Pica or a novel fluid management strategy?

One of my favorite patient is a chronic fluid abuser. Today on rounds I noted that she had been doing better with this. She proudly showed me her new way of coping…rocks.

She is sucking on rocks rather than drinking. It takes all types.

If you ever get a chance to hear Ridley Baron don’t miss it.

A few weeks ago my hospital brought in Ridley Baron, a pastor who underwent a terrible tragedy that subsequently became even more horrific due to a medical error.

Here is a peak at his talk, I wish he would put more online, but he has his reasons for not doing it.

He does a great job of letting healthcare workers glimpse what the hospital experience is from the eyes of the victims. Inspirational.

Blogging as an academic endeavor

From Skeptical Scalpel (twitter)

Since I dropped out of the business of training residents, I have been actively blogging and not cranking out mindless publishable research. Here is an interesting fact. I have no doubt that far more people have read what I have written in my blog for a year and a half than ever read all of my 95 published works combined.

Sing it brother! It takes me about a hundred hours to prepare a de-novo talk for grand rounds. I will then deliver it to an cohort of 50-80 docs with a collective GCS of 10. After the last audience question the lecture video will be filed in the medical library never to be found again. The lecture is not searchable or discoverable and the work is largely lost.

An average post at PBFluids will get more views than the grand rounds in the first few days and if it is linked by RenalWeb other aggregator it will get enough page views to fill one of the great conference halls of the national meetings. After the first week the post continues to be an eternal flame of searchable and discoverable data. To me the relative impact tips way toward blogging as a more significant form of academic communication but to the powers that grant career advancement it is a meaningless toy.

Dogs, squirrels and evolution

This is my dog Bo.
Bo is a Woodle. I wanted to name him Chewbacca.

He loves to chase squirrels.
On google image search the top suggested related-search for squirrels is squirrels with guns

He was chasing squirrels all over my neighbor’s lawn, much to the delight of the 6-year old twins that live there. I proceeded to tell them the story of the only time Bo caught a squirrel.

I was jogging with Bo and he saw a squirrel. He chased the rodent for 10 feet until the squirrel climbed a tree. Bo looked up the tree and tried to jump a few times but the squirrel was too high. I told Bo that maybe he’d catch the next squirrel and we started to run down the block. Then the squirrel fell out of the tree and landed right in front of Bo. Well, Bo grabbed that Squirrel in his jaws and killed it faster than you could say “rabies shot.” It happened so fast all I could remember was the sound of his little lungs being punctured by Bo’s teeth. (Six year olds love the gory details. Bilateral pneumothorax, gotta be a quick way to die.)

Then I asked the twins, do you think that squirrel was a good climber?

They answered, “No.”

Do you think that squirrel’s babies would be good climbers?

They answered, “No.”

Do you think that squirrel is going to have any more babies?

They answered, “No.”

That’s why squirrels are so good at climbing trees. The ones that are bad at climbing, die and can’t have babies. We call that evolution.

And I call that a teachable moment.

Come on America, Its not that hard.

Gallup Poll Feb 2009

Level of support for evolution from wikipedia

Doctors are like the pyromaniac fireman

A patient, on Friday, explained that doctors are like the pyromaniac fireman who when he’s not putting out fires is secretly setting them so he can fight them.


Well, on that same day I saw a patient who previously had uncontrolled blood pressure. I had gotten her blood pressure under control with a combination of torsemide, spironolactone, carvedilol and amlodipine. Her office blood pressure  was 123/72 with a heart rate 86. During the visit she told me that she had fallen three times in the last few weeks. Her standing blood pressure was 96/53 with a heart rate of 96. On her previous visit I had extinguished and set a new fire at the same time. Her previous blood pressure had been in the 150s. Controlling her blood pressure was the right thing to do medically but undoubtably it was the cause of her recent falls and my attempt to trim long term morbidity resulted in her being exposed to increased short term morbidity.

Pyro fireman.

Another patient I saw has advanced diabetic nephropathy, CKD stage 4. He needs an ACE inhibitor or an angiotensin receptor blocker to stave off dialysis, unfortunately he cannot tolerate them because of recurrent of hyperkalemia. A few months ago I added a loop diuretic to control edema and hypertension and a couple of weeks ago he returned for a follow-up. His potassium was 4.6 mmol/L. The loop diuretic had increased kaluresis enough that I felt that I had some room to give another trial of renin-angiotensin blockade. Yesterday I received a call informing me of a critically high potassium in this patient.

Pyro fireman

These cases are not limited to clinical medicine, the ACCORD trial tried to determine if normalizing the Hgb a1c in diabetics reduced cardiovascular mortality. Better diabetic control caused increased total mortality.

In OnTarget the combination of an ACE inhibitor and an angiotensin receptor blocker was tested to see if it could reduce cardiovascular events. The  combination was a favorite among nephrologists as a way to stave off dialysis in patients with persistant proteinruia despite single drug renin-angiotensin blockade. Dual blockade was the fashion mostly in response to the subsequently retracted COOPERATE trial. In OnTarget there was significant increase in renal dysfunction with dual ACEi/ARB and a trend toward increased dialysis:

“…whereas the rate was increased in the combination-therapy group, with 65 patients (0.8%) undergoing dialysis”

Pyro fireman, academic style. 
It’s what makes medicine so difficult, the more you try to help your patients the more you expose them to unintended, adverse reactions. I feel that so little of medical education prepares us to balance these competing end-points, how do you judge what is an acceptable risk of hyperkalemia, how do you balance the risk of hypertension versus the risk of orthostatic hypotension?

Fellow-level lecture on urea kinetics

I reworked an old lecture from ’05 on urea kinetics. The old lecture had a hideous purple background, so changing that to black would have been enough but I added a number of cool touches to fully update it. It worked pretty well, though the end’s pacing is off.

PowerPoint | PDF

I especially like the sequence walking through using the iPhone to calculate the simplified single pool Kt/V. Its amazing how many people don’t realize that turning the calculator sideways brings up scientific functions. I love watching their faces light up when I say, “Now turn it sideways.”

The lecture uses the three randomized controlled trials on dialysis to introduce and explain the three varieties of Kt/V:
  1. NCDS: to discuss single pool Kt/V
  2. HEMO: to discuss equilibrated Kt/V
  3. Frequent Hemodialysis Network in center study: to discuss standard Kt/V
I have another hour long time slot in December to talk about dialysis prescription. I’m going to discuss the recent data on dialysis interval and mortality
What else should I talk about?

Steve, you put a dent in the universe

The link is to  Apple.com
Google, keeping it classy
jonathon mak

Brian Lam on Steve Jobs during the lost iPhone 4 story
Flags at 1 Infinite Loop
Steve and wife, Laurene, after his last product introduction, WWDC 2011 iCloud 

John Siracusa’s touching remembrance

In the official version Richard Dreyfus is the narrator. I had never heard this version with Steve at the mike.

Egg Freckles is a Apple website, the term is from a Doonesbury comic poking fun at the Newton’s terrible handwriting recognition.

Gruber, always subtle, changes the background of Daring Fireball to a darker, almost black, grey.