospital. Cost is between $1,000 and $3,500.

If you have a pet story that you would like to share, or an experience with this condition please add it to our Storyline page at  Pawbly.com.

Please also follow us on Pawbly.com, our Jarrettsville Vet, or our Jarrettsville Vet Facebook page, Twitter @FreePetAdvice, and YouTube. 

Find What Breaks Your Heart AND Change It. How Imposter Syndrome Battles Compassion Fatigue

There is this pervasive gnawing of vulnerability following me. I'm running without the time to look back to see their red eyes of furious feverish pursuit hunting us, while in my arms lies some sick-dying desperate soul to save. It is always the same dream. All on me, all alone and fleeing.

In the trade we call it "imposter syndrome". Any mortal who is honest with themselves and humble in the magnitude of this profession understands that we cannot be everything to everyone and yet also be expected to hold the bar to the scrutiny of the specialists should the shit hit the fan.

At some point the dam breaks and you accept that you can only be true to your own sense of ability meets inability. You also learn to always be honest, inside and out. After that the cards fall where they will and you go on.

I have lived about 10 years as a veterinarian between insecurity-hugging-imposter AND activist-holding-up-compassionist. Quite a dichotomy. Plato's symposium meets my real-life. I can only be pulled into two different directions for so long. Every two headed-four legged sideshow freak suspended in formalin died for the same reason; at some point either one half dies, or they both do.

There is not one day that we aren't reminded how fragile life is and how many suffer just to survive.
One of 17 feral cats we are trying to save in the middle of a harsh winter this kitten weight 2.5 pounds and is over 6 months old. She should weigh at least three times that. Instead parasites, pneumonia and fighting for resources has stunted her to this state. Could you walk away? 
After all there are thousands, millions (?) just like her.

There are quotes of inspiration that transition into motivation. If you dwell long enough they can even convert your unsettled  inertia into purposeful kinetic momentum. I am one of those people. I don't like the sidelines. I don't wait for a coach to blow the whistle of permission to enter the game. Sunday I euthanized half of the patients I saw for the day. Quite the statistics to drive my point home. Death waits for no one. You can grow old, decrepit, and exhausted waiting for permission.

"Find out what breaks your heart, and do whatever you can to fix it." Abby Wambach. 

If I were one of the tattoo yielded kids I would have it emblazoned on my wrist. (You know the web-slinging place of Wonder Woman days.)

My heart breaks every single day that I am in practice. There isn't one day where we aren't faced with the reality of the state of our profession. People need us and we are not there for them. These people LOVE their pets and are desperate to help them. They get faced with closed door after closed door of unwillingness to even speak to them, never mind offer real meaningful care. It is the example of the desertion of humanity at its most basic. For me it is the most classic day-to-day reminder of how broken our society is. The smallest and weakest always suffer far beyond the wealthiest's purview. They land here, in our doorway, begging, every single day. To turn my back on them is torture, there is no denying their existence and yet there is no time to try to negotiate the terms to resolution.

I am left with a soapbox, a desperate call for action, and a profession who has come to terms with the divide between responsibility, profit, and castigation. It breaks my heart. It propels me to act and it leaves me vulnerable as the scale overflows my practices ability to hear the cries from below.

Maddie. My muse.
The source of the inspiration that broke my inertia.

This shadowed mob of lynch men is real. If you don't think that we live in an angry hateful world ask whoever is on the other side of your political affiliation. We are not so tolerant of the other side. It weakens us all. The system doesn't like change. It fears disruption as a vulnerability deserving of inoculation, eradication and excision.

If I am not heartbroken by the indifference that is so overwhelmingly pervasive in our professional culture I would be both an imposter and a liar. There is a point where you get pulled apart and die from collateral damage to the host. How can I kill the girl who still gives a damn, remain sitting on the sidelines waiting for the pandemic of indifference shored up by excuses and vitriol to blame the other half to win?

If the statistics were available my point would be fueled by a mob so great the profession would fracture into its own broken system of public health practices and couture clinics. The non profits would start dominating the landscape at a precedence the corporate practices would take note of. If the advent of the human medicine minute-clinics restructured access to quick affordable basic care the high volume-low cost practices diversify to meet the need. The walls of secret hidden price schemes based primarily on lack of access and professional pursed lips will fall. If epi-pens were met by lawsuits and lynchings the vet profession better start looking inward.

Let's take some examples; if there is a 90% cure rate with medical intervention in urethral obstructions what is the economic euthanasia rate? How do we justify this growing statistic of unaffordable care when nothing about the treatment plan has changed? How do we answer the public when the cost of this treatment has escalated from less than $800 to over $4,000 in a decade? The difference is corporate profit.

There are inherent rights to every living thing;
1. They all are in the same race. Live and perpetuate living. It is fundamental and undeniable.
2. Action and inaction have consequences.
3. Inner truth is the only salvation to inner peace..

What are you willing to lose in an effort to remain whole? It is a question I ask myself every day as I try to outrun and outlast the mob at my heels.

Like every other civil movement there is a groundswell of people demanding change. For me, in this movement to return medicine to the place of compassionate discussions focused on patient care, and not corporate profits, it is a return NOT a redirect. It will take a war of anger, heartbreak and unwillingness to tolerate the system as it stands, or has evolved into, before the negotiating will begin. In the end the indifference for profit will never prevail. I don't care if this is over "property" and responsibility. It is about love, companionship, and ultimately our ability to recognize that each species, and all beings within these species, need each other.

Where am I? Just swimming against a tide of forgotten little guys still trying to save every single wet nose and still fighting for their tiny voices to be heard with a sea of sharks behind me.

What is my soapbox going to get? A voice on a stage with a megaphone to amplify the stories of the souls we have forgotten to serve. There is a change looming on the horizon, a mob who will have to answer some tough questions, and a whole population of under served who will have their day of reckoning.

What breaks your heart?

And what are you doing about it?

August. Found as a stray at the shelter with a broken femur.
Recovering with us and looking for a home.
She's the most precious kitten!

If you are interested in help for your pet and don't know where to go please find us here at Pawbly.com. It is a free online community dedicated to educating and inspiring pet people everywhere. It is free to use and open to everyone.

I can also be found at Jarrettsville Vet in Harford County Maryland. Visit our Facebook page here, or see our online Price Guide at our website jarrettsvillevet.com