Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, November 11, 2007

Shooting Up the Cat

I had a very interesting day yesterday. The Mighty Hunter, who had been walking a little funny the day before, refused to put weight on his right front paw.

I tried my best to figure out what was wrong: I palpated the whole limb very carefully but didn't elicit any reaction from him. He wasn't particularly in the mood to be handled, though, so I wasn't sure I hadn't missed something. By the time I had showered and dressed, Darling Spouse was really worried about him. Our regular vet didn't have any appointments available so we decided to try a local emergency vet place we'd heard about.

TMH went into the carrier easily, something else that really scared the shit out of us. I drove; Darling Spouse held the carrier, crooning to TMH as we tried to find the place. The cat was crying; it's the only word for the sounds he was making. Then he started panting. Very uncharacteristic for this guy. Needless to say, we were getting more and more scared.

The logical, clinical part of me wasn't really worried. The overwhelming likelihood was that it was something musculoskeletal, and that we'd be sent home with anti-inflammatories instead of having to leave the dude there for surgery. I doubted trauma, even though he insists on going outdoors, because I would have expected an injury to start with symptoms at their most severe instead of the progression -- albeit fairly rapid -- that we observed. But the part of me that wasn't a vet thought, "What if it's something serious, like in his lungs?" I didn't know if an apical lung lesion could produce referred pain to a front limb or something like that.

We found the place after only a few wrong turns. Let me just say this: I'm in the wrong business. The facility was absolutely gorgeous; huge waiting room; coffee and cookies -- for the humans; a basket of doggie treats on the counter. The receptionist was awesome: friendly and attentive. I filled out the shortest form I've ever seen in a medical office. A nurse came out to triage TMH; making sure he didn't have something immediately limb-threatening like a clot, we were told later, but then we had to wait while another woman's critically ill dog was cared for.

Eventually we were taken back where TMH had his vitals taken. I have to say one thing for this cat: at least he's cooperative with medical care. He wasn't crying or panting anymore. In retrospect, I'd have to say he was taking his emotional cues from us, and we were feeling better about him now that we were doing something for him. The nurse set him down on the floor and sure enough, he began walking around on three legs, confirming that he was lame. (At first we were worried he'd walk perfectly normally and were reassured that that actually happens all the time. Not this time though. Definitely something wrong.) We left him on the floor while we waited for the doctor. After cruising the room he came back over to where I was sitting on a small bench next to the exam table. He carefully jumped up onto my lap and then back up onto the table; definitely guarding his right front limb, but we were encouraged.

The vet was great; young; very cool. Seemed to appreciate TMH's dudeliness. Did a complete exam. (Totally cracked me up later to read the documentation: "Neuro: cranial nn intact; proprioception intact; mentation good." WTF? He never asked TMH what his name was or if he knew the date or where he was.)

In order to do a very thorough exam of the right front limb we held the cat for him: on his back, cradled in my arms instead of right against the cold metal table; rubbing his belly. Once again, TMH cooperated beautifully. (Anything for a belly rub.) The vet was pretty sure the dark marks on the right paw pad were specks of dirt and not dried blood, but he said he couldn't be sure there wasn't something in there. He thought the metatarsal pad was a tiny bit swollen and a bit warmer than the other one. Darling Spouse and I looked at each other, suddenly remembering the broken glass in the street next to the driveway left by the garbage men. Had TMH stepped on some and gotten a piece stuck? I would have expected it to hurt a great deal more than TMH was letting on if that was the case. Still, x-rays were definitely indicated.

Off we went to the waiting room while TMH was radiated, but then we were invited back to view the films on a monitor in a gorgeous wood-paneled office area. The glimpses we got on the walk back showed that the rest of the facility was just as impressive as the waiting and exam areas. There on the monitor was an enlarged x-ray of a cat's paw. (Now, of course, I regret not taking him up on his offer to burn me a CD of the images. I wasn't thinking of blogging at the time.) "Right there," he pointed. Sure enough, the base of the fifth metacarpal had a small but definite non-displaced chip fracture.

How the hell had he done it? No idea. What to do? Let it heal. No cast or anything. Just three days of an anti-inflammatory. (It turns out cats' livers don't tolerate NSAIDs very well, hence the very short course.) Which one? Meloxicam; Mobic, for humans. Metacam for animals. Same stuff, of course.

TMH had already received a dose SQ (subcutaneously.) They were going to send us home with two more oral doses for him for the next two days. I looked at TMH. He was actually much better about letting vets handle him than us. The idea of catching him, immobilizing him (I couldn't squirt something into his mouth while rubbing his belly) and forcing something into his mouth that he didn't want filled me with something between trepidation and terror.

"Can I give it to him sub-Q?" I asked. I've had cats all my life and have seen all of them get shots. It really did look ridiculously easy.

I said the vet was cool. "No problem. They have so much skin, it's ridiculously easy." He showed me how to lift the skin of the back and inject into the V formed by pulling it up. "He won't even know you're doing it."

Back home, TMH looked almost stoned. I wasn't sure if it was the drug or the relief of being home. He slept very well all day.

This morning it was shot time. I took one of the two syringes they'd given me ($14 apiece; I told you I'm in the wrong business) each containing 0.1 cc of Metacam, then found TMH upstairs on our bed. I lifted the skin with my left hand and went to pull the cap off the needle with my teeth. The needle came off the syringe; it wasn't a Luer lock. I let the cat go, shoved the needle back onto the syringe and pulled the cap off.

Let me interject here that I give shots all the time; immunizations and allergy shots; obviously this is flu shot season. I usually use needles that are 5/8" long, going in at a 45 degree angle for SQ and a 90 degree angle for IM. (Yes yes yes; I've been told a million times I need to use longer ones; but I've hit bone going into a small toddler's arm with the 5/8", and I've also read that there's no difference in efficacy if it doesn't get into the muscle, so that's what I do.) This was a tiny little 1 cc syringe; I was expecting a similar sized needle.

So imagine my surprise at having uncapped a one inch, twenty gauge weapon I was supposed to stick into my cat! Ok; they have a lot of skin; the skin on the back -- where I was injecting -- is probably the thickest skin on their body (like humans; only place thicker is the soles of the feet.) Here goes nothing.

I lift up the skin on the back and poke the needle into the V, inject as quickly as I can (one whole whopping tenth of a cc) and get it the hell out.

The cat doesn't even notice. In fact, he rolls back over and waits for me to rub his belly. Which I did. Interestingly, within five minutes he's fast asleep. I go in to shower and when I come out of the bathroom, he's still passed out, spread-eagled on his back.

That meloxicam must be some great shit.


At Mon Nov 12, 09:13:00 AM, Blogger Lynn Price said...

Great story, Dino. Hope Mr. Kitty is feeling better. What am I saying? Of course he's feeling better. He's a stoner.

At Mon Nov 12, 10:38:00 AM, Anonymous Anonymous said...

Glad to hear it was nothing serious.

His behavior in the car on the way to the clinic sounds like a stress reaction. Some cats can become very vocal and even hyperventilate.

What did this all cost? Probably less than a comparable visit for a human, I'll bet.

At Mon Nov 12, 10:52:00 AM, Blogger Dreaming again said...

ok ...does this anti inflammatory make humans go spread eagle zzzzzzzzzzzzzzzzzzzzzzzzzzzz

I want some ....

I'm flaring ... I want some ...seriously ... I want some!

At Mon Nov 12, 11:38:00 AM, Anonymous Anonymous said...

Don't you just dream about opening a cash-only medical practice like that? I do. People could get wonderful medical care if they simply stopped looking at it as an entitlement. When people expect everything to be paid for by insurance and allow the insurance companies to behave the way WalMart treats its suppliers, they should not expect cookies in the waiting room.

At Mon Nov 12, 01:21:00 PM, Blogger The Ethical Miss said...

After all the broohaha on Slate about how to say no to a vet, your posting made me tear up with joy. Thank you for being a patient owner and an open-minded medical professional.

At Mon Nov 12, 01:57:00 PM, Blogger Sara said...

Dying. To. Hear. How. They. Did. Neuro. Exam.

At Mon Nov 12, 04:16:00 PM, Blogger Dr. Val said...

TMH got a march fracture... and on Veterans Day no less...

At Mon Nov 12, 04:55:00 PM, Blogger BranvanBen said...

Sadly enough, people seem to care about animals more than other humans. There are significantly more shelters for stray animals than there are homeless shelters for humans.

It makes sense though; pets are a luxury, humans are everywhere. It's simple supply and demand.

At Mon Nov 12, 06:09:00 PM, Blogger coriakindvm said...

Hey, from a DVM-thanks! Always glad to hear one of our human counterparts attest to our "real medicine" skills. (I will mention that not all emergency clinics are quite that plush, but we do try to make them look nice.)

I can post a brief rundown of how we do a neuro exam if anyone's interested. ;-)

At Mon Nov 12, 07:23:00 PM, Blogger #1 Dinosaur said...

Lynda: by all means! Inquiring (human medical) minds are dying to know how to do a neuro exam on a cat. Especially the mental status exam. I have another cat whose facial expression never changes; I think he's autistic. (His original owner, my step-daughter, disagrees; she says he's wonderful and loving; I say fine, he has Aspergers.)

All but 1: Thanks for the kind words. Neat blog, btw. I also checked out that Slate article you mentioned: those cases are different, and frankly I agree that it sounds like some vets go overboard. Perhaps I've been fortunate not to have run into any like that; my vets have generally been of old/curmudgeonly vintage. In any event, I'd like to think I'd be able to exercise common sense when confronted with situations like that. They may be my babies, but they're only animals.

Anon 11:38: Re: cash only practice: it's my ultimate goal. Maybe within the next five years; within the next ten for sure.

At Mon Nov 12, 08:44:00 PM, Blogger The Ethical Miss said...

You want neuro exam? I'll give you neuro exam!

In vet med, mentation refers to the patient's responsiveness - it can be BAR (bright alert responsive), QAR (quiet alert responsive), QDR (quiet depressed responsive, obtunded (quiet, depressed, only responsive to painful stimulus), stuperous (agitated but only responsive to pain), comatose (obvious) or dead. QAR and BAR are "normal".

We also do a full cranial nerve exam - can they smell food, + menace response, pupilary light response, cotton ball test (toss a cotton ball and see if they follow it), is either eye deviated laterally or rotated laterally (easy to tell in a cat), + corneal reflex, sensitive to internasal stimulus, + palpebral reflex, any ventromedial deviation of the eye, do they salivate, can they hear a loud sound from behind, + gag reflex, any atrophy of the trapezius or brachiocephalicu muscles, and is there tongue atrophy.

Then we do spinal reflexes - biceps tendon, triceps tendon, crossed extensor reflex, extensor carpi radialis, withdrawl reflex, patellar tendon, gastrocnemius, cranial tibial, and sciatic reflexes. Is there anal tone, + tail reflex? Is panniculus present?

Finally, we get to postural reactions - conscious proprioception, hopping, hemi-walking, wheelbarrowing, extensor thrust, and limb placement (unobstructed and "blind").

It takes about 5-10 minutes, but we get a lot of info, even if we can't tell if the patient knows who they are, where they are, and when they are. And even a student like me can pretty accurately give a neuroanotomic diagnosis for lesion location. ;-)

(Lynda, tell me if I've missed anything ... I'm still floating high from finishing boards today)

At Mon Nov 12, 11:29:00 PM, Anonymous Anonymous said...

Readers - although sometimes vets use the same drugs as MDs, please don't give your cat a dose of your Mobic if he/she's having a bad day. The dosing is VERY different, and it is too easy to kill your cat.

And I'm sure neuro exams in infants are very similar to neuro exams in vet med.

Oh - all my cats know their names :-)

At Mon Nov 12, 11:47:00 PM, Anonymous Anonymous said...

Awesome post. The whole time I was reading it, I was wonderinghow much it would cost. What were the damages? Took one of my four to the emergency vets (nice, smart people but in a very non-fancy strip mall) and after a UA, kitty Augmentin, abdominal film, and a short stay for enemas, I was $500 poorer. They charged me $100 to start with and then gave me "estimates" for how much two more portions of his care would cost and charged my credit card ahead of time each time. Don't get me wrong, I was happy to pay--they got my poor kitty better very quickly! As a human doc, I just find the vet business very interesting.

I also had to take another of my kitties to a vet ophthalmologist (I personally have never seen an ophthalmologist). That place was much fancier, and, after the emergency vet experience, I was pleasantly surprised it only cost $100.

I really think the vets are much better than us human docs in a lot of ways--all those different species to know about, for one. I realized just how good they are with procedures when I got a new tiny kitten (same one who later needed the ophtho) and my vet grabbed her teeny little very hairy paw and drew a venous blood sample out of it lickety-split. I was amazed. I probably could have missed drawing blood out of a vein as big as HER WHOLE PAW because it's been so long since I've had to do it.

You vets are very cool.

At Tue Nov 13, 02:39:00 PM, Anonymous Anonymous said...

Re: Cash Practice-"Maybe in 5 years, 10 for sure". At the rate I am seeing expenses climb relative to payments for services, a plan to go all cash needs to be more like 1 year!

Why do people pay their vets, massage therapists, plastic surgeon's (who don't have time to consent their patients), dermatologists and psychotherapists cash? Because they have to!

At Tue Nov 13, 05:10:00 PM, Blogger tk said...

My doc gave my mobic for a neck injury--I thought it was an anti-inflammatory . . . It doesn't have that effect on me!

At Tue Nov 13, 05:12:00 PM, Blogger tk said...

tom--one problem in healthcare is the mindset that people have regarding paying for healthcare. We need a paradigm shift. tk

At Tue Nov 13, 06:33:00 PM, Blogger Dr. Val said...

All but 1 - fascinating neuro exam. I'm going to try the wheelbarrowing test with my kitty tonight. I'll skip the anal tone, though... ;)

At Tue Nov 13, 09:22:00 PM, Anonymous Anonymous said...

Hey, I didn't know that TMH was on Meloxicam. His cousin-kitty is also on it, 0.05 cc every 2-3 days indefinitely, for discomfort associated w/ benign biliary cystodenoma (diagnosed nine months ago). Also, I'm VERY experienced shooting up cats SQ -- you'll remember that another cousin-kitty needed sub-Q fluids during his last year or so of life, due to kidney issues. (Start the dishwasher, take out the trash, hydrate the cat became my standard get-ready-to-go-to-bed routine each night during that period.) That cat (granted, an unusually mellow one anyway) never batted an eyelash, just purred away happily that he was the center of attention. (Incidentally, if anyone else is in the same position, get your fluids & supplies from, not from your vet -- it's about 1/3 the cost if you get it online.)

At Tue Nov 13, 09:38:00 PM, Blogger #1 Dinosaur said...

KMD: You're just showing off the fact that you can type/pronounce "benign biliary cystadenoma."

BTW: Cats don't have eyelashes. Still, that dude was indeed very mellow.

At Fri Nov 16, 01:27:00 PM, Anonymous Anonymous said...

"Why do people pay their vets,..."
Well, one reason is that vet treatments are a lot cheaper. For example, when my cat was a kitten she needed a surgery to remove a nasopharengeal polyp that was growing from her middle year. Since the surgery involved cutting into the ear bone (and potentially damaging nerves), the vet choose to invite a specialist from NYC to do it. The complete bill for the surgery, anesthesia, a couple nights stay at the vet's -$2100. And this is in expensive practice in Westchester cty, NY. Can you imagine a complicated surgery on a human done by a specialist who had to drive/take a train for an hour to get there and a two-night hospital stay for $2100? Surely, routine visits to a doctor are cheaper, but the cost of drugs and repeated visits can quickly add up.

Granted some procedures - X-ray, teeth cleaning are more expensive for cats; but then they involve anesthesia so you cannot really compare.

There is also pet insurance that people can buy that covers routine visits too. Had the cost of vet care been as expensive as human care, there'd be more people buying pet insurance.

Plastic surgery is in a different category, but then people who get it are usually better off financially than the majority.


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