They talk about those cases that stick with you for many reasons, but ones that meant so much to you that for the rest of your life when you see a patient with that name you will think of that special case. I had one of those this week. Patches.
Patches came to the ER with an ATE, or arterial thromboembolism.
Let me give you all some medical background first:
cats get this type of heart disease where their heart's walls get thick and blood flow becomes more stagnant, creating a perfect environment to form big clots in the heart chambers...with bad luck and progression of the disease these clots can break off, fly through the blood stream, and lodge at a distant site, stopping blood flow to that site with a huge blood clot. Most of the time these cats seem fine to owners, they have no idea they have heart disease, until they throw the clot. Most of the time the clot is thrown to the legs, often back legs. The cat's blood supply to his or her legs is cut off. You can imagine, this makes it so the legs are non-functional, and as the cells die from loss of blood supply it is excruciatingly painful. Commonly the cat develops congestive heart failure within 12-24 hours of throwing the clot. If the cat survives the episode with extensive critical care in the hospital (which they will have statistically a 50% chance of doing) they then have 40-60% chance that they will have another similar or worse episode in the next 9-12 months. Naturally, you can imagine, most owners when told this on presentation to the ER decide to euthanize their cats. Additionally, most vets tell owners to euthanize upon arrival cause they know the prognosis is poor. But still, if owners have the money and the vet is not pushing to euthanize a painful cat, the cat could survive and do well, its just that the odds are against him.
Patches was one of those cats. The ER vet who admitted him at 11pm on Tuesday urged the owners to euthanize, but they wanted to try and hold out for their sweet boy. He was transferred to me on cardiology on Wednesday morning.
He was on tons of pain meds when I first met him, so naturally he was happy. Our cardiac evaluation including a PE and echocardiogram did reveal the usual underlying severe heart disease. Despite our discussing the poor chances and the likelihood that Patches would develop congestive (and possibly fatal) heart failure in the near future, the owner loved him and wanted to give him another day. Patches was a brave boy, and I began to believe that while he had lost the function of both hind legs, his caring owner would help him become one of those few survivors with lots of TLC and intensive home care.
The next morning I came in to find Patches' cage empty. At first I thought "Hmm, he must of been doing well, so they moved him from ICU to the general ward." but after seraching there I got more nervous...I found him, in the oxygen cage hooked up to EKG monitors, IV fluids, and other monitors in ICU. Not good.
Patches had reperfusion injury. Sometimes when cats get through the clot part, their body can develop collateral vessels to their legs, and even regain some function (though minimal). The sad part is that when the vessels reach the dead legs all the breakdown products from the dead muscles circulates the entire body, causing all sorts of changes to the bloodwork, severely slow and abnormal heart rates, and multi-organ damage or failure. Despite this horrible turn for the worse, Patches owner was excited that he might be regaining some function to his legs, she wanted us to keep trying. We put Patches on SO many drugs to manage all the horrible things happening to his body, and through all this he continued to love my affection and visits to his cage.
I was sad, and was told yet again that my patient would probably die overnight, but I arrived the next morning and found that he was starting to improve. It seemed the worst of his reperfusion had ended. His right leg still didn't work, but it looked like some of his left and at least two toes on his left leg were functioning. However, his kidney values had slowly been rising ever since he had first come to the hospital, and that morning was the first morning that had reached dangerously high levels. After all this, Patches was in renal failure. Of course, with aggressive IV fluids we might be able to reverse it, or at least slow it so he could live comfortably at home for quite some time. But, when a cat has heart disease and you give him too much fluids you can easily push them in to heart failure. And we had Patches on a very high rate of IV fluids this whole time since we had been watching his kidney values slowly rise.
And for the first time since I had known him, Patches was acting depressed. Instead of his usual exuberant greeting when I came to check up on him, he only had the energy to open one eye and acknowledge my presence. If I was kind enough to place my hand near him, he would gently use his paw to pull my hand closer so that he could rest his head on my hand. After all this, we discussed Patches bad state with his owner again. Amazingly, he had survived the worst of his heart disease, but now his kidneys were failing. His owner then revealed that she did not want Patches to die in the hospital, nor to be euthanized. Instead, she wanted a "natural death" for her cat. She decided it was time for him to come home. I would of been fine to have his owner take him home for a day or two to spend his last hours with his family. But instead she was taking him home to slowly starve to death and have his kidneys give out on him over the next two weeks, or if his heart disease flared up, he will drown in the fluid in his own lungs. I have never been so sad. Euthanizing great pets is hard, having patients you care about die in the hospital despite your care sucks. But to make it this far, to pour all our work in to saving this cat against the odds, and for him to pull through and do it too, only to have him taken away to suffer and wither away, was heart wrenching for me. I cried so much last night for him. I hope that maybe he will continue to defy the odds, and while the chances of him surviving to be a semi normal cat (without back legs working of course) are about 1 out of 200, he might be the one.
Good luck Patches, you have definitely left an impression on me, my heart is with you, and whenever I meet a cat named Patches I will think of you.
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