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.

My Top 10 Feline Feeding Tips.

My cat Magpie contemplates breakfast while perusing the passing food choices available 
on the others side of the windowpane.

There are few shortcuts to success in this march toward the final curtain call. When I talk to my clients about how to best care for their cat(s) I focus on essentially a very few topics.

I remind my clients that we really "are what we eat, and we get what we pay for."

For cats, the strictest of carnivores of all of our domestic species, the poorer the diet, and the more contained your cat, the more likely you are to have problems.

Cats are roamers and hunters. They are lean muscled inquisitive beasts who all roar loudly on the inside even if they purr quietly on the outside. They are built to eat flesh, and not chewy cookie like food, they are also less tolerant to the accumulation of adipose (fat) tissue then other species. They tend to accumulate fat around vital organs, like heart, and suffer significantly if that fat remains. The consequences are staggering and severe. Joint disease in 4 and 5 year olds when I typically only see it in 15 plus year old fit cats. Diabetes, the terrible consequences of this disease are often life-threatening and life-costing. Recurrent chronic infections, overwhelming amounts of urine that isn't always deposited in the litter box. Difficulty breathing, poor coat, inability to clean themselves leaving fecal matter stuck to the back of the rear legs and tail area. It is a sad reality that many cats struggle with obesity simply because we, their parents, are feeding them a poor quality kibble based diet.

Tigger presents for a pat.

Here are my recommendations for what and how to feed the felines in your life;

1. Rely on canned food and minimize access and quantity of dry food. 
A normal sized middle aged house cat (8-10 pounds) should be fed 1/2 of a high quality 5 ounce can twice a day. In my home for my 4 cats I use Science Diet. I vary the flavors to keep my cats interested and avoid problems posed by an exclusive single animal based protein. If your cat is used to eating only dry, and is currently overweight start at 1 can twice a day. If they aren't finishing it start to reduce to 1/2 can twice a day.
Confession Notice; The number of clients who tell me that "They cannot feed canned food," is ludicrous. When I ask "why?" The answer is almost invariably, "because I don't like the smell or the mess." I have trained myself to not respond the way my gut wants to. Instead, I remind them that the best diet choices available are freshly killed small rodents.

2. Offer 1/2 cup of dry food per cat a day. This should be age, lifestyle, and appropriate for any underlying disease(s). Again, in my home I use Science Diet adult feline. In general, most of my obese, diabetic cats have been on a poor all-you-can-eat food trough dry food. Worst yet, they are cartooned, day-glo foods with packages that look like these;

Cartoon logo, day-glo colors, and weird shapes,
the junk food telltale trifecta.

Drumstick and fish shapes, with filling..

Filling and "soft inside, crunchy out"
and a cartoon character.

3. Choose a high end commercially available diet. My personal favorites are Science Diet. I have fed it to my cats for decades and I have seen this company stand by their product, their patients and my non-stop veterinary help requests for decades. (I am not paid, compensated, nor biased in any form by any company). I typically buy multiple cases of different flavors and offer a mixed variety to my cats. It is important to not feed one type, or allow your cats to become addicted to only one flavor or type. Having your cat find a favorite can lead to them becoming intolerant to any other foods and make a treatment of a disease by change in diet incredibly difficult.

4. Food and water bowls should be emptied and cleaned at each meal.

5. Pay attention to who is eating and how much they are eating. Too often we catch a sick cat after days to weeks of reduced eating. Free feeders are the most difficult to monitor for adequate food intake. If it is out all of the time many people don't know when, or how much the pets are eating until it they are very skinny and weak.

6. I love water fountains for cats. They seem to enjoy running water, and it encourages drinking. I also like to add cat grass to them. The cats often enjoy the greens and they are fresh and organic.

7. Any kind of diet change, especially for cats, can be difficult. The best advice is to do it so slowly and so gradually that they don't realize it is happening. For the first few weeks (or months if needed) leave the wet food out and gradually reduce the amount of dry available. If your cat is finishing all of the dry and demanding more give in, but try to make it the highest quality dry available. If they are being reluctant to try the wet add a tiny bit of canned tuna, or chicken/beef baby food, or even lunch meat. 

My cat Wren, takes a little love bite nibble.

8. If your vet advises that your cat should be on a prescription diet I would still recommend that you try a gradual transition. If you cat is not so keen on the new diet it is better to have some of the 'good' versus all of the 'bad'. Let them decide how fast you can transition them. If you are having a difficult time with the prescription food ask your vet about other options. In many cases there are a few different manufacturers and a few other options.

9. Cats are ALWAYS in charge. The old "eventually they will get hungry enough and eat it," is NOT TRUE for cats. Cats can, and do, go on hunger strikes that can lead to irreversible life-threatening liver failure or disease. Surrender before they prove their point with an expensive potentially deadly disease (hepatic lipidosis). If your cat is getting so finicky that they are refusing the best stuff, start feeding other stuff. In the end a cat has to be eating, and as disease, or age, advances feed them whatever you have to to keep them eating. Try the following; gravied canned foods, chopped cooked chicken, fish, shellfish, meats, hot dogs, baby food meat flavors, tuna, or any of the foods or treats from number 2 above. In the clinic we have a special 'junk food' section that we pull out as our secret weapon to encourage our sick cats to eat.

10. Embrace the challenge that is the independent intelligent spirit of a cat. They have their reasons for every decision that they make. They need more than most of us can offer in a life of jobs, kids, responsibilities, and convenient diet choices. Too often we are not meeting their dietary needs, their inquisitive curious minds, and their exercise stamina. I have become an advocate of lots of choices, loads of mental and physical stimuli and an appreciation that we, unknowingly, and unintentionally asked them to live a life of boring captivity. Take your cats for a walk (try a harness or an enclosed outdoor cat cage), or even a playmate to chase and play with in the house. What about a cat room with shelves on the walls, cat trees, and an indoor garden of their own?

If you have any tips, or thoughts on how to best care for cats please leave me a comment. If you have a pet care question please visit me anytime at Pawbly.com. Pawbly is a free open pet community designed and dedicated to helping pet people care for the pets in their lives.

I am also available for veterinary care at the vet clinic, Jarrettsville Vet, in Jarrettsville Maryland, or on Twitter @FreePetAdvice.

The Yellow Flag, Cats and Jaundice

In veterinary medicine they are called "pearls." 

Those tiny tid bits of wisdom handed down generation after generation to those vets that come after us. They are the pieces of information that we have learned by experience and not by endless pages of publications.

This pearl is about jaundice. Jaundice is when you turn yellow. It is a very very bad sign in veterinary medicine. For cats is it especially tragic. When you see a feline patient this jaundiced the prognosis is very poor.

Why do I mention such a tragic thing? Because jaundice does not happen overnight. 

The medical term for jaundice is icterus. It is not a disease it is a clinical sign, like coughing is to a cold.

This pearl isn't to imply that jaundice, and whatever disease or illness that caused it isn't curable, but it is about understanding the severity and gravity of treating it.

When you see your pet with even the slightest tinge of yellow (look at the gums, the ears, the sclera (white part of the eye) the sparsely haired part of the belly, anyplace), then it is time to immediately see your vet.

The darker the jaundice becomes the more severe the disease has progressed. Get help immediately!

This is an excellent article on the causes of icterus. In my never ending quest to help more of you I am going to cheat and re-use their information. After all, I do not have enough time to re-invent the wheel, just help more of you get on the bus to healthy-ville.

Written by Ernie Ward, DVM for VCA this is thorough article can help you navigate through the treatment options after the diagnosis is made.

What is icterus?

Icterus is also known as jaundice or yellow jaundice. It refers to an excessive accumulation of a yellow pigment in the blood and tissues. When icterus has been present for any length of time, it will discolor many tissues and will become visible as jaundice on most body surfaces, including the skin.

"Jaundice may be difficult to detect in cats that have pigmented (dark) gums or skin."

Since most of a cat's skin is covered by fur, jaundice is most easily seen in the gingivae (gums), the sclerae (white part of the eyes), and the pinnae (ear flaps). Jaundice may be difficult to detect in cats that have pigmented (dark) gums or skin.

What makes a cat likely to develop icterus?

Risk factors for icterus may include the presence of fleas or ticks, infection with feline leukemia virus (FeLV) or feline infectious peritonitis virus (FIP), residence in or travel to areas endemic for liver flukes or fungal diseases, prolonged anorexia, and ingestion of drugs or toxins.

What causes icterus?

The pathological causes of icterus fall into three major categories:

1)    Destruction of red blood cells. The process of red cell destruction is known as hemolysis. It can occur within blood vessels (intravascular hemolysis) or in the spleen and liver (extravascular hemolysis). Hemolysis causes a type of anemia called hemolytic anemia, which is different from blood loss anemia that is a result of external hemorrhage from an injury.

2)    Liver disease. Any disease or condition that damages or destroys liver cells can cause icterus.

3)    Obstruction of the bile duct. Bile is stored in the gall bladder and transported into the small intestine by the bile duct. If bile becomes abnormally thick, if gallstones form in the gall bladder, if the gall bladder or bile ducts become inflamed, or if the liver becomes swollen so that the bile ducts are constricted, bile flow will become obstructed.

How is icterus diagnosed?

The diagnosis of icterus itself is usually straightforward, by means of a physical examination. Occasionally, a blood sample is drawn for some other reason and the serum is noted to be yellow before the cat becomes visibly jaundiced. In these cases, the yellow serum is usually an indication of impending problems, and your veterinarian will recommend a complete diagnostic work-up.

"Determining the cause of icterus can be a challenge and requires a systematic approach... first step is to perform screening tests..."

Determining the cause of icterus can be a challenge and requires a systematic approach. There are several potential causes for icterus within each category listed above; the first step is to perform screening tests to determine which of the 3 categories is involved and to narrow down the list of likely diseases. Based on the preliminary tests, your veterinarian will perform additional tests to determine the cause of icterus in your cat.

How is hemolysis diagnosed?

Your veterinarian will perform a test called a CBC or Complete Blood Count. The CBC measures the number of red blood cells, white blood cells, and platelets (important for normal blood clotting). If an automated machine is used to perform the CBC, the red blood cells will be measured by a direct red blood cell count. As part of the CBC, tests called the PCV (Packed Cell Volume) and/or the hematocrit will determine the proportion of the blood that is red blood cells. These measurements will indicate whether the cat is anemic. Other components of the CBC will help determine whether the anemia is caused by hemolysis, including an examination of a blood smear to look for immature red blood cells, abnormal red blood cells, or unusual clumping of cells.

What causes hemolysis?

Hemolysis can be caused by toxic plants, chemicals, drugs, parasites on the surface of the red blood cells, heartworms, autoimmune diseases, and cancer. Several additional tests may be needed to determine which of these is causing the hemolysis and resulting icterus in your cat.

How is liver disease determined to be the cause of jaundice?

A biochemistry profile, which is a group of 10-30 tests, is performed on a blood sample from the cat with icterus. The biochemistry profile contains several tests that are specific for liver disease. The main liver enzymes are alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and total bilirubin. In some cases, your veterinarian will also recommend a bile acid analysis, which assesses liver function.

"A study of liver tissue (biopsy) or liver cells (cytology) is necessary."

These blood tests will indicate that liver disease is present, but not its cause or whether it is reversible. To make that determination, a study of liver tissue (biopsy) or liver cells (cytology) is necessary. This can be done in one of three ways:

Fine-needle aspirate and cytology - To perform this procedure, a small gauge needle is inserted through the skin into the liver. A syringe is used to aspirate some cells from the liver. The cells are placed on a glass slide, stained and studied under a microscope. This is the least invasive and quickest test, but it has certain limitations. Because only a few cells are obtained, it is possible that a representative sample from the liver will not be obtained. It is also not possible to view the cells in their normal relationship to each other.

Needle biopsy - This procedure is similar to the fine-needle aspirate except a larger biopsy needle is used. Often, this test is performed during an ultrasound examination and is called an ultrasound-guided needle biopsy. The needle biopsy gives a core of tissue, not just a few cells. The sample is fixed in formaldehyde and submitted to a pathologist for analysis (a technique called histopathology). General anesthesia is required, but the cat is anesthetized for only a very short time. The core biopsy allows the pathologist to view the cells in their normal relationship to each other. However, the veterinarian cannot choose the exact site of the liver to biopsy because the liver is not visible. Therefore, it is still possible to miss the abnormal tissue.

Surgical wedge biopsy - The cat is placed under general anesthesia, and the abdomen is opened surgically. This permits direct visualization of the liver and the surgeon can choose the exact site for biopsy. A piece of the liver is surgically removed using a scalpel. This approach gives the most reliable biopsy sample.

What types of liver disease cause icterus?

Some of the causes of liver-related icterus include infectious diseases (feline leukemia virus (FeLV), feline infectious peritonitis (FIP), fungal diseases), neoplasia or cancer, hepatic lipidosis (fatty liver syndrome), and cholangiohepatitis complex.

How is bile duct obstruction determined?

Cats with obstructed bile ducts are usually extremely icteric. In addition to the discoloration in the sclerae and gingivae, their skin is usually an obvious yellow color.

"Ultrasound examination is a more accurate non-invasive way to evaluate the gall bladder and bile duct. "

The gall bladder and bile ducts must be examined to confirm the presence of an obstruction. Although this may be possible using radiographs (x-rays), an ultrasound examination is a more accurate non-invasive way to evaluate the gall bladder and bile duct. Exploratory surgery is occasionally necessary to properly evaluate the cat for biliary obstruction.

What causes a bile duct obstruction?

The most common causes of bile duct obstruction in cats include pancreatitis, abdominal trauma, abdominal or liver cancer, gall bladder stones (gallstones), liver flukes, and severely thickened bile.

What do we do to treat icterus?

Icterus is not a disease; it is a clinical sign indicating that an underlying disease is present. When the underlying disease is diagnosed and treated successfully, icterus will resolve.

Will my cat recover?

The prognosis is dependent upon the underlying cause. Some diseases causing icterus are fatal, but others have a good prognosis for full recovery.

This client information sheet is based on material written by: Ernest Ward, DVM

The full article can be found at Icterus