Such findings on physical examination were small triumphs. To detect with my hands and eyes an abnormality later confirmed by lab tests, X-rays, or ultrasound was thrilling. There were times I still felt shaky, but the mechanistic ritual of the exam, performing the same sequence of movements on every dog and cat every time, provided a bedrock of experience I’d come to trust.
“When did you first notice something was wrong?” I asked Zeke’s owner, Mrs. James. She was a short, fair-haired woman I guessed was in her late fifties. Her wedding band was overly snug and worn. Her clothing was unremarkable: a knee-length skirt and nondescript sweater that would suit a job in an office cubicle. A nervous tightness gripped the skin around her eyes, and she fiddled with the pleats of her skirt, her ring, and her hair.
“He seemed fine until a day or so ago,” she replied. “He vomited three times yesterday, or maybe the day before. Yellow bile. No food. He does that sometimes, but today he seemed like he didn’t feel good, so I took him in to my vet.”
“When did he last eat?”
“We put fresh food out every day, so this morning, I think.”
“Did you see him eat?” I refined my question.
“No, but he likes to sneak a bite when I’m not looking. I don’t always pay that much attention.”
“When was the last time you saw him at the bowl?”
“Come to think of it, not for the last week or so. Sometimes my husband feeds him, sometimes I do. I suppose his bowl’s been pretty full since last weekend, but I thought my husband was topping it up. We fill the bowl and then Zeke eats as much as he wants, which is usually all of it, isn’t it, Zeke? He loves his food.” Her hand fretted on Zeke’s back, his fur growing darker and flatter from the heat of her palm.
“He loves treats,” she said. “He’ll do anything for them. He’ll even beg on his back legs like a dog if I ask him. That’s about the only activity he’ll do, though. Sleeping and eating, those are his favorite things.”
Typical cat, I thought, picturing my own three felines who were probably napping on the couch at that moment, but were always instantly and demandingly awake an hour before feeding time.
* * *
—
Each species presents unique challenges to a veterinarian, but cats, true to their inscrutable nature, can be particularly difficult. The fear induced by a visit to the vet’s office only compounds the problem. Nervous cats may refuse to walk, slink skittishly around the perimeter of the exam room, or hide in the darkest corner of their carrier, which can make assessing their gait and neurologic function challenging. Their heart and respiration rate, body temperature, and even blood glucose levels can become elevated due to the release of stress hormones, and these parameters can be almost useless diagnostic tools in certain cats.
The cats who manifest their fright with aggression are formidable patients, as Tiger had already taught me. Fred, my own mild-mannered but nervous kitten, became a screaming ball of claws and teeth when I took him in for his neuter. He pulled out his intravenous catheter while recovering from anesthesia, spraying himself and the walls of his cage with blood while hissing and swatting at anyone who tried to help. I felt like an embarrassed parent with a toddler in a tantrum. “He’s nothing like this at home,” I wanted to say, imagining I had some control over my pet’s behavior.
Despite humans’ centuries-long association with cats, it has been only in the past one hundred years that the veterinary profession has considered feline patients. It took the Industrial Revolution and the development of the motorcar for veterinarians to turn their attention away from horses and to smaller companion animals. Cats have evolved little, if at all, over this period, but our attitude toward them has radically shifted. Kidney transplantation has become a routine procedure for specialized feline surgeons; and specifically formulated medications for cats and the array of food in pet stores attest to the massive social and economic change the domestic cat has undergone in less than a century.
Cats are now the most popular pet in the United States, with the ASPCA reporting that 74 to 96 million cats are owned as pets, compared to 70 to 80 million dogs. But they lag significantly behind their canine counterparts where veterinary care is concerned. Given that the act of getting a cat to the vet can leave you exhausted, bloody, and smelling of excrement before even leaving the house, it is unsurprising that cat owners are reluctant to take them in for preventive care. For cats, a waiting room of barking, panting dogs, being wrestled out of their carriers, the indignities of rectal temperature taking, and the further invasion of blood sampling or vaccine administration explain their objections.
Unfortunately, avoiding preventive care means that treatable diseases may not be detected until it’s too late for effective treatment. And cats, particularly if they live in multi-cat households, can obscure the signs of disease that might alert us to a problem sooner. Litter boxes are kept far from human activity, so toileting behavior is rarely witnessed. Food is left in free-feed bowls, so consumption is not quantified. And cats naturally spend a large portion of their day lying around doing nothing—how can an owner tell, then, if lounging is simply enjoying the sun or is a result of weakness or lethargy? It is often only when their behavior becomes inconvenient—vomiting on a favorite pair of shoes, or peeing on the clean laundry—that veterinary attention is sought.
Although these problems with providing veterinary care for cats are easily identifiable, their solutions are less obvious. There is no easy, foolproof method of getting a reluctant cat into a carrier, into the car, and to the vet’s office. Home visits can alleviate the stress, but it’s not possible to take X-rays, perform extensive diagnostics, or pursue intensive treatment at home. The American Association of Feline Practitioners’ Cat Friendly Practice initiative was designed to make vet visits more comfortable for cats. Separate waiting rooms and treatment areas for cats and dogs and the use of calming cat pheromones have been identified as ways to alleviate feline stress at the vet, but these measures are beneficial only if our patients make it into the office.
Zeke’s previous medical record showed that his visits to the vet had been sporadic, and I didn’t know how he’d behaved the last time he’d gone in for a broken claw, but his highlighter-hued skin justified his attitude in my examination room that day. The bilirubin coursing through his bloodstream and depositing in his tissues was likely causing nausea. Toxins normally excreted by his failing liver were accumulating in his brain, causing changes in the delicately balanced chemistry that could result in depression and coma.
“I think Zeke hasn’t been eating well for longer than we think,” I said.
“But he seemed fine a day or two ago,” Mrs. James replied.
“I know this seems out of the blue, but Zeke most likely has a condition called hepatic lipidosis, which can occur suddenly. We usually see it in overweight cats who stop eating, sometimes because of stress, a change in food, or another disease.”
“Zeke doesn’t get stressed. He’s so laid-back. He spends most of his time lounging around.”
“I don’t mean stress the way we think of it. Stress for a cat could mean a visitor coming to stay, a new cat in the neighborhood, or even moving the furniture around.”
“I can’t think of anything that’s changed. Our routine’s been the same.”
I nodded. “We don’t always know why some cats develop hepatic lipidosis.”
I explained how, when an overweight cat stops eating, energy is released from fat stores, rather than from food. Mobilized fat travels to the liver for processing, but instead of being metabolized, the lipids become trapped within liver cells. The liver cells fill with fat, like bloated balloons. Just like a hamburger and fries for lunch makes you sluggish in the afternoon, the fat stops the liver cells from working properly. The liver starts to fail, suppressing appetite further, and more fat is mobilized and deposited in the struggling cells. A
vicious cycle ensues. Ultimately, the liver gives up, and death from liver failure can result.
Mrs. James’s expression became progressively stricken while I described the reason for Zeke’s illness. Her hand was motionless on his back.
“Are you saying he could die?” she asked.
“Some cats with severe lipidosis die from the disease, but I’m hopeful that if we can get food into Zeke we can start reversing the liver failure.”
Relief flashed in her eyes. “I was saying to my husband that we should try a different food. I thought he was just being picky; you know how cats are.”
“Unfortunately it’s not that straightforward. Most of the time when cats start to get picky about their food it’s because something is making them not feel good.”
“But maybe he got tired of his food. We usually feed him the same kibble; maybe he wants more variety.”
“I know it might seem that way, but Zeke is too sick to want to eat on his own right now, and we need to make sure that he’s getting enough calories to reverse the damage to his liver.”
“I’m sure I can get him eating at home; he did eat a treat this morning. I can hand-feed him, right, Zeke?”
Mrs. James’s sudden optimism was disconcerting, but not unfamiliar. She had transferred her grief and anxiety over Zeke’s illness into a more manageable concern. My words about liver failure and death were eclipsed by the more pressing matter of a visit to the pet store to purchase new cat food.
The clinical reality, however, was more urgent and less easily addressed. Without adequate nutrition in the next twenty-four to forty-eight hours, it was likely that Zeke would die from irreversible liver failure. To rely on his appetite was too big a risk to take. The only way to ensure we could meet his caloric needs was to place a feeding tube.
Zeke’s feeding tube placement would be straightforward. Despite the need for a scalpel, suture material, and other instruments that usually made my hands shake, I’d performed the procedure enough times to find a grip-stilling confidence. I would ease a thin, flexible tube through a small incision in Zeke’s neck and into his esophagus. It was satisfying to think of his liver recovering with each liquid feeding—the fat bubbles deflating; the cells returning to their normal size and to their work, processing toxins and bilirubin.
“Zeke’s condition is too serious for him to go home,” I said. “He’s going to be in the hospital for a few days.”
“Are you sure there’s nothing we can do for him at home? He’s never slept a night out of the house. I don’t think he’ll like being in the hospital, will you, Zeke?”
Zeke was motionless, his body hunched and his head resting on the table.
“If I thought there was something you could do at home, I would tell you,” I said. “But Zeke’s liver is so badly damaged that he needs hospital care right now. Without it I don’t think he’ll make it.”
She nodded and smiled briefly. “I thought you’d say that. It’s not just up to me, though; I’ll have to call my husband at work. Let him know what’s going on. How much is this going to cost?”
“I’ll have my staff bring in an estimate.” I paused. “I also wanted to mention that Zeke will need tube feeding when he goes home.”
“He will? How does that work?”
“Don’t worry about it at the moment; let’s get Zeke home with you first. But we’ll give you full instructions when it’s time for his discharge. Usually the feedings are two to three times a day, and take twenty to thirty minutes each.”
“How do people do that? We both work full-time. I don’t know how we’ll manage that.”
I tried to look reassuring. I wanted to treat Zeke; he had a potentially curable disease with no long-term consequences—a rare occurrence in the world of small-animal internal medicine.
“I know it sounds overwhelming,” I said. “But once you get into the routine it’s quite straightforward.”
Zeke’s owner’s face was difficult to read; her lips looked blanched in the fluorescent light of the examination room. She clasped the phone she’d pulled from her bag on mention of her husband. I wanted to add more words of reassurance, promise Zeke’s recovery and return home, but I couldn’t guarantee it. I stepped out of the room to plan his treatment and diagnostic course for the next twenty-four hours.
If Zeke survived his initial hospitalization, his prognosis was good. But some cats with hepatic lipidosis didn’t eat for a month, or two, or even longer, and needed tube feeding every day until they began eating again. I thought of my routine, of how I was out of the house for fourteen or fifteen hours on workdays, and of how the time I spent with my cats was limited to sleeping in bed with the top sheet tent-pegged by feline bodies. How would I find time to blend and warm the food, flush the feeding tube, administer medications, and then patiently feed sixty milliliters of warmed, meaty gruel several times every day?
* * *
—
What and how we feed our animal companions is crucial to the bond we share with them. It is also big business, with the global pet food market estimated to be worth $74.8 billion in 2017. But only 150 years ago cats survived on what they caught, and dogs lived on household scraps, and, if particularly lucky, bread soaked in milk.
What we feed our pets is as much a lifestyle choice as what we eat ourselves. For some owners, feeding is a tangible, quantifiable measure of love. Our ideas of good cat and dog nutrition are influenced by our personal food preferences, advertising, and our ethical and philosophical beliefs. It is unsurprising, given the complex nature of our relationship with food, whether human or animal, that more than 54 percent of dogs and 59 percent of cats in the United States in 2016 were reportedly obese. And the link between obesity and disease in our pets is well documented. The catalog of health problems encountered by overweight cats and dogs includes shortened life expectancy, orthopedic problems, and metabolic diseases, including Zeke’s hepatic lipidosis. Zeke’s dietary habits had inevitably led him to my consulting room, but that was not a discussion I wanted to broach with Mrs. James in our first meeting.
* * *
—
My role was to get Zeke home. I understood what lay ahead for his owner, but I couldn’t understand how the placement of a thin, flexible feeding tube might affect her relationship with Zeke, her husband, or the other unnamed people in her life.
I knew little about my client—only that she had an overweight cat, a husband, and a job. I knew what Zeke liked to eat and where he slept. I knew he liked to carry a small, balding toy mouse around the house, that he preferred water from the faucet, and that he’d stand on the kitchen counter demanding his after-dinner drink. I didn’t know if his owner was squeamish about tubes and syringes and holes covered with bright bandages.
I didn’t know if the smell of blended cat food would make her skip her own breakfast. I didn’t know if her husband would help with feedings. Would he prepare the food? Go to Target to buy a designated blender? Would she lie to him about the cost of Zeke’s treatment? These were questions beyond the scope of taking a history. But my success as Zeke’s doctor was intimately connected to his treatment at home. I could get him through the next few days. I could recheck his bloodwork and body weight, adjust medications, and provide new feeding directions, but once he was out of the hospital, Zeke’s recovery would depend on his owners.
I returned to the exam room twenty minutes later, after Mrs. James had approved the estimate. Zeke’s large, striped body was awkwardly lumped across her knees. She scratched gently behind his ear, but the movement of his chest told me that he’d failed to summon a purr.
“We’ll get treatments started right away,” I said. “We’ll place an intravenous catheter, begin fluids and medications, and run more tests to evaluate his liver. I’ll call with an update once I have more information. Do you have any questions?”
“You’re going to t
ake good care of him, aren’t you?”
“Of course. We’ll do everything we can to get him home as soon as possible. I know how important he is to you.”
“We want you to do whatever needs to be done. I don’t know what we’d do if we lost him. He’s our baby, aren’t you, Zeke?” A flush of emotion spread from her eyes, and I realized that her earlier joviality had been a cover for the tears she was trying not to shed.
I scooped Zeke gently out of her lap.
Once Zeke and I returned to the treatment room, I pounced on the head technician, Shannon, and quickly relayed my diagnostic and treatment plan. I was accustomed to the bustling pace of Penn—supplies ready, techs awaiting instruction.
“Hang on,” Shannon said. “You need to slow down.” She was a few years older than me and had worked at the practice from its opening a year prior. Her engagement ring glinted in the fluorescent lights—a status symbol I considered impractical given the fur that must regularly get caught in its tiny prongs. She reminded me of Elisa, with a similar attention to her appearance, but with less sexual ferocity. She, nevertheless, ruled the internal medicine service with the same intimidating steel.
But, despite being the youngest and least experienced of the three-doctor internal medicine practice, I was no longer a trainee. I hadn’t yet achieved board certification like my colleagues, but I craved the respect afforded to the other specialists.
“I can’t get all these treatments down while you’re talking so fast,” she said, “and I have to finish with John’s last case. You’re going to have to wait.”
I frowned. “But Zeke has hepatic lipidosis. He’s really sick and we need to get started with him.”
I watched impatience ripple across her jaw. “I know you’re worried about your patient,” she said, “but you have to give me some time.”
My Patients and Other Animals Page 12
