What would you do?

Re: What would you do?

Anthony Todd — Fri, 04 May 2012 23:25:47 GMT

[quote user="David Mills"]can't display the signs. We see a lot of these with their back ends covered in crystals weeks-months afterwards, because, at the heart of this disease there really appears to be no consistently effective treatment apart from rehoming to a less stressful environment[/quote]

I can't believe that the total complete cure for the vast majority of FLUDT cats has been overlooked.

[sorry, back on my hobby-horse yet again]

[quote user="David Mills"]back ends covered in crystals[/quote]

gives you a clue, surely. These used to be almost always struvite, totally cured on the right diet, and I won't go into that again, but there are plenty available. Oxalate is more difficult and you can go from struvite to oxalate if you over react to one or the other.

The problem ones are where there are no crystals found and "stress", which I think is total baloney, is flavour of the month; as it is the palatable diagnosis ignoring the ancillary advice of strict diet change and increased water intake which actually cures the condition.

Re: What would you do?

Alex Gough — Fri, 04 May 2012 19:53:35 GMT

Sorry wrong thread! Damn multiple windows!

Re: What would you do?

Alex Gough — Fri, 04 May 2012 19:52:30 GMT

The chocolate calculator on VIN has some interesting jokey cartoon style animations of dogs vomiting, tremoring, seizuring and dying. One not to show to worried owners!

Alex

Re: What would you do?

Evelyn Barbour-Hill — Fri, 04 May 2012 18:44:55 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Cat Henstridge"]He was great! He also showed how smaller syringes are more powerful than larger ones by giving volunteers different sized ones filled with water, fixing them to either end of a line of drip tubing and getting them to push.[/quote]

It comes to the same thing in practice I know, but it's the internal diameter of the syringe that makes the difference. Assuming the operator applies the same force with thumb, the water pressure will be greater the narrower the syringe. Very basic hydraulics.

[/quote]

Sorry! Sorry! That's wrong. My brother would be very scathing.

The pressure is exactly the same thoroughout the system. It's the differences in bores between big syringe, small syringe and tubing that make the system burst at the big syringe's joint to the tubing.

Yours

I.B. Notsoclever-Afterall.

Re: What would you do?

Clare Tapsfield-Wright — Fri, 04 May 2012 18:08:21 GMT

My personal view and in response to the original post is that i hope I would also have advised her to monitor the cat and call back if the cat got worse. If she was actually hysterical then I might have suspected there was more cause for concern than the symptoms spoken about suggested and would probably phone her back after an hour or so for my own peace of mind. In the circumstances if she was insisting the cat needed to be seen we have in the past sent a taxi and added the cost to the bill . Yes we have been left with a bad debt on similar occasions but at least I can sleep at night .No practice charity or otherwise should point blank refuse a to a suffering animal on the basis of cost alone and make no provision whatsoever to help a suffering animal . In this case either the vet did not think the cat was suffering enough to warrant an emergency call or if he did he should have sent a taxi, a nurse , called an RSPCA inspector or attended himself. The fact that the cat died of a blocked bladder is distressing to know in hindsight as we know that it will have suffered an unecessarily prolonged horrible death .

Re: What would you do?

Alet Engelbrecht — Fri, 04 May 2012 14:30:09 GMT

[quote user="alex gough"] I too don't see the point of xraying prior to unblocking. Afterwards, definitely. I think how quickly things can be done affects what you do. If you can get bloods for a potassium level and an iv line in 60 seconds, (which I think is a reasonable time scale for that sort of thing), then you can make a decision whether to give some iv insulin and/or glucose which can be working while you get on with unblocking. As everyone knows, some cats unblock very easily, and some don't and I don't know how you tell in advance how long the one in front of you is going to take. [/quote]

Ditto. Except, I think ultrasound is more useful than radiographs in FLUTD.

I have no experience with perineal urethrostomies, other than assisting with the correction of a botched one as a student. I have also not yet needed to refer a blocked bladder, but I have unfortunately put one or two cats to sleep on the owner's request (mainly monetary reasons). We were taught that if you correctly manage them from the beginning, cases nowadays will rarely progress to surgery. I generally have an extended consultation with the owners about management - water intake, feeding, stress, intercat interaction, litter tray management, etc. During my career, I have also only come across a handful of cats that has had PU's in the past. I often see recurrent cystitis in both males and females and I believe many clients can be educated to recognise the early signs in males suffering from FLUTD prior to blockage.

Sorry, totally on a tangent from the original question.

Re: What would you do?

Alex Gough — Fri, 04 May 2012 13:49:02 GMT

[quote user="Anthony Todd"]This wasn't a criticism of your specific case or yourself but rather of the common protocol now of not unblocking, or even attempting to unblock, without a GA, bloods and an Xray prior to relieving the cat.[/quote]

Is this a common protocol? I think you might have set a straw man argument there. I too don't see the point of xraying prior to unblocking. Afterwards, definitely. I think how quickly things can be done affects what you do. If you can get bloods for a potassium level and an iv line in 60 seconds, (which I think is a reasonable time scale for that sort of thing), then you can make a decision whether to give some iv insulin and/or glucose which can be working while you get on with unblocking. As everyone knows, some cats unblock very easily, and some don't and I don't know how you tell in advance how long the one in front of you is going to take.

Alex

Re: What would you do?

Kate Richardson — Fri, 04 May 2012 12:22:04 GMT

[quote user="Julie Innes"]

Bit surprised to hear people talking about cystocentesis as a "new" thing! I was taught it (and it was done on my own cat) at vet school- and I am nearly 17 years qualified!! I thought it was a run-of-the mill procedure, and a godsend when faced with a difficult to unblock cat- just gives you a little breathing space! I don't do it very often, but I've never thought of it as a big deal, to be honest!

[/quote]

Hurrah!! And after all aren't we as vets supposed to learn new things and keep up to date with new procedures anyway?? If you aren't doing cysto's in cats, you probably aren't checking anywhere near enough urine samples on cats, which means you are missing out on a lot of important info...and seriously, they are not difficult and as Alex and others have said, minimal risks, even in a compromised bladder-putting a very fine needle into once to relieve the pressure will reduce the compromise. I think they are probably easier than taking blood samples (which also carries risks) and in general I find it is better tolerated than taking a blood sample depending on how you position the cat.

Re: What would you do?

Alet Engelbrecht — Fri, 04 May 2012 12:04:36 GMT

[quote user="Anthony Todd"]Never heard of the idea of catheterising caesars though and nor has a mate of mine, still practising., let alone doing a cysto.... where did the idea come from and why?[/quote]

Sorry, I did not make myself clear - Lorna is correct, I meant 2 emergencies concurrently.

Re: What would you do?

Lorna McHardy — Fri, 04 May 2012 09:49:18 GMT

[quote user="Anthony Todd"]

Never heard of the idea of catheterising caesars though and nor has a mate of mine, still practising., let alone doing a cysto.... where did the idea come from and why?

[/quote]

LOL, I wondered that... and then decided Alet probably meant two emergencies at once and needing to buy time for the blocked cat. Unless I've missed a new idea

Re: What would you do?

Anthony Todd — Fri, 04 May 2012 08:53:34 GMT

[quote user="Julie Innes"]cystocentesis as a "new" thing![/quote]

Anyone got some historical knowledge? Not mentioned in the 70s AFAIK, when blocked cats really were common.

Re: What would you do?

Anthony Todd — Fri, 04 May 2012 08:50:36 GMT

[quote user="Alet Engelbrecht"]Don't worry, not taking it personally![/quote]

No, nor me. It's funny how unblocking bladders comes up again and again and, not that I'm involved now, but I reckon there are improvements in protocols and cystos sound as if they're one helpful idea.

Never heard of the idea of catheterising caesars though and nor has a mate of mine, still practising., let alone doing a cysto.... where did the idea come from and why?

Re: What would you do?

Julie Innes — Fri, 04 May 2012 08:49:54 GMT

Re: What would you do?

Alet Engelbrecht — Fri, 04 May 2012 08:32:36 GMT

Don't worry, not taking it personally!

I fully agree full bloods and x-rays aren't necessary - why do we have fingers to feel and ears to hear. My colleague unblocked a cat with local last week. Also an interesting comment from Danielle Gunn-Moore at a CPD about 2y ago that doing a rectal massage in some of the urethral spasm cases will cause relieve (tried, but not so easy when the cat's awake and already not very happy).

At the end of the day, our clinical examination should tell us most of what we need to know and the diagnostic aids are merely to confirm our suspicions and not to make the diagnosis. I also agree that the younger generation of vets (of which I consider myself one too), do rely on 'modern technology' a lot, when we aren't doing the animals or the owners any favours. [I remember my mum telling me how she already had the spleen out in a dog with a splenic haemangiosarcoma, when her young assistant came to get the dog after finally setting up the ultrasound machine.]

Re: What would you do?

Anthony Todd — Fri, 04 May 2012 07:30:36 GMT

[quote user="Alet Engelbrecht"]Would you still refuse to do a cysto[/quote]

As I've said above I think a cysto is a new and good idea if you can't unblock quickly but I still wonder whether pre-unblock bloods changes anything as is admitted?

This wasn't a criticism of your specific case or yourself but rather of the common protocol now of not unblocking, or even attempting to unblock, without a GA, bloods and an Xray prior to relieving the cat.

As an aside, and by the way, I've never found whistle tip catheters any help in flushing urethrae[?] because the fluid is directed sideways rather than forward, around the crystals or plug.

Open- ended cleared urethra[s] much easier.

Re: What would you do?

Alet Engelbrecht — Fri, 04 May 2012 06:47:15 GMT

[quote user="Anthony Todd"]

1. Why not inblock the cat stat?

2. Surely there are greater risks if you GA a cat with a cocktail of depressant drugs if the [K+] is raised, let alone 9. The published death rates would tend to suggest there is!

3. How does a raised/normal/low [K+] change your immediate treatment. And you can't change the [K+] quickly either.

4. Why can't you begin your specific treatment based on your bloods after what is often a 10 minute cath. and relief, [when the all-important [K+] is already dropping and may return to normal with or without the specific treatment?

5. Many blocked cats don't need a G/A, often local alone, avoiding the high death rates with the delay and the cocktail of depressants.

[/quote]

I think the point in this case was decompressing the bladder, for which I used a cysto (see below, [quote user="Anthony Todd"]cause should be investigated and corrected if possible[/quote]). I did not employ a cysto to delay catheterisation indefinitely, merely to buy myself a few hours.

In this particular case, the cat was in shock, hypothermic (35C), collapsed and barely conscious apart from the occasional low grade growl. The HR was 80. It did not need GA - you are right. But it was not as straightforward to stick a catheter into that penis. Believe me, I did try. My 'cocktail' of drugs in this case, included buprenorphine, and a glucose spiked saline drip. I decompressed the bladder as best as I could in this emergency situation by doing a cysto.

PS: It takes 30s to get a blood sample for potassium and it was run at the same time as I 'decompressed' the bladder. The HR was 80, the K value was probably unnecessary, so yes, I delayed my specific treatment for 30 seconds.

Several hours later the cat was sitting up, much more comfortable and stable enough to give propofol, and yes, still hyperkaleamic. Even with propofol, I STILL could not pass a small jackson's cat catheter. Even the 24G jelco (without the needle) got stuck at the base of the penis. I finally, with a lot of patience (which I am not known for), managed to pass a slippery sam.

I am just suggesting that it is not all that black or white and I try to use all my skills appropriately. Would you still refuse to do a cysto if you have a bitch on the table being prepped for emergency C-section and (with your other emergency the blocked cat) you cannot pass the catheter immediately consciously?

Re: What would you do?

Anthony Todd — Fri, 04 May 2012 00:58:50 GMT

[quote user="Alet Engelbrecht"]But I would actually rather cysto and stabilise the cat with the HR of 80 (didn't need the iStat to tell me the potassium is 9, but I had to see it), than anaesthetise and catheterise immediately. Maybe I was lucky that I saw him early morning (although the poor thing obviously had to suffer all night).[/quote]

This says it all [again] and I reply [again].

1. Why not inblock the cat stat?

2. Surely there are greater risks if you GA a cat with a cocktail of depressant drugs if the [K+] is raised, let alone 9. The published death rates would tend to suggest there is!

3. How does a raised/normal/low [K+] change your immediate treatment. And you can't change the [K+] quickly either.

5. Many blocked cats don't need a G/A, often local alone, avoiding the high death rates with the delay and the cocktail of depressants.

A quick google found this:

http://www.nda.ox.ac.uk/wfsa/html/u17/u1712_01.htm#hyp3

and in it this;

If there are ECG changes or the concentration is greater than 6.5mmol/l the incidence of serious cardiac compromise is high and rapid intervention is necessary. A plasma potassium of less than 5.9mmol/l has been suggested before an elective operation. The cause should be investigated and corrected if possible.

so the sort of levels in blocked cats must make a G/A even more dangerous and seems, to me, the obvious cause of the high death rates reported by the universities and the much lower rates, if any at all, quoted by practitioners and dinosaurs.

but then there's this one case:

The operation was carried out successfully and cardiac signs and symptoms of hyperkalemia did not occur despite of potassium blood levels of 8.1 mEq·l⁻¹. General anesthesia could be safe in hyperkalemic patients as long as the treatment for hyperkalemia is initiated before and during the surgery and hyperkalemia inducing agents are avoided.

http://onlinelibrary.wiley.com/doi/10.1111/j.1460-9592.2008.02567.x/abstract

and then, finally this:

SIGNIFICANT preoperative hyperkalemia is considered a contraindication to anesthesia.1–3 Retrospective studies have detected an

association between hyperkalemia and increased mortality in hospitalized patients,4–6 and surgical patients,7–9 but reports of perioperative morbidity directly attributable to hyperkalemia are actually quite rare.4,5,8–10

[the numbers are references]

from

GENERAL ANESTHESIA 553

CAN J ANESTH 2003 / 50: 6 / pp 553–557

6. The sooner you unblock the quicker the cat recovers and the more thanks he'll give you. And it's more humane!

Re: What would you do?

Alet Engelbrecht — Thu, 03 May 2012 22:21:37 GMT

[quote user="Hannah Wynne Richards"]I've never heard of humans having needles stuck intothier bladders, so until I do, I won't understand the veterinary fad for doing so[/quote]

It is called supra-pubic aspiration in humans.

http://emedicine.medscape.com/article/82964-overview

I really find cysto's very helpful, especially in cats. When Idexx's 'Senior wellness checks' used to include basic urinalysis, we did at least 5 a day (mostly cat practice). My basic monitoring for chronic renal disease is blood pressure, urinalysis and urea/creat/phos. Correlating these - the drop in USG is seen so much earlier than the rise in the blood parameters. Not many owners can (1) get urine samples (2) if they can, it is often contaminated with litter/katkor/dirty litter tray gunk and (3) old and stale by the time it is delivered to the practice.

I am not proposing to indiscriminately cysto every cat. But I would actually rather cysto and stabilise the cat with the HR of 80 (didn't need the iStat to tell me the potassium is 9, but I had to see it), than anaesthetise and catheterise immediately. Maybe I was lucky that I saw him early morning (although the poor thing obviously had to suffer all night).

Re: What would you do?

Evelyn Barbour-Hill — Thu, 03 May 2012 22:18:42 GMT

This can be of importance in endodontics.

Yours sincerely, I. Knowitall.

[quote user="Cat Henstridge"]You can talk until you are blue in the face that owning pets are a privilege and not a righ[/quote]

Not a privilege (maybe it is in North Korea). It's a right. In a free country anybody can own anything they like as long as it's not specifically illegal. A pet is a luxury, not the same thing at all.

Re: What would you do?

David Mills — Thu, 03 May 2012 21:26:47 GMT

[quote user="Malcolm Ness"]We see these presenting OOH from other practices and common comments from the owners of previously recurrently blocking cats include, Why wasn't an operation suggested before now?, and How come your bill for an operation is less than I paid each time to have it unblocked?[/quote]

I'm still uncomfortable with PU's early on in the course of the disease, largely because it addresses the blockage only - the cat still has the cystitis, but merely can't display the signs. We see a lot of these with their back ends covered in crystals weeks-months afterwards, because, at the heart of this disease there really appears to be no consistently effective treatment apart from rehoming to a less stressful environment, which gets forgotten about often after a PU; these poor cats are in pain for an age. There is a definite trade off between the morbidity of repeated unblockings/hosp and PU but I'm not sure where that lies.

How many times do you let it recur before PU?

Re: What would you do?

David Mills — Thu, 03 May 2012 21:20:19 GMT

I'll spell it out.

[quote user="Malcolm Ness"]

If those same charities want to restrict their "offer", limit their reach or otherwise define or qualify their largesse

[/quote]

[quote user="David Mills"]

It is made abundantly clear to all clients the extent of the service offered by charity clinics - generally, as using less expensive drugs, fewer diagnostic procedures, and cheaper surgical procedures - as a compromise between offering a reasonable service to as many clients as need it and improving the welfare of animals as much as we can within our means. In some cases - no different to private practice - more advanced procedures, diagnostics and drugs will be offered if the client can pay to cover the cost of these (charities, perhaps to their discredit, do not enquire about savings etc), but generally provision of standard services is subsidised - we cut our cloth according to our means, and the alternative for the vast majority of our clients is no veterinary care at all.

[/quote]

[quote user="Malcolm Ness"]it behoves them to make that abundantly clear in all their press and TV advertising as well as their cosying-up to ageing antipodean cabaret performers and their masquerading as Veterinary Hospitals. [/quote]

[quote user="David Mills"] just in the same way as advertising material the profession wide is glossy, promotional, so are charities in their promotional material - it is a frankly perverse stance to expect them to set out exactly the level of service 'offered', just like it would be for a private practice to say 'yes we can do cruciates, we're OK at them, but no more'. And of course charities would jump at the chance of having a wildly successful TV series featuring them 'masquerading' (define hospital, Mr Ness? Have you ever visited the RSPCA ones featured and seen the work they do?) as veterinary institutions - indeed its a no-brainer for anyone with any PR nouse, as Fitzpatricks and RVC have found[/quote]

I will add: does your referral centre promo material clearly state "only for those who can afford £X for Y procedure" Of course it doesn't. Quite why you expect charities to be explicit in the level of service offered in promotional material is truly perplexing, bizarre even. The comparison with Fitz/RVC simply illustrates this point - there was nothing in those programmes whereby the level of service/cost/standard was explicitly expounded. I realise that charities are different in that it is the general public giving money - but some people simply want to give to animal charities, and they mostly want that money to go to helping animals directly.

[quote user="Malcolm Ness"]their masquerading as Veterinary Hospitals. [/quote]

[quote user="David Mills"](define hospital, Mr Ness? Have you ever visited the RSPCA ones featured and seen the work they do?) [/quote]

[quote user="Malcolm Ness"]There is a nasty mixed message being sent out to needy owners of pets and the incident that started this thread is the inevitable consequence of that message-mixing.[/quote]

[quote user="David Mills"]It is made abundantly clear to all clients the extent of the service offered by charity clinics...the message-mixing to which you refer is neither nasty nor responsible for events in the OP, because, at the coalface the message is quite clear, repeatedly...our assertion, repeatedly, Mr Ness, is that we all have sparkly new premises and offer whizz-bang surgery as standard. It ain't that way, at all.[/quote]

I'll add: there are no explicit service offers made that would have helped the original woman, or cat, in this instance, because it is fantastically uneconomical to do so. Just as it would be in PP (assuming owner didn't pay). We occasionally make exceptions, and, in this case, had this cat had a reported hx classic of blocked bladder, we would have done. But the crux of the issue is that if you do it for thins that aren't emergencies at weekends word quickly gets around - in fact in the days after the last taxi run we had more than 3 times requests for such.

Re: What would you do?

Malcolm Ness — Thu, 03 May 2012 17:44:46 GMT

[quote user="David Mills"]

You are making the classic mistake of lumping all a charity's actions together, with a good dousing of prejudice and misinformation. It is made abundantly clear to all clients the extent of the service offered by charity clinics - generally, as using less expensive drugs, fewer diagnostic procedures, and cheaper surgical procedures - as a compromise between offering a reasonable service to as many clients as need it and improving the welfare of animals as much as we can within our means. In some cases - no different to private practice - more advanced procedures, diagnostics and drugs will be offered if the client can pay to cover the cost of these (charities, perhaps to their discredit, do not enquire about savings etc), but generally provision of standard services is subsidised - we cut our cloth according to our means, and the alternative for the vast majority of our clients is no veterinary care at all. Your assertion, repeatedly, Mr Ness, is that we all have sparkly new premises and offer whizz-bang surgery as standard. It ain't that way, at all.

I am really confused as to what you expect charities to do when it comes to garnering financial support. Now, I don't wish to enter into a circular argument about the long term good of charity care. But, just in the same way as advertising material the profession wide is glossy, promotional, so are charities in their promotional material - it is a frankly perverse stance to expect them to set out exactly the level of service 'offered', just like it would be for a private practice to say 'yes we can do cruciates, we're OK at them, but no more'. And of course charities would jump at the chance of having a wildly successful TV series featuring them 'masquerading' (define hospital, Mr Ness? Have you ever visited the RSPCA ones featured and seen the work they do?) as veterinary institutions - indeed its a no-brainer for anyone with any PR nouse, as Fitzpatricks and RVC have found. To somehow conflate this with the day-to-day dealings of vets in charity hospitals is perverse, irrational, and (wilfully?) cynical.

The message-mixing to which you refer is neither nasty nor responsible for events in the OP, because, at the coalface the message is quite clear, repeatedly. That is your interpretation of events, from the outside; I can see how you arrive at such, but it is still wrong.

[/quote]

You are free to have a go at me but please, stick to what I wrote - much of the above bears little relation to the opinion I passed which was remarkably limited in its scope and made in response to your own post which started the thread. I made no mention of clinical standards, RVC, Noel Fitzpatrick, Cruciates, my "expectations" of charities, Vets in Charity Hospitals, the day to day dealings of those vets, nor did I make any assertions, repeated or otherwise. Still, it is always nice to have someone tell you what you think.

Re: What would you do?

David Mills — Thu, 03 May 2012 14:34:27 GMT

[quote user="Malcolm Ness"]

[quote user="David Mills"]We are, but this is too simplistic. As others have intimated, it would be all very well sending a taxi or somesuch round for this case, it would likely have saved the cat's life, but the question is where does it stop?[/quote]

It is not too simplistic at all. The charities (RSPCA, PDSA and Blue Cross) promote themselves as providers of veterinary care for those who can't afford private veterinary practices. If those same charities want to restrict their "offer", limit their reach or otherwise define or qualify their largesse then it behoves them to make that abundantly clear in all their press and TV advertising as well as their cosying-up to ageing antipodean cabaret performers and their masquerading as Veterinary Hospitals.

There is a nasty mixed message being sent out to needy owners of pets and the incident that started this thread is the inevitable consequence of that message-mixing.

[/quote]

Re: What would you do?

Cat Henstridge — Thu, 03 May 2012 13:31:56 GMT

[quote user="Lorna McHardy"]

[quote user="Cat Henstridge"]

I went to a great talk some years ago at BSAVA with a mad American speaker, who showed how you could pass a knitting needle though a ballon without bursting it if you were gentle. Once I saw that I was much more confident to do them.

[/quote]

LOL! Sounds like a great speaker :0))

[/quote]

He was great! He also showed how smaller syringes are more powerful than larger ones by giving volunteers different sized ones filled with water, fixing them to either end of a line of drip tubing and getting them to push. The one with the larger syringe always got a soaking!

Back to the original post. Clearly in your situation you couldn't have gone anyway and I am amazed the charities sometimes send out taxis to pick up pets, if this got out I am sure it would be open to abuse. However, it does irk me somewhat that it seems an owner cans shift responsibility of a dilemma like this onto a vet, both legally (although I know the area is a bit fuzzy) and morally, when it is their failings that have lead to the situation. Obviously, it seems this lady deserves our sympathy but that doesn't absolve her completely. A taxi, pet or otherwise, would be expected to be paid to collect the cat, so why shouldn't we to treat it?

You can talk until you are blue in the face that owning pets are a privilege and not a right but people will still have them and in many cases, like the lonely and elderly, should and the charities do a great job of providing support. However, we do need to get the message out about vet costs and how we do represent value for money. There is a groundswell of opinion we are just expensive, and you will never change the hardliners opinions, but we shouldn't just be sitting back and doing nothing to change things. I know it is hard to get the national press to print positive vet stories but if our representative bodies were in the habit of feeding them through regularly, some would eventually make it to the public domain.

Re: What would you do?

Malcolm Ness — Thu, 03 May 2012 13:16:31 GMT

[quote user="Anthony Todd"] when I graduated from Brisbane, in 1961[/quote]

1961 - that must have been very shortly after Christopher Columbus invented Australia.