Wednesday, September 17, 2008

learning the cost of declining

when i work days (as i did monday) - i generally take over care for the ICU cases that came in the previous night and help internal medicine see appointments. emergencies during the day shift are unusual. yet on monday, we received a call from a local vet saying that he was sending us a cat in respiratory distress.

said cat was 2 years old. about a month prior to her seeing me, she had developed open-mouthed breathing. the owner rushed her to the vet. he recommended chest xrays and a feline leukemia/feline AIDS test and bloodwork - all of which the owner declined. backed into a corner, he treated the cat with steroids and an antibiotic. the kitty responded well and was normal for a few weeks. but the respiratory distress came back. kitty was returned to the vet - and again, full diagnostics offered. the owner refused. kitty was treated with the same medications and sent home. 2 weeks later, the respiratory distress returned. the owner finally agreed to have xrays of the chest taken.

the news was not good. the chest was full of fluid. the vet treated the cat for possible pulmonary edema (fluid in the lungs) with a diuretic called lasix, gave a bronchodilator to help the cat breathe, and sent it to us for further diagnostics.

a chest full of fluid in a young cat is a very bad thing. there are 4 typical substances that can be in the chest: blood (hemothorax), chyle (which is fluid from the lymph system), pus (pyothorax), and transudate (proteins and cells that are normally confined to the bloodstream/tissues). pleural effusion (fluid in the chest cavity NOT the lungs) in a young cat can be caused by many things. none of these things are good. FIP (feline infectious peritonitis) was my first and foremost concern. this is a terrible and uniformly fatal disease of cats. it is a mutated strain of a fairly benign gastrointestinal virus called corona. there is no cure - and it is typically a disease of young cats. so i was worried about that. other causes include an overwhelming infection in the chest (bacterial usually), feline leukemia virus, feline AIDs virus (although less likely), an idiopathic condition where the chest fills up with chyle - but the reason is never understood, heart failure either primary (a condition of the heart) or secondary to something like heartworms (yes, cats get heartworms too!).

none of those are great things for a cat to have at the age of 2 (or any other age!).

when the kitty got to us, i could see immediately that she was having a great deal of difficulty breathing. she was using her abdominal muscles to pull air into her lungs. the xrays that came with her confirmed fluid in her lungs - but there was something else. the cranial (toward the head) part of her chest cavity looked awfully solid. less like fluid and more like a mass. this immediately worried me.

kitty was placed in the oxygen cage while i prepared everything to tap her chest. when all was ready, i removed kitty from the cage. that didn't go so well. kitty was apparently feral at some point - as the huge, painful scratch on my right wrist can attest. after some heavier drugs than i would normally employ in a cat with respiratory disease, she was calm enough for me to tap her chest and remove the fluid. i collected enough for a culture (for bacteria) and for a pathologist to look at the fluid and tell me if they saw cancer cells.

after the tap, i re-xrayed kitty and was dismayed to see that there was indeed a mass in the chest. it was located in the front of the chest (in an area called the cranial mediastinum). it's location made me very suspicious that the cat had a type of cancer called mediastinal lymphoma.

i went back to the record to see if the owner had ever consented to a feline leukemia test. sure enough, she had not. she had wanted to forego the $50 cost of the test. i asked my technician to run a snap test for me, while i looked at the slides i had made from the chest fluid. my heart sank, even though i was expecting it - when i looked at the slides. lymphocytes everywhere - moderate to large sized and not terribly mature. the slide was very consistent with lymphoma. at about that time, the tech tapped me on the shoulder and asked me, "guess what your results are?"

i looked at her evenly, "strong positive for feline leukemia?" she nodded.

feline leukemia is a well-known disease of cats that is transmitted through close social contact such as mutual grooming and sharing of food bowls. it can lie dormant in a cat for years before making appearance. typically the cats that we see are either very young or very old. the presence of leukemia has been linked to the development of lymphoma - a cancer of cats (and dogs) that i've talked about here before. dogs do great with chemotherapy and can usually expect another year to a year and a half of good quality life. cats - on the other hand - are all over the map when it comes to responding to chemotherapy. the fact that this cat already had fluid in her chest, a large mass making breathing even more difficult, and was feline leukemia positive did not bode well for her long term survival.

i discussed this with her owner, who elected to take kitty home on steroids (which shrink lymphoma and explain why kitty responded so well to the first 2 treatments at the referring vet) and bring her back for euthanasia when the time came to do so.

in the end, we spent $1100 to diagnose kitty's disease, tap her chest, and hospitalize her for the night in oxygen. if the owner had elected to have her feline leukemia tested prior to this - and vaccinated possibly - she would have spent $75. that doesn't make her a bad owner. don't misunderstand me. i understand the financial crunch all too well - despite my "lucrative" position as an intern. and in the end, this woman paid a great deal of money to understand exactly what was wrong with her pet and treat it as best as possible. so she was a concerned owner who wanted to do what was best for her cat.

but remember this story when you see your veterinarian and they recommend routine testing and vaccines. finding a problem early can save you a great deal of money in the long run. more importantly, it can prevent your animal from unnecessary suffering. i'm not advocating blind acceptance of whatever your veterinarian recommends - shots yearly, etc. be an informed pet owner. but if you're reluctant to do something preventative for financial reasons, just think of the financial burden if your pet actually comes down with the disease or condition you could have tested for and prevented for so much less.

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