New month. Back on the consult service.
Dr. Jabri is the consult fellow and we are going to read the NephSAP on GNs. Should be good.
Teaching Medical Students: Potassium
A couple of Fridays ago I did my second lecture for the medical students at Providence Hospital. I lectured on potassium.
The handout is good but gets a little light on content towards the end. I will revise this before the next lecture.
Potassium booklet form for printing
Potassium handout for iPhone
Acid-Base lecture for ER residents
Yesterday I gave a great lecture on interpreting ABG results. I added a problems set for gap-gap analysis and added a section on the osmolar gap. I also improved the anion gap section with my new favorite nemonic. Forget PLUMSEEDS, forget MUDSLEEPS, forget MUDPILES. The new hotness is GOLD MARK:
- G Glycols
- O 5-Oxoproline (pyroglutamic acid)
- L L-Lactic acid
- D D-Lactic acid
- M Methanol
- A Aspirin
- R Renal failure
- K Ketoacidosis
This new nemonic was published in a letter in the Lancet (thanks vincent bourquin). I love that it drops the silliness of paraldehyde that no one uses anymore and drops isoniazid and iron which hardly ever cause an anion gap.
I also stumbled across a cool article on the sensitivity of the anion gap for lactic acidosis. Surprisingly an anion gap is only found in 58% of patients with an anion gap.
Additionally I cleaned up a bunch of the lecture. I still have not reformatted it for the iPhone so the handout is traditional 8.5×11 without a booklet form.
Teaching Medical Students
Last Friday I started teaching third year medical students. This is the first time I have taught medical students (in isolation, there are always medical students at my lectures for the residents) since 2003, when I ran a teaching section for renal physiology for first year medical students at Pritzker School of Medicine, University of Chicago with John Asplin.
I am now teaching the medical students two lectures every rotation, the first on sodium and the second on potassium and calcium. I hope to expand this to ABGs and another electrolyte lecture so I can isolate potassium and spend an entire hour on it.
I modified my Don’t Panic handout for the students. During the lecture I realized that the SIADH section was weak and too complex for the students. I will probably change it to focus on the fact that ADH reduces water excretion and that this can be adaptive (early CHF, volume depletion, hyperosmolar) or maladaptive (SIADH). I will change the section on the dilution of urine to a background box as I think it is important but only interesting to nephrologists and similar wierdos.
I will add a focus on a few clinical scenarios with increased ADH.
I still need to expand the hypernatremia section.
Sodium and Potassium for ER residents
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.
Sodium iPhone format
Sodium booklet format
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.
Calcium and the great case report
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.
Acute renal failure: Seder Style
I gave the internal medicine residents of St John Hospital an ARF lecture Monday morning. This was a basic ARF lecture. No Powerpoint. I gave this lecture Seder Style. Every resident in the room read a paragraph or two. The Haggadah was a booklet-sized handout of 28 pages (8.5 by 11 sheet turned sideways with two pages per side so the 28 pages were only 7 sheets). Besides text and illustrations the booklet includes questions for discussion, case studies, and problems.
I’m pretty proud of it.
Dysnatremia resources
Working on a lecture for next week on fluids and electrolytes. Do I lecture on anything else?
These resources from the Journal of Record are invaluable:
SIADH by Ellison and Berl
Hyponatremia by Adrogué and Madias
Hypernatremia by Adrogué and Madias
Teaching on 2 Ell: Anemia and CKD
Late post from June.
Near the end of the month our fellow the amazing Dr Jabri gave a lecture on anemia. Good talk.
Here are his lecture notes.
NephSAP for Consult Service Education
One of my weaknesses as a faculty member has been teaching during the consult service. I do a lot of bedside teaching and have tried to do some Practice Based Learning by having the fellows pull articles and research specific questions.
What I haven’t been able to incorporate is formal teaching. Most of my repertoire of teaching materials, up to recently, have been power-point presentations. These are totally wrong for the collegial learning relationship I enjoyed and want to provide for my fellows. Powerpoint stifles two-way communication and reinforces the model of master to apprentice.
On the recommendation of one of our Staff, Dr. El-Ghoroury, I have started a daily reading session with the consult team. We are going through the 2007 Acute Renal Failure and Critical Care NephSAP. So far it is working great. We are spending 40-60 minutes before rounds reading and discussing the material. Then on rounds I see the fellows using the material in their presentations to me. They tell me they like it. I plan on having them pull interesting references to delve deeper into the text.