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.

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

New kid on the block: The Kidney Doctor

I first met Ajay Singh when he came to St John Hospital as part of a symposium on chronic kidney disease in 2004 or 2005. It was a great meeting and Singh gave two memorable lectures.

The first was a dismantling of the MDRD equation as an accurate measure of GFR. He was speaking against an equation that was way better than a simple creatinine but had some real problems, especially when used in patients without kidney disease. It was a inflammatory and a bit wonky for a conference directed to primary care doctors. Here we, the local nephrologists, were trying to get our doctors to recognize occult CKD by abandoning serum creatinine in favor of the superior eGFR and then the invited expert comes in and tells them how stupid this is.

His second lecture was the correction of anemia dog-and-pony show. He gave an amazing and persuasive presentation in favor of correcting of anemia in renal disease. Though the data was all retrospective and observational it was clear that Dr. Singh was personally a few steps past equipoise. At the time CHOIR was in full swing recruiting and retaining patients and my group was part of that process as a research site for CHOIR.

Five or so years later he returned to talk with our fellows and staff regarding anemia. This was after the publication of CHOIR, but I believe before the release of TREAT, though my memory is a bit hazy on the timing.

What I do remember is that he talked about the dangers of correcting anemia and the lack of data supporting its use. I remember being so angry. I felt that for the last half dozen years I had worked to convince my CKD patients that they needed to enroll in our anemia clinic, needed to come to our office for EPO shots and iron infusions, and that all this would make them feel better, protect their heart and prolong their life, all purported advantages of ESA therapy. And now Mr. Harvard returns and tells us that this is wrong, without ever apologizing, without even mentioning how he’d jumped the fence.

I stopped him mid-lecture and told him that the last time he’d been in Detroit he’d been telling us how important it was to treat anemia and now he had completely changed positions. Dr. Singh paused, looked at me, and gave the best answer possible. I can’t remember his exact words, so I’m paraphrasing here,

“The data has changed. Now we know more and what I’m telling you is what is currently correct. In medicine, there is no room for intellectual loyalty. We must be loyal to our patients not our theories. The reason my position has changed is that I am following the data. Would you want me to do anything else?”

His answer completly satisfied me and it extuinguished my rage. I was better able to deal with my regret and embarrassment at having to abandon a long held belief and practice pattern at the feet of new data.

His new blog is off to a flying start with a productivity that hasn’t been seen since Nate Hellman and quality that, to my eyes, no one can match.

Thanks Ajay, I’m looking forward to following your blog.

I love the smell of July 1st in the morning

As has been the tradition since 2008, I had the honor of giving the morning report on July 1st for the St John Hospital and Medical Center Internal Medicine Residency Program. July one, openning day of the academic year. The conference room was crackling with the energy of fresh interns and the equally excited second years ready to run their own teams.

Giving the lecture was a lot of fun. There were a lot of insightful questions, some because the questioner is terrified and others to show how smart she is. Nobody looked sleep deprived, so the ratio of deer-in-the-headlights to asleep-at-their-desk was unnaturally high.

The lecture covered three topics:

  1. total body water and how to choose an IV fluid
  2. diuretics
  3. dysnatremia
There is no way I could get through the deck in the 50 minutes of time we had. It probably would take 90 minutes to cover it all. In delivering the talk I focused on the mood of starting this great adventure.
Here are some tips to using this presentation:
The first slide has Munch’s Skrik, which I explain translates as July 1st

Slide 4 has my favorite quote about kidney function. Homer Smith essentially uses 150 words to explain the point that the job of the kidneys is not to make urine anymore than the job of a factory is to make smoke.

The lungs serve to maintain the composition of the extra-cellular fluid with respect to oxygen and carbon dioxide, and with this their duty ends. The responsibility for maintaining the composition of this fluid in respect to other constituents devolves on the kidneys. It is no exaggeration to say that the composition of the body fluids is determined not by what the mouth takes in but what the kidneys keep: they are the master chemists of our internal environment. Which, so to speak, they manufacture in reverse by working it over some fifteen times a day. When among other duties, they excrete the ashes of our body fires, or remove from the blood the infinite variety of foreign substances that are constantly being absorbed from our indiscriminate gastrointestinal tracts, these excretory operations are incidental to the major task of keeping our internal environments in the ideal, balanced state.  

Slides 5-9 emphasize that this topic is not a niche topic, the issues of fluids and electrolytes comes up everyday, on every patient.

Slide 11, warn everyone that the unfortunate person who gains 30 kg in this slide is a medicine resident gorging on donuts at morning report.

Slide 18, remind everyone that LR is for surgeons. Deny any knowledge of the reason for this peculiarity. Explain that this is further evidence that they are an alien species unrelated to hard working, honest IM docs.

Slide 27 Explain that the question, “Would you give a drowning man a glass of water?” was taught to me by one of the most foul-mouthed senior residents when I was an intern. I want to show that the lessons learned this year will be the stories you tell interns decades later. Interns will learn more this year than any other year of their life, except their first year of life.

Slide 29 recommend everyone read House of God

Here is the lecture in PDF and Powerpoint

And the baby with the baboon heart. Or It’s an iPad world

I was giving my cardiorenal syndrome lecture on Friday and during the question and answer session one of the residents asked why furosemide drips were more effective than boluses. I explained about the results from this Cochrane review and this recent RCT. Unfortunately I had not read the table of contents from this weeks NEJM:
So of course one of the interns mentions the article and asked if I had read it. I copped to the truth but what happened next was incredible. Across the lecture room I could see dozens of iPads flick to life as nearly everyone started pulling up NEJM.org to check out the latest.

Medicine is magical and magical is art
The Boy in the Bubble
And the baby with the baboon heart

Go green: recycle your organs

On of my patients, whose daughter had a kidney transplant, came into clinic wearing this T-shirt. Love it.
It says. “My child contains recycled parts. Be a hero, be a donor.”

Remember Nate Hellman

Nate started the most important innovation in nephrology education since NephSAP, the Renal Fellow Network. Nate died, tragically, a year ago this past Sunday. We all stand on the shoulders of giants and Nate passed long before his work was done. In addition to thinking of Nate, we should also thank Matt Sparks and Conall O’ Seaghdha for picking up the pieces and transforming RFN from what was largely a one man show into the institution it has become.

Best urine quotation

“What is man, when you come to think upon him, but a minutely set, ingenious machine for turning with infininite artfulness, the red wine of Shiraz into urine?”

Isak Dineson, Danish author (1885-1962)

I first heard this quotation from my mentor Adrian Katz. Only Adrian would compare the wine you were currently drinking to urine. 

Kayexalate: risks and benefits

When I was a fellow I got an opportunity to write the chapter in Intensive Care in Nephrology on Disorders of Potassium Homeostasis.

Dr. Murray, the editor and my fellowship program director, told me that I couldn’t use review articles or text books as references. It was a golden experience. I systematically went through all of the pearls I had collected on potassium and drilled down to the original data.

The primary conclusion I had after months of exploring the stacks of The Crerar was that the wall of knowledge that I had assumed backed up all of our clinical practices was more like a chain link fence with isolated points of solidity but mostly holes. Science could provide a rough outline but too much of medicine is based on conjecture and reasoned guesses.

One of my finds was the near total lack of data showing cation-exchange resins to be effective. In the chapter I wrote:

…Two recent studies have questioned the effectiveness of SPS [sodium polysterene] resins, but until larger studies corroborate these findings, SPS resins remain part of the therapy for acute hyperkalemia. (106, 122, PDF) SPS and sorbitol usage have rarely been associated with intestinal necrosis; whether this is due to sorbital, the resin, or other factors is unclear. (123, 124, 125)

The key table from the Gruy-Kappal article showing the lack of effectiveness of SPS resins

This was actually the revised paragraph. The first draft was much stronger. I railed against the use of kayexylate given the lack demonstrated benefit and the emerging data on the dangers of this medication. I was ready to throw kayexalate on the hyperkalemic trash heep along with bicarbonate. My co-author, John Asplin calmed me down and had me moderated the section. He explained that despite the lack of data, SPS resins have a long history of use and explained that though I have the option of using dialysis, intensivists often find themselves in binds where dialysis is not available and they need an extra-renal method for potassium clearance.

I can appreciate Asplin’s wisdom now. In the last decade I have used SPS resins innumerable times in patients with and without ESRD, though my data is circumstantial I am believer in the effectiveness of this drug. I hope the latest publicity about the purported ineffectiveness of Kayexalate leads to well done large studies rather than a loss of this effective medicine.