Blocked Cats, UO, How Far Has Veterinary Medicine Fallen?

Blocked cats are my professional obsessive jam. The urinary blocked cats, this one disease which is almost always curable, (and, lets be real honest, how often can we say that in vetmed?), affects primarily young otherwise perfectly healthy cats. It is also the most egregious example of how far vetmed has distanced itself from helping the patients who need us most. In the olden days, (i.e. the days of my formative veterinary exposure, when the music was 80's pop and the hair was big), the vets that I worked for would have never-ever, ever, even contemplated turning a blocked cat away. It wouldn't have mattered whether it was 5 minutes until closing, or, if we had never seen the cat/pet parent before. Nothing would have stopped the vets of the days before the specialists, the fancy ER's, corporate ownerships and astronomically expensive off-shore vet schools from treating these cases, and doing it affordably. Vetmed was so honorable in those days that we offered help and asked for payment later. There was a foundation of trust, a pragmatic approach with integrity, and every vet knew that they had to treat or the guy down the road would. We never passed the patient by. We always had the practices credibility on the line. Every client mattered, and, therefore every pet mattered. Euthanasia was reserved for the cases that failed to get better after we had done our best to provide what our patients needed, never before. 

UO (urinary obstructed) cats are the best example I can give of how much vetmed loves money, and how horrifically we fail the most underserved and vulnerable among us. If I had one wish it would be that every single veterinarian loved this jam as much as I do. Every single veterinarian would see these patients as miracles just awaiting our healing hands and a little reconstituting from a slow iv drip. How can I help other vets see these cases this way? How can I inspire and motivate a whole profession to look deeply into the eyes of a treatable feline, remind themselves to invest all that we are, and save them all? How can I remind us to be kind, to be compassionate, to help people who desperately love their pets like family, and  save the world, just because we can?  

This is Figaro. This is his story. His life, his chance at surviving his acute urinary obstruction, and all of the accolades, frustrations, desperations, and phone calls his mom had to make to save him. This is what vetmed has become. It is also everything vetmed should be ashamed of having become. 

Figaro is a young, healthy cat who has been loved, cared for, taken care of his whole life. He has been to all of his vet visits, and his mom has done everything she was ever told to do for him. He was perfect and loved, until he was sick, very sick, and his mom rushed him back to the place she knew he belonged. The place where people would help him.

Figaro's mom noticed that he was not feeling well. He wasn't walking normally, and he wasn't eating or drinking. She called her vets office immediately and they told her to take him to the ER. Which is technically the right answer, and all too often the only answer most small, private practices, already too busy to stay on time veterinarians will give. The biggest problem with this answer is that this is too often a place that most pet parents cannot afford to utilize. Most pet parents walk into an ER expecting that the veterinarians will help them. Save the lives of the pets they adore, and be treated with hope, respect and compassion. This is what you will get if you have deep pockets. Financial stability and access to about $3,000 to $30,000. This is what vetmed is today. This is what all of the things that veterinarians, corporate ownership, and lust for profits, salaries and mental well-being cost. It just costs lives too.

Figaro's mom went to her vets office anyway. She knew them, they knew her and she wasn't comfortable being sent somewhere else. They left her in the waiting room, took her cat to the vet in the back and the vet palpated a full, hard bladder and knew he was blocked. She sent her to the ER.

This is Figaro's mom's letter about her experience. I asked her to write it because she is not alone. Figaro is one of so many that I see. Figaro's mom was just brave enough to share her side. She is a survivor, and now so is her cat. She is an advocate, a voice, and a beacon of hope that the profession will start to listen. 

Maybe if enough people start to ask themselves how their part contributes to this responsibility will will begin again to protect with compassion. We will do so because we can, and because we want to. Because this does save the world. It does pay forward, and it is what we owe those who came before us and those who will follow after us.

The ER did what they always do in these cases. They alert you to the cost of the exam. The technicians collect a history and your pet goes to the back for an exam. The exam reveals a hard, painful bladder that cannot empty. You are given an invoice with every possible diagnostic needed, every bad turn, and every worst case scenario covered. In the last decade the estimates for this have gone from $2,000 to over $8,000. 

Figaro's mom was given a $2,700 estimate.

I don't send people to the ER without warning them of the estimate that they will be given. Why? Well, because I didn't go to vet school to send my patients to a euthanasia based on economics. I didn't go to vet school to send my patients elsewhere to be denied care. I didn't go to vet school to send my cases to other places who aren't going to help them. I didn't go to vet school to have my clients feel ashamed, embarrassed, humiliated, and helpless. In some cases these otherwise young, healthy perfectly normal perfectly fine cats are euthanized as the most "compassionate way" to treat this disease. We call this economic euthanasia. In other cases the pet parents can only afford a quick unblocking and then they get sent home. This treatment option, although relieving the immediate problem, makes the next unblocking (you the ones I get asked to do a day or two later) much harder to do. 

Figaro's mom had access to $400. Her estimate at the ER was about $3,000. They, (to which I have to add that I am surprised and hopeful that this is the first crack in the facade of finding a way to provide care outside of the approved corporate income driven recipe), offered care based on the clients ability. Was it great care? No. Was it ideal care? No. It was a quick palpation to diagnose and a passing of a urinary catheter to remove the obstruction and then he was sent home. 

He was sent home without all of the care he needed. He was heavily sedated, poorly responsive and his mom had been firmly told that Figaro needed to eat a special diet, and only this diet, for the rest of his life. He was so depressed, chemically incoherent and incapable of walking, eating, or responding to her pleas to eat the food and use the litter box (therefore proving to her that he wasn't blocked again). 

Figaro's mom called her vet the next morning. They couldn't fit her in until the next day. She was so worried that he needed to be seen sooner that she started calling other vets offices. She called explained Figaro's dilemma and then added that she had no money left. She kept calling when everyone turned her away.

She called us and told us that she was worried he had reblocked. We told her to come in to see us immediately. It helped that I was at work and the staff knows that this is my jam.

Figaro was not blocked. He peed as soon as I gave his bladder a gently squeeze. He was gorked on the medications from the ER, and needed the extra time that the $2,300 would have gotten. He needed intravenous fluids, pain medication and an antibiotic. He needed the toxins that build up in the kidneys after you cannot pee to be flushed out. So that's what we did. Figaro only needed a few things from us. He didn't need a long stay, or an expensive list of invoiceable items. He was a cat who needed just a little more help, with a mom who needed help on how to take care of him. Figaro and his mom needed us to be what all of us should be. Helpful on their terms.

The next day we got a call from our local Animal Control. They wanted to confirm that Figaro had been seen by us?

Seems someone had dropped a dime on Figaro's mom for cruelty and neglect after she had failed to show up for the recheck appointment she said she would. 

Here is where Figaro's story takes its next troubling turn. What was Figaro's mom supposed to do? She knew he needed help so she reached out to the place she had always gone to. They sent her elsewhere. They sent her to a place she couldn't afford. Then they give her a discounted service that isn't enough for her cat, and then call Animal Control on her. They report her. 

If she hadn't found us it is very likely that he would have been in much worse shape the next day, or that they wouldn't have given her a way to pay? What then? Likely AC would have forced her to find a vet, or, bring him to the shelter to be euthanized. Figaro deserves better, so does his mom.

Our Office Manager called the ER to inquire about why they called Animal Control to report her. This is the reply they gave us.

I did call the ER to discuss Figaro.  I spoke with their Hospital Director.  Please see highlights below from our conversation -

 

• ER saw Figaro to unblock him
• Owner only wanted Figaro unblocked and wanted meds to go home. 
• Owner seemed untrusting of ER and did not seem to understand how critical a blocked cat can be. 
• ER discharged Figaro under the impression he would be seen at original vet office the next morning, however no Direct Transfer of Care was in place
• ER has a pamphlet that they give clients who are struggling financially.  The pamphlet includes resources and information for Vet Billing, they did try to point her in the direction of Helping Hands and let these folks know they should try to find a vet that accepts payments.  I am surmising that this may be where they get our information from, if they go to the VetBilling website and search for a vet in the area who participates they find us. 
• The following morning owner called as Figaro was not doing better, they were surprised that she was reaching out as she had told them initially he would be seen at her original vet office.  It was in that conversation that she told them that she did not have an appointment with original vet office until the following day, 8/28
• It was at this juncture that they did call AC for a wellness check - they were concerned that owner did not understand how critical Figaro was and that she had been dishonest in when he would be seen.  They were concerned he would not be seen at all.

What would you do?

What would anyone with limited resources and a pet they love who is in desperate need of help do?

How does this profession address these cases? 

How does the veterinarian, who is justly worried about Figaro, do?

It is with all of this in mind that Jarrettsville Vet has started to have these discussions.

This is the letter we are now using with clients when we can't decide what to do with a case that burdens our hearts, pulls our compassionate souls from our guts, and leaves us unable to sleep at night. 

“We care about your pet and your pets care.  We are concerned that there was not a follow up appointment after the veterinarian recommended it. Your pets condition was not stable enough to provide a dismissal of care. Please call us to arrange a recheck appointment or let us know if you found a recheck appointment elsewhere.

If you have any concerns about the cost of this care, or any future care here at Jarrettsville Veterinary Clinic please call and ask for me or one of the other managers. We will be happy to offer options for you and your pet.

We have called the numbers we had on file and sent an email to address you provided. We hope to hear from you by the end of business tomorrow. If not we will these concerns on to animal control to be in accordance with the state mandates. “

What do you think?

Here is what the ER has come up with to help cases that come to us.           

The ER is 100% on board to do this and do regularly do so with a Direct Transfer of Care.

• With a Direct Transfer of Care they will send everything in place.  They will suture in a urinary catheter, send IV, etc.  They also will not fill meds there as the client could fill cheaper at their regular vet.
• A conversation between doctors is what initiates the Direct Transfer of Care.
• In the past owners have said they were transferring to their regular vet and didn't, they had a pet return septic when a catheter had stayed in place.  Therefore they will not leave everything in place without that conversation.
• If one of our clients is in conversation with one of our doctors about transferring care it is important that our doctor reach out to the ER so the Direct Transfer of Care can be in place.

Here is the site for Maryland reporting of animal cruelty. 

So where do I go from here with my resolute disbelief of how far we have come, and how much we are enabling suffering for both our clients and our patients. Well, I suppose you will have to wait and see.

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?"

Or,

"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 Pawbly.com. 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.