What to do?

I'm a little aggravated by a phone conversation I just had with my vet's office. Maybe my expectations are too high ... well, let me lay out the situation so you can judge for yourself.

The Basics:

Isabella is diabetic. Isabella has a recurrent vaccine-associated fibrosarcoma which seems to make her limp. Isabella's vet (Dr. H) prescribed metacam, an NSAID, for pain. This drug can be quite hard on kitty kidneys, so she first did a blood test to verify that Isabella's kidney function looked OK, and then asked that I bring her back in for another blood test after two weeks on the drug to make sure that things weren't going south. So far so good.

Four days later:

Isabella got sick. I stopped the metacam (in case that was the cause) and took her to the vet for fluid-fluffing, etc. This time I saw Dr. S (for the first time) who a) said don't bother wit the metacam, and b) very, very strongly encouraged surgery - repeatedly if necessary - for her tumor. (We can take it out every 4-6 months for quite a while.) These two docs clearly have very different approaches. That's OK - it's good to get a variety of viewpoints. I'm not a fan of the serial-surgery idea, though.

Two more weeks:

Isabella is feeling and acting all perky and normal again, so I decide to re-start the metacam for a couple reasons: 1) she's still limping, and 2) there's some discussion among some vets that anti-inflammatory meds might slow tumor progression. Hey - that's worth a shot! So I start it up again, which also starts the clock ticking on Dr. H's request for a blood test after two weeks on the med.

And another two weeks:

Ding! Time for a blood test. We scamper over to the vet for the blood draw (no appointment necessary!). When I get there, I say I need a blood test because she's on metacam. Blank looks from the front office staff. To check her kidney values, I further explain. Oh! OK - that's a full blood panel, and $90. (Yikes!!! I sure hope I don't have to do this every two weeks.) The cat is whisked away and her blood is letted (can I say it like that?) and I'm told to call tomorrow for results. While I was waiting I noticed that they had a new associate listed on the business cards - Dr. M.

Today:

I call for the blood results and am told the doctor will call me back. When the call finally comes, it's the new associate - Dr. M. (Sigh - where's Dr. H???) The call goes something like this:

Dr. M: Hi It's Dr. M from the Cat Hospital. I'm calling about Isabella's blood test results. I'm concerned - her blood sugar is quite high.
Me: Well, she's diabetic.
Dr. M: Yes, I read the chart and saw that. Is she on insulin?
Me: Yes - she's on PZI; has been for two years. (which is no doubt in the chart...)
Dr. M: She doesn't seem to be regulated.
Me: Sigh. No, she's never been regulated. It's a challenge.
Dr. M: Feline diabetes is a tricky disease...
Me (hoping to get to the point): The reason for the blood test is that she's on metacam. Do her kidney values look OK?
Dr. M: Oh yes, everything looks good. Kidney and liver functions seem fine.

(we discuss a bit about how often to re-test, after I explain WHY she's on the metacam and how much she's getting - which is also in the chart.)

Dr. M (coming back around to her agenda): We might need to adjust her insulin dose.
Me: I test her blood sugar and mess with the dose. I've never been able to regulate her. Do you have any experience with other insulins, like Lantus?
Dr. M: Yes - Lantus is a good insulin. The problem with human insulins is that we're at the mercy of the market. Several human insulins that worked well for cats have been pulled off the market. So we like to stay with veterinary insulin.

(At this point I resisted the urge to point out that veterinary insulins are just as subject to market pressure as anything - wasn't PZI completely unavailable for years? Didn't Idexx just announce that they're not going to make it anymore??)

Me: Since she's been so hard to regulate I've been thinking about a change, but then the fibrosarcoma came up, and I can't decide if it's worth messing around with.
Dr. M: If everything's been done with PZI, Lantus would be the next thing to try.
Me: Well, I'll think about it some more. And I'll bring Isabella in for another blood test in three months.

That was it. On the plus side - there's obviously another vet in the practice who's quite interested in diabetes. And she's heard of Lantus (yay!). On the down side -- hello!! Did you read the chart???

I know they're very busy. I know she probably had a stack of callbacks she wanted to get through on a Friday night. But really - next time, start out with the reason for the test (metacam / kidney values) and then move on to your other agenda.

I think I'll talk to Dr. H about Lantus. What have I got to lose?

Report on the New Vet

Isabella saw the new vet last Tuesday. Oh My Goodness – what a difference. I brought lots of BG charts for her – showing the kitty’s response to various insulin dosages. To me, they all looked the same: jagged peaks and valleys of un-regulation. The vet looked them over and then looked at me.

“Actually, these look pretty good.”

Huh? I was stunned. Old Vet would have chastised me and implied that I was lying about her food intake or something. New Vet said “This is a cat. She’s not going to follow any rules.” New Vet was able to see an overall lower trend on the higher doses and encouraged me to try going to 2 units. I’m scared of 2 units – since Isabella has always gone low on that dose -- but I’m giving it some thought.

Other things from New Vet:
- New insulin. They dispense BCP instead of PZI Vet. Much cheaper! Though they had to order U40 for me since they normally dispense U100. I’ll wait until she’s been on the BCP a while before trying the 2 units, I think
- She’s not a believer in tight regulation. She’s a “manager,” not a curer. That’s OK, though. At this point I feel confident enough about what I’m doing to try some things below the radar and report to her.
- She only wants to see occasional BG charts via fax and the actual cat every six months, unless something urgent arises.
- She has a sense of humor and she’s not afraid to use it.

Overall, a huge improvement and I’m thrilled. I finally feel like I have a partner in this feline diabetes thing. Whew!

Vetting a new vet

Isabella has an appointment on Tuesday with a new vet. I have high hopes that this one will be a little more clued in about managing feline diabetes than her current vet.

No that the usual guy is bad – not at all. It’s just that I’m the only client he’s ever had who uses hometesting to monitor blood sugar. He can’t look at the numbers I give him and make sense of them because he just doesn’t have the experience. He needs to see my numbers, and urine test dip sticks, and blood tests for fructosamine levels and see how they all relate in order to learn. But I can’t afford to be his learning curve – those fructo tests cost 70 bucks a pop. Seventy of my bucks.

So I asked around for vet recommendations. The first place I called is not accepting new clients. The second, though, sounds pretty good. The front office gal told me that they have “dozens” of diabetic clients (it’s a cats-only practice) and that they teach owners to hometest. One of the three vets in the office sees all the diabetics. Then I talked to the vet and she basically passed my interview. So Tuesday the Isabella and I will visit to see how I like her in person. I’ll bring some blood glucose numbers and talk about curves and dosages.

I really hope I like her, and the clinic. Isabella is eight months into her diabetes experience and she’s not regulated at all. I really need some help understanding if regulation is a possibility and what I need to do to get there. I need someone to talk to who doesn’t think I’m a micro-managing head case. I need a veterinary partner.

And yet I feel very guilty about ditching the old vet. I dread the thought of calling and asking for copies of Isabella’s records. It seems like passing judgment (“Thanks, but you’re just not good enough for me.”) I’ll do it though. Because my cranky little diabetic deserves a doctor who knows what’s what.