Tube is Out, But Concerns Remain

Yesterday, we took Arthur to his vet Dr. Plotnick and we came into the appointment with concerns about Arthur's eating. As I mentioned in my most recent post, Arthur has been eating on his own, but not the 250 calories per day we had been aiming for so he was still getting a tube feeding or two every day.

We went into the appointment assuming that his feeding tube was going to be staying in for the foreseeable future and that we were going to have to keep shooting for normalcy. However, Dr. Plotnick was persistent in his belief that we should remove Arthur's feeding tube right away. He told us that, now that Arthur's liver has returned to normal, if Arthur eats every day but eats less calories he's not in immediate danger of going back into fatty liver syndrome. He also said he believes that the presence of the feeding tube itself might be holding Arthur back from eating as much as he should.

He said we don't need to obsessively count Arthur's calories as long as we see him eating consistently. We have a follow-up appointment next Friday to see how Arthur's weight and health do in his first week without the tube. If it's a problem, we can always move back to force feeding with a new tube or a syringe.

So we made the leap. The tube is out and, though Arthur has a bandage around his neck while the hole heals up (about 36 hours), he is now tube-free and we can see that he is much much happier. He was affectionate throughout this ordeal, but he is even more affectionate now. The picture above shows him snuggling on the ottoman between our feet. When we took this shot, we were sitting watching a movie and he came up and sat on Liz's lap and kneaded her and then sat on mine and then settled between our feet.

He has been eating, but the usual nibble here and there. However, to be honest, the amount he is eating might be equivalent to what he was eating before he got sick. It's hard to say because he always snuck into the kitchen and grabbed some kibble when nobody was looking rather than eating huge amounts right when we put food down (like his brother does). We have seen him going into the kitchen late at night to grab more food.

We are cautiously optimistic that he has turned the corner and will be eating enough on his own. As usual, Dr. Plotnick has made us feel really confident in what we are doing. He is an amazing veterinarian, we have a ton of faith in him, and we believe we can't really go wrong. He's done as much for our mental health as for Arthur's physical health.

If you've read about our saga with the old vet, you know that the old vet had said at one point that we shouldn't worry about how much Arthur was eating and we wrote that off as bad advice when Arthur's condition worsened. However, as Dr. P pointed out, there's a big difference between that time and this one. When the old vet told us we shouldn't be concerned about Arthur's food in-take, he was in the throes of intense liver disease. Now his liver is normal and Dr. P tells us that he will not go back into fatty liver if he has a few days where he is eating less than we would like.

However, you'll forgive us for still being a bit obsessive about how much Arthur is eating and still watching him closely. Hopefully he starts eating a bit more in front of us.

Another side effect of the tube removal is that, once we remove the bandage tonight, Liz will start sleeping in the bedroom again. She has been sleeping on the living room couch every night for the last month so she could keep an eye on Arthur at night and make sure his brother didn't wrestle him and pull the feeding tube out. With no more tube, we can both go back to sleeping in the bedroom.

Tons of Frustration as Arthur is Eating Less

As you may have read, Arthur's liver numbers came back normal last week. And indeed he looks much healthier and acts much healthier. He's been very active and assertive, even trying to wrestle his brother (which we break up, because of fear it will dislodge the feeding tube). He even nags us for food, but then when we go in the kitchen and give it to him, he eats maybe two licks or just rubs our feet.

On a good day, he's eating maybe 100 to 125 of the 250 calories he needs on his own, but the past couple of days have not necessarily been good days. This morning I spent about two hours trying to cajole him into eating, after he woke me up and begged for food.

Here's how it went:

1. 7 a.m.: Arthur knocks on the bedroom door and wakes me up (Liz is asleep in the living room where she sleeps to watch the boys at night). I get up and open up a can of Solid Gold Tuna for Arthur and dump some dry food for Beowulf. Arthur runs over the bowl and starts eating, but after a few licks, he tries to follow me back to the bedroom. I leave the food out for an hour, but he doesn't go back.

2. 8 a.m.: I go back into the kitchen weigh the food bowl (it's like .5 ounces lighter than it was so maybe he got 15 calories). I then put down dry food for Arthur. I make him follow me in and put tuna flakes on top of the kibble. He eats the flakes, but none of the kibble. I try this several times. Each time he follows me back to the bedroom rather than staying in the kitchen and eating. I sit on the kitchen floor with him for a while. He still won't eat.

3. 9:30 a.m. I tell Liz Arthur needs his full 83 calorie tube feeding again. The same thing happened yesterday and last night for his night feeding.

Good News

I got one of the best phone calls of my life this morning. If he'd been there in person I would have embarrassed myself and him by hugging and kissing him. Who is this "him" you ask? Why our vet, and he called bright and early this morning to give me the results of Arthur's blood work and urine analysis.

::Drum Roll::

Our baby boy is almost good as new :) His liver values are back to normal and everything from his bloodwork to his physical examination say that he's just about ready to have the tube removed and put all this behind him IF he starts eating again on his own.

So our new mission is to get him to eat on his own. At the Dr's suggestion we will be skipping some of his tube feeding times in the hopes that he will be hungry enough to eat his food. This afternoon I skipped his feeding and removed all available food that he could snack on. I gave him a new cat nip toy I bought and waited. Around 5pm he started bugging me and when I put down a can of Solid Gold Tuna he devoured most of it. Now this could be a result of the appetite stimulant we gave him yesterday, or actual hunger but if he can keep this up we can be sure he's recovered and ready to have his tube removed :)

Check up Results

Took Arthur in today for another weekly checkup with the vet. Hes now 14 lbs up from 13.6 last week and the Dr is very pleased with his overall demeanor and the fact he has little to no yellow color anymore. Even the low grade fever he's been running the last few visits is gone and by all accounts Arthur is doing well.

The only fly in the ointment is the fact that he still isn't eating much on his own. The Dr is still puzzled over this and gave us an appetite stimulant to use as needed to try and help Arthur eat more by mouth and less by tube. He took some urine and blood samples to do tests and will call us tomorrow with the results.

While the last few weeks have been stressful and trying in the extreme we are beyond happy with the new vet and the level of care he has been getting. These weekly visits are a benchmark of how much Arthur is improving and gives us a chance to get answers to questions and suggestions for what we can do differently or improve on in regards to his care.

We cant thank all of you enough for you support, ideas and suggestions during this time. It means a lot to us and we cant begin express our appreciation :)

Arthur Eating Very Little With a Side of Frustration

Arthur appears to be doing better in a lot of outward ways. He's much friskier, has gained weight, and he doesn't look jaundiced anymore. Last week when we saw him, the vet was encouraged. That said, getting him to eat is a huge challenge and he seems to be making zero progress in terms of his appetite.

The strange thing is that he is very interested in being fed. Around scheduled feeding times (for him and his brother), he will become very assertive and follow us around meowing and trying to lead us into the kitchen. As we dispense food into the bowl, he gets so excited that he tries to scale the counter to get to it. But then we put the bowl down for him and he rubs his face against the rim of the bowl and lies down. If we walk away from the kitchen, he follows us. If we stay in the kitchen, he starts rubbing his face on our feet and being his affectionate self, but is more interested in us than in eating.

We have managed to cajole him into eating a bit by sitting on the floor with him and repeatedly waving bonito flakes in front of his nose and then dropping them in the bowl. Sometimes he'll eat a few pieces or licks of food out of our hands. We might have to sit there stroking him and encouraging him for 20-30 minutes to get him to eat maybe half an ounce of food. What are we doing wrong? What haven't we tried?

Arthur Eating a Bit, But Very Difficult to Measure How Much

What a weekend it has been! I won't bore you with my non-cat life, but I had to take a business trip to Philadelphia this weekend while Liz stayed home with the boys. I tried to get home Saturday night, but the weather was a disaster. I bought an Amtrak ticket for a train at Philadelphia's 30th street station at 7:30 pm on Saturday and was stuck on the train (and another they made us change to) for over 10 hours, getting home at 6 a.m. I am wiped and so is Liz from caring for the boys by herself while waiting for me to get home. Meanwhile, I have a ton of work to do for Monday morning.

Anyhow, Arthur's still eating in small fits and starts, but here's the rub: he really wants dry food rather than wet! I feel like all of the feeding sins we committed with Arthur and Beowulf are coming back to haunt us.

For those unfamiliar with our whole cat life, I'll list the sins:

• Feeding Mostly Dry Food: We used to feed wet food a lot, honest! For the time Arthur and Beowulf were kittens until they were about 3 years old, our feeding schedule was to open up a 3 oz can of wet food in the morning, wait 30 min for them to eat (or not eat) some, then put down a couple of 1/4 cup scoops of dry food that would sit there all day for them, and then do the same can + dry food routine in the evening.
  
  Where did we go wrong? Over time, they slowly stopped having any interest at all in the wet food so we were basically throwing out a couple of cans of food a day. We tried every type of canned food you can imagine: Wellness, Merrick, Weruva, California Natural, Newman's Own, Spot's Stew, Blue Buffalo, Abady, Felidae, Eagle Pack, Evolve, Wysong, Fromm, Innova, Nature's Variety, and many more. We tried THEM ALL, almost every flavor. The only food they would sometimes eat was Solid Gold Blended tuna.
  
  I suppose we could have refused to feed them dry food at all, but our worry was that they would just stop eating and end up sick (like Arthur is now).
  
  So after a while, we cut back on the wet food cans they were refusing to eat and we started to just feed dry food, but a high-quality, high-protein type. We alternated between Solid Gold Indigo Moon and California Natural Chicken and Brown Rice. Solid Gold Tuna cans became a once-a-week treat.
• Free Feeding: So the other problem, even with the dry food, was that they never ate it all at once. Arthur and Beowulf would eat a little bit of their portion and then leave some. We would let it sit in the bowls as they would come back again and again at random throughout the day to eat.
  
  In Beowulf's case, we would always see him eat a good portion of his food at the time we put it in the bowl, but in Arthur's case, he would often eat later when nobody was watching. In fact, if we walked into the kitchen while he was eating, he might stop what he was doing and want to rub up against us instead of eating.
• Feeding on-demand: We have a rough schedule of feeding at 7 am and 7 pm (give or take an hour), but throughout the evening, Beowulf frequently demands fresh food. How does he demand it? He'll start meowing at us very loudly and the more we ignore him, the more wild he gets. He'll start jumping on the dining room table he knows he's not allowed on and he'll escalate to attempting to knock over a lamp. The way to silence him? Go in the kitchen and dispense food for him.
  
  The problem here: We completely LOST TRACK of how much Beowulf was eating and Arthur was eating. A lot of dry food was/is actually wasted b/c they don't eat it all and demand we give "fresh from the bag" food
  
  The strange thing about Beowulf's behavior is that there might be plenty of food in the bowl, but he wants me (primarily me, not Liz) to come into the kitchen and dispense fresh kibble for him straight from the bag. The bowl could be filled up, but he only wants the freshly dispensed kibble. One exception: sometimes, all he wants is for me to follow him into the kitchen (where the bowls are) and watch him eat the kibble that is already there. The key element,I guess, is my watching.
  
  Unlike Beowulf, Arthur rarely asks for food on his own, even when he is healthy. When he was healthy, he would follow Beowulf into the kitchen when I do a scheduled (morning or evening) feeding and he might have a few bites of kibble then or he might just walk away and come back later to eat when nobody was looking.

So what's happening now? I think Arthur wants a return to normalcy, the normalcy where he sneaks in there and eats dry food and we have no idea how much or little he is eating. That's not good.

When we first got the tube put in the other week, he had no interest in the dry food we left for his brother and we got him to eat an ounce here and there of wet food (usually Solid Gold Tuna). Now, he is opposed to the wet food (won't eat it) and is sneaking in and grabbing some kibble and eating it, but we're having a hard time measuring the calories and knowing how much he ate versus how much Beowulf ate and, considering we never knew the exact amount they were fed, now we're really confused.

I tried on-schedule feeding Arthur 1/4 cup of dry food (an ounce) today and he was very interested in eating it, but in the end, had maybe 1/8 of an ounce of food, not enough to count against his tube feeding. And for him to eat that, I had to drop some bonito flakes in the bowl.

The irony of all this is that Arthur is now becoming assertive about leading us into the kitchen and "asking" for food, but in the end, he is primarily rubbing his cheeks on the bowl and rolling over for a belly rub (for some reason, he has always liked to be petted and rubbed in front of the food bowls). So the tube feeding continues, but we're confused.

I don't want either of the boys to stay on an all-dry, free-feeding diet, but I don't want to do anything that discourages Arthur (or even Beowulf) from eating. Advice please.

Arthur's Mouth Checks Out, But He Still Won't Eat

It feels like we're living with an anorexic food connoisseur. Arthur has a great interest in food and being fed, but doesn't touch anything we give him now. He actually is nagging us for food and circling the food bowls and rubbing his mouth against the bowls, but no matter what food we put in there, he won't touch it.

I actually think the amount of food he is eating now is less than before we put the tube in. Perhaps he is less naturally hungry, because he is getting nourishment from us. But we're very concerned.

Today, we took him back to our excellent new vet, Manhattan Cat Specialists, for a scheduled check-in / check-up. The doctor said that Arthur definitely looks better than he did last Friday. He is much less jaundiced and he has gained weight. The doctor also noticed that he is friskier and generally acts more like a healthy cat.

That said, Arthur still had a low-grade fever when they took his temperature at the doctor's office today. They said maybe he gets a little warmer from stress so they asked us to take his temp at home later in the week and get back to them.

The vet did check out Arthur's mouth at our request and said that his teeth and gums look fine. The vets going theory is that Arthur isn't eating because he is nauseous so he gave us anti-nausea medicine. We fed to Arthur today, but he still isn't eating on his own. However, he does seem to be making his nauseous face much less and he sat still for his feedings.

What We're Fighting For

I've written a lot of posts lately without pictures so I thought I'd share this one I just snapped of Arthur and Beowulf holding hands while they rest in our bed.

Liz and I can't tell you all how much it means to us to have read all your well wishes for Arthur and for us. Some of you have said Arthur is lucky to have us as cat parents, but really we're the lucky ones. I hope this picture gives you a sense of why I say that.

On a side note, Arthur is feeling a bit more frisky and hence is getting harder to tube feed. However, his appetite for self-feeding is still very small, with him eating maybe an ounce or half an ounce of food the couple of times we've tried to feed him today. One small thing I noticed: he takes a long time (maybe 3 to 5 minutes) to eat a very small amount of food and food often falls out of his mouth.

The original vet said his teeth are ok, but I have to wonder if he is having trouble chewing and swallowing his food.

Falling Into a Routine

So, for better or worse, we are working our way into a feeding tube routine. We are now feeding Arthur three times per day, once in the morning, once in the afternoon, and once in the evening.

For the morning and evening feedings, we offer him canned food first. Sometimes, he'll eat an ounce or two of the canned food, but not nearly enough to meet his calorie requirements. So we'll wait 30 minutes to an hour and tube feed him again.

It's kinda discouraging to see him walking away from the food he could eat himself, but it's a huge relief that we have the tube to help us through that. The weekend before we had the tube in, we were freaking out trying to get him to eat. Now, we just put the food down for him and walk away. If he doesn't eat it, we don't sit on the floor begging him to do it, because we know he'll be nourished.

We are still really paranoid about leaving him unsupervised even overnight. Our normal routine when he was well was to go into our bedroom when we were ready to sleep and leave the door open. The boys would then wander in and out of the bedroom at will for a while after we went to bed. However, ultimately, every night we had to kick them out of the room and close the door, because at some point around 3 a.m. or 4 a.m., at least one of them would get frisky and start doing all kinds of wild things like ripping tissues out of the tissue boxes or trying to scale the TV set.

So for several hours each night, we normally sleep with the door closed and let the boys run wild in the living room. Then we get up and feed them sometime around 7:30 a.m. (or earlier if I need to use the bathroom).

However, right now, we don't feel like we can give them those few hours alone in the living room while we are in the bedroom with the door closed. So Liz has slept out in the living room every night since Arthur came home with the tube while I sleep in the bedroom. Liz is able to deal with the lack of sleep, which is a blessing because she can keep an eye on Arthur.

One of these nights, Liz will come and sleep in the bedroom with me again, but for now, we're glad she can keep a closer eye on our sick boy.

Follow Arthur's Feedings in Real-Time. Help Us Streamline

This is a micro level of info that you probably won't find interesting, but since my wife and I have created a google doc spreadsheet to track the combination of Arthur's tube feedings and self-feeings, I thought I'd share it:

http://spreadsheets.google.com/pub?key=tnEd9ZQhmqSPnyHUplyqbKA&gid=0

We are trying to figure out how to make this more efficient. It is very time-consuming. Please send tips! Four times a day, we do this now at every feeding:

I. First offering Arthur a bowl of canned food, which we have weighed and calorie counted.

II. Driving his brother Beowful out of the room and locking him in the bedrooom (we have a 1 bedroom apt so not much room here), but we don't want to hurt Beowulf's feelings so we lock him in with dry food (he won't usually eat wet). We have to isolate Arthur from Beowulf during feedings b/c Arthur won't eat in his presence and, if Beowulf should eat from the same bowl, we won't know how many calories Arthur got.

III. Wait about 30 min or so to make sure Arthur is really done eating, while dealing with angry screams from Beowulf to let him out of the bedroom or while letting him out and watching him to make sure he stays in the livingroom.

IV.Prepare the syringes with food and medicine while deducting the amount of calories Arthur ate (he is usually eating an ounce of food out of a 3 oz can - so maybe 25 to 30 calories, which lets us deduct a fair amount from his syringe)

V. Find Arthur, lay him down in his bed, try to get him relaxed. Inject 5 ml of water into tube to flush it. Then his regular feeding 25 to 45 ml depending on how many calories we deduct.

We are feeding him at the rate of 2 lines on the syringe (2 ml) per minute so just the syringe feeding alone is taking like 15 to 20 minutes, after prepping the syringe (5 min), and giving him the original food and waiting for him to eat it (30 min). The whole process is easily an hour or more and that's 4 times a day.

Deducting Calories for Self Feeding, a Math Challenge. Are We Passing the Test?

If you have a moment, I have a big question I need help with. We have been instructed by everyone (new vet, old vet, hospital vet) to try to feed Arthur normally before each tube feeding. This is good, but making the situation very very tricky, because he is eating on his own, but not an equivalent amount of calories to the tube so we're having to do some math to try to figure out how many tube calories to deduct based on what he consumed.

Here's how we're doing it. If you have any ideas, please tell us how we can do it easier and better. About an hour before each tube feeding, we offer Arthur a can of wet food we think he'll like. Before we give him the bowl, we weigh both the empty bowl and the bowl with the food in it (strangely the same empty bowl seems to vary at between 2 1/8 and 2 5/8 ounces). We sit with him in front of the bowl stroking him and encouraging him to eat. Usually, he actually DOES EAT for a good 5 min, but I guess he is not putting a lot in his mouth at once, because when we go back to weigh the bowl, maybe it ends up being .5 ounces or 1 ounce less than it was before.

We leave the food out for a good hour and sometimes he goes back for more. This morning, for example, we had a bowl of solid golid tuna out for him for an hour. When it first went down, he ate like .5 ounces (not enough), but when I came to take it away an hour later, he ran into the kitchen and stuck his head in and ate about another ounce. We don't know if we did the right thing, but we skipped his morning tube feeding, because we know that the 3 oz can of solid gold tuna has 100 calories (we actually had to call solid gold to ask) and so we figure he ate about half or 50 calories in that sitting. That's a bit less than his tube feeding of 64 calories, but we spotted him the 14 calories this time.

Are we doing this right? Even if we are, it's driving us nuts. Leaving food down, sitting on the floor and nudging him toward the bowl, hoping he eats enough and then trying to deduct the calories from his next tube feeding. Also, we're not sure if our digital scale is accurate enough to really get this down to the ounce. For example, at one point, I weighed the bowl after he had eaten a noticeable amount, and the weight came out higher than before I put it down.

We would love to just stick to the convenience of tube-only feeding, but we want Arthur to eat on his own and, somewhat uniquely for a cat with Fatty Liver Disease, he actually has an appetite and leads us into the kitchen to give him food.

Arthur Still Very Sick, But We Feel a Little Better Due to New Vet

First of all, I just want to thank everyone who has been commenting on these posts and replying to my questions on various forums. I'm sorry that I haven't had time to respond to everyone personally, but I want you to know that Liz and I are really inspired and encouraged by your comments, well wishes, and prayers and I think they are making a huge difference in our health and Arthur's! Please keep them coming!

The photo above was taken on Liz's camera phone a few minutes ago. That's a sleepy, unkempt me tube feeding Arthur while Beowulf sleeps next to him and leans his head on my feeding arm to support me and his brother. That's the kind of being Beowulf is; he is always there to heal and support me, Liz, and his brother, always there to lean on you, purr, and make you feel better. Don't believe the glowing eyes in the shot!

This afternoon we had our first appointment with our new vet, Dr. Plotnick of Manhattan Cat Specialists. I deliberately avoided naming him in the prior post before where I said I had made an appointment with a new vet, because I didn't want to name names until I had actually had my appointment and met him. Now, I definitely have a strong opinion. Dr. Plotnick and his entire staff are incredible and, after our visit, Liz and I felt like we had a new lease on life for ourselves, not just Arthur.

Dr. Plotnick spent a long time with us, answering every one of our questions and putting our minds very much at ease about the feeding tube and what could happen with it. Where the vet hospital had put the fear of God into us about the tube popping out at any moment and Arthur neednig to be rushed into the hospital for emergency treatment, Dr. Plotnick explained that, even if the tube came out, we would simply put a band aid over the open hole in Arthur's neck and then bring him in the next day.

On a side note, his staff also rewrapped the tube and repositioned it so it isn't bumping into everything now. Strangely, the hospital had used a really long tube which complicated things.

He and his team explained to us that we did not need to stay up 24/7 watching Arthur to make sure he does not pull the tube loose. That may sound like a very minor thing to say, but to us, it's a lifesaver.

I could spend a much longer post -- and perhaps I will at some point-- talking about everything that is right with Dr. Plotnick and Manhattan Cat Specialists, because they are just amazing. But right now I'm going to selfishly go to bed in a few minutes and enjoy some of the lost sleep Dr. Plotnick has given back to me.

But before I sign off this post, here's an update on the most important thing, Arthur's health. The doctor agrees with the diagnosis that Arthur has fatty liver disease. However, he did discover (something our old vet did not) that Arthur has a fever. He believes the fever is evidence of some kind of underlying infection, but none of the prior tests done by the hospital or our old vet were able to detect an infection.

The old vet / hospital did put him on the Enrofloxacin antibiotic because they suspected some kind of infection, but they never could tell what it was. Without doing further tests -- which he does not recommend at this time -- our new doctor cannot tell what the infection is. However, he prescribed an additional antibiotic that should fight other types of infection so, even though we don't know the exact infection, we're hopefully fighting it. We're also getting another liver med that is going to help with the bile flow (I forget the name, but I can share that later).

Dr. Plotnick told us not to retest the liver values too frequently; he said this whole process is going to take several weeks and that we shouldn't even test Arthur's blood again for three weeks. What a difference from the hospital and other vet who wanted to retest his liver values today and then possibly rush him into exploratory surgery if we didn't see improvement or if the number didn't at least hold steady. Dr. Plotnick told us that liver values may go up and down throughout treating this disease and you can't just keep looking at them every day or even every week.

Despite the fact that we don't need a new blood test for a while, we are going to bring Arthur over to MCS weekly until his next test, just because Liz and I want the staff to check his tube, take his temp, and look at his weight, just to see if there's any trouble with those things. Finally, we have a plan and next steps for Arthur that don't involve rushing him to the hospital or setting frightening deadlines like "if he doesn't get better soon, we might want to cut him open."

Oh, and on another note, Dr. Plotnick did tell us what he normally does / would have done if we had been his patients when this all started. He said he would have done a single procedure where
he did a sonogram-guided liver biopsy and inserted a feeding tube at the same time. Apparently, a sonogram-guided biopsy is a better way to get results than the myriad of aspirate biopsies and separate sonograms that were conducted by the hospital and our old vet. It also sounds like it would have been thousands of dollars cheaper.

Before I go to bed, which I must, I have one open question here. What do I say to our old vet? She actually, without prompting, called today and left me a voicemail message asking us to come in for the next liver test (the same one we're not doing for 3 weeks) and to pick up some medication (cream-based antibiotics) she had ordered last week that we no longer need. I suppose Liz or I need to call her back and tell her, but I'm not looking forward to it. I think I will just say that we've chosen a more "full service" vet and leave it at that. The thousands of dollars that she got us to spend on a haphazard patchwork of tests and emergency hospitalizations are gone and I can't see anyway to get them back, though I hope our pet insurance will reimburse us some of it. The potentially dangerous advice that she gave us by saying "as long as he eats, he'll be ok" is water under the bridge now.

There's probably no point in arguing and I guess I should thank her for detecting Arthur's illness in the first place, though I'm sure another vet would have also and would have handled it a lot better. What would you say?

Can the "Crisis" Come to an End?

We'll be seeing our new vet at 4:30 pm today and we have many questions for him. The most important of these is: how much can we relax?

Yesterday when I spoke to him, I asked the new vet if it was a good idea to switch doctors in the middle of "a crisis" like this. He said "what crisis? He's on a feeding tube. You know what to do. This is not a crisis."

"It is for us," I corrected him.

For the past 10 days, Liz and I have been in "crisis mode" 24-7 with Arthur. If it wasn't rushing him to the vet and hospital for tests and then worrying about him when he was at both of those places overnight, it has been monitoring and caring for him at home.

After he got home from the hospital last Thursday, we spent hours every day and night watching him to see if he ate and then cajoling him to eat and sometimes spending hours sitting on the kitchen floor with him, petting him, and begging him to have a few more licks from the bowl.

Now that we have the feeding tube inserted, we have more concerns. Will the tube pop out when we're not looking? Will he got caught on something he tried to rub against? Will his brother, who has been very sweet, decide he's ready for a play fight? Since he came home with the tube, Liz has stayed up all night every night watching him to make sure nothing happened to the tube. During the day, she has caught a few naps between feedings during the day, when both Arthur and Beowulf seem more sedate. The lack of sleep, food, and leaving the house is taking a MAJOR toll on her health. It's no picnic for me either.

In the mornings and at night, we try to feed him regular food and then hang our hopes on his every lick and bite or lack thereof. We watch his mood and behavior as we're watching him. Is he looking better or worse? Could he be getting worse, despite our best efforts? Does he need a biopsy? What would that mean?

I would love for the new vet to tell us "listen, you really can relax. I'd like to see him reposition the feeding tube so it doesn't seem like it's about to get caught on something, to give us some reassurance about Arthur's progress, and to give us some advice we can use. We're willing to stay up all night monitoring him every night, but it is taking its toll on us in a huge way.

Trying Out a New Vet Tomorrow

Here's the latest update. My friend and world-class cat sitter Leslie Kaufman recommended that I speak with her vet. She told her vet I would call him and I did and I was very impressed with his knowledge and straightforward answers to my questions. Based on our conversation, I've decided to take Arthur to see him tomorrow and, unless the visit goes poorly (in terms of our interactions with him and his staff), he will be our new vet from now on. I was very impressed with him over the phone, where talked to me free of charge for 35 minutes! That's more advice and info than we got out of the hospital doctors after spending thousands with them.

Leslie's vet actually did not say anything that would directly contradict or criticize the work of my current doctor or the hospital doctor. He said he didn't think I needed a second opinion or to come see him. However, the conversation we had revealed a few things to me:

• Our current vet outsources services Leslie's vet can provide in-office: Every single one of the expensive tests and procedures we just put Arthur through at the hospital could have been done at significantly lower cost in the vet's office. However, our current vet apparently isn't capable for whatever reason of doing much in her office so her reaction to any kind of illness is to refer people over to NYVS, which is New York's most expensive hospital.
  
  Imagine if your human doctor had to refer you to the hospital emergency room any time you came in with something more severe than a head cold. It would be very expensive, because the hospital emergency room is much pricier than the doctor's office.
  
  We can't put an exact number on how much the tests, IV, feeding tubes, etc, would have cost us at a vet's office, but it sounds like the whole thing would have cost less than half of what we paid so far, conceivably far less than half. If for no other reason than to save money on any future procedures or tests, we have to switch vets to someone who is capable of doing more in their own office.
  
  In addition, I now understand (though I don't think it's cool) why the hospital doctor keeps trying to punt me back to the vet for answers and the vet keeps trying to punt me back to the hospital for treatments and answers. The hospital relies on the vets for referrals; they are an emergency and special care facility and they do not want to be someone's primary point of contact. They want to supplement what the vet is doing. Unfortunately, if the vet is like ours and keeps punting us back, it seems like nobody is taking charge of the care.
  
  
• Don't panic about the feeding tube! The vet hospital told Liz that, if Arthur throws up, we need to rush him over to the hospital for emergency care, because he may dislodge his feeding tube. Leslie's vet told me that is not the case and we don't need to panic. Liz and I were freaking out thinking that if we even found a tiny puddle of vomit on the floor and thought it might be from Arthur that we would have to rush him for emergency surgery (at huge cost and trauma). We hear that's not the case.
  
  
• Don't expect overnight results: The hospital told us to take Arthur in for another liver enzyme test tomorrow and expect to see improvement less than 48 hours after he started on his feeding tube. Leslie's vet said we shouldn't expect to see any significant change in Liver enzyme results for a week or more.

So I feel a bit better and I look forward to meeting the new vet in person.

Liz successfully tube-fed Arthur twice so far today. He is supposed to get 4 feedings today. We were able to skip the morning feeding b/c he ate half a 3 oz can of Merrick Cowboy Cookout food. The evening feeding is coming soon. Hopefully, he will once again eat of his own accord.

Arthur Home With Tube In. More Vet Impressions

So I came home from class tonight (really felt like I couldn't miss class two weeks in a row) and Liz had picked Arthur up from the vet already and gotten instructions. He is feeling groggy from the anesthesia. Liz was told to keep an eye on Arthur all night tonight to make sure he doesn't fall asleep with his head in the water or food bowl and presumably to make sure he doesn't disturb the tube.

The picture above shows Arthur practically passed out in front of the bowl. He did actually eat a 1/3 to 1/2 of the bowl before he laid down again. What concerns me about this tube is the placement. Any time he rubs his head against anything (which he does all the time), he is jostling the tube. Did the vet put it in the wrong place?

He is supposed to get 4 meals a day for a total of 250 calories for the next few days. He is supposed to get his liver values checked again on Friday and hopefully we will see improvement. As I said in an earlier post, the hospital wants to do a biopsy if he doesn't improve, though Friday is not necessarily a firm deadline for improvement.

I am VERY concerned about the tube. On the one hand, I think it's necessary to help him consume enough calories. On the other, I think they positioned it very precariously on his neck. If it comes loose, if he vomits, if he bleeds, if anything happens at all, he has to be rushed to the hospital again.

Call me a nattering naybob of negativity but I'm concerned that the hospital doesn't care about helping Arthur at all. For over $5,000 in medical expenses, not only have they failed to make him better, but his liver numbers actually went up. And they don't seem even remotely interested in answering questions or providing us with the information we need to help him.

This morning, I brought a printed listed of questions to the hospital. I waited patiently for the doctor to come over and explain the procedure. Then I started asking her questions. She said "it sounds like you put a lot of thought into this, let me take your paper so I can properly answer your questions when you come in later."

When Liz came in later, she did not get to speak to the doctor, but to a vet tech instead. The vet tech handed her back the paper. You can see in the picture below how seriously she took our questions.

If you click the image, I believe it will enlarge so you can see my Qs and her As or lack there of. The first question, "how much food does Arthur need to eat each day?" is one that she would not explicitly answer for us last week and which our regular vet would not answer either, until the feeding tube was put in today and they finally said "250 calories."

Was asking about required food intake too much to ask? If we had known about that 250 calorie number over the weekend, we might have been able to act upon that information, feed him high-calorie feed and prevent him from getting worse. Instead, I was shooed away by both the vet and the hospital doctor, both of them annoyed by my questions and telling me things like "if he eats at all, you shouldn't worry" or "I can't really tell you how much your cat needs to eat" or "don't believe things you read on the Internet about how much a cat with fatty liver disease needs to eat."

Anyhow, right now, we can only pray that the feeding tube works, that Arthur gets better, and that we can move on from this.

Biopsy Or Not?

So, my wife just got a call from the hospital; Arthur came through the feeding tube surgery ok, though for good measure they are going to charge us for an additional blood test (we don't know how much yet) b/c they tested his blood clotting to see if he would bleed too much. That means the feeding tube procedure all by itself will have cost well over $1,100.

Liz will be picking up Arthur in a couple of hours and will receive food and instructions at that time. However, they already told her that we need to get his liver test redone in just 2 days. If the test does not show significant improvement on Friday (less than 48 hours from now!), they are saying they would like to do a liver biopsy.

A liver biopsy would involve cutting him open at very significant cost (if a feeding tube is $1,100, and a couple of blood tests is $3,200, what do you think open chest surgery is - $10,000?) so unfortunately I think the hospital is "rooting" for this outcome. The biopsy would, we guess, determine whether he has cancer or not, but if he does, it doesn't sound like much can be done.

My question: Is less than 48 hours enough time to see the kind of improvement they are looking for? If the test numbers come back the same or worse on Friday, should I go along with their biopsy, ask for more time, or go for a second opinion somewhere that has no association with this hospital?

While we wait, vet questions.

At this moment, Arthur is at the hospital, presumably about to or already undergoing his feeding tube surgery. We're waiting to hear from them and haven't yet. In the mean time, I have a question, which I posted elsewhere earlier, but thought I would share here as well.

As I said earlier, I am not 100% happy with my vet right now, though Liz still does so the opinions expressed here are mine alone.

Questions:

1. Should I start shopping around for a new vet right now or wait until Arthur hopefully recovers?

2. If I do shop around for a new vet, here are the choices I have narrowed down to. Remember that I live in Manhattan.

What do you think of each (my apologies if any of these people find this post on Google and see me talking about them)

Choice #1: The Manhattan Cat Specialists (http://www.manhattancats.com/). This one is recommended highly by my cat sitter Leslie, who has used them for years. She says she can get me a free phone call with the head vet, Dr. Plotnick, just to take my questions and decide whether I want to use them.

A few negatives here:

A. They are very far from my apartment (long, expensive cab ride)
B. They work with the same overpriced hospital (NY Veterinary Services) that my current vet has been tossing us to. The bad side of that is that I'm not a huge fan of NYVS and their extreme charges. The good side, right now, is that it would be an easy transition at the moment, because Dr. Plotnick has a relationship with NYVS so he could easily consult with the doctors there on what they saw and did to Arthur. If I talk to Plotnick, I will ask him whether he performs some of his own surgeries rather than constantly turfing people to the hospital like my current vet. If he can do things like add/remove a feeding tube in his office, maybe his relationship with the NYVS isn't that problematic.
C. Practice will probably be as expensive or more than I'm paying now.

Positives:

A. My cat sitter knows all the city vets and picked this one.
B. Dr. Plotnick sounds good (http://www.catchannel.com/experts/arnold_plotnick/default.

Choice #2: ASPCA Burgh Memorial Hospital (http://www.aspca.org/aspca-nyc/berg-memorial-animal-hospital.html). A friend of Franny's recommended I call their head of vet medicine, Dr. Murray. Dr. Murray does not see new patients anymore, but I ended up talking to her administrator for like an hour and the administrator advised me to seek a second opinion and to demand my current vet give me more info.

Pros:
* ASPCA is known for being affordable
* Michelle, the administrator I spoke to, seemed to geniunely care a whole lot about Arthur, calling me about 3 times throughout the day even though I'm not a client (yet) and paid her nothing.

Cons:
* I don't know a lot about the doctors there
* They have some very poor ratings on Yelp and other online comment services, these talk about long wait times and more of a public clinic atmosphere
* Also, very far from my house.

Choice #3: The Cat Practice (http://www.thecatpractice.com/). I actually don't know much about this place, except that I found it online and it has really strong user reviews. It's also only about 15 blocks from my apartment, which is still a cab ride but a short one.

Pros:
* Close to home
* Good reputation (at least as I've seen online)
* Web site makes it sound good

Cons:
* Allegedly expensive
* They don't know me and I don't know them at all. I have an "in" with the other two vets.

Choice #4: Stick with my current vet. Current vet is located walking distance from my house and does not charge exorbitant prices, except that she is constantly trying to pawn us off on the hospital for procedures / tests I wonder if she could have done in her office. My wife likes her, but I am losing confidence in her after she A.) was slow in returning some phone calls, B.) Would not give us a straight answer about Arthur's diet or condition and C.) Thought he was fine until I had to ask her nicely to conduct a blood test that she didn't think was necessary.

Pros:

Close to home
Knows our case very well
Seems like a nice enough person
Her own services are not overpriced, when she's not sending us to the hospital

Cons:
In my opinion (but not Liz's), she exercised poor judgment in a number of areas:

a. She would not give us a straight answer about arthur's food in-take, saying only "if he eats even a tiny amount, that's ok." And when I said I had heard / read different, she said "don't trust the Internet."
b. If we listened to her, Arthur might be a lot worse right now, because she said he was getting better, until we forced her to do a test.
c. She seems to want to refer us back to the hospital whenever possible. Couldn't another vet be performing some of the needed procedures/tests - the sonogram, tissue tests, and feeding tube insert -- in his/her own office at less cost? When we asked her if she could refer us to a less-expensive hospital, the only option she offered was to not insert the feeding tube and "see what happens."

SO MY QUESTIONS ARE:

A. Should I switch now or wait until Arthur is better?
B. If I do switch, who to?

Please Pray for Arthur (an Update)

I don't want to spend too much time rehashing everything that has happened to Arthur (and us) over the past week, but I'll point to a forum thread on About.com where I've been discussing the whole thing under the user name geekinchief23.

Here is where we stand right now. Arthur came home from the hospital last Thursday (2/25) with some prescriptions and an order to get back to eating. As you may know by now, he has fatty liver disease, a condition which is curable if the cat gets the right amount of food into them fast neough.

Over the weekend, we got Arthur to eat and he has eaten a bit every day, but we were concerned that he was not eating enough. By our count, he is a 13.5 pound cat and has been eating maybe 2-3 ounces of food per day, if that. However, his behavior has improved, though he is traumatized by being force fed the beyatryl antibiotic pill every day (he'll get a skin solution for it soon). My wife Liz and I have been whipping out a can of his favorite food, Solid Gold Blended Tuna, maybe 3 times a night and maybe one of those 3 times, he will actually want to eat and will eat maybe 1/3 or 1/4 of a 3 oz can. In between he will have maybe 5 to 10 pieces of kibble, though a lot of the kibble crumbs are falling out of his mouth.

So my wife Liz and Iwere concerned: Was he eating enough? Unfortunately, nobody would give us a straight answer about how much he was supposed to be eating. We called the internal medicine specialist who saw him at the hospital (which nearly wiped out our savings by conducting $3k worth of tests) and they said "we can't really tell you how much is enough. Don't worry about it."

We talked to our own regular Vet who said "if he's eating anything at all, he will be fine." Call us worry warts, but neither of those answers inspired confidence in us. Today, we took him into the vet and where normally Liz goes by herself b/c I'm at work, I left work for the afternoon so I could go with her. I talked to the doctor and demanded some answers about the amount of food he should be eating.

Again, she reiterated her extremely vague response. "If he's eating at all, I wouldn't worry," she said. I said "he's eating about 2 ounces of food a day. Isn't that too little?" She said "maybe that's normal for him."

She weighed Arthur and indeed he had gained weight since his last weighing. He was now 13.5 pounds where he had weighed in at 13.2 when we brought him in the day before. She said "I think he's doing great, but if you really want and it would make you feel better, I'll run a blood test on him now while you wait to check his liver values again." I said, "yes, please run the test."

Liz and I sat in the waiting room for about 20 minutes and then the doctor came out with a sad look on her face. She said that his liver values had taken a significant turn for the worse. Where his liver number had been 4.2 when he left the hospital, it is now 7.0 (higher is worse).

She said to us: "Hmm, maybe he isn't eating enough. I called the hospital and they suggest putting in a feeding tube." A feeding tube is something we had been asking about and suggesting ourselves (against both the hospital's and her objections) since he was diagnosed.

So tomorrow, he is going back to the hospital and will get a feeding tube installed, probably at an exorbitant price that will really hurt us. We are praying that he will now be ok, but of course, the hospital and vet are not inspiring confidence with their vague and incorrect answers.

We thought about taking him to another vet and we were considering an appt with one at the ASPCA, but right now I feel like I don't want to start over with a new doctor while his condition is declining like this. If we get the feeding tube in and he starts to improve, maybe then we can take him to some place that doesn't know him or maybe this is just a lesson-learned that we need better people to care for him and Beowulf in the future.

I will tell you candidly that this illness has been very very hard on Liz and I. We are not eating or sleeping. We have constant stomach aches. We are distracted and we're not ashamed to admit that, even though we are not religious people, we are doing a lot of praying lately. Please send your best wishes, positive thoughts, and prayers, not to us but to Arthur. He's going to need them.