Urgent: Anti-anemia shot 9 times overdosed on late-stage CKD cat

Our Dusty started Darbopoetin 25mcg/1ml shot two weeks ago for her anemia. The 25mcg was supposed to be given in 10 times, once a week. An anemia specialist, who prescribed this med, did the first shot on May 16. All the following shots are supposed to be done by our family vet. She did so last Saturday and was about to do the third shot today, then we realized there is a huge disaster: she had injected all the rest of the 25mcg into Dusty last Saturday, and the bottle is empty now.

The problem is on the label, which says “Give 25 mcg under skin once weekly unless otherwise directed” (Please see the attached). Then the vet gave whatever in the bottle to Dusty in one injection.

The family vet called the specialist. Now both of them don’t know how to handle the situation. To make it more heart-broken, today’s blood work shows Dusty’s CRE 8.1 and BUN 104, increasing rapidly from CRE 6.0 BUN 72 on May 11 (Please see the attached).

In the past two weeks Dusty did show signs of improvement. She has better appetite, drinking and urinating more. But she has become significantly less active, sleep more than ever.

Any suggestions are highly appreciated. Is this rapid increase in CRE related to the overdose? Is there anyway to antidote Darbopoetin? Can we take any legal action for this perhaps fatal harm to our poor kitten? 

For more about Dusty, please refer to this thread: http://www.thecatsite.com/t/294266/our-cats-creatinine-is-7-7-and-rises-fast-what-can-we-do

Gotta say Tommy, that is a huge flub up on their part. You need to call and ask to speak with the practice manager and the owner(s). Mention you are concerned enough to file a complaint with the State Veterinary Medical Board. http://www.tbvme.state.tx.us/Complaints.php

Darbepoetin or Aranesp, should be administered at 1mcg/kg/week for a minimum of 2 doses, monitoring the PCV and slowing injections as the packed cell volume increases from 15% to a more manageable homeostatic state of 22-28% at best. A renal cat is unlikely to return to 30% or greater, more normal estimate of red blood cell production, as their kidneys can't generate that much erythropoetin, even with supplementation.

GI side effects, neuro side effects, anaphylaxsis, and fever without infection are all risks of administering darbepoetin. When 25mcg is administered all together to a cat, they must be closely monitored for these side effects. Your regular vet followed the bottle, administering the full bottle as indicated. Your internist is responsible for the error. Their is no "confusion" and it's ludicrous and immoral that either DVM would act like they don't know what to do or who is to blame. First priority, take care of their patient and client. Second priority, accountability, restitution, and consequence.

Within Internal Medicine at GCVS, it appears only 2 internists have experience. The bottom 6 below these 2 on their website have very limited experience. I would not have them managing a chronic renal insufficiency cat with acute episodes in my hospital, especially using any erythropoetin stimulating product, as this should be prescribed, considered, and administered by experienced doctors. If a veterinarian new to using Epogen or Aranespt, they are mentored by an experienced doctor, closely supervised, who is asking them analytical questions that led to their decision to use the product, how they'd use it, how they'd monitor efficacy, advising on best route and frequency of administration in their experience, side effects to monitor, etc.

I hope of the 7 internists on their site, an experienced internist is on Dusty's case. The pharmacy error could either be a technical error from the pharmacy, or an error prescribing directly from the internist themselves.  Either way, the error is the fault of GCVS as a practice regardless, and their license and reputation are at risk due to such oversights and mistakes at the expense of patient health and customer service.

Most specialty practices with an ER or critical care department rely heavily on ER for the majority of their budgeted income. Specialists such as IM or surgery are secondary to the ER.  Speaking to the internists themselves after such an oversight needs higher supervision and power present, such as the whole hospital manager (not department manager) with or without an owner present. This is a huge error and do not let them minimize its detriment to patient health, patient care and management, or customer service.

At this point, Dusty would have been better served by a very experienced feline practicitioner who is well-versed in renal disease, management, home care, and administration of Epogen/Aranesp, rather than a specialist, even though they have brief additional education and testing/board certification prior to being considered a diplomate of internal medicine. I can think of 4 doctors of my past, regular DVMs, that would never have made such a mistake, before the product left the hospital, as it is a rarely used product, temperature sensitive, and would get triple checked prior to dispensing.

Support staff and reception would have been "checks and balances" in place to limit such mistakes, also reviewing the label and the invoice/record prior to checking you out. Anything that didn't make sense would have been obvious, unless they have inexperienced staff, or poor pharmacy and customer service protocols in place, lacking quality assurance control by having multiple departments within staff checking one another's work prior to "finalizing" and dispensing to/charging a client.

I am so very sorry you are enduring this Tommy. What a terrible, alarming experience. I hope the specialist and your regular vet learns from this, the most important factor, so it never happens to another patient again.

Right now, IV fluid diuresis is important. It can help perfuse her organs while the potential GI distress, central nervous system effects, immune system and kidneys adjust to the sudden increase in erythropoetin. Even now that is affecting her as darbepoetin takes 1-2 weeks to have effect. The sudden elevation in BUN and CREA is not a coincedence and shouldn't be treated as such.

Also, they need to comp her next darbopoetin treatments after she gets over this hump. And have a monitoring quality control system in place throughout further administrations and infusions. At most, one 25mcg vial is separated into 10 injections, but isn't common to split into 6 injections. 2 or 3 is unheard of as no domestic cat is large enough to warrant this dose.

Increase her prebiotic, aka the psyllium husk, or if still persisting, use of Epakitin, then this powder while her BUN is that high. The excess nitrogen from dietary protein conversion will be bound by the fiber in the GI tract, prior to absorption in the intestines. Probiotics are also important, as is iron supplementation and B complex supplementation through the next 2 weeks while she has this high dose of darbepoetin on board, so her body has the ingredients needed to make hemoglobin, then RBC's, as she needs dietary iron/B complex, or all that darbepoetin stimulates erythropoetin that then has no way of making RBC's without these other 2 crucial components available in the bloodstream. They did not evaluate her phosphorus or calcium levels. Ensure these are checked, as her phosphorus may be highly elevated, higher than ever, with CREA that high.

There is no "toxicity treatment" like when a critter intakes toxic doses of NSAIDs, human narcotics, garlic/grapes, or topical flea/tick meds, for example, reversing effect, binding darbo in the blood, or excreting darbo in the urine; they just have to get through it, after absorbing it. Supportive care and monitoring are the primary factors.

Some toxicologists with SPCA and Pet Poison Helpline are slow to formulate the plan, and experience with darbo is more critical than toxo recommendations or theories about treatment. Some don't recommend hospitalization and intravenous fluid flushing with this is the single most important part of many toxicity cases. Supportive care is the biggest component.

Very sorry this happened. I hope for the best with Dusty. I do agree with Puck, that's a  large mistake there. If I were you, I would file a report for negligence regardless Dusty's condition, they did wrong, there is no room to make mistakes when you're in a medical field, human or animal. Please keep us posted on Dusty. Positive thoughts and prayers will be sent for you both.

We've scheduled IVF on Monday with the family vet. But she is concerned that IVF may make it hard to assess the changes in red blood cell levels. Should we hold on the IVF for a few days?

@puck  , when you said prebiotic and probiotic, were you talking about the binders?  We've changed Epakitin to Aluminim hydroxide, as you suggested.

Dusty stops eating today and sleeps more than ever. Looks the overdose began to take effects now.   

One more question. For IVF, how many days we should plan? Our family vet looks always reluctant to put Dusty on IVF for more than one day. Yet Tania's CKD guide suggests much longer, for instance, 3-5 days, or even over one week.

Your regular vet shouldn't be reluctant. If they are, then their comfort level and expertise managing an anemic renal cat needs to be considered. Dusty would benefit from a doctor that is more experienced, with nursing/assistant staff that monitor her throughout her stay, maintaining IVF daily, at a rate that isn't excessive. LRS at 15mL/hr, for example, would greatly benefit her without overloading her heart or over-diluting her blood. I managed renal/heart disease cats on IVF every night. They do very well. Your baby has hypertension, but not even heart disease yet, to consider alongside her renal disease when treating her.

Her HCT/PCV is at 20%, and if she drops to 15% or lower, at their cost the vet needs to administer packed red blood cells or whole blood, as her needing any of this directly coincides with the specialist and the rDVM administering Aranesp incorrectly, for which both should have their license and their clinic's license on the chopping block. pRBCs or WB shouldn't be administered by a regular DVM that is unfamiliar with administering blood products either. Their staff won't know what to look for, how to monitor, throughout the infusion. They need to understand how critical their mistake is, and they need to work to help Dusty, not sit back wondering what will work, unsure, wary now of being associated with the cat they overdosed. Fix it. Correct it.

Then, own the mistake and place measures in the future that:

a.) won't allow such a wrong label to ever leave the specialty hospital again, a hospital that should already be thorough and have staff double-checking, as they are a specialty hospital. That is what they are paid the big bucks for. They claim specialty, something bigger and better than rDVMs, yet no rDVM I ever worked for (over 6 clinics, over 20 doctors) sent out an erythropoetin stim product mis-labeled. Or Tumil K in a bag of fluids. Food for their thought...

b.) will cause a regular vet to pause, read a label carefully, and consider how that may be wrong. I get transferred meds every day from other hospitals, and do not blindly follow the label. My local vet school Teaching Hospital won't even accept outside Rx's, even if prescribed that day and brought to them immediately, as they can't account for appropriate dosing, filling, and labeling of the outside prescription. Sometimes, furosemide is in that bottle rather than famotidine, a huge mistake, very different drug, and toxic if given to a patient that doesn't need it.

Discrepancies between the patient weight/history and the dose are caught, addressed with the ER clinician, internist, oncologist, etc and the dose WE are going to give is decided and placed on the patient's daily treatments. Your vet really wasn't familiar with the product at all to see that label, give the bottle, and not question why it said to give 25mgc... which was another error. A typo on a label, rather than read 25mcg, tells me the error lies with the specialty practice, going too fast, so fast they misspelled mcg, as well as placed poor directions on their label.

Her potassium needs to be checked. If low, she needs KCl added to her LRS fluid bag, prior to administration. Again, if your regular vet isn't familiar with this, such as adding TumilK to fluids, find one that is.

This website is pretty accurate with my area's local feline practitioners, vets that are well versed in cats, clinics with cat friendly entry/exit, etc.

http://www.catvets.com/cat-owners/find-vets-and-practices  Taking them your file, full of Dusty's bloodwork results, history with renal disease and hypertension at your regular hospital, as well as at the specialty hospital, and getting Dusty on IVF pronto is important. Call around and see which ones keep a couple units of pRBCs or WB in their fridge. See which ones carry darbepoetin, so it wouldn't be a "special order" because they use it every week, at a minimum, to keep it in stock like that. These are the kind of vets Dusty needs. Proactive. Experienced. Well versed in kidney cat, hypertensive cat, potentially heart disease cat down the line as kidneys affect heart, and administering Aranesp, pRBCs, and IVF to such potentially critical patients.

Many regular vets that see both dogs and cats are well versed in cats. Many aren't.  You may benefit from a boarded feline practitioner, with at least 5 years post boards under their belt practicing. Practicing feline medicine gives them way more education than those boards, or honestly, than vet school. An avid vet student that wants to be a great practitioner, will get a lot of tech/nursing experience under their belt while preparing for or during vet school. They learn so much practically, like this. Then, shadowing as a vet student in training, asking questions, soaking up knowledge. Some are good at faking it, charming mentor doctors and all their clients. When I have a shadow student that is good, I encourage them to practice, knowing they'll be one hell of a doctor, and shouldn't go into research. Some should only work for pharma, food co, or research, they are just not good practicing animal doctors.

Dusty is my prayers. I'm talking her up to my future young vets, vet students, and techs/nurses in training. Perfect example of a well treated cat, good owner compliance, with a lackluster veterinary team. We look out for one another in my field, but we also help each other see our mistakes, and counter them, improve, make it all better. Vets that hide it are no good, send the manager out to talk, deny accountability. A vet that owns up to it, admits it, and works to repair it and prevent it, is a vet worth keeping. They learn constantly. They improve constantly. This is the vet I am proud to associate with, and comfortable using for my own babies.

If it was me, i'd print out all of @puck's comments and bring them to the vet with me and ask the vets to read it.  ANd i'd look for the most qualified vet i can get.  The current vets need to own this so much that they need to help you find a more qualified vet than themselves (imo).

We are in Houston area. Do you have any recommendations for a vet?

@puck, would you say we can choose any one of the vets with a "gold car friendly practice" icon in the website you recommended?  

Our current family vet is the Cat Veterinary Clinic. They have pretty good review on google, which is why we chose it in the first place.

Dusty stopped eating and urinating yesterday, the first time since the anti-anemia treatment started two weeks ago. A dim light of hope is that she ate a little bit this morning. 

puck said:

[...]

This website is pretty accurate with my area's local feline practitioners, vets that are well versed in cats, clinics with cat friendly entry/exit, etc.
http://www.catvets.com/cat-owners/find-vets-and-practices 

[...]

Many regular vets that see both dogs and cats are well versed in cats. Many aren't.  You may benefit from a boarded feline practitioner, with at least 5 years post boards under their belt practicing. Practicing feline medicine gives them way more education than those boards, or honestly, than vet school. [...]

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I can vouch that this web site is accurate with vets in my area as well (I'm in the Pacific Northwest). Spot on.
Highly recommend using this site to find a good vet for your kitties.

PushPurrCatPaws said:

I can vouch that this web site is accurate with vets in my area as well (I'm in the Pacific Northwest). Spot on.
Highly recommend using this site to find a good vet for your kitties.

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Thanks. My current family vet is also on this site. How do you decide which one is the most qualified?

tommy2015 said:

... My current family vet is also on this site. [...]

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Oh my goodness. Do you mean, the "family vet" whom you mention above, which "... injected all the rest of the 25mcg [Darbopoetin] into Dusty last Saturday, and the bottle is empty now." ??!

That. Is. Not. Good.

(yes - Inserting your "Cat Veterinary Clinic" at that web site shows three vets at this practice as being members of the AAFP, I see that now.)

Please re-read puck's comments in this thread. You have a decision to make in regards to how you will move forward with this family vet. Meanwhile, Dusty needs good veterinary care and soon, I should think.

IMHO, especially considering she has stopped urinating, I would think she needs the IV diuresis sooner than later.  In your other thread you mentioned you have an appointment set up for Monday to start this.  I'd be trying to get it started sooner.  Figures that it's the weekend now .  Tommy, has YOUR Vet made any strides in what to do with this issue?  Have they made any calls to UC Davis or other well know veterinary schools who use Darbopoetin  in their studies?  THEY need to be taking some action too.  It shouldn't be entirely up to you to figure out what to do here.  In the meantime, Dusty's life is at stake, as I'm sure you know.  

Are you at least still doing her sub-q fluids every day... I'm still very concerned with no urination, and wondering whether or not she is getting any fluids on board?

I'm worried for Dusty. I am afraid unless she gets fluids she's not going to last much longer especially once all the medication kicks in. To be honest, I don't even think she should be home, she needs to be hospitalized. This is urgent. I agree with mrsgreenjeens. The Vet should be trying to fix what they've done wrong.

mrsgreenjeens said:

 
IMHO, especially considering she has stopped urinating, I would think she needs the IV diuresis sooner than later.  In your other thread you mentioned you have an appointment set up for Monday to start this.  I'd be trying to get it started sooner.  Figures that it's the weekend now

.  Tommy, has YOUR Vet made any strides in what to do with this issue?  Have they made any calls to UC Davis or other well know veterinary schools who use Darbopoetin  in their studies?  THEY need to be taking some action too.  It shouldn't be entirely up to you to figure out what to do here.  In the meantime, Dusty's life is at stake, as I'm sure you know.  

Are you at least still doing her sub-q fluids every day... I'm still very concerned with no urination, and wondering whether or not she is getting any fluids on board?

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Dusty urinated today, and ate a little. She always sleep, much more inactive than ever. We are going to send her to vet on Monday for whatever treatment possible. A problem is that the family vet is not very proactive. She thought Dusty is dying soon and IVF is at most a waste of money. We will have to push her to take action.

At this stage we may not have time to find a better vet.

I am thinking to fight with the specialist clinic (Gulf Coast Veterinary Specialists  in Houston) that made this accident. In addition to reporting to the Texas State Veterinary Medical Board and the Better Business Bureau (they are a member), where else can I file a complaint?

tommy2015 said:

 
Dusty urinated today, and ate a little. She always sleep, much more inactive than ever. We are going to send her to vet on Monday for whatever treatment possible. A problem is that the family vet is not very proactive. She thought Dusty is dying soon and IVF is at most a waste of money. We will have to push her to take action.

At this stage we may not have time to find a better vet.

I am thinking to fight with the specialist clinic (Gulf Coast Veterinary Specialists  in Houston) that made this accident. In addition to reporting to the Texas State Veterinary Medical Board and the Better Business Bureau (they are a member), where else can I file a complaint?

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BBB is pointless...essentially you pay a fee and you're a top BBB member; stick to the Texas State Veterinary Medical Board, look into civil suit filing with your local magistrate, as that is a nominal fee, and get your ducks in a row with paperwork. If they are a member of AAHA, report them. It they are a member of the State Veterinary Medical Association, report them. If they are a member of any local business clubs, i.e. part of packet given to new residents through city council welcome wagon, etc, report them.  Especially as they appear to be shirking responsibility, accountability, and rectifying the situation.

If you are at a Gold Cat Vet clinic already, then investigate other doctors within the practice, and absolutely talk to the hospital manager and owner(s). Your current rDVM sounds inexperienced. Not only by the darbo fiasco description, but

• by their "dumbing down" or actually adding Tumil-K powder to sterile injectable fluids,
• by their excessive use of calcium supplements in a renal cat (there are alternatives to calcium carbonate, aka Epakitin, that should be used for a moderate to late stage renal cat like Dusty),
• by their hesitation and direct denial to utilize better GI protectants for ulceration and
• denial to use aluminum hydroxide, available as a gel and powder, which any cat hospital worth their weight should have in large supply as it's Cheap and widely used by renal cats, and renal disease is the 2nd most common ailment of geriatric cats;
• by their excessive recommendation for full panel bloodwork every 4 wks rather than rechecking electrolytes/phos/Ca/urine specific gravity/PCV every 2wks (typical renal labwork maintenance, choosing the applicable values that tend to flux with renal cats and can help indicate med/therapy changes), less once her Crea was down a bit and phos/K kinda within normal limits,
• and they did not initiate starting potassium supplementation themselves, as you had to request this.

There are numerous red flags for me. I am, frankly, surprised they are a Gold Cat Vet clinic by the AAFP site, as regular small animal practices I've worked for in NC, MD, and CO have better standards of care, well versed use of Epogen/Aranesp, carry both of these, AlHO gel and powder, numerous diet options, both typical Rx renal as well as Dave's Pet Food low protein/phos/Na, add KCl to fluids daily for critical patients, not only renal cats get low K, let alone what the specialist is accountable for, as a boarded, tested, verified internist. Redonkeyulysses as I like to say in my field.

I will review some clinics, talk to cohort on my vet networks, and see about other rDVMs, but for now Dusty needs that oh so time-critical supportive care of IV fluids, possibly an esophageal feeding tube to get her through this, so she isn't forced to eat while nauseated, omeprazole daily, and possibly pRBCs, 1 to 2 units. Hold them to it Tommy. You are her advocate, as you have been all along, through so much with her. They must respond accordingly, and take ethical medical action to help her, even if they hadn't flubbed, it's their job to place the patient's well being as a top priority, to do all they can to behoove her, not harm her. Waiting is harmful. Denial is harmful. You are not a trigger happy lawsuit fiend, you are a justifiably concerned advocating owner for your baby. They need to get their thumbs out of their bums and act.

Praying for you, Dusty, family, and the moral instincts of her vets.

puck said:

 
BBB is pointless...essentially you pay a fee and you're a top BBB member; stick to the Texas State Veterinary Medical Board, look into civil suit filing with your local magistrate, as that is a nominal fee, and get your ducks in a row with paperwork. If they are a member of AAHA, report them. It they are a member of the State Veterinary Medical Association, report them. If they are a member of any local business clubs, i.e. part of packet given to new residents through city council welcome wagon, etc, report them.  Especially as they appear to be shirking responsibility, accountability, and rectifying the situation.

If you are at a Gold Cat Vet clinic already, then investigate other doctors within the practice, and absolutely talk to the hospital manager and owner(s). Your current rDVM sounds inexperienced. Not only by the darbo fiasco description, but

• by their "dumbing down" or actually adding Tumil-K powder to sterile injectable fluids,
• by their excessive use of calcium supplements in a renal cat (there are alternatives to calcium carbonate, aka Epakitin, that should be used for a moderate to late stage renal cat like Dusty),
• by their hesitation and direct denial to utilize better GI protectants for ulceration and
• denial to use aluminum hydroxide, available as a gel and powder, which any cat hospital worth their weight should have in large supply as it's Cheap and widely used by renal cats, and renal disease is the 2nd most common ailment of geriatric cats;
• by their excessive recommendation for full panel bloodwork every 4 wks rather than rechecking electrolytes/phos/Ca/urine specific gravity/PCV every 2wks (typical renal labwork maintenance, choosing the applicable values that tend to flux with renal cats and can help indicate med/therapy changes), less once her Crea was down a bit and phos/K kinda within normal limits,
• and they did not initiate starting potassium supplementation themselves, as you had to request this.

There are numerous red flags for me. I am, frankly, surprised they are a Gold Cat Vet clinic by the AAFP site, as regular small animal practices I've worked for in NC, MD, and CO have better standards of care, well versed use of Epogen/Aranesp, carry both of these, AlHO gel and powder, numerous diet options, both typical Rx renal as well as Dave's Pet Food low protein/phos/Na, add KCl to fluids daily for critical patients, not only renal cats get low K, let alone what the specialist is accountable for, as a boarded, tested, verified internist. Redonkeyulysses as I like to say in my field.

I will review some clinics, talk to cohort on my vet networks, and see about other rDVMs, but for now Dusty needs that oh so time-critical supportive care of IV fluids, possibly an esophageal feeding tube to get her through this, so she isn't forced to eat while nauseated, omeprazole daily, and possibly pRBCs, 1 to 2 units. Hold them to it Tommy. You are her advocate, as you have been all along, through so much with her. They must respond accordingly, and take ethical medical action to help her, even if they hadn't flubbed, it's their job to place the patient's well being as a top priority, to do all they can to behoove her, not harm her. Waiting is harmful. Denial is harmful. You are not a trigger happy lawsuit fiend, you are a justifiably concerned advocating owner for your baby. They need to get their thumbs out of their bums and act.

Praying for you, Dusty, family, and the moral instincts of her vets.

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According to this site (http://www.catvets.com/cat-owners/find-vets-and-practices), our family vet (named "Cat Veterinary Clinic") is not a "Gold Cat Friendly Practice". Would you suggested us changing to one with the Gold title?  But this Monday we may still have to go to Cat Vet Clinic for IVF.

In the meantime, I am writing to the specialist who made this accident, pushing them to take action to save Dusty. Do you think this is advisable? Or maybe we should go to a better vet directly? 

@tommy2015  I think you should go to another Vet, this current one seems to waiting for Dusty to pass on as they are afraid of a lawsuit. I would think they would fear the harm they've caused your cat first and foremost, but it seems they don't. By any chance can Dusty see a Vet today? I know it is a good deal of work getting files and getting everything ready, but the longer you wait, the less time there may be for Dusty to get help.

I'd take her to a critical care/ER specialist immediately. You could return to Gulf Coast and stick solely to their Urgent Care dept today and tomorrow. Or to North Houston Veterinary Specialists critical care dept. The only negs associated with each seemed to be money based, typical stress response after owners spend thousands, or can't afford to treat their pet, refuse euthanasia, and decline treatment, but take their pet home to "monitor it themselves."

Look for others open today. Both of the above are familiar with IV crystalloid and colloid therapy, as well as IV pRBC and WB infusions. They have the tech and experience to evaluate chemistry, lytes, CBC and a blood smear slide to see just where Dusty is physiologically. Fingers crossed her K hasn't plummeted, her Phos nor Ca aren't sky high, and she's not too dehydrated. PCV has hopefully held at 20ish%. They'll help recognize what needs treating, and review the cost for hospitalization, IV fluid administration, bloodwork, and potentially include in the estime pRBC/WB, which you can ask them to wait until the doctor tries fluid therapy alone if they think will be effective. Otherwise, an estimate for an esophageal feeding tube should also be included, with cost of special diet and educating you how to maintain at home (tutorial fees/bandage material fees). Reviews of their nursing staff regarding patient care and communication are good.

Hope you can get help soon! Hugs to you and Dusty!

puck said:

 
I'd take her to a critical care/ER specialist immediately. You could return to Gulf Coast and stick solely to their Urgent Care dept today and tomorrow. Or to North Houston Veterinary Specialists critical care dept. The only negs associated with each seemed to be money based, typical stress response after owners spend thousands, or can't afford to treat their pet, refuse euthanasia, and decline treatment, but take their pet home to "monitor it themselves."

Look for others open today. Both of the above are familiar with IV crystalloid and colloid therapy, as well as IV pRBC and WB infusions. They have the tech and experience to evaluate chemistry, lytes, CBC and a blood smear slide to see just where Dusty is physiologically. Fingers crossed her K hasn't plummeted, her Phos nor Ca aren't sky high, and she's not too dehydrated. PCV has hopefully held at 20ish%. They'll help recognize what needs treating, and review the cost for hospitalization, IV fluid administration, bloodwork, and potentially include in the estime pRBC/WB, which you can ask them to wait until the doctor tries fluid therapy alone if they think will be effective. Otherwise, an estimate for an esophageal feeding tube should also be included, with cost of special diet and educating you how to maintain at home (tutorial fees/bandage material fees). Reviews of their nursing staff regarding patient care and communication are good.

Hope you can get help soon! Hugs to you and Dusty!

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And after this is done, I would try to recoup the bill from BOTH the Vets who wouldn't take immediate action to try to rectify their mistake (along with the other action you will be taking, reporting them to the Medical Board, etc. )  There is no way this added expense should be on YOUR back.  They should have immediately taken her and started this protocol rather than just throw their hands up in the air and send her home.  I'm fuming about this entire thing, as I'm sure lots of people here are