Do We or Do We Not Step on People's Toes?
Her name was Mrs Larson. The first time I saw her, she was in renal failure and in an ICU bed hooked up to monitors that were reading her vital signs. She was still able to take her 5 minute, supervised smoke break and make small banter. Her case was a complicated one and her most eminent problem was a blood pressure of 210/135. To add to her problems, her failing kidneys could not generate enough growth factor for her bone marrow to produce red cells and more importantly, platelets which help with clotting. She had been demonstrating signs of platelet deficiency, displaying pinpoint hemorrhages on her legs we call petechia. The next day I saw Mrs Larson, she was obtunded and had a tube inserted into her mouth to facilitate breathing. Her blood pressure on that day, although decreased, was still a critical 190/120. The nephrologist I was clerking with inquired with the nurse about her blood pressure medication and found out that the cardiologist placed Mrs Larson on a hydralazine regiment to be given every 6 hours.
"The cardiologists," said the kidney doctor, "believe that hypertension is the realm of the heart. But we nephrologists disagree. It has nothing to do with the heart and everything to do with the kidneys."
I could not agree with him more because even a low life, bottom feeder, insignificant medical student such as myself knows that it is the kidneys that make a substance called renin which eventually causes another substance to be produced that potently constricts vessels. This is the kidney's response when it perceives either a decreased blood flow through its canals or a decreased sodium concentration. This is when kidney panics and tries everything in its power to preserve the filtration that is passing through its sieve so that it can still function as a the almighty waste disposal and preserver of ionic balance in the body. But who am I to question a cardiologist who has been in practice antediluvian and is older than snot?
"The heart," said the nephrologist, "is but a victim of the kidneys."
Mrs Larson's poor heart, being the penultimate pump, was attempting to pump blood to her body against a pressure that was one and a half times greater than normal. And as with all pumps that have to work that hard, it will eventually fail. This is when cardiologist antediluvian and older than snot comes in, or is supposed to at least.
"It is my humble opinion that hydralazine works if it is used effectively and if I were to treat this patient's hypertension, I would have placed her on a constant hydralazine drip over a period of 24 hours."
The nephrologist continues: "There are too many cooks in the kitchen. If you go to a restaurant and you see more than one cook, don't eat at that restaurant."
As we walk away from Mrs Larson' s ICU bed, I couldn't help thinking how come there is such lack of communication among the different disciplines of medicine. Dr Nephrologist had to walk away because he thinks that is the best he can do for that patient and also because there is more to medicine than just medicine. There is the politics of medicine; the fear of "stepping on people's toes" because come the next day, even if Mrs Larson no longer existed, we still have to work with each other and have to feel self important and smart and the king of our specialty. How can it even be conceivable that a nephrologist, a mere kidney person, could know how to effectively treat hypertension and anything to do with the heart?
Open mindedness is not in the repertoire of words that a medical doctor seems to possess. There is this ego business we have to constantly nurse for how dare someone second guess how I choose to treat an ailment. I have the experience and I will cure this patient.
In the realm of things, where does Mrs Larson fit into all of this?
The next day when we are at rounds, ICU bed 7 has not a crimp in its neatly folded sheets. No one has slept in it for the past 24 hours. It's monitors are silent and dark. There are always 3 scenarios when this happens. First is that a patient is better and no longer requires intensive care and have, hence, been moved to a bed on the floor; second, the patient's attending has decided to transfer him to another facility; third, there was an over night code and all the progress of medicine was unsuccessful in reviving him.
Mrs Larson chose option number 2 but not before she developed a hemorrhage and bled into her brain. She was transferred into a hospital with a neurology critical care unit where she remained in a coma.
On Friday during rounds, I found out that Mrs Larson died. In the Lingua de Medicina; she chose option 3.
In my minute knowledge of things and comprehension, I still think the what-if's. The what if someone had said to the cardiologist: "Hey, I know your vast experience on hydralazine but if it doesn't work, can we try this?"; the what if the cardiologist said: "Maybe I need to discuss this case with a group of other doctors and see what they think."; the what if we had tried harder and addressed her decreased platelets because in our infinite knowledge we could see the potential intracranial hemorrhage and prevent it.
What if it was just her time to go?
I opened a discussion with my fellow noneties in medicine. They all seemed to say: "No doctor deliberately goes out and wants to do harm to the patient." Yes, afterall, we pledged to a code of nonmalfecience.
But daily, by our complacency, by our intractable egos, by our inability to be humble, by our stubborn insistence on not wanting to step on people's toes, we are doing the harm.
If Mrs Larson cannot fight for herself, who will?
"The cardiologists," said the kidney doctor, "believe that hypertension is the realm of the heart. But we nephrologists disagree. It has nothing to do with the heart and everything to do with the kidneys."
I could not agree with him more because even a low life, bottom feeder, insignificant medical student such as myself knows that it is the kidneys that make a substance called renin which eventually causes another substance to be produced that potently constricts vessels. This is the kidney's response when it perceives either a decreased blood flow through its canals or a decreased sodium concentration. This is when kidney panics and tries everything in its power to preserve the filtration that is passing through its sieve so that it can still function as a the almighty waste disposal and preserver of ionic balance in the body. But who am I to question a cardiologist who has been in practice antediluvian and is older than snot?
"The heart," said the nephrologist, "is but a victim of the kidneys."
Mrs Larson's poor heart, being the penultimate pump, was attempting to pump blood to her body against a pressure that was one and a half times greater than normal. And as with all pumps that have to work that hard, it will eventually fail. This is when cardiologist antediluvian and older than snot comes in, or is supposed to at least.
"It is my humble opinion that hydralazine works if it is used effectively and if I were to treat this patient's hypertension, I would have placed her on a constant hydralazine drip over a period of 24 hours."
The nephrologist continues: "There are too many cooks in the kitchen. If you go to a restaurant and you see more than one cook, don't eat at that restaurant."
As we walk away from Mrs Larson' s ICU bed, I couldn't help thinking how come there is such lack of communication among the different disciplines of medicine. Dr Nephrologist had to walk away because he thinks that is the best he can do for that patient and also because there is more to medicine than just medicine. There is the politics of medicine; the fear of "stepping on people's toes" because come the next day, even if Mrs Larson no longer existed, we still have to work with each other and have to feel self important and smart and the king of our specialty. How can it even be conceivable that a nephrologist, a mere kidney person, could know how to effectively treat hypertension and anything to do with the heart?
Open mindedness is not in the repertoire of words that a medical doctor seems to possess. There is this ego business we have to constantly nurse for how dare someone second guess how I choose to treat an ailment. I have the experience and I will cure this patient.
In the realm of things, where does Mrs Larson fit into all of this?
The next day when we are at rounds, ICU bed 7 has not a crimp in its neatly folded sheets. No one has slept in it for the past 24 hours. It's monitors are silent and dark. There are always 3 scenarios when this happens. First is that a patient is better and no longer requires intensive care and have, hence, been moved to a bed on the floor; second, the patient's attending has decided to transfer him to another facility; third, there was an over night code and all the progress of medicine was unsuccessful in reviving him.
Mrs Larson chose option number 2 but not before she developed a hemorrhage and bled into her brain. She was transferred into a hospital with a neurology critical care unit where she remained in a coma.
On Friday during rounds, I found out that Mrs Larson died. In the Lingua de Medicina; she chose option 3.
In my minute knowledge of things and comprehension, I still think the what-if's. The what if someone had said to the cardiologist: "Hey, I know your vast experience on hydralazine but if it doesn't work, can we try this?"; the what if the cardiologist said: "Maybe I need to discuss this case with a group of other doctors and see what they think."; the what if we had tried harder and addressed her decreased platelets because in our infinite knowledge we could see the potential intracranial hemorrhage and prevent it.
What if it was just her time to go?
I opened a discussion with my fellow noneties in medicine. They all seemed to say: "No doctor deliberately goes out and wants to do harm to the patient." Yes, afterall, we pledged to a code of nonmalfecience.
But daily, by our complacency, by our intractable egos, by our inability to be humble, by our stubborn insistence on not wanting to step on people's toes, we are doing the harm.
If Mrs Larson cannot fight for herself, who will?
posted by Hello, this is McKWong MD at 8:22 AM
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