March 1, 2012

Today I had a meeting with the young couple from 9.40 am to 11.30 am as the young couple wanted answers as to why their 8-year old neutered male cat had died during treatment at Vet 2 which was associated with a veterinary surgery of Vet 1.

The cat had an inflamed penis and difficulty in peeing and in the opinion of the owners, should not have died based on this medical condition. It was a reasonable deduction and the husband had emailed me informing me of the cat's death as I had treated him in April and November 2011for Feline Lower Urinary Tract Disease (FLUTD). This case is reported in FLUTD

Basically, XXX had a relapse of FLUTD and the couple had sent him to Vet 1 for treatment, owing to proximity of location.

Answers were wanted as Vet 2 had performed an autopsy and said that the cause of death was unknown.

"Could it be anaphylaxis or allergy to cefloxalin given together with the calcium in the IV drip?" the wife wanted to know as she had researched the internet and there was information on the adverse drug reactions using the combination, in human beings.

"It is very difficult to ascertain that the drugs had caused his death," I said as the owner had described that the cat was discharged home in a stoned state, being unable to stand or walk normally and then had pale gums and breathing difficulty in the evening. The cat was rushed to Vet 2 around midnight and he passed away despite X-rays and treatment. "Adverse drug reactions in people may not apply to the cat and vice versa."

So, what was the cause of death? The couple had spoken to the proprietor of the surgery but was no wiser. They showed me the medical records and 2 X-rays taken before death. One lateral X-ray showed black air inside the lung. The V/D X-ray showed that the lungs and chest area were opaque. It was hard to explain why.
The blood test showed a low platelet count.

Low platelet count. I discussed the case later with Dr Daniel who said that the cat have died of internal bleeding leading to or as a result of low platelet count. It was plausible. For example, traumatic injury to the lung (lung bleeding was reported in the autopsy) due to the "feisty" cat being nursed and changing of the litter, catheter and urination bag etc.

But the low platelet count by itself would not have killed this cat as I have had seen such cases of lower platelet count in toxaemia and tick fever and the dogs survived.

"In any case, an autopsy done by the same practice would not be credible as there was a conflict of interest," I said. "An independent veterinary body ought to have done the autopsy." The owner was not aware of the need for this procedure.

Vitamin C dosage The cat was given high doses of Vitamin C daily by IV during the 5-day hospitalisation. "This practice believes in high doses of Vitamin C in treatment," I said. "Whether the dosage killed this cat, it is hard to determine."

Sedation - valium and ketamine IV during hospitalisation. Would the daily IV injection to sedate the cat for ease of handling and changing of the litter cause death by cumulative dosage in an old cat that was already stressed out and frightened? I believe it would but Dr Daniel disagreed. This would account for the owner's observation that the cat could not lift up his head, that his eyes could not track finger movement and that after the 2nd day of hospitalisation, the cat looked "stoned" and could not even give a soft meow as usual.

"Why would the vet discharge a cat when he was not well?" the wife asked me.
"It could be that the cat would be better nursed at home," I said. "Since the cat was feisty (aggressive), it would be very difficult for the nurses to nurse and clean him. In the first place, this cat could have been better nursed at home. Vet 1 had proposed home nursing with the catheter inside the bladder. Struvites were reported and this would be much better to manage at home for a ferocious cat.

I can't figure out why the owner did not consult me after Vet 1's treatment was unsatisfactory in their opinion. This was what they did in April 2011 and then in November 2011. Proximity to Vet 1 was the reason given for this time-pressed couples.

"I would not go to the same car mechanic near my house if I know that he had not repaired my car to my satisfaction," I said frankly to the couple as they were the type who wanted answers to a death of the cat for knowledge and prevention and not for litigation. We could converse frankly rather than beat around the bush. "For car in bad state, it would be for safety reasons. For a pet, it could be a matter of life and death."

It was difficult to find the correct answers to this cause of death. I believe it was the cumulative effects of sedation. I could imagine that another dose of sedation was given (as stated in the records) every day as the cat showed ferocity when the litter was changed daily or frequently. There was the urinary bag attached to the catheter to be changed. Medical records stated the cat was "feisty" on two days and so sedation had to be given.

"What should we do if we have a cat?" the wife asked.

"Get a female cat," I said. "FLUTD is less likely in a female cat. For male cats or dogs with struvite urinary stones, a monthly urine test and 3-monthly X-rays for pets with struvite urinary stones is advised. But no cat owner will comply."

"Did you follow my instructions that the cat should not be given treats?" I asked. "I had recorded 'no treat' in the blood test result too."

The cat was given canned C/D diet after 2 months of S/D diet since April 2011 when the couple had consulted me.

"Well, 2 weeks before consulting Vet 1 in February (2012), I did give him dental treats."

"This should not be given," I said. "Struvites could be formed as a result and this lead to urination difficulty and an inflamed penis."

"The penis was inflamed because the tip of the penis had been bitten off," the wife said. "You were the one who told us in April 2011. Do you remember? You extracted the broken canine tooth as that could be the cause of irritation and injury. So his penis was diagnosed 'inflamed' by Vet 1 but it was due to the fact that he had no tip."

Owners who love their pets very well remember all treatments like elephants as their pets are family. "I remember Tobi for his hissing at me," I said. "He did not like vets. Did you give other treats as well?"

"Some love letters, as it was Chinese New Year," the wife recalled.

"Some, but not all cats and dogs with a history of struvites in their urine cannot eat other food as the problem will come back to cause peeing difficulty," I said. Her cat was one of this category. If the owner gives a strictly controlled diet, usually there is no problem.

It was a sad day and I hope that the couple had received some answers as everyone learns from experience. There is no other way. Reading widely on your pet's health problems may give insights and knowledge of what had happened to other people's pet and thereby instituting preventive measures to ensure that your pet's health is optimal. For example, dental scaling to keep the teeth and mouth free from infection, enabling the cat to eat well and without pain. Cats need to groom themselves and therefore clean teeth without periodontal diseases are more important to them as compared to the dog.

Proximity to the vet surgery is convenient but sometimes, it is best to find a vet that can handle your pet's more complex health problems. A practice that has different doctors attending to your pet may not be in the interest of your pet. However the same vet treating your pet may not be suitable and a second opinion may be needed if the outcome of treatment is not to your satisfaction.


P.S. In a recent liposuction death case in Singapore, the patient was given more IV anaesthetic as he moved during liposuction. He died not long after the end of the liposuction procedure. On autopsy, 13 intestinal perforations were found. However, these were not said to be the cause of death. The IV anaesthetic given in more and more doses as the patient moved was said to cause him to die from asphyxiation as he could no longer breathe normally.  The cause of death was said to be over-sedation with propofol.