OMG - something positive!!

"Diagnosis:  Functional (flow) murmur:  We did not identify a hemodynamic source of Scruffy's heart murmur and this murmur is not associated with any structural defect.  Sometimes murmurs can be heard with other disease states or secondary to stress (fight or flight response.)  No therapy is indicated for this murmur.

Diet:  Please ensure that ScruffyPumpkinPattyPaws is eating and drinking.

Treatment:  No cardiac medications are indicated at this time.

Restrictions:  None."

Whoppee.  And I liked this doctor, too.  She was very accessible, and nice to Scruffy, and willing to take time to answer my questions.  (I was somewhat less fond of her when I paid the bill and it was $507.  That's over $1000 in two days.  If you could see me now, you'd know that I'm shaking my head in utter amazement.)

The ultrasound showed a totally normal heart.  The doctor said that sometimes as cats get older, the position of their hearts in their chests can change, which can cause slight murmurs.  His blood pressure was also normal - 140mmHg.  No restrictions on fluid administration, either, which is good news for the CRF.

She suggested that we return in 4-6 months for a recheck echocardiogram to monitor for any progressive changes as a result of his anemia.    We'll see.....

They brought Scruffy out in his carrier and put him in an exam room, and then came to get me from the waiting room.  They left me with him to wait for the cardiologist to come to talk to me.  I looked in the carrier, and Scruffy was sitting in his kitty pi with his back to me.  And nothing I could do or say would convince him to turn around.  He's quite the expressive little fellow, isn't he? He never turned around at all until we were in the car and on our way home.  :-)

Tiptoeing Through The Trauma (and other detritis)

Today is exactly one month since Scruffy's cancer was diagnosed, and he was in the hospital.  And since the oncologist told us, without treatment, his life expectancy was around four weeks....  But, here we are!

Scruffy's once luxurious  whiskers are now brittle and wispy.  Some of them have already fallen out, apparently.  Side effect of chemo....
 :(

Pre-chemo whiskers, white and soft and numerous....

We had what was most likely our last visit with Dr. B, the ophthalmologist, today.  He gave me a big hug as we were leaving.  Nobody said, "Scruffy probably won't be here for the next visit in four months",  but it was in the air.  He'd been called in to look at the ulcer in Scruffy's eye while he was hospitalized, so he knew what was going on medically.  I cried.  As usual.  He's a very nice man; he took care of Black Kitty, too,  almost 15 years ago when he got glaucoma.  It's nice to know one good vet specialist, in case someone else, God forbid, gets some horrible eye disease.  Today's visit showed that, while the corneal ulcer from a couple weeks ago has healed, there is still some scar tissue and inflammation - which requires four days of the ointment we had back when Dr. B saw Puffer in the end of January.  And, his eyes were severely dry - because of dehydration?  I don't know - and now we've got something called Genteal Gel Severe (well, actually, I bought the Genteal Gel Drops Moderate/Severe, because, although they were both $10, I just thought that, given all the stuff I have to do to him nowadays, another drop would be easier for both of us.  I guess we won't know if it's working or not, come to think of it, since we probably won't be back. ) Ocular pressure in both eyes was 11, which is excellent.  And that little stripe that has turned up at the bottom of his right eye, beside the second melanosis, is indeed another melanosis, but it's not raised and not a matter for concern, even if we weren't in the clutches of the other diseases.

The little line in his right eye is a new melanosis.  The blur beside it is an older one that has changed very little in almost a year.

My little cat, who never meowed once in the almost 9 years I've had him, has taken to making this awful, croaking meow at the oddest moments.  It's a little unnerving.  I don't know how to interpret it - is he having discomfort?  Is there something wrong that I could fix if I could figure out what it was?  It seems strange that all of a sudden there are all these noises coming out of his little mouth.

The return of diabetes has turned out to be pretty much of a non-starter.  He hasn't had a shot since last week, and to be honest - and I can't believe this is even true - I keep forgetting to test him.  As long as he's under the renal threshold, and since the urine test strips aren't registering anything, including glucose, there are way too many other things to worry about.  At this stage, I'd be more concerned that he'd end up hypo than anything else.  His bg today at the hospital was 153, which isn't horrible, or shootable.....  And he even gained an ounce and a half since last week.  Pretty good for a cancer kitty, huh?

Good news today - his phosphorus level was down from 10.1 last week to 7, and the iCA was 1.27, down from 1.60.  Major improvement, although it has required enormous, mind-boggling  effort from me - feeding has become a big, drawn-out ordeal twice a day.  (The in-between feedings, just for Scruffy - are okay; nobody else has food that he thinks he has to eat instead of his own.)  It is somewhat rewarding to know that the phosphorus binder and the lower phosphorus food seems to be working.  Bad news was - and it's really pretty bad - creatinine was 6.2, up from 6.0 last week, and BUN was >140, which is as high as they are able to measure, I guess.  Last week, it had been 138.  I don't have a good picture of what exactly, if any, the relationship is between phosphorus/calcium  and BUN/Creatinine.

I talked to the oncologist today about stopping the chemo.  It's pretty obvious we're in a race here to see if the kidney failure gets him first, or if the cancer comes back and does him in.  Either way, the doctor seems to think that if we're lucky and things go well, we might have a year, and that, in his opinion, the kidneys are going to be the winner of the race.  I didn't really understand why, if the tumors were gone, we needed to even be talking about a two year period of chemotherapy, but apparently, remission of the tumors doesn't mean that there aren't still a bazillion lymphoma cells floating around inside him, just waiting for someplace to land and launch new tumors.  And while the expense has quickly reached the overwhelming stage, just reducing the weekly quantity of blood tests would significantly reduce the cost.  Today's appointment was $300, but $200 of it was bloodwork......  Trouble is, I have such a need to know if it's working.  You know, like I have to try twice as hard if it's not, so I NEED to know every week what's doing inside him.  Well, maybe not.  I don't know.  I have to think about it, I guess.

When he came home from the hospital, I made a chart of medications, etc. that he needs every day.  Because, given the vagaries of my memory these days, there was otherwise no way he was gonna get anything that was right.  And now there's all this new stuff to remember.

 I made a new one tonight, that will hopefully keep things straight.  One of the new additions is Cytoxan, a chemo drug that I had to order from someplace in Arizona.  It's apparently a capsule, and is to be given to him every other day for a month. I have to wear latex gloves in order to handle it.  Geez.  I don't want to even think about giving it to him.  He's very hard to pill, to begin with, and he's already got a whole mess of other pills to swallow that AREN'T poisonous.   I haven't been able to bring myself to open the box, although it arrived yesterday in the mail.

Tomorrow, we have an appointment with a cardiologist, to see what the deal is with the heart murmur, and to check his blood pressure and to find out what amount of fluids is safe to give him on a daily basis.  And after we come home, I'm not taking him ANYWHERE until his next chemo appointment, a week from now.

Sometimes I get so mad at myself for feeling so whiny and overwhelmed.  Poor Scruffy is the one who's doing all the suffering and dying........

One last picture, thinking about his Quality of Life:

This is blurry because he's actually IN MOTION - jumping down from the third level of the cat tree, where he had gone to see if he could eat whatever someone else had left (that didn't have phosphorus binders in it!).  Now, true, he doesn't look too hot, and he has that unpleasant urine-y odor to his skin/fur, and he's lost some weight - but LOOK AT HIM!  So determined to eat that he's hopping around four feet off the ground!  This is what I can't seem to explain to some of my family members, who think that I'm keeping him alive out of some selfish need of my own, or that he's such a huge burden.  Neither is true, at least not right now, I don't think.  And I am taking such pleasure in sharing this time with him, however long it lasts.  He's such a responsive little guy, and so focused in getting whatever he wants, it makes me laugh.

So, I guess we'll keep muddling along for as long as we're allowed to have that privilege.

Bits of Scruffy to hold in my heart....

1) Yesterday, it was an amazing February day in Pittsburgh.  Although it was chilly, it was a beautiful day, and oh, the sunshine!  It just poured in the windows on the front of the house.  (Which would have been even more striking if I would ever get around to calling the window cleaner to come!)  There were a half dozen places on the cat trees where there was a huge droplet of sunshine, just begging for a cat to come and nap there.  The sky was the most brilliant blue...  All in all, it was stunning.

Around 3:00, I decided I had to drag myself out to get cat food and kitty litter.  But, when I sat down in my chair to put my shoes on, Scruffy came waddling over at his top speed, hopped up on the couch, walked across the end table, and plopped himself down on my leg.  And then he looked up at me like, "Well, put your hand over here so I can sleep!"    Which I did, because having him nap in my cupped hand is one of my favorite things in all the world.  And he immediately slipped off to sleep.  I was preparing to follow him - well, can't very well buy cat food and kitty litter if you can't get out of your chair, right? - and take just a TINY rest, when Milkshake must have noticed that there was napping going on.  He jumped up, too, and settled in between Scruffy's side and my right arm.  And then he put his tail, his head, and his left front paw around Scruffy - just encircled him with white furry body parts.  And the three of us slept until something woke me up two hours later.  We were still warm and snuggly and peaceful, and it made me so glad that I'd stayed home.

2)  For years, Scruffy has found it necessary to supervise my showering.  As soon as I turn the water on in the shower, there he is, sitting in the middle of the bathroom.  Except for the couple of months before he got cancer, when I was - and yes, I'm ashamed - so mad at him for peeing on the rugs repeatedly that I could hardly look  at him.  And he obviously got the message, because he pretty much avoided me.  This makes me so sad, but I guess there's nothing to do about it now....  He didn't come to sleep with his head in my hand any more, he  didn't show up when I got a shower, and I frequently had to hunt all over the place to find him to give him his pills.  When Claudia, the animal communicator said he offered to make a deal with me - if he could stop taking prozac, he'd stop peeing - I was dubious, but agreed.  And suddenly, we were back to normal.  No more hiding, no more avoiding me, and even, for a while, no more peeing on the carpet.  It lasted about four months, and then he started again.  I told him, as patiently as I could, that I couldn't live with that behavior.  But he didn't stop it, so last November or December, I started giving him the prozac again - half the previous dose, and I explained that it wasn't to punish him, I just needed him to stop.  (Yeah, I know, it sounds psycho, but....  you do what you need to do, I guess.) And it's been okay, oddly.  He never started hiding again, or avoiding me; he pretty much did stop peeing on the rug.

Anyway, so the other day, I was going to get a shower, and he didn't show up.  He was sleeping on the heated mat on the window ledge in the kitchen.  I went out and woke him up and said, "Hey, Puffy. Tubby Uppers?"  Yeah, baby talk, I know.  And he just sort of looked at me blankly, and then put his head back down.  So, I went back to the bathroom.  Got a really long shower - till all the hot water was used up! - dried my hair, got dressed, and when I opened the bathroom door, THERE, sitting in front of it, was my little Puffer.  He'd gotten himself up and dragged his poor sick little body all the way to the other end of the house so he could sit in the bathroom with me, and I'd closed the door so he couldn't get in.  I felt so bad.

3)Scruffy was the most laid back cat I've ever had.  Nothing bothered him.  The day I brought him home, back in 2003, he wandered all over the house, paying no attention to the three other strange cats - including Poor Psycho Picklefritz.  He poked around the basket the cat toys were in, he sniffed their food dishes, he stopped to look out the front windows.  And then,  suddenly, a half hour after he arrived, he started to shriek in pain.  I had NO idea what was wrong. Touching him was impossible - it was clearly agonizing.  My sister and I managed to get him into a carrier and into the car.  We drove to the closest vet that was open - where it turned out, he had a urinary tract blockage.  Apparently due to stress, oddly, for a cat who gave no appearance of being stressed.  This was the first of three blockages that had to be surgically undone.  Were they all because of stress?  Got me. He was still my calm cat that nothing bothered.  I had to poke him with the sweeper to get him to move out of the way.  He didn't mind the hair dryer, he loved when strangers showed up.... Just pretty much oblivious.  As long as no one touched his tail.

Three or four years ago, after a dental, he had a major personality change.  I don't know what could have happened to him - it was the same vet I'd been taking him to for years, and he'd had several other dentals.  No explanation, but all of a sudden, my laid-back kitty turned into a raving monster at the vet.  Hissing, spitting, howling, scratching, biting - I never would have believed it was the same Scruffy.  When he developed the melanosis/melanoma in his eye and we started having fairly frequent appointments with the ophthalmologist, I accidentally came up with a solution to what was becoming a real problem - I stuck a kitty pi in the carrier.  It was possible to just slide him in and out of the carrier, and as long as no one did anything to him that required taking him out of the pi - he was fine and dandy.  It worked at the regular vet, too.  He'd go back into the carrier and spit and carry on, but as long as he had his pi, he was good to go.

4)  Scruffy looooved riding in the car.  (This started before he got diabetes and I learned all the good stuff about feline safety and health from FDMB.)  He loved to sit on the lap of whoever wasn't driving and look out the window.  So, I hunted around and found a "Doggy Seat Belt", size small.  It was perfect for him.  Just a sort of harness, covered with fake lambs' wool.  You slipped it on the dog/cat, adjusted the straps, and hitched it to the car seat belt.  I was real proud of myself for coming up with such a perfect solution to how to take him in the car by myself.   Until......  I looked over, and realized that he had somehow figured out how to slither out of the Doggy Seat Belt, and he was standing on the seat, looking out the window.  Talk about panic - I pulled over so fast,  I hit the curb.  That was the last trip with the Doggy Seat Belt.  My other "good idea" for taking him in the car was to buy a baby sling sort-of-thing.  I thought I could just put it on, stick him in it, and he'd just sit there while I drove.  Another fantasy, unfortunately.  He didn't want any part of the "just sitting there." He lasted about five minutes, and then he wanted OUT.

Oddly, one last thing about the car - his glucose level would drop.  I mean, DROP.  The first time I noticed that he had a kind of wild-eyed look in his eye, we were on the way to the chiropractor in another county.  I pulled over and tested him - yes, I took his meter where he went - and he was at 27.  He'd spent years in the 300's and 400's, put him in the car, and he's 27.....  At one point, he was in really high numbers for a long time, and I actually stuck him in the car and drove around to see if it would help lower his bg.   It didn't.

5)  It's kind of funny to think about how cats never get to go outside.  Well, probably not funny to the cats, but.... I feel very strongly that I do not want cats that have access to the outside - although we've never ever had a problem with fleas on the ferals I've brought in, I know they're lurking out there!  Along with garter snakes, and cars going up and down the hill too fast.  All good reasons why my cats are indoor cats.  But, in a moment of lunacy, I thought that it would be wonderful if they all had little walking jackets - with matching leashes!, and we'd go for little walks in the yard.  I ordered these cute little nylon "jackets" - just a rectangle of brightly colored nylon with a Velcro buckle for adjusting the size.  I started with Milkshake, who of course had to do that silly "oh, my god, what did they put on my back, it weighs a ton, I can hardly walk, I'm smashed into the ground, how could anyone do such a thing to a sweet cat like me...."  You know the routine.  But, eventually, he caught on.  And he actually DID walk and sniff the grass, and I took a lovely picture of him standing on the sidewalk, surrounded by the last of the pretty purple rhodendron blossoms.

Encouraged by all that success, I thought Scruffy could be my next victim.  I got him all strapped in - and he didn't need to flop onto his side in terror or anything!  And we went outside.  Walked around the house, pretty successfully, but as we came around to the driveway side, he took off around the car.  And wedged himself on the far side of the front tire of my car.  I'm shrieking and clicking on his retractible color-coordinated leash, when all of a sudden, it flew back toward me, and there was no cat at the end of it.  NO CAT.  I was in a panic.  He'd been a stray, and had never really shown the least desire to go outside ever again.  And  I'd forced him to!  Dumb.  I went around and around the house, calling him frantically.  (And trying to avoid the snakes that I knew were just lying there in wait for me.)  No sign of him.  After fifteen minutes of frantic, exhausting searching, I thought, maybe if I go inside he'll come to the door. So, I did.  No Scruffy.  I went to every door, opened it, and called him.  No sign of him, but then, all of a sudden, I heard a cat howl.  I ran outside, and there he was - sitting at the end of the house, yelling at the top of his lungs, and waiting for me to come and get him.  Which I did.  And then, I put away all the little walking jackets and the matching leashes, and no one here EVER goes outside, except to go to the vet.

6)  The day, the second week in January, 2012, when I took Scruffy to the vet for bloodwork so he could have a dental, I was totally unconcerned about the results.  Except for the occasional higher than usual cholesterol result, which was probably related to the diabetes, he'd never had anything in his bloodwork to worry about. We joked about how Scruffy "never not eats."  And then oddly, the next morning, he didn't want to eat.  No nuzzling all the other dishes, no gulping down his own.  Very peculiar.  And then the vet called with the results, and that very first high calcium level.  And ALT and AST were a smidge higher than normal.  The beginning of the end.  With no warning, no sign that inside him things were going horribly wrong.

Back to the prozac, and eating.  Prior to our "bargain", I was giving him his prozac every morning, in a pill pocket.  He's very hard to pill - it's like there's not enough space in the back of his throat or something.  When Milkshake opens his mouth for pills, there's all kinds of room back there, but Scruffy..... not so much.    So, every morning we had this big ordeal with the pilling.  It would take multiple attempts usually.  He could spit a pill out and it would land three feet away.  Or twine its sticky gooey self into his long, scraggly fur.......  So, anyway, eventually, I'd manage to cram the little pill ball into him, and he'd jump down to eat.  And he would sit and eat and eat and eat - I have never seen a cat eat the way he would.  Totally focused on how much he could get into his stomach.  And then, he'd throw up all the extra food - and the PILL - in a disgusting mess on the floor.  And in ten minutes, he'd be back in the kitchen, chomping away at the food that was left, while I  forlornly poked through the pile of barf to see if the pill was really in there or not.  And whether you believe it or not, it was INTENTIONAL.  He knew exactly what he was doing, and he did it every morning!

Oh, there's so much more.  Eight plus years, with this dear cat with the enormous personality.  Not nearly long enough. He's still sitting at the top of the steps waiting for me when I come home.  He wakes me up 12 times a night now, headbutting me so I'll scratch his ears.  I've been exhausted ever since he came home from the hospital.  He has been totally fixated on me, and on food, since he got here all those years ago.  He doesn't bother any of the other cats.  He has spent 8 years trailing around behind me, waiting for me to sit down so he can climb up onto my lap.  He has always been a barfer - ate and ate and ate till he threw up, and now, on chemo, he hasn't thrown up once.  That ragged fur that somehow always looked so smooth in pictures.  The giant fluffy tail that no one is allowed to touch, and the teeny-weeny, two-inch-high legs.  I always thought that his stomach was dragging on the ground until the first time I shaved him for the summer; he had a regular cute little cat body under all that fur!  The awful, horrible thing that was growing in his eye, and that could have shortened his life three years ago;  I guess that was lucky, wasn't it?   I talk to him 20 hours a day, because  he's always right there behind me.

How am I gonna get used to his not being here?

Quality of Life

I seem to be drifting, or maybe rolling along kicking and screaming, I don't know - toward trying to find acceptance of the potential loss of Scruffy.  It's clearly inevitable - despite the apparent remission and disappearance of the lymphoma tumors, his kidneys are overtly on borrowed time.  Special food, fluids,  phosphorus binder, (and a new addition, a probiotic intended specifically for CRF cats given to me by Choy-Foong) - and yet, the kidney bloodwork just gets worse and worse and worse.  I don't want him to suffer; I don't want to keep him alive just because I  need to have him here. And yet, despite the hopelessness of the situation, and the stress of trying to maintain him as best I can, I am convinced that he's not ready to leave yet.

This is the Quality of Life Scale, developed by a vet named Alicia Villalobos:

Quality of Life Scale1         The HHHHHMM Scale
Pet caregivers can use this Quality of Life Scale to determine the success of pawspice care. Score patients using a scale of 1 to 10.
Score	Criterion
H: 0 - 10	HURT - Adequate pain control, including breathing ability, is first and foremost on the scale. Is the pet's pain successfully managed? Is oxygen necessary?
H: 0 - 10	HUNGER - Is the pet eating enough? Does hand feeding help? Does the patient require a feeding tube?
H: 0 - 10	HYDRATION - Is the patient dehydrated? For patients not drinking enough, use subcutaneous fluids once or twice daily to supplement fluid intake.
H: 0 - 10	HYGIENE - The patient should be brushed and cleaned, particularly after elmination. Avoid pressure sores and keep all wounds clean.
H: 0 - 10	HAPPINESS - Does the pet express joy and interest? Is the pet responsive to things around him or her (family, toys, etc.)? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be close to the family activities and not be isolated?
M: 0 - 10	MOBILITY - Can the patient get up without assistance? Does the pet need human or mechanical help (e.g. a cart)? Does the pet feel like going for a walk?  Is the pet having seizures or stumbling?  (Some caregivers feel euthanasia is preferable to amputation, yet an animal who has limited mobility but is still alert and responsive can have a good quality of life as long as caregivers are committed to helping the pet.)
M: 0 - 10	MORE GOOD DAYS THAN BAD - When bad days outnumber good days, quality of life might be compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware the end is near. The decision needs to be made if the pet is suffering. If death comes peacefully and painlessly, that is okay.
*TOTAL=	*A total >35 points is acceptable for a good pawspice

                                                        
1.Adapted by Villalobos, A.E., Quality of Life Scale Helps Make Final Call, VPN, 
09/2004,for Canine and Feline Geriatric Oncology Honoring the Human-Animal 
Bond, by Blackwell Publishing, Table 10.1, released 2006.

I can't bring myself to sit down and do this, to assign points to Scruffy's life,  right now.  Just looking over the categories, I think strongly that I'm right, he's not in the lower ranges at this precise moment in time. There is, I have to admit, some comfort in thinking that somewhere along the way, this chart could be helpful in pushing me to make a reasoned determination that we can't go on.  But not now.  For now, we'll keep doing what we can do.  I am seriously considering giving up the chemotherapy.  It's incredibly expensive, it's starting to seem to have side effects that are unpleasant for Scruffy, it may be contributing to the kidney failure (although the oncologist has said that the drugs they're using are not kidney-toxic...), and I have to keep reminding myself why I am putting him through this.  Which is a good question, of course.  Why?  Not just "because I can."  Sincerely, I want to allow Scruffy to be here as long as he wants to, and as long as it's possible for him to be comfortable.

When this whole nightmare began - can it be only a few weeks ago? - and The Puffer ended up in the hospital, I was desperate to find an animal communicator to talk to him - to tell him that I would come and get him, because I didn't even get to say good-bye to him - and to find out if he thought he wanted to go on.  Two communicators talked with him.  He was saying then that he was just tired, "drained".  While he was still in the hospital, he seemed to be more hopeless, more ready to give up.  Once he came home, and he resumed what was pretty much his old life, with the addition of a whole bunch of medication and vet appointments and the occasional insulin shot again, he just was himself.  Wandering around with that ploofy, untouchable tail in the air, sleeping in my hand, eating enthusiastically.  I keep saying,  "If you didn't know he was dying, you'd never know he was dying."   And that's still true, although his appearance is getting pretty sad, with all the shaving and the weight loss, particularly in his little face.  He doesn't jump as well, but then, he's old, and he's got horrible diseases - what do I expect??  The essence of my ScruffyPumpkinPattyPaws is still there, still as oblivious to pretty much everything but me and food.  So, I feel like, as long as there isn't pain involved, as long as he can still enjoy his food, and the contact and affection I can offer him in huge quantities, we're still in the game. I don't know for how long, and I wish I could arrange the end to be the way I want it to be, without the vet and his cold stainless steel table, but.....  What's the Alcoholics Anonymous motto?  About changing what can be changed and accepting what cannot?  I guess that's where we are. Reaching somewhat desperately for acceptance of something that should never have even happened.  It stinks.  (Obviously, I have a ways to go to find that stupid acceptance....)

My sweet boy, on the day that we learned that the tumors were gone.  Very short-lived euphoria......

The Ups and Downs of Having a Cat with Cancer......

and kidney failure and a heart murmur.....  At this point, it appears that it's mostly the downs. Maybe it was because all this happened so quickly and so unexpectedly - the first week of January, when I took Scruffy for bloodwork so he could have a dental and his calcium level was elevated, cancer and kidney failure were certainly not anything that I would have ever expected to be dealing with just two weeks later.

Last week,  (Feb. 9) I left Scruffy at the Hospital for his ultrasound and bloodwork.  Although the schedule included another chemotherapy treatment, I had pretty much decided that - unless there was shockingly good news from the ultrasound , indicating that the chemo was working - I was going to tell the doctor that we had had enough, and would just allow Scruffy to live out his life. Since the ultrasound scheduling is uncertain because they only have one machine and emergencies have priority, I had to drop him off at 8:30 AM.  When, by 2PM, I hadn't heard anything, I called and asked if anyone had seen my Scruffy.  The oncologist got on the phone and told me that the ultrasound had found that the tumors in his liver and spleen were gone.  "No evidence."  I was so shocked and surprised that I had to ask him to hold on a minute while I cried.  Nothing in Scruffy's appearance or behavior would have led me to believe that he was suddenly tumor-free.  In fact, I had cancelled an appointment with his ophthalmologist on Monday because he was so lethargic and miserable.      Additionally, the bloodwork showed that the ionized calcium level was back in the normal range - 1.31!   Hematocrit and hemoglobin were both low, but the oncologist felt that it would be safe to give another treatment.  I agreed, although I didn't understand at that time why it would be necessary if the tumors were gone.  Obviously, my knowledge of lymphoma is minimal.  As we were ready to leave the hospital, I asked if they had done a phosphorus blood test.  Choy-Foong had sent me Meowzi's can of aluminum hydroxide, and I wanted to know what his most current phosphorus level was.  To compare the huge improvement I foolishly expected to see, as it turned out.  The level was 10.1.  Horrifying.  (Normal is 2.6 to 6.0.) His other kidney values were not good, either.   BUN was 114 (norms - 15-34), and creatinine was 4.6 (normal - 1-2.2)  The assumption was, with low protein/low phosphorus food, and the addition of the aluminum hydroxide, those values would improve significantly.

Anyway, I brought him home after the treatment.  This time, like two of the previous three chemotherapy treatments, he didn't seem to have any particular reaction.  He wasn't lethargic, he ate voraciously (on his own - I have given him very little cyproheptadine (appetite stimulant) since he started treatment, maybe five or six 1/4 pills.) His fur was less spiky.  He was up wandering around more.  He was just himself.   He still smelled unpleasantly like urine- my theory is that, since he has such long fur, when they shaved his stomach for the first ultrasound, he could no longer gauge exactly where he was on the kitty litter when he peed - every time he hopped out of the box, he was soaked from his neck to his tail.  It has been very cold, inside the house and out, and I really was hesitant to give him a bath, but the odor was becoming hard to tolerate, and it seemed like we could use a sort of "celebration."  I have some wonderful vet shampoo that smells like coconut, and without a whole lot of commotion or carrying on - although with a lot of growling! - I scrubbed up my little Scruffy, from his shoulders down to the untouchable tail.  He even let me dry him with the hair dryer - noises like the hair dryer and the sweeper have never bothered him.  Except for his tail, which was unfortunately still wet and tangled four or five hours later....  Anyway, he looked wonderful.  And he doesn't hold a grudge.  (See how much softer and less spiky his fur looks!)

Scruffy thinks that I can't get a shower without his supervision - he's sitting here waiting for me to show up...

This week, since the "no tumor" news, has been a stress-filled blur, pretty much.  I had already made a list of low phosphorus canned cat foods that he might eat, and had bought three or four different kinds of "kidney diet" vet foods.   Armed with these foods, and the aluminum hydroxide, I started what I hoped would be a dietary routine that we could maintain and that would keep the kidney failure at bay. Not so much.....  The first problem that came up was the fact that - despite how pleased I was that Scruffy's appetite was so healthy - his pattern has always been to eat his own food, and then to cruise all the other cats' dishes and polish off whatever he finds there, too.  With the aluminum hydroxide, my plan was to add a measured amount - based on his weight and the dosage on the can - to his food.  It's supposedly tasteless and odorless.  And after the first couple tries, Scruffy didn't appear to care that it had been added.    (Unlike the Miralax, which he needs because he had been constipated a week before and I don't ever want him to have to go through that again, and aluminum hydroxide is likely to be constipating.)   The goal is to make sure that no food is ever permitted to be in his stomach without an accompanying dose of aluminum hydroxide to bind to the phosphorus and carry it out of his body, instead of allowing it to get to his kidneys.  Hence, a "phosphorus binder."  So, I had to find someplace to put the dishes for the other cats where they could eat, but Scruffy couldn't get to their food.  And, conversely, to prevent the other cats (especially Milkshake, who had had low phosphorus on his last bloodwork!) from eating Scruffy's stuff.  Everyone else appeared to be convinced that Scruffy's food - special diet and additions aside - was WONDERFUL and TASTY and WELL WORTH GETTING YELLED AT.  Scruffy has not been jumping very well since beginning chemotherapy, so I thought that maybe if I put the other dishes on the cat tree, he wouldn't be able to get to them.  Which worked exactly one day.  The second morning, I carried all the dishes to the living room, which required half a dozen trips - and before I finished delivering all of them, Scruffy was up on the second level, chowing down on Fancy Feast.....  Feeding is now still a work in progress - the best success so far involves feeding Scruffy up on the counter after he gets his pills while everyone else waits.  If he fills himself up first, he's less intent on eating from the other dishes.  Less intent, however, not "disinterested."  :-(

The second problem is that Scruffy's a nibbler.  He eats for a couple minutes, then wanders away and comes back in an hour and nibbles again.  Since he has been off insulin - 2008 - I've always free fed.  They can eat whatever they want, whenever they want.  Which does NOT work now that Scruffy can't eat anything that doesn't have the phosphorus binder in it.  I don't think I can solve this one.  I can't make him eat when he's not interested.  Well, yeah, I could force feed him, I guess, but when he's eating well on his own - just not conveniently for me - I think it's a quality of life issue that I don't have the right to interfere with.  The best I can do appears to be to stay with him while he's eating, chasing away anyone who wants to share his food, and to pick it up and put it away somewhere when he's done.  And then, to watch and see when he strolls back out to the kitchen (or climbs the cat trees!) and get out his previous dish again and see if he'll eat from it.  It's taking quite a chunk out of my day.

Third problem:  I have to write to someone on the Feline Phosphorus Management Yahoo Board and find out about this aluminum hydroxide management stuff.  I can't get in my head why dosing for it should be based on the cat's weight.  The formula is supposed to be to give a specific amount mixed in with food - 100mg x the weight - 10 pounds, for Scruffy, divided into two.  Well, if he only ate twice a day, maybe that would work.  But it seems to me - and I'm sure wiser, more experienced people developed the formula and there are dozens of reason why I'm wrong, believe me - that it should be based on the amount of FOOD instead.  If he's eating six times a day, then there are presumably four times when he doesn't have any concurrent aluminum hydroxide in his stomach when the food's there, right?  I don't know.  I do know, I'm making myself crazy trying to get all this stuff right.

Last night, I took Scruffy to our regular vet, to make sure he wasn't constipated, and to see if he thought that B-12 should be added because of the newly developed anemia.  (I'm sort of floundering around here - there are all these medical problems, but the oncologist isn't supposed to be handling all the specialty needs, I guess, like cardiology and internal medicine.  The diabetes, I can handle.  Everything else, not so much.)  To my surprise, he didn't think it was particularly necessary, or that there was any reason to add B-12 for anemia at all - I don't know enough to know if that's true or usual, just that many of the people on the Yahoo CRD board seem to be giving B-12, and I thought, since it's water-soluble, that it would be safe and useful.  He was willing to order some injectible B-12 for me.  Since we were there, I asked for bloodwork to be done to check what I just assumed would be the "improvement" in his phosphorus levels, and the hematocrit level.  To my distress, there was NO improvement.  None.  His phosphorus level, after all this fiddling around with special foods and phosphorus binder and whatever - was still 10.1, and even worse, the total calcium was 14.6, which is an indicator that the Ionized Calcium is no longer in the safe normal range.  BUN was 100 - slightly better, but not good - and creatinine was even worse - 5.0.  Hematocrit was 19, had been 20.  I'm so depressed.

I also asked for a referral to a cardiologist for evaluation of the new heart murmur - referred to as a "II-III/VI" murmur.  I want to be sure that giving fluids is safe for him, and to have an amount that's correct.  Also to know about his blood pressure - many of these CRD/F cats seem to be on blood pressure medication to benefit their kidneys.  We just were given an appointment for Feb. 24 at 1:00.  We have TWO appointments for Feb. 23 at the same place, one for the ophthalmologist, and one for another chemotherapy treatment.

Are we approaching the point of "diminishing returns"?  When exactly is enough enough?  Can I justify the stress and distress for both Scruffy and me, as well as the incredible expense, when it is starting to look horrifying apparent that there isn't going to be a good outcome for my sweet boy?  I felt justified in not having "put him to sleep" - how I hate that phrase, they're not sleeping, they're DEAD - a couple weeks ago as a variety of people seemed to feel I should have done.  But where is the cut-off point? When is it hopeless?  I'm not ever going to be "ready" to be without him.  But I don't want to keep him alive if he's in pain or if he's clearly ready to go.  At this point, he's exactly who he has always been.  A little scragglier, a little wobblier, but not near the time when some horrible decision has to be made.  He's not.  He's really not.

Chemotherapy

Scruffy is getting the Madison-Wisconsin Protocol (25 weeks total)

Week 1:  CBC, Vincristine IV, Asparaginase (Elspar) SQ, Prednisone PO

Week 2:  CBC, Cyclophosphamide (Cytoxan IV, Furosemide (Lasix) IV, Prednisone PO

Week 3:  CBC, Vincristine IV, Prednisone PO

Comes Week 4, at which point there's a problem to be solved:  Scruffy's kidneys are not doing well.  The Week 4 drug - Doxorubicin (Adria) IV, Diphenhydramine IM, and Prednisone PO is very hard on kidneys.  I didn't retain all of the discussion with the oncologist, but it appears that, if we don't use the Doxorubicin, then we're no longer doing the Madison-Wisconsin Protocol.  And he named another Protocol - I want to say "CHOP", although I'm not sure that's right.

Week 4 also includes "CBC, ECG, *ECHO" as well.  Dr. E said that he thought it might be a good choice to do another ultrasound next week, to see if there has been any change in the tumors that would indicate that the treatment is having a positive effect.  I don't know what *ECHO is.  I have another paper they gave me that is a description of a variety of chemotherapy options; maybe it's listed in there.

Week 5:  CBC - blood work only.

Week 6:  CBC, Vincristine IV

and so on, alternating the 3 drugs.  Six months of treatment, when the life expectancy they gave us for "successful treatment" was four to twelve months........

The only good thing about all this so far is that there appear to have been NO side effects or reactions to the chemo at all.  Scruffy was in the hospital for the first dose of vincristine, but I did see him the next day, and aside from the trauma of hospitalization and catheterization and chemo and not eating.......  Well, he didn't look good, but he was responsive, and he actually ate a little bit for the first time in more than two days.  The second treatment, also no side effects.  I do think that he's mildly nauseated generally, and have been giving him Zofran (ondansetron) every 12 hours since he came home on Jan. 23.  He's eating fairly enthusiastically - I have only given him cyproheptadine twice in the last week and a half; it seems to make him hyper, and he was eating adequately without it.  Peeing and pooping appear to be normal, also.

Sadly, the steroids (dexamethasone IV, then prednisone pills)  immediately raised his glucose level.  When he came home, I got ketodiastix and started checking his urine.  (He's not nearly as regular as he was in the old days!)  Always above the renal threshold, which for him seemed to be around 180.  So, on Monday, Jan. 30, I started him on Levemir again.  (Day 1392 of his being OTJ, which breaks my heart.  Everything breaks my heart these days....)  Tiniest little dose - under the zero line - seems to have a significant effect.  And whatever I remember from four years ago - which isn't much, apparently - I don't know that it will apply now.  Because now, in addition to the cancer, he's got daily fluids added to the mix.  Today, for example,  (recorded in his spreadsheet, linked on the righthand column) he started out at 258.  I'm pretty sure there was virtually no insulin in the shot I gave him the night before, hence 258.  I gave him another "under the zero line" shot this morning, and he apparently dropped most of the day - he didn't appear to have started back up until +12, and was only at 119.  I don't think I can risk shooting that low without any idea how he's going to do.  Maybe this method won't work so well with Lev, which needs patient, stable dosing, but given the other circumstances we have to deal with, I don't see that it can be helped.  Every hour that he spends under 180 is a plus for his kidneys.