Monday, March 10, 2008

A Case of Diabetic Mismanagement? (Kentucky)

This post is about vets that I think are bad, even though the State Veterinary Board found nothing wrong with what they did. And, it is a good example of the kind of complaints that get dismissed. Moreover, this story strikes close to my heart -- as it is about a diabetic cat.

What is particularly disturbing to me is that it appears to me that this cat -- a diabetic -- was being mismanaged and not properly treated by her primary veterinarian (NOT the veterinarian who the owner filed a complaint against), and that this led to repeated crises (hypoglycemic emergencies for the cat.) Ultimately, the cat was taken to another hospital to be treated for hypoglycemic seizures. According to the allegations, instead of receiving a "bolus" (large infusion) of dextrose (water with sugar in it) to raise her blood sugar, was given only a glucose drip, in spite of a very low blood sugar and severe seizures. [Interestingly, when interviewed by the Board, another vet at this hospital claimed the cat WAS given a bolus, but this is not jiving with other statements or the records.] It seems evident to me that this cat's diabetic emergency was NOT dealt with aggressively enough, possibly therefore leading to much more severe brain damage than would otherwise have occurred. Yet, the Kentucky Board dismissed the case, saying there was "insufficient evidence to warrant disciplinary action." Although the owner filing the complaint was not mad at her primary veterinarian, it seems evident to me that the primary vet's mismanagement of this cat's diabetes in fact created the situation in which these repeated, devastating attacks of hypoglycemic occurred -- ultimately leading to the brain damage that caused the cat to be put to sleep. Here is the story:

The complaint filed by the owner said this:

"I took my cat to [Animal Hospital B because it was clsoe and I could not get to [Animal Hospital A] on Saturday, 10/1/05 at 1pm. She was having a severe reaction to insulin (she is diabetic). I told th evet that she was diabetic and needed to be stablized -- they took her in the back and they told me to call back before they closed at 3, which I did. I was told [vet name blacked out] would phone me later with an update. I got home around 5 and there was a message from the vet to call her, which I did. She said PeeWee was still having seizures (which is not normal at all when I take her to [Animal Hospital A] and that a vet tech would be in at 8 to check her blood and would call me with a status report. At 8:30 a vet tech called and said it was very bad ("critical.") She was still having seizures and her blood sugar was dangerously low."

[Note to reader: This cat has now been seizing with very low blood sugard for 7 and a half hours. This can cause severe brain damage, as it did in my cat who was allowed to keep seizing for hours.]

"I said that I have to come get her and take her to [Animal Hospital A]."

[Note to reader: Animal Hospital A is the place this person usually took her cat, for repeated prior such episodes, where they were apparently able to treat the cat with a bolus infusion of dextrose -- but more on that later.]

"When I got there she led me back to my cat and I said I need to take her NOW! The tech kept stalling saying [vet's name blacked out] will be mad and I need to pay. I don't know how long this went back and forth but to this point my cat had been having seizures for seven hours ad I was not happy. Her blood sugar level was 13."

[Note to reader: normal blood sugar for a cat is 60-150. Readings less than 30 are VERY DANGEROUS and can lead to seizures that cause permanent brain damage.]

"I finally got my VISA card out and gave it to her to keep and told her to give me my cat NOW!!! When I got her to [Animal Hospital A] her temperature was 93 degrees and they even asked me to consider putting her down." [Note to reader: Normal body temperature for a cat is about 102 degress. Severe hypothermia often accompanies severe hypoglycemia.]

"PeeWee would have died at [Animal Hospital B]. [Animal Hospital A] had her semi-conscious and semi-responsive in less than an hour when I got there."

So what is up with this story? Reading through the rest of the record, many things become clear:
PeeWee was in bad shape when she got to Animal Hospital B. The vet, in her response to the complaint, describes PeeWee on admission: ". . . in very bad shape, elderly, hypoglycemic, seizuring, hypothermic, meowing, drooling." Then the vet says that they started a glucose drip. They DO NOT say anything about a bolus of dextrose, which is called for in such severe cases.
[Another vet from this hospital later claimed a bolus was given, but this contradicts other statements and the records.]

This vet also notes that the owner reported to him that PeeWee had prior incidents like this since she had her dose of Lente insulin increased.

In the Board's interview with the owner who filed the complaint, the owner said that when she had taken PeeWee to her regular vet for hypoglycemic emergencies the vet "would give her a bolus of sugar IV and she would respond in an hour or so." [Note: A bolus is a larger amount delivered at once, rather than a slow drip.]

This raises a very important question: WHY was PeeWee in repeated crisis? What was wrong with PeeWee's primary treatment regimen -- prescribed by her vet -- that had her in a state where she was having repeated hypoglycemic emergencies?

In the course of the investigation, the veterinary board got a statement from the regular vet. One thing to remember is that the REGULAR vets are the people who had recently increased PeeWee's insulin dose.

The regular vet said that when PeeWee was rushed to them after the owner retrieved her from Animal Hospital B, her glucose was still less than 20 and she was in a coma. She said that PeeWee was "overhydrated" and had a bag of Lactated Ringers solution attached to her leg from Animal Hospital B. [Note: Lactated Ringers does not have ANY sugar in it -- which is what PeeWee needed]

[Another vet also attested that when PeeWee was brought into Animal Hospital A, "She had a catheter in place and a bag of fluids attached to it. The bag was labeled Lactated Ringers Solution, so I assume that is what was in the bag. There was no writing on the bag indicating glucose had been added, so I assume no glucose was in the fluids." [Note to reader: This statement raises questions about whether PeeWee got ANY needed glucose AT ALL at Hospital B!!!!] The vet adds: "There was approximately 300cc's of fluid left in the bag, so I assume 700 cc's had been given." This is a HUGE amount of fluids to give to a cat, and the vet notes that the cat was "overhydrated."

In her statements, regular vet ffom hospital A said: "We changed the fluids to Normal Ringers with 5% dextrose and gave her a bolus of 25% dextrose . . . at midnight [two hours after she was brought in] the glucose was still less than 20. We gave her another bolus of Dextrose and by 4:00am she was eating ravenously. Her glucose was still only 30."

The owner took PeeWee home the next day, only to have to return with her the following day, saying PeeWee had "collapsed." This time, PeeWee's blood sugard was 599. The vet did discharge PeeWee in the evening after giving her fluids and insulin "with the understanding to check the glucose four to six hours post insulin for two days."

This is what I find so disturbing. While it is good the vet talked to the owner about hometesting in this circumstance, blood sugar testing on a diabetic cat shoud be done at the time the shot is given -- not just many hours later -- and it shoudl be done EVERY day, not just after emergencies. Moreover, Lente insulin is a humulin insulin -- not one of the better insulin for cats.

The vet goes on to say:

"[PeeWee] returned on October 8th with a glucose of less than 20. We gave her a bolus of dextrose and put her on Normasol. By 4:00 pm the glucose was 30. The owner took the cat home at 8:30 that night . . . on the 16th she returned with the cat not eating and dry heaving. The glucose was 686. The owner okayed treatment for 24 to 48 hours to see if she improved. By 11:00pm there was no improvement and the owner elected to euthanize her."

Now, here is the good example of how vets stick together, protect each other, and blame their clients for everything:

"The owner had trouble leaving the cat with us long enough to stablize her initially. Who knows if the cat would have responded if she had received a bolus of glucose at Dr. [vet's name blacked out -- vet from Animal Hospital B]. She had brittle diabetes and age against her."

These statements outrage me as someone who has cared for three diabetic cats. It is clear to ME that this veterinarian, from "Animal Hospital A" -- the main veterinarian, was not adequately managing this cats diabetes in the first place, therefore the cat was in a state of chronic crisis. In spite of these repeated episodes of brain-damaging hypoglycemia and life-threatenig hypERglycemia, this vet does not make ONE mention of re-evaluating her patient's insulin protocol, diet, or home monitoring. She just blames the cats failure to do better on "brittle" diabetes and "age."

This is unconscionable in my opinion, and the statements of a delusional vet who is failing to take responsibility for her lousy protocol that is endangering, repeatedly, this patient's life. There are MANY things she could have done -- and did not do -- to help this owner help this cat.

1. Change to another type of insulin. In recent years it has become evident that Humulin insulins -- like "Lente" -- the insulin this cat was on -- are rarely the best choices in cats. Many other insulins are available, specifically both PZI insulin and Glargine (also known as lantus) are longer acting than lente and less harsh in the cat, resulting in a flatter curve and providing better regulation. In spite of the repeated trouble this patient of hers was having, it seems at NO time did this veterinarian question her own protocol -- including the insulin. To my mind, this is outrageously irresponsible.

2. Counsel the owner to implement dietary changes that improve diabetic control. It does not say in these records what food the cat was eating, but it is also well known that diabetic cats should be on a diet of low-carb canned food. This helps avoid the highs and lows that PeeWee experienced. I highly doubt this (in my opinion LAZY) vet was doing that.

3. Counsel the owner to TEST THE CATS BLOOD SUGAR before EVERY shot, ALL the time -- not just spot checks in the 2 days after a crisis. This cat clearly needed closer monitoring and management at home -- the owner would have no way of knowing this. The veterinarian should have counseled the owner to test PeeWee's blood sugar before every shot, and also whenever possible mid-cycle, every day. This poor cat could have been receiving shots of insulin when her blood sugar was already too low to need it. No doctor would advise a human client to inject insulin into himself without testing his blood sugar first -- to do that is highly dangerous. But owners don't know that unless vets tell them.

It seems evident to me that this cat's diabetes was being chronically mismanaged by her original vet, and then she received inadequate treatment in a hypoglycemic crisis which allowed brain damage to occur.

Do you want to know how to save your cat from such tragedy if he or she should become diabetic?

The best thing you can do is to join an online community dedicated to caring for diabetic pets. There are two out there that I would recommend:

The members of these lists -- conscientious owners of diabetic pets themselves -- will counsel you on how to hometest you cats blood sugar, and have a wealth of information on insulins and diet. Much of this information is taken DIRECTLY from the most current, cutting edge thinking in diabetic care, which unfortunately, many vets are not up on.