musings of a salt whisperer
I have been doing a monthly fluid and electrolyte conference for the residents at St. John. Today we did a case of hypernatremia initially due to hypercalcemia and then due to nephrogenic diabetes insipidus.
My favorite way to lecture is to pass out a personally written chapter on the subject and then collectively read the hand-out. I call this lecturing “Seder-style” named after the ritualistic dinner of the Jewish holiday Passover.
The booklets have four pages on each sheet of paper but you need a computer program to reorder the sheets so the booklets come out right. I used to have a print service that did this for me but it stopped working when I upgraded to Snow Leopard. I found this web service BookletCreator which does a great job with this.
Here are the original PDFs I uploaded:
Here are the bookletized PDF the website created:
Perfect.
UPDATE: No longer free.
Otsuka is pushing tolvaptan (Scamsca™) hard. We are getting detailed a lot, and I hear that the cardiologists are also getting an earful. Honestly, the data looks a little thin to me. The drug is the most reliable method for tackling persistent SIADH. But that’s rare. In my experience, usual care fixes almost every case of hyponatremia within a day or two. There are a minority of cases that don’t respond quickly. These episodes of persistent hyponatremia worry me. Unfortunately, tolvaptan doesn’t feel like a good option for these patients. We know from the SALT studies that a week after you stop the drug the sodium equals the control group and the drug costs $300 per day (average wholesale price (PDF), retail price). I find it hard to prescribe a $9,000 per month drug for chronic therapy. I’ll stick with salt tablets, furosemide and water restriction.
I did my standard Acid-Base work shop with the medical students and Providence Hospital last week. Here is the handout. Corrected an embarrassing error on page 9 and changed a few of the problems a little bit.
Yesterday I started on the consult service mid-month. We are experimenting with having the atendings rotate from the dialysis floor to the consult service every two weeks. I am skeptical because of the lack of continuity but in the spirit of 80-hour weeks we are trying it out.
Yesterday I lectured on electrolyte free water clearance and tea and toast syndrome.
Here is the lecture on Electrolyte free water:
The online version doesn’t look great. Download the file and then try it.
The lecture on tea and toast syndrome is below:
Lecture on IV Fluids and sodium
I had eight 3rd year medical students. I did a quick pole and 6 of the 8 had or were planning on getting an iPhone/iPod touch. One student had an Android G1. No Blackberries, no Windows Mobile.
Is it too early to declare a winner in the medical smart phone arena?
On July first I gave a lecture on IV fluids, total body water and hyponatremia. This handout is similar to the lecture I give to the medical students titled sodium and water. It adds a half baked section on potassium but this handout really needs to have th sodium section tightened up and shortened, the potassium section finished and short sections on the treatment of phos, magnesium and calcium disorders.
On July 9th I gave a lecture on acute renal failure. The handout is 28 5.5 x 8.5 pages. The book is designed as a workshop with questions and points for discussion throughout.
In the past few weeks I have been working on two presentations. The first was to Genzyme’s scientists and the second was grand rounds at Providence. I have been spending way too much time working on those two talks. Thankfully the bones of both talks were the same. I spoke on the problem of chronic kidney disease on the elderly, specifically whether CKD was over diagnosed (yes it is) in this population and can it be safely ignored (no it can’t).
I’m not completely through the gauntlet yet. I still have to provide a chapter on lifestyle modification for the control of blood pressure.
But I can’t describe the awesome feeling of relief from delivering the grand rounds this morning.
For those of you with iWork and Keynote here is the presentation:
The Two Faces of Geriatric CKD
I have been editing our consult month syllabus adding the links for the study materials as we go.
Today we fell off the syllabus. The acid-base lecture on Wednesday revealed a chasm of ignorance. We need to really pound on the basics. So today, instead of doing a Powerpoint style lecture on non-anion gap metabolic acidosis, we sat in a conference room with a couple of calculators and pounded through 23 ABG problems.
While we were going through the questions, part of me wanted some tunes. Just saw Slum Dog last weekend.