I gave a lecture to the third-year medical students at Providence hospital on Friday. I thought the lecture went well but on saturday I was going over an admit note by one of the students in the class. The patient was admitted with DKA but had a combined metabolic acidosis and respiratory alkalosis. This student didn’t do the Winter’s formula calculation and missed the respiratory disease. Of course so did everyone else on the admitting team.
Frustrating.
Here is the handout. I added a couple of things since giving the lecture on Friday.
Update: I corrected a mistake in one of the delta bicarb questions. Sorry.
Yesterday I lectured the St John ER residency program. The ER residency has an impressive commitment to education. They set aside a half day every wednesday for their resident to get dedicated didactic time. They have great attendance with a good number of attendings showing up.
I have been asked to give three lectures and yesterday was the first. I gave a double lecture (running time about 90 minutes) on sodium and potassium. The fact that I could run over the standard 50 minute alotment normally given for medicial education is due to the fact that they have blocked an entire afternoon rather than try to shoehorn a lecture into lunch or before rounds.
The sodium lecture was the first time I used the Sodium handout I created for the St John IM residents. I gave the lectuer Seder-Style with the residents reading different sections, answering questions and me adding commentary. The ER residents are smart and empowered to ask questions. I felt that there was great two-way interactivity.
The potassium lectuer is an abrdged potassium lecture which is stripped to the bare bones of differential and treatment. It is a traditional powerpoint lecture. Immediately when I started this lectuer I saw about half a dozen exhausted interns fall asleep. My next project is to create a potassium haggadah.
I gave my first lecture to the residents at Providence Hospital on Friday before Labor Day. I did a new lecture on calcium. I tried to base this lecture around this incredibly interesting patient I had a few years ago at St. John.
He was a young man who came in with a fracture due in part from his rip-roaring uncontrolled secondary hyperparathyroidism, which had actually progressed to tertiary hyperparathyroidism. We treated his hypercalcemia, got him a parathyroidectomy and then watched in horror as his hypercalcemia switched to hypocalcemia as part of a wicked case of Hungry Bone Syndrome. To cap it off he developed acute symptomatic hypocalcemia after meeting Alonzo Mourning.
On that one admission, in one patient my team got to see and study:
Renal osteodystrophy with skeletal complications
Diagnosis and management of Hypercalcemia
Diagnosis and management of tertiary hyperparathyroidism
Diagnosis of Hungry Bone Syndrome
Management of severe hypocalcemia
Relationship of ionized calcium to pH
I call it the greatest case report ever told and regarding calcium it probably is the best.
Again I provided the resident with a booklet and did the lecture Seder Style. This was the best use of that style yet.
Just got my second rhabdomyolysis patient in the last 2 months. Both had anuric acute renal failure and both had CPKs over 100,000.
In fellowship, the dogma was that sodium bicarbonate was ineffective and could do harm. The reasoning was that alkalinizing urine made calcium-phosphate less soluble, increasing the likelihood of calcification in the tubule extending the renal damage.
Recently, I found a paper from the Journal of Trauma 2004 by Brown and Rhee (Alternative) which showed compelling trends for improved outcomes with mannitol and bicarbonate. What was so impressive to me was that as the disease got more severe (higher CPK) the experimental group appeared to do relatively better. The authors were prevented from reaching a significant p value primarily by having too few patients with severe rhabdo.
I will use the handout from a prior morning report on the subject for the teaching session on Monday.
