Thursday, August 4, 2011

why is it always the nice ones?

There's an expression in ER medicine - "Nice pet, nice owner = bad disease."  This saying stems from the general observation that, on average, the mean, fractious, angry feral cat can survive any diagnosis, and usually has an easily fixable condition, whereas the loved, indoor only, perfectly cared for cat with loving clients who can afford the highest quality of care will end up with a terminal disease.

This case is no exception.

"Slash," a 4 year old, mostly indoor cat presented after being hit by a car just in front of his family's home.  His clients tried to keep him indoors because they knew the risks of cars, of other animals, and were concerned about Slash eating birds and endangering songbird populations.  Slash seemed to be unhappy in the house, and after several months, despite their better judgement, they decided to give him a couple of hours during daylight, to enjoy the greater outdoors.

The client's worst fear came true last week, when Slash ran out from underneath a car, and was hit crossing the street.  He was immediately unable to walk, vocalizing and in pain.  He arrived to the ER quickly, and was in shock.  IV fluids were initiated, pain medication was started, and a neurologic exam was performed.

Slash was able to feel his hind limbs when pinched, but was unable to move.  Radiographs were the next step at determining the cause of his injury.  Pelvic fracture? Spinal trauma? Vertebral body fracture?  The other abnormality on Slash's initial physical exam is that his breathing pattern was altered.  It appeared as if when he breathed in, his entire chest was sucked in, instead of his chest expanding with every inward breath.

Radiographs revealed a very serious injury - Slash had a vertebral body fracture with compression of his spinal canal.  He would need surgery by a specialist the following day to repair the compression, and his recovery would take time.  Regardless of the cost and associated dedication to care, his family was committed to pushing forward.  No other injuries were present, and with this degree of dedication, Slash had a chance at a normal life.  Despite Slash's abnormal breathing pattern, there were no broken ribs to explain the pattern.  He was oxygenating normally at this time, and there was nothing we could do except for watch carefully for any changes.

After Slash recovered from his shock, his status improved for a few hours before they came crashing back down.  Around 3am, Slash began to have difficulty breathing and was placed on oxygen.  Recheck radiographs revealed a large amount of fluid in his lungs, and a very enlarged heart.  Despite lack of a heart murmur, Slash apparently had significant underlying heart disease, in addition to suspected bruising of his lungs from the trauma.  He continued to deteriorate quickly, even with discontinuation of intravenous fluids and addition of diuretics.  As he struggled to breathe, it became apparent that Slash was heading for disaster.

His family was contacted and wished to continue to provide every possible intervention for Slash.  Slash  was sedated in order to facilitate intubation and control his airway.  This intervention allowed sufficient oxygen to be delivered to his body's tissues (especially the brain and heart).   Fluid was dumped through his ET tube, and positive pressure ventilation was initiated.

Over the next 5 hours, we monitored Slash intensively.  Slash had a dedicated technician monitoring him, and we attempted to wean him from being intubated several times, before it became obvious this was not going to be possible at any near time frame.  Slash needed to be on a ventilator for 24-72 hours, or longer, to determine if he would ever again be able to ventilate his own body.  Our theory and the only logical cause is that ascending spinal cord inflammation, or the direct trauma and concussion of the spinal cord, resulted in paralysis of Slash's intercostal muscles and / or his diaphragm, which resulted in failure of the body's ability to effectively ventilate.  Like many neurologic injuries, there was/is no direct repair.  The only option was to support his body's vital signs, and wait to see if it would ever improve.   This time frame could literally be days, weeks, or never.

Unfortunately, his breathing pattern never improved.  Consultation with the surgeon confirmed my exam and knowledge, and we discussed the complexities of the case with the clients for hours, while they visited with their beloved Slash.

After lots of tears, much discussion, and careful consideration, the family made the difficult decision to euthanize Slash.  We were all crushed by the tragic outcome, but knew that the family had made the right decision.  Slash's chance for recovery was very small, and the cost and suffering associated with that small chance would have been astronomical.

Rest well, kitty.  You will be missed by many.

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