This March, I am going to climb to Mt Everest Basecamp (EBC), altitude 17,900 feet. Actually I will be going a bit higher to Kalapathhar at 18,500 feet but no one knows what Kalapathhar is, so EBC it is. This is an 8-day trek and I want to do some physiology testing along the way. I am going to bring a pulse oximeter, a sphygmomanometer and some urine dipsticks to do serial urinalysis. I have a pretty strict weight limit. So careful choices need to be made with regard to equipment choices.
In terms of physiology testing I have multiple subjects willing to be part of my science fair.
My questions to the readers of PBF, is what questions can I answer?
I believe that everyone is going to be on acetazolamide.
I am interested in water intake, cramps and exercise fatigue. I could probably get that data with a daily survey and then I could correlate it with pulse oximetry and urine specific gravity at the end of the day’s hike.
I am also interested in peak specific gravity as we go up the mountain. Does it fall with increasing hypoxia? But this may be hopelessly obscured by the acetazolamide.
I would like to do some cognitive testing as we go up the mountain.
What other questions should I try to answer. What other medical instruments should I take? Bioelectrical impedance?
Saturday November 4, 2017 I accepted the Robert Narins Award from the ASN. This is the highest honor I could ever receive for the work that I have done in medical education.
Here is how ASN describes the award:
The Robert G. Narins Award honors individuals who have made substantial and meritorious contributions in education and teaching. This award is named for Robert G. Narins, who is also the first recipient of the award.
Dr. Narins’ contributions to education and teaching started in 1967 when he was appointed to the faculty of the University of Pennsylvania. At Penn, and on the faculties of UCLA, Harvard, Temple and Henry Ford Hospital, he taught and mentored many residents and fellows. For eight years he chaired the ABIM’s Nephrology Board and also worked on the ACP’s Annual Program Committee. His contributions to education in the fields of fluid-electrolyte and acid-base physiology are prodigious and well-recognized.
Dr. Narins was also involved in the creation and planning of many ASN educational programs during Renal Week and throughout the year, including: Board Review Course and Update, one and two day programs at Renal Week, Renal WeekEnds, and NephSAP. He also was instrumental in the decision to develop the Clinical Journal of the American Society of Nephrology (CJASN), the establishment of the Fellow of the American Society of Nephrology (FASN) program, and negotiated the successful partnership agreements with HDCN and UpToDate. Dr. Narins has been at the forefront of collaborative efforts with the American College of Physicians to increase the exposure of nephrologists to relevant updates in Internal Medicine and internists to chronic kidney disease. Collaborative educational programs with societies in Europe and Asia have helped to spread education and teaching in nephrology on a global scale.
To be recognized for this is amazing. I feel that social media and internet-based, distributed learning that leverages the skills and perspective of a large group of self-appointed experts is, and will, continue to swamp the old model of a few, highly selected, experts.
In many ways, the reality of internet distributed medical education is the opposite of what people believed it would represent. I remember hearing people speak about the best lecturers being able to distribute their wisdom to the world through IP switching. The conventional wisdom was that the internet would allow all medical students to learn from the best teachers. The internet would eliminate location and size limits of the lecture hall so we would all get the Harvard education.
Social media altered that future.
Instead of one vision being distributed to a million impressionable minds we got a million visions being distributed so that each mind could find the one that worked for them.
We are in the midst of a massive democratization of medical media.
Social media in medical education is moving us from broadcast video to YouTube, from radio and audio books to podcasts, from books and journals to blogs and tweets, from a few highly selected authority figures to a large number of educator hobbyists.
And I am just a participant in this. I am an early adopter. I am at the front of the wave. However, I didn’t create the wave, and I can’t control it; I’m merely surfing the leading edge. And I believe ASN recognizes that. I believe that the ASN awarded me the Narins award as a symbol that distributed, social media-powered-learning, is now a valid and growing part of primary and continuing medical education. ASN is among the first of the medical societies to recognize this. I salute ASN for resisting the urge to circle the wagons and fight the inevitable. ASN should be commended for recognizing and embracing this new epoch in medical education.
That said, as much as I believe I was a just a symbol of the revolution that I am part of, they did pick me to be that symbol and for that I am grateful. And I would like to thank the people that have brought me on this journey.
That tweet is totally true. And in the rush to compose a coherent thank-you speech in my adrenalin addled brain I glossed over and missed some essential people.
The Patron Saint
Burton D. Rose. My favorite part of the Narins Award Legacy Video is when Rose says that Robert Narins brought fluid and electrolyte and acid-base teaching into the mainstream (1:35) and set the path for him.
I love this because Rose set the path for me, in two ways.
One: Rose’s Clinical Physiology of Acid-Base and Electrolyte Disorders was the bible that taught me renal physiology and inspired me to pursue a career in nephrology. I bought it during my third year of medical school when I told the intern that I was working with that I was confused by eletrolytes. He suggested this book. Talk about a bad answer to a small question. I wanted a 5-minute lecture on what fluid to order and my senior suggested a 916 page, $70 tome.
But I was an idiot and I bought it.
And though it sat on my shelf for a year before I started it, when I began, I could barely put it down. I truly believe that one can draw a direct line from that terrible advice given to me at the Allen Park VA in 1993 to my position today. Sometimes bad advice can lead to the greatest of outcomes.
Rose’s book is a masterpiece because it strives to make the reader build a robust mental model of how the kidney works. Once that model is complete, it becomes easy to understand all of the electrolyte disorders.
Two: When I was an intern I was telling a doctor how much I loved Rose’s yellow electrolyte book and he told me to look him up in PubMed. I had previously looked up Berl and Schrier and I expected much of the same, but this is what I got:
Seven. Seven articles in pubmed by the great Bud Rose. The man that has done more for medical education and patient care than anybody since Osler (based on his work with UpToDate) had seven articles in PubMed in 1996. Go ahead, see for yourself. This convinced me that I could be a medical educator without being a medical researcher. I could pursue what I loved, without being distracted doing what I had little interest in doing.
Joshua Schwimmer. Josh was the first nephrology blogger. I had been a long time reader for years before following his trail and starting Precious Bodily Fluids. And after a few months, Joshua gave me my first link and turned the microphone on. Thanks Josh.
PBFluids and @Kidney_Boy stand apart as the only signifigant projects I have done alone. Everything else of significance has been done with a collaborator, co-author, or co-creator. This is an indisputable case of “I couldn’t have done it alone.”
Sarah Faubel as a co-author on the Microbiology Companion and The Fluid Electrolyte and Acid Base Companion
Joel Smith as co-creator of Alert and Oriented Publishing
#NephTwitter is a colorful and engaging place with an always on conversation anchored by people around the world. Here are a few of the people that populate that community.
Tom Oates, Roger Rodby, Paul Phelan, Michelle Rheault, Francesco Iannuzzella, Hector Madariaga, Graham Abra, Nikhil Shah, Matt Graham-Brown, Ian Logan, Scherly Leon, Dearbhla Kelly, Silvi Shah, David Goldfarb, Richard McCrory, F. Perry Wilson, Raymond Hsu, Benjamin Stewart, Brian Stotter.
My partners at St Clair Specialty have been involuntary partners on this journey and have been great. St Clair Specialty is a practice that values people that contribute to nephrology. This was clear from past CEO, Robert Provenzano, who was a major contributor to nephrology as a scientist and president of the RPA. And it is also clear with Keith Bellovich, RPA board member and chief of nephrology at St John Hospital and Medical Center. At a more single minded-practice, I could not have contributed to nephrology education as I have.
And lastly, and most importantly, I could never have contributed to medical education without my family. I need to thank the eternal patience and understanding of my wife, Cathy, and my kids, Laura and Simon Topf. Thank-you.
If you have been annoyed at all of the broken links at PBFluids. My apologies. Blogger doesn’t host any files so to use them you need to host elsewhere. For this reason alone I recommend WordPress or SquareSpace for people who want to start blogging.
Tonight I fixed the Handouts tab. A few weeks ago I fixed the Books tab. All of those links now work. Next up: the Lectures tab.
Question: Should old lectures that may contain out of date material be taken down, or remain up?
This past Saturday I gave a talk at the ACP of Michigan on SGLT2 inhibitors.
The talk went well, except my HDMI to thunderbolt converter failed in a big way and I had to export the presentation to Powerpoint and run it off a Windows Machine. Yuck.
I used visual abstracts from EMPA-REG and CANVAS as a significant part of the presentation. This segment demonstrates how I used them. What killed me was the cool animation, where the third panel flips to reveal the renal outcomes, was handled with complete incompetence by PowerPoint. Otherwise PowerPoint did a pretty good job displaying my slide, but botching my favorite animation in the entire presentation is bordering on unforgivable.
Exertional Rhabdomyolysis during a 246-km Continuous Running Race
SKENDERI, K. P., S. A. KAVOURAS, C. A. ANASTASIOU, N. YIANNAKOURIS and A. MATALAS. Exertional Rhabdomyolysis during a 246-km Continuous Running Race. Med. Sci. Sports Exerc., Vol. 38, No. 6, pp. 1054 – 1057, 2006. Background: To evaluate the effect of continuous, moderate-intensity ultraendurance running exercise on skeletal muscle and hepatic damage, as indicated by serum enzyme activity measured immediately following the race. Methods: Thirty-nine runners of the Spartathlon race (a 246-km continuous race from Athens to Sparta, Greece) who managed to complete the race within the 36-h limit participated in this study. Mean finishing time of the study participants was 33.3 T 0.5 h and their average age, height, and body mass were 41 T 1 yr, 174 T 1 cm, and 67.5 T 1.1 kg, respectively. Blood samples, taken a day before and immediately after completion of the race, were assayed for the following variables: creatine kinase (CK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (F-GT). Results: A dramatic increase in most of muscle and liver damage indicators was observed. The mean values for CK, LDH, AST, and ALT after the race were 43,763 T 6,764, 2,300 T 285, 1,182 T 165, and 264 T 37 IUILj1, respectively. These values were 29,384 T 4,327, 585 T 89, 5,615 T 902, and 1,606 T 331% higher than the corresponding values before the race (P G 0.001) for CK, LDH, AST, and ALT, respectively. However, there was not a significant increase in F-GT levels. Conclusion: Muscle and liver damage indicators were elevated at the highest level ever reported as a result of prolonged exercise, although no severe symptoms that required hospitalization were observed in any of the participants. The data suggest that even moderate-intensity exercise of prolonged duration can induce asymptomatic exertional rhabdomyolysis. Key Words: CREATINE KINASE, LACTATE DEHYDROGENASE, SPARTATHLON, ULTRAENDURANCE EXERCISE