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.

Bloody Urine. What to do when it's your cat's?

Cameron

The cosmos is sending me a flurry of bloody urine kids recently. As Sherlock Holmes would say, "There has to be a reason?" I guess without being able to put my finger on it I am left to deduce that is just the universe begging me to put another blog out for others to benefit from. (After 5 pets I got the message and got my butt to the desk to type this).

There are two ways these cases present at the clinic.

1. Due to the lack of an opposable thumb your cat is unable to grab a marker and write on the walls "Need a little assistance here!" and so they are left with the next best way to inform you of their plight by peeing on your clothes, your bed, the carpet, or whatever place that isn't the one you provided. After the anger passes you notice that there is a pink tinge to the urine and you think, "Huh? maybe Fluffy is trying to tell me something?"
2. Your cat seems to have developed a special affinity for the litter box and is repeatedly posturing to urinate/defecate, or you hear screams, moans, whimpers from the box as they are straining to take care of business.

To cement my point;

Your cat is only NOT GOING IN THE BOX, BECAUSE THEY NEED YOUR HELP.

They are not mad at you, they do not harbor spite, regret, ill-will, or any tiny yearning for you to look at them with disapproval, disappointment, disgust, or the most popular reason cats are sent to shelter/ purgatory/death.

Every cat with abnormal or inappropriate urination, (or even acting oddly in any way shape or form), warrants a trip to the vet.

Every vet has seen a cat die from a urinary blockage. A blocked cat is, in almost all cases, a treatable, reversible condition that if treated early enough can be completely cured.

Which leads us to discussing;

What are the urinary health clues to look for;

1. Any cat appearing to have difficulty passing urine,
2. Licking at the genitals,
3. Frequently visiting the litter box,
4. Producing small amounts of urine,
5. Any change in color to the urine, (Even absence of color denotes a possible medical problem),
6. Foul smelling urine,
7. Not using the litter box, (going outside of the box),
8. Painful belly,
9. Distended belly,
10. Reluctant to move,
11. Lethargic,
12. History of urinary tract infections, urinary blockage, crystals in the urine, etc.

Cameron snuggles with his mom.

My opening line to any and every urinary tract patient, suspected or otherwise, is the same. It is a simple and time proven dialogue.

Start with a physical exam! Because if your cat is blocked you won't be able to get a urine sample, (as you are waiting your cat might be dying). If you see your pet straining, or producing small amounts of urine bring in a urine sample if or when possible.

Cameron arrived with his mom and a small pill bottle sample of red urine. Cameron had a history of urinary problems. His writing on the wall is peeing in the dirty laundry bin. Of great benefit to both all of the laundry was done and the urine was visibly bloody. Mom poured a sample into a bottle and headed to us for a visit.

It is worth mentioning that there are a few important things to discuss about urine samples;

1. The urine sample must be fresh. Get it to the vet as soon as possible. If you can't deliver it immediately place it in the refrigerator for storage. After 24 hours it should be thrown out.
2. If, and when possible, obtain and use the first morning urine sample. These are the most accurate when we are analyzing concentrating ability, (i.e. how well your kidneys are working).
3. Catch the sample midstream in a clean dry vessel. Last week a client delivered a sample that they had "scraped off the ground." We cannot separate dirt, mud, asphalt, cat litter (they do make sterile plastic litter for use in trying to get a urine sample from cats), or the dirt, bacteria and normal floor flora of your home. Don't waste your money analyzing a contaminated sample.
4. Urine samples are best analyzed in the clinic as soon as possible. Crystals and sediment is influenced by time delay, shipping and handling. 
5. Cystocentesis is the preferred method of collection in many cases. I know it sounds scary but veterinarians routinely use a needle and syringe to collect a urine sample from the bladder. 
6. An ultrasound can be invaluable at looking at the internal surface and contents of the bladder. It is also very helpful in obtaining a cystocentesis in a small bladder.
7. There are those urine samples that are so bloody they are difficult to assess for bacteria. If this is the case do a follow up urine sample as the color of the urine returns to clear or yellow.

Here's the thumb nail version of my bloody urine speech. Hematuria (blood in the urine) is a sign of a problem. The presence of blood DOES NOT diagnose infection. To diagnose a urinary tract infection you must have BOTH BACTERIA AND WHITE BLOOD CELLS in the urine. Sometimes we do see blood concurrently with infection, but often we do not. 

Hematuria

In veterinary medicine we do a very poor job of differentiating and diagnosing INFECTION VS INFLAMMATION. We skip a lot of important steps (often to save money), but we do so at the expense of our patients.

Inflammation will often cause blood to appear in the urine. 

There are a few things that influence urinary tract problems. They include; 

• Genetics. We can't change your genetics, so, we move on to..
• Exercise. There is a correlation to obesity and overall general health. Keep your pet at a healthy weight, trying to treat other diseases without addressing this is almost always futile, and ultimately costs your pet their quality of longevity.
• Diet. This is imperative to be talking about. Listen to your vet and keep your mind open to different foods that just might cure your cats urinary problem. Heck, in almost all urinary disease cases I believe the diet CAUSED the urinary issues. I suggest a high quality wet food with added water. I see most of the UTI cases eating cheap, poor quality dry cat food.
• Disease. Recurrent UTI's warrant further diagnostics. Look for things like diabetes, allergies, bladder stones, etc.

If you or I saw blood in our urine we would go to our doctor, provide a fresh urine sample that would be immediately checked with a urine dipstick. From the doctors office the sample would go to a lab where it would be grown in a petri dish to diagnose the type(s) of bacteria present AND the best antibiotics to treat that specific bacterial infection. This is called a culture and sensitivity. We often skip this test due to cost (about $100) and just provide antibiotic for two weeks.  

Without a C &S we guess what bug your pet has AND we guess which antibiotic is best to use AND we guess that we gave you enough to kill every bug. If the infection returns we don't know if we guessed any of these wrong. Guess less by doing a C & S.

A few  keys take home points:

1. A straining cat can be a blocked cat and THIS CAN BE FATAL QUICKLY. Get to the vet immediately.
2. Once you have one infection you are predisposed to others. Watch the size of the urine clumps in the litter box and encourage water intake. I love water fountains.
3. Talk about diet and change the diet if needed. You get what you pay for and you are what you eat. I don't quite know why but vets don't discuss enough about why these happen, how to best diagnose them, treat them, or avoid them. It is my goal to not have your pet suffer twice with the same affliction. This is only attainable by discussing your pet with your vet.
4. A cat not using the litter box is a cat begging for help. Not a reason to surrender, euthanize and NEVER EVER PUNISH A CAT. It is ineffective in all cases and will back fire on you every time.

Our last batch of summer 2014 babies up for adoption.

If you have a pet question or concern you can ask them for free at Pawbly.com. Pawbly is dedicated creating a place where people exchange pet care information to help pets lives across the globe.

If you want to talk to me about a pet care related item you can find me in person at the Jarrettsville Veterinary Center, in Jarrettsville Maryland.

You can also find me on Twitter @FreePetAdvice.

Feline Marking. How to Help Identify It and Address It.

Today's blog is about addressing aspects of feline marking or spraying. In the previous blog I mentioned that the subject of urination and cats is one of the most tenuous and emotionally charged subjects veterinarians face. Urination problems are the most common behavioral issues in cats. I have more sad endings to this one single problem than every other behavioral issue combined.

A few weeks ago I met a client for her cat’s exam. Her very gentle, affectionate declawed cat was loving all of the attention he was getting with me during his exam. As I examined him she started talking about how loving he was to the family. I inquired why he was so dirty? She replied that he was an outside cat because he was peeing in the house. He had been peeing in the house for many months, and she said that she had tried everything (sadly, she never came to see any of us vets), and she told me that it was he either go outside or she was going to put him to sleep. I have heard this many times from many people. Every time I apologize to that pet, knowing that there is some reason, and some plea that is being ignored. I asked her if I could microchip him now that he was an outside cat. She replied, “No, I don’t want him back if he is ever found.”

"Inappropriate elimination" is defined as lack of consistent use of the litter box, versus "marking" which is associated with a behavioral component where the cat claims property, or challenges others for territory. It can also be a sign of stress, anxiety, or fear.

A behavioral assessment of "marking" should only be done after a medical etiology has been ruled out. A veterinary behaviorist can assist in diagnosing and treating marking, and should always be utilized when treating this problem.

This article was compiled from a lecture by Benjamin L. Hart, DVM, PhD, DACVB, UC Davis. Given at CVC East, Baltimore, MD. 2009, and Hart, Hart and Bain, Canine and Feline Behavior Therapy, 2nd Ed, 2006, Blackwell Press.

It is important for the pet guardian to understand that cats are attracted to previously soiled areas. This is important because cats with their very astute sense of smell use a community waste area. They are attracted to an area that smells as if it contained fecal matter. This scent is undetectable by us. However, just the opposite is true also. If the area you are requesting them to use as a bathroom is too concentrated for their liking they will repel it. Remember the intention is to make the toilet area for your cat attractive to them, although it might not be as attractive to us.

It is very important to clearly distinguish between “inappropriate urination” and “marking.”

Inappropriate urination/defecation is characterized by;

·        Cats posture to urinate. They squat, lower the back end and empty their bladder. The litter box is used sometimes, infrequently, or not at all.

·        Cats will soil areas such as carpet, clothing, planters, or other items on a horizontal surface.

·        Cats with early signs of litter box aversion may straddle the box, shake their paws, or not covering their waste.

·        Often the inappropriate behavior starts as urination but may progress to defecation.

Cats that “mark” are most often characterized by;

·        Standing to place small amounts of urine most often on a vertical surface.

·        They continue to use the litter box to urinate and defecate.

·        The marking is usually done because of some difficult to identify inciting cause. It may be stress of other cats or pets in the house, or an outside cat.

Basic household guidelines are to keep a very clean litter box. It should be checked daily and all waste should be removed. Provide enough litter boxes so that the cats have a choice and do not have to challenge each other for a place.

We as parents make the common mistake of picking a litter that pleases us, based on its ability to clump, or its scent, or even its low price, but there are many, many, options out there. Try an at-home litter and litter box preference test by offering many sizes and shapes of boxes. Try covered, uncovered, tall, shallow, large and small. Also try many types of litter. Try sand, potting soil, clumping, non-clumping, crystals, wheat, pine, paper, etc. Let your pet have a vote and provide them with the options they feel most comfortable with.

Clean the litter boxes daily by scooping or removing the waste. Weekly the boxes should be dumped and the litter changed. The litter boxes should be cleaned with a mild detergent. Avoid all harsh smelling cleaners like ammonia, bleach, pine, or citrus. Cats have very sensitive noses and they will not want to be in a box that is too strong smelling.

If your cat has soiled in the house the area must be cleaned so that no trace of previous soiling can be detected. The product the author recommended is KOE (kennel odor eliminator) available at Amazon. Areas that have been soiled should be cleaned and removed from access. A common trick to keep the cat off of a previously soiled area is to purchase carpet covering and place it upside down. Cats will not try to walk on the plastic and the small plastic tacks that grip the carpet are uncomfortable to step on.

When all else fails try to confine the cat to a small space. The small space acts as a sort of re-training tool. It can re-enforce litter box etiquette and for a cat that has stress as a factor in the aversion the confinement might help ease their worries. A small space might be a large dog crate, a bathroom, or a small private area. Once the cat is using the litter box regularly again you can gradually allow the cat to have access to the rest of the house. Confinement for some cats might actually be stressful, and more stress might compound the aversion. So confinement should only be used as a last resort.