903. DRAFT - Searching for answers - The cat with the FLUTD - partial report

I am writing a draft of searching for answers in the case of the cat with the FLUTD that died after 5 days of hospitalisation at Vet 2. It is quite an emotional case for the young couple and for me too as the cat had been my patient too in April 2011 and I had written a case report to bring veterinary medicine alive for the poor vet students who are studying so hard to pass their examinations. Case studies will help them learn better than thick notes from their lecturers.

Tobi was one of those cats who hates vets and was outstanding for his hissing behaviour to warn vets and assistants not to touch him. See my report at:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

Suddenly I received an email from the owners that the cat had died and the email is as follows:

E-MAIL FROM OWNER DATED FEB 9, 2012

On Thu, Feb 9, 2012 at 4:12 PM, ...@yahoo.com.sg> wrote:
Dear Dr Sing A belated Happy Lunar New Year to you. I trust this email finds you in good health and standing. Its been quite some time since our male cat Tobi was treated at your wonderful practice. Unfortunately our beloved Tobi has passed away on Saturday, 4 February 2012. Just a bit of history. Tobi was admitted to your care on 24 April 2011. His case is listed in your website under cat cases-UTI -1st FLUTD.The cat can't pee again dated 12 June 2011. Shortly after his discharge, we moved into our new home. Tobi recovered well as there were no territorial cats and stress was kept to a minimum. He was maintained strictly on Hill's C/D wet food. However, sometime from October 2011, he seemed to be licking his private area again though not as frequently as when he had UTI , he was also peeing normally with good volume. His disposition and general health was very good. This continued until February 2012 when we noticed his urine volume seemed to have lessened somewhat and his penis appeared to be inflamed. We brought him to a vet(shall not mention the company name) who gave him an injection of antibiotics and anti-inflammation and discharged. Two days later, it did not seem to get better, we brought him back to the vet again, a blood test was performed with several struvite crystals detected. The vet advised us that a similar injection could be given or a catheter could be inserted. We chose the injections as we were trying to avoid Tobi being warded as it may be more stressful. In order to give the injections, Tobi had to be put under G.A. as he was putting up such a struggle.

Anyway it was done and he went home. Yet again two days he was still having difficulty peeing, this time we opted to bring him to another branch (this branch was 24 hrs with larger facilities). Tobi was sedated, warded with a catheter inserted and put on a drip via a Y-site. He was also given daily IV feeds with Cephalexin and calcium, diazepam amongst others. He seemed fairly alright the first two days, it was only on the 3rd day that we noticed he appeared rather "subdued", quiet, not he's normal fiesty self. By the 4th day ,he was lying down the whole time and didnt seemed to respond to us. We attributed this to possible lethargy and medication. The next day, his blood tests were normal and after a cursory examination he was declared fit for discharge despite the fact that by now he could not even stand up or move, we bascially had to carry him into his carrier to be brought home. We reached home in the mid afternoon and put him in the room, again we had to carry him out of the carrier.

From the time we reached home right until 10 pm, Tobi condition just deteriorated, once in while he would sort of jerk himself to another area in the room, Im not sure how he did this as he was immobile from the front quarters, his eyes could not track movement, he was drooling brown liquid and had raspy breathing. We took him back to the 24 hr branch at around 10.30 and the vet on duty arrived about 15 mins later,another blood test was conducted plus a chest x-ray, all looked normal, tests for leukemia and FIV was also done, clear as well. At about 11.30am, Tobi convulsed, expelled fluid and stopped breathing, we had opted for DNR.

An immediate autospy was done, organs again were all fine. Nobody seems to have an answer for his death. Needless to say, we are extremely saddened as well as puzzled by his sudden demise, more so when he was brought in for what ought to be a routine treatment for am inflamed penis. Instead five days later, we are having to cremate him. We have since search everywhere for anything information that might explain his sudden death. From what we found, we suspect, of course this may speculative at best, but it appears to be anaphylactic shock ( the question is what was the cause). Again we suspect it could he may have been allergic to one or more of the medications prescibed via the IV drip. Admittedly there could be numerous other possible causes. However we feel it seems to fit the symptoms Tobi displayed - pale gums, immobility, drooling, low temperature, increased heart rate. We are not ones to assign blame or find fault. Nonetheless, suffice to say we are disappointed with the level of monitoring at the vetirinarian branch Tobi was in. We are well aware that cats are notorious for masking pain and discomfort but honestly to discharge a cat that can't even stand on its feet! It would be like a doctor discharging a patient who can't walk and asking him to go home. While Tobi's blood tests looked fine, a more thorougly physical examination would have raised one or more red flags. From the time of his passing, not one person from the vet had called to offer their condolences or at least offer some theory as to Tobi's death. It's as if that there was no obvious cause, so nobody can be bothered about it. My wife and I are still coping with his passing but we are doing well. I just thought that since you treated Tobi twice and did such a wonderful job each time, we would like to let you know what has happened since then. Thank you for taking time to read this long email. Meanwhile, we wish you all the best in your practice and your great care towards all animals, big and small. P.S. we would have like to gone back to you but the distance was a bit prohibitive. Anyway we thought it would be just a routine treatment but...... Best Wishes & Regards J & S



E-MAIL TO OWNER DATED FEB 10, 2012

Further to my email,
1. was there an X-ray of the kidney and bladder done?
2. I can review, free of charge, the treatment records and procedures done on Tobi for you and your wife to understand more of what had been done and to learn from the case. I do not do it for litigation or complaint to AVA purpose. If you want the review, you will need to get the vets to give you a detailed report and they should have no problems doing it.





Dear Dr Sing

Our profound appreciation and thanks for your condolences and offer to review the case.

In response to your first email,

1. Yes it was a urine test that showed the struvite crystals.
2. DNR - do not resuscitate
3. Two X-rays done on Sat (approximately an hour before he died)
4. Urine test - Sorry I'm not sure at which point in time you may be referring to. When he was warded or on the day of his passing?
Even though we are still coming to terms with Tobi's death, we are at peace. Our intention to learn what happened was never about assigning blame or instituting litigation. If there is an practice that could perhaps be improved or certain medications that may cause potential complications, we would like to highlight to the veterinarian concerned so that it may something they could look out for in the future that may help prevent another unfortunate outcome. Tobi's death, tragic as it is, may perhaps prove beneficial in providing valuable lessons so that a similiar result can be avoided in the future. We would like to think that a vet practice or any business for that matter would welcome feedback for the betterment of their business and ultimately better care and results for their patients.

We had already obtained most of the work that was done except for the X-rays shortly after Tobi's passing. We have also scheduled an appointment with the owner of the practice this coming Tuesday. Again, we are meeting him not to lay blame but to gain a better understanding of why certain things were done and to address certain issues which we feel could be improved on. We hope that by doing so, all of us can learn from this experience and hopefully make a difference in the quality and care for all animals.

I will discuss with my wife to arrange a time to meet you. We hope we are not putting you throught too much trouble in reviewing this case as I know you are very busy and what little spare time you have is limited.

Best Regards
J & S




E-MAIL FROM DR SING Friday, 10 February 2012, 7:32
Subject:Re: UPDATE ON TOBI


Further to my email,
1. was there an X-ray of the kidney and bladder done?
2. I can review, free of charge, the treatment records and procedures done on Tobi for you and your wife to understand more of what had been done and to learn from the case. I do not do it for litigation or complaint to AVA purpose. If you want the review, you will need to get the vets to give you a detailed report and they should have no problems doing it.




E-MAIL FROM DR SING DATED Feb 10 2012




All vets learn from experience including me. I am most interested in reviewing your case for my own learning and to make improvements in the processes of FLUTD.

Presently, I am writing SOPs (standard operating procedure) for some procedures like urinary stones in dogs to ensure a consistent practice amongst the younger Toa Payoh Vets' vets as I cannot live forever.

Urine tests and X-rays (2 views) on the day of consultation or next day will be most useful. Urine bacterial culture and antibiotic sensisitivity tests as well.

Best wishes.

DRAFT REPORT - NEEDS TIME TO REVIEW AND COME TO A CONCLUSION.
TODAY'S MARCH 13, 2012 FINDINGS BY ME ARE:

On 4.2.12, on emergency admission and around 45 minutes before the death of Tobi,

1. the blood test did show an abnormally low platelet count. This may be a cause internal bleeding or may lead to internal bleeding, gasping for air and death. Lymphocytes % was below normal (immuno-suppression?) but total WCC was normal. RBC was normal. FeLV and FIV tests were negative. So, was there a starting viral infection acquired? Hard to say.

2. The BUN and CRE values were still normal but trending towards the higher end of the range of values just before death.

3. The necropsy result stated that the cause of death was unknown. However, necropsy should be done by an outside party to avoid conflict of interest. There were interesting necropsy findings such as patches of atelectasis in lungs, haemorrhages in the bladder (indwelling catheter? intra-bladder injection of baytril and Vit C?).

4. Intra-bladder injections of baytril and Vitamin C on the first day of admission. As each vet has his or her own method of treatment, I would only say that I do not practise such procedures and cannot comment further.

5. Salivation in the cat on the 5th day of hospitalisation was recorded in the case report. As to its significance, it is hard to say.

6. Sedation was given several times via the IV during the first 4 days of hospitalisation to control the "fiesty kitty". This leads to a loss of control of the reflexes leading to asphyxiation?

A combination of the above factors could contribute to death.