Philosophy and Technique of Med and Sub-Q Administration

The following observations are based on the experience my wife and I had with Coco, our calico Persian female whom we treated for 2 1/2 years for CRF. Coco died in February 98. Due to lack of funds and the inability to find a vet with real experience in long-term treatment of CRF cats, most of the treatment was seat-of-the pants navigation based on extensive self-education from an old veterinary handbook and various books on biochemistry, nursing, and human medicine. Unfortunately, without any real diagnostic training, I missed/misinterpreted symptoms which, had they been properly interpreted or confirmed by tests, might have enabled us to extend Coco's life additional years. My assumption is that most owners of CRF cats find themselves in a similar position as primary caregiver, probably with more regular testing (Coco went for over a year without a blood test because we could not find a vet that could get a sample unless Coco was at death's door). Some of what I write will probably match what others have written, but hopefully some of the more subjective things will be new and helpful. Since cats all have different personalities, they may react differently than Coco did. There are some traits which are probably common to all cats, including intelligence and the ability to draw conclusions, which any caregiver may use to advantage to make the experience easier and safer. Many cats are capable of developing a bond of communication with their caregiver which enables them to cooperate in their own treatment. The trick is to make your cat want to cooperate.

1. RECOGNIZE YOUR CAT'S INTELLIGENCE. This means two things: believing in your cat's ability to understand and draw conclusions, and respect his right to know and decide for himself.

For a long time, I tried everything I could think of to make pill-taking easier for Coco. I coated them with butter to make them go down easier, wrapped them with cheddar cheese to make them taste better, surprised her while she was sleeping and off guard, etc. The result was always a frantic struggle, which all too often resulted in Coco talking me out of taking the medicine right then (she had a strong defensive reflex up to the end). Coco, who loved and trusted me more than anyone else, had drawn the conclusion that when I had medicine in my hand, I became a ruthless attacker who wanted only to subdue her and force things down her throat. She knew that normally I had her best interests at heart, and was reacting to what she perceived as a temporary fit of insanity on my part.

One day, in desperation, I had a talk with her. I held her in my lap on her favorite pillow, and while petting her gently but firmly, held the pill in front of her where she could see it, and explained that I needed to give her the pill to make her feel better. Instead of rushing to get it over with, I grasped her head with my left hand from behind, putting my thumb and fingers into the corners of her jaws to spread them, but not insistently. I gave her the right to refuse the first time, petted her some more, and tried again.

When she determined that I was not going to try and overpower her, she cooperated, and the pill went down much easier. From that time on, I always showed her anything I was going to put in her mouth, and she eventually accepted pill-taking as part of her routine. It was not the act of taking the pill that was so frightening, as much as the feeling of being ambushed.

This does not mean that everything always went smoothly. Sometimes the pill would pop right out after being put in several times, and I thought that she was spitting it out on purpose. As it turned out, I was just not getting it far enough back in her throat. When she flicked her tongue, she was actually trying to swallow, but the pill flew in the wrong direction. I had to overcome my fear of her choking in order to make sure that I placed the pill as far back as possible, and then quickly close her muzzle and stroke her throat to help swallow. When everything went smoothly and the pill went straight down, she seemed proud of having done her job well, and she was always praised and petted extensively. The positive reinforcement made her want to do well at a difficult job.

Part of the importance of patience deals with timing. Coco's real fear of taking pills was a fear of choking if it went down wrong. Even at her best, she always had a nervous anticipation that she would do it wrong. When it was time to take the pill and everything was in position, she would open her mouth and make practice moves as if to swallow. Her job was to swallow immediately. My job was to time it so that the pill was in the right place at the right time, neither too early or late. Sometimes this meant I had to wait and gauge her rhythm, or it would just bounce off of her tongue.

Sub-Q treatments are much easier for a cat to become accustomed to, because they can feel immediate results that they can associate with the treatment. By the time Coco got to the point where she needed daily treatments, she was feeling like you or I would after a long day's walk through Death Valley on a summer day without a canteen: headachy, tired, stiff, and generally worn out. After about 25 ml, the headache would go away, and she would relax and start to purr for the remainder of the treatment. Knowing this, it was important to make treatment time a cooperative, bonding experience. If you go to start an infusion with a fear that you are going to hurt your cat, it will be sensed and the cat will be nervous. In the beginning, I used to have to chase Coco around the room, pin her down, wrap her in towels, etc., and the whole thing was a tiring experience that took up to two hours. After we developed an understanding and a routine, the whole affair could be done in less than 20 minutes at a slow drip.

2. BE SENSITIVE TO YOUR CAT'S NEEDS. After we had progressed to the point where neither of us was afraid of the treatment, it began to happen that after a little of the Ringer's had gone in, Coco would just get up and walk away. The first few times it took me completely by surprise, I was not restraining her at all, and she actually walked off the needle and left it streaming out. My response was to chide her and tell her she knew better than that, and to make sure that I always held a hand in front of her chest to stop her if she tried to leave. My assumption was that, feeling better, she figured she didn't need anymore. However, even though I held her, she would get to that point and struggle and insist on getting up and leaving.

After a while, I noticed that she was always getting up for one of three things: the cat box, food, or water. Feeling better after a little Ringer's, she suddenly had an overwhelming urge to do something that she had neglected while she was feeling down. We found that if we followed the simple routine of offering her food and water and taking her to the cat box before giving her a treatment, she would sit pleasantly for as long as needed. Since these are all basic rights of any animal, we called the procedure "reading Coco her rights". She got so good about sitting still that on more than one occasion I was able to leave her hooked up while I put her off of my lap and walked across the room to answer the phone. Once, after midnight, we both fell asleep and I woke up to find a very juicy kitty who had taken over 500 ml and was still sleeping happily.

3. ESTABLISH A ROUTINE. Cats love ritual. It helps them know what to expect, so they do not feel out of control. It also provides them a way to communicate, because they can develop ways to initiate the ritual/routine, and this is how the cooperative bond develops. I don't know if all cats can or will do this with all people, but I suspect that most cats have the intelligence to do it with one human.

It starts with positive reinforcement, you know, like training a dog. The difference is, you are not bribing the cat to do what you want, you are providing him with a reason to want what's good for him. The more minor rituals you have, the better the chance of the bond developing. For example, Coco like to drink out of a water glass while Connie held it in her hand. Connie thought it was cute, so she always made a big fuss about it. When Coco wanted water, she would climb up on her special pillow on the bed, facing Connie (who was recovering from foot surgery), stand at attention, and wait. Connie would fill the glass from a bottle she kept full by the bed, and praise her as her tongue lapped against the opposite edge of the glass.

The point is that a bond was formed, and communication occurred. The same principle of establishing a ritual helped in all of the medications Coco had to take, especially when adding new ones. Coco's favorite treat was freeze-dried liver treats, which I would break up and feed her by hand. Whenever I had to give her a new medication, I always gave her liver and lots of praise after she had it as reinforcement. After a few times, the liver was no longer necessary, and could be reserved as a pure treat. In later stages, she had numerous medications to take at the same time. I always gave them in the order of least-liked first. That way things got progressively better for her. Pills came first, because they were her greatest anxiety. If she had more than one pill to take, the first would be the largest and most difficult to take. Next came antibiotics, if she was getting any at the time, because she swallowed liquids much easier. Then came her vitamin drops, which were rarely a problem because they tasted like fish oil. Finally, as her greatest reward she got her sub-q treatment. Eventually, since she wanted her sub-q, she did what was necessary to get it.

At first, I initiated the ritual. I would pick her up and take her to her food dish and wait. If she did not eat, I would take her to the cat box. Finally, Connie would put the pillow on her lap and pour her some water. After she had been read her rights, we proceeded to the business at hand.

After a while, as soon as I started hanging her Ringer's bag and changing the needle, Coco would visit her food dish and cat box, and approach Connie for water if she wanted some, then settle down on her pillow with her back offered for her treatment. That was her signal that she was ready to start the whole medication sequence. Eventually, she would omit the visits to the cat box and food dish unless she actually needed them. On those occasions if I tried to give her her rights, she would object, as if I was treating her like a child. At those times we said that she had "waived her rights". We eventually accepted the fact that she knew the routine and her part in it, and that her part was to take care of her actual needs. She was able to do this without going through unnecessary steps in the ritual.

What I have been trying to say (and I did not intend to write a treatise), is that if you find yourself in the position of having to treat a family member of the furry variety, it does not need to be an ordeal. If you let the administration of medicine become a contest, the cat will probably win (and die). If you build a working relationship, you may enter into an intimacy as pure as that between a mother and her suckling child, but with a being more intelligent than any newborn.


MISCELLANEOUS TECHNICAL TIPS

SOURCES OF SUPPLIES: SHOP AROUND.
When Coco had her first sub-q treatment at the vet's, the charge was about $15. When they showed me how to administer it and gave me a 1-liter bag and setup, the charge was the same. I imagine this is typical. Since it became apparent that treatments would continue indefinitely, I made some phone calls to pharmacies to check for case prices. It took a number of calls, because most pharmacies don't deal in hospital supplies. Finally I found a pharmacy that was associated with a hospital (not the in-house, but in a medical office building adjacent) that filled the vet's prescription, and charged $35 for a case of 12 on the 1-litre lactated Ringer's, about $12 for a box of 100 needles, and about $6 for the tubing setup. Prices did vary, so make sure you find the best price in your area. For Winstrol, which is vet-only (non-human), the price at the pharmacy was much higher than the vet's price, as is probably the case with most vet-only drugs. The unit cost was much better in quantity, though. Always ask for the price on 50 or 100, and ask where the price breaks.

NEEDLES: USE THE RIGHT SIZE.
When first started on Ringer's, the vet prescribed #18 gauge needles, which are monsters. I hated the thought of sticking Coco with them for hundreds or thousands of times, so on the first refill I asked to try #20 gauge. They worked just as well with the drip regulator wide open as the #18 did with it partially closed. Eventually I found that #21 gauge worked acceptably well, though not quite as fast. By this time, Coco was accustomed to her treatments, so we were in no hurry. In addition to being relatively painless, they generally go in more smoothly. (We tried #22 gauge, but it was too slow.)

NEEDLES: DO NOT REUSE.
Modern disposable needles are exactly that: disposable. After one or possibly two insertions, they are no longer sharp enough to slip gently through the skin and are difficult and painful to use. Also, the aluminum seating by which they are joined to the plastic sheath begins to corrode alarmingly soon after contact with a saline solution, clogging the needle with a white powder. I used to re-cap the needle after use and leave it on the setup to preserve a sanitary seal, then change to a new needle and flush it immediately before the next treatment. Tubing sets, however, may be reused continuously as long as sterile precautions are taken: hang the new bag, remove the seal plug, remove the set from the old bag and immediately insert it in the new. I only found it necessary to replace the setup every few months, when the tubing became limp and crimped from the shutoff wheel. (Try to move the wheel slightly each time so it bites in a different place.)


FLOW RATE:
Especially with the smaller gauge needles, flow rate is affected by several things:
1. The manufacturer of the tubing setup, which includes the drip chamber. They are rated in drops per ml. Ask the pharmacist to get the smallest number of drops per ml (larger drops). Worth it even if he has to special order from a different supplier and get a carton of six (which could last a couple of years).
2. Height of bag. If the bag is not at least 3 feet above the needle, the flow could be slower. This is especially true of a partially used bag with less weight pushing the flow.
3. Lead of the tubing. The tubing should be arranged so that the flow is always downhill or horizontal from the bag to the needle. If the fluid has to travel uphill against the friction of the tubing, the flow rate will be reduced, sometimes significantly. If there is slack in an excessively long setup, this slack should be supported rather than allowed to sag and create an uphill slope.
4. Air in tubing. Air bubbles are not dangerous to the patient in subcutaneous injections, however they can completely stop the flow of fluid, or slow it down until the bubble has passed. Always inspect the line for bubbles before starting. If they are found above the regulator wheel, they can be made to rise back into the drip chamber by flicking the tube with your finger. If they are below the wheel, they may be similarly moved to the needle end of the tube. At any rate, the new needle should always be flushed briefly to ensure that it contains no concealed bubbles and that the fluid comes out as a steady stream.
5. Lie of the needle after insertion. See more detail under needle insertion.

NEEDLE INSERTION: THE MECHANICS OF THE NEEDLE.
A hypodermic needle is not just a hollow tube with a point on the end. If it were, it would not be pointed, because the hole would negate the point. It is actually a hollow wire with a beveled face and cutting edges ground on the leading sides of the bevel. It is not designed to pierce at a 90 degree angle like a nail, but rather to slice into the skin at a shallow angle (less than 45 degrees, more like 30), with the flat side of the bevel (which contains the hole) up. Attempting to insert the needle with the flat turned the wrong way will result in unnecessary effort at best, probable punching through the skin rather than cutting, leaving a larger hole, and at worst failure to penetrate. You should be aware of the location of the flat before putting the needle on the setup, if possible by looking through the translucent sheath. This avoids the necessity of exposing the sterile needle to the unsterile atmosphere before inserting the needle. The sequence I always used for changing needles was:

1. 1. Grasp the line in the same place I would when inserting the needle thumb on top, and get rid of any kinks that might cause it to twist once inserted.
2. Remove the new needle from its sterile package, and locate the flat.
3. Take the old needle (and its sheath) off of the setup, and immediately replace it with the new, still in its sheath.
4. Inspect the line for bubbles, and tap any out as described above.
5. Remove the sheath, squirt out just enough to see a steady stream with good pressure, replace sheath.


The needle should be fully inserted at an angle as described above. (Actual technique was demonstrated by your vet, so I will not go into tents, etc.) There is the very real possibility of back pressure gradually forcing the needle out, so I always kept my thumb lightly applying neutral pressure to hold the needle in.

After starting the flow, always look at the drip chamber to make sure that there is a steady flow. The drops should go at a steady rate, depending on the factors above. If they don't and the line has been freed of air and flushed, there is an insertion problem which can probably be solved without taking out the needle. First, try withdrawing the needle a tiny amount. It could be that the tip of the needle has lodged in something like the inner surface of the skin or muscle, and the hole may be blocked. If this had happened you probably would have felt a resistance at the end of an easy insertion. Next, try twisting the needle around its axis (as if you were twirling it between your fingers) without changing its direction or angle. It is likely that the flat of the bevel containing the hole is resting against something that is impeding the flow, so twisting it to one side or the other will give the fluid a place to go. Quite often, if an extreme twist is necessary to maintain the flow, it will put tension on the tubing making it want to twist back. If this is the case, use a free hand to gently form a loop to contain the tension, which can be laid across the kitty's back. This will save some writer's cramp from trying to fight the reverse twist through the entire treatment.

PILLS: GET A PILL SPLITTER
A lot of doses are half a pill or a quarter pill, and they are difficult to split with a sharp knife or razor blade. Many pharmacies sell pill splitters for about $3 that do the job quite nicely once you get the hang of it.

PILLS: HIDING THEM IN SOMETHING DOESN'T ALWAYS WORK
I found that on large pills, putting them in cheese, etc. actually made them harder to swallow, because it made them larger. If the pill is put on the back of the tongue where it is swallowed automatically, the cat probably will not taste it. On pills that were consistently a problem due to size, I just split them and gave them in two halves.

LIQUID ANTIBIOTICS, VITAMIN DROPS: USE A DROPPER, NOT A SYRINGE.
I found that when I tried to use a syringe for liquids, quite often most of the dose would splash out and be wasted because it went in too fast. Eye droppers with a rubber bulb give more control. Do not assume that they come only one way, quite often you can request a dropper. If not, buy one.

I also found that Coco could not easily handle a full ml without spilling some, so I always gave her drops half a dropperful at a time. She could not easily swallow in the position I held her (head tipped back), so I always immediately released her, she would turn over, swallow, and then let me give her the second squirt.