"A Forgetful Lung Cancer Patient With Hyponatremia"

I have a standard method for evaluating serum sodium. I will present a stepwise system that I encourage you to use. Internal medicine requires some compulsivity, and electrolyte disorders require you to work through the possibilities carefully.

1. Look for pseudohyponatremia. The easiest test here is a serum osmolality, as true hyponatremic patients have decreased serum osms.
   
   
   1. Causes of pseudohyponatremia include 3 endogenous and 2 exogenous factors:
      
      
   1. Endogenous
      
      

      Hyperglycemia Hypertriglyceridemia Paraproteinemia

   2. Exogenous (iatrogenic)
      
      

      IV mannitol Glycine used in transurethral prostatectomy

2. If the patient has true hyponatremia, check volume status
   
   
   1. Volume contraction -- Volume contraction stimulates antidiuretic hormone (ADH), so the patient retains free water, making the patient susceptible to hyponatremia. Volume contraction-related hyponatremia responds to volume expansion.
      
      
   2. Edematous states -- This occurs mostly with heart failure and cirrhosis. These patients have effective intravascular volume depletion; again, ADH is stimulated, and they do not excrete free water. These conditions respond to treatment of the underlying cause.
      
      
   3. Euvolemic patients -- see below.
      
      
3. The highest energy level with hyponatremia occurs when the patient is euvolemic.
   
   
   1. First, check urine osms. If the patient has dilute urine (urine osms < 100), then the problem is likely:
      
      
      1. Psychogenic polydipsia
         
         
      2. Beer drinker's potomania
         
         
      3. Tea and toast diet
         
         
   2. If the urine osms are elevated, first check for 4 conditions:
      
      
      1. Chronic kidney disease (CKD) -- elevated serum creatinine (probably 2 mg/dL or greater). CKD patients have an impaired ability to dilute their urine.
         
         
      2. Addison's disease
         
         
      3. Hypothyroidism
         
         
      4. Use of thiazide diuretics (which impair urinary dilution)
         
         
   3. If the urine osms are elevated and the above 4 conditions are excluded:
      
      
      1. Consider physiologic stimulants of ADH: nausea, vomiting, pain, narcotics
         
         
      2. Consider transient causes of increased ADH: pulmonary processes, intracranial processes
         
         
      3. Consider drugs; the most common class I have seen in 2006 is the SSRIs
         
         
      4. If all of these are absent, consider the possibility of a condition causing long-term SIADH (syndrome of inappropriate antidiuretic hormone secretion)

Final Exams Provide a Reality Check

Aaron Singh -- It’s 6 am, and I’m sitting by myself on the top floor of my College library. The sun’s first rays are beginning to peek through the modern glass ceiling, and I’m still plowing through a series of Pharmacology lectures. In recent days I have earned the dubious honour of being the biggest customer at the College coffee vending machine, being too lazy to crawl all the way back to my room to make my own, and I’m now on a first-name basis with the College janitors who come in at 4 am to clean the library and prepare it for another working day. The librarian doesn’t bother cleaning up my books when she finds them anymore, knowing that wherever I’ve run off to, I’ll be back soon. Sigh.

So why am I working so hard, you ask? Well, firstly, it’s out of sheer panic. You see, ladies and gentlemen, just recently, about the same time I cracked my first textbook open a few days ago, I discovered an urgent truth that (I like to think) many medical students (just not the ones around here) probably discover around the time they sit down and begin hardcore revision (studying) for final exams:

I have forgotten how to revise.

No, really. All year I’ve been frolicking around on stage (which explains the death threats from my tutors) and making half-hearted attempts at studying (which explains the death threats from the lecturers who mark my essays). Now I’m getting death threats from my neurons, as I overload them in a last-ditch attempt to prepare for exams in 2 months.

So why this last-minute studying? Well, taking inspiration from Kendra’s last post, I could go on about how I signed up to be a white-coat-wearing, patient-seeing doctor hungry for clinical experience, and didn’t expect the hardcore academic training we get in our first three years.

But nope, the reality is simply that I'd lost myself for a while. I’d forgotten how hard I had to work to get into medical school in the first place, and how hard we all promised ourselves we’d work once we got here. But fortunately for me, a combination of caring tutors and overly competitive manic coursemates has opened my eyes while there’s still time. I may have to work overtime for a bit, but it’ll be worth it in the end; if I get my choice of third-year course, I may finally get some clinical exposure! But that’s a story for another post…in the meantime, I have a far bigger question looming on the horizon:

Black or white coffee?

April 10, 2007

What Makes a Truly Good Doctor?

Ali Tabatabaey -- In my eyes, internal medicine is the toughest clinical area of them all. The knowledge is so vast and the diseases so overlapping, that if anyone can keep track of what’s going on here, they are not going to have any trouble anywhere else. It’s here that the final but most important ingredient to becoming a good doctor is put to the ultimate test: Clinical Judgment.

That is why, if you look a bit closer during your internal medicine training, you’ll realize that the demographic characteristics of your class are changing! The students who used to be ranked first and carried the report cards with most A+ on them might suddenly not seem so successful when it comes to treating patients. On the other hand, the students who had always been looked down upon because of their low marks during basic sciences and even externship, might actually seem like they’ve turned on their turbo engines.

It’s almost as if learning the stuff you need to know is one thing, and actually practicing what you’ve learnt is a totally different thing. It’s like being warped from one world into another without warning.

If you look around you can find lots of interns and even some practicing doctors that are very knowledgeable, but when it comes to treating patients, they often can’t find the best way and end up requesting lots of lab and para-clinic studies. When you’re drowning in a sea of knowledge you will grab anything in sight, fearing that you might miss something. Approaching every patient from the shortest and most cost effective path is a delicate skill that many textbook docs fail to master.

So don’t forget: on your way up this ladder, always have the patients in mind. Figuring out the true cause of their illness, using the least amount of cost and time, is a very tricky task that will ultimately separate the okay docs from the best.

All I’m trying to say is that knowing all the textbooks and even clinical data still doesn’t make you a good healer. Now, not knowing these things probably makes you a bad one, but still, becoming a good doctor is much harder than it seems.

April 18, 2007

My Father's Daughter

Posted 04/26/2007

Lara Devgan

"I have sugar poisoning," my father told me when he broke the news. It was a breezy summer night, and I was seven years old. I had never heard of type II diabetes. "I'm like the ancient mariner," he said. "Glucose, glucose everywhere..."

Eighteen years later, my favorite childhood memories with my father make me cringe -- ice cream on Fridays after school, sugared strawberries on Sunday mornings, Thanksgiving pecan pie. When I arrive back home in California for winter break, he is saddled with pill bottles, insulin syringes, and a zippered bypass scar down the center of his chest. My father, the respected ENT surgeon, can't save his own life.

It's not that my father doesn't make an effort. Indeed, there is a shelf in the refrigerator devoted to vegetables and a drawer in the kitchen filled with packets of Equal. But the running shoes I gave him for his birthday sit in a comer of his closet, barely used, and he still eats tiramisu for dessert. "Sugar tastes good," he tells me. The corners of his mouth turn upward in an easy, unplanned smile. And for a moment, his resistance to change seems decidedly life-affirming.

"I don't know what the future holds," he half-protests, half-admits, "but I know I like sugar in my coffee." We are sitting in a Starbucks in Santa Monica. Christmas music is playing in the background, and a line of fashionable people waits to buy Frappuccinos.

"I'll die of a heart attack," he says calmly. His emotions have been lost in the realm of clinical probability, abstracted into mechanical blips on computer screens. "I'm an old man," he says, sipping his coffee. "I've lived through World War II, Vietnam, Civil Rights. My father died; my children moved out... I lived through that, and I promise, I'll live through this." He waves around his double-cupped latte as if toasting a life of suffering.

I cup both hands around my tea, and my father slowly drinks his latte, which he has sweetened with saccharine to make me happy. He beams me an entry from the journal he keeps in his Palm Pilot: "I try to leave loved ones with loving words because I am afraid that every day will be the last. So much to do and so little time left. I still have not become the person I wanted to be."

***

It is not uncommon for good doctors to be bad patients. The medical center where my father works is populated by a smoking internist, a drinking cardiologist, and a surgeon who eats hot dogs for lunch. "Doctors are just people," says one of my father's colleagues, a young pediatrician who moonlights at the medical center. "You see in them what you see in everybody else -- smoking, overeating, drugs. Doctors not following their own advice are like cops not driving the limit." Doctors have an element of self-subordination fundamentally built into their personalities. "You put yourself last," she goes on. "You've got sickness and suffering all around you -- that's your first priority." My father nods. "Why do you think I stopped going to all those doctors?" he protests. "Half of them can't even take care of themselves."

My older sister has always taken a hard line about our father's diabetes. "It's about self-discipline," she says, with an edge in her voice. "When you realize that, you can stop banging your head against the wall." She is honest in a way that I have always wanted to be, and her frustration with our father, like mine, runs deep. Doctors have an invincibility complex, she tells me. "If he's going to be so cavalier, then what can I do?" she asks pointedly. She has her own life to live, her own job, her own struggles, far away from California. "After all, no one can save you but yourself."

But my mother knows that life is short. After growing old together for the past 38 years, both she and my father feel the anxiety of aging. "Sometimes doing what you like -- even if it's self-destructive -- makes you feel like you're young again," she says. "It helps you hang on to a past that's not there anymore." She looks around at the yellowed photographs that clutter her bedroom. She and my father have filled this house with so many dreams, and she is afraid that they will die when he does. "It's like the shadow under the candle," she sighs. "There is always darkness under light. Your father gives so much love and care to others, but that warmth comes at his own expense."

***

My father drives me to the airport at the end of my vacation. I am on my way back to medical school, to a journey that he once took, a future as uncertain as his. It is not yet 6 in the morning, and we watch the sun rise against the backdrop of downtown skyscrapers. I want him to know that everything I learn about comes back to him. Every molecule, every organ, every failing of the human body that I commit to memory over late nights at the library -- it all gestures back to him, his failing pancreas, his weak heart.

It is hard to sit next to him, a portrait of so much that I admire and detest, with such calm. Watching him fall apart makes me want to cry, scream, bang my head against the wall. I once read that love is just an excuse to look deeply into another human being's eyes. He looks over at me, sadly, lovingly. His face is wrinkled with the lines of a million apologies and excuses. I have been straining to see into my father's soul all this while, and the only thing I know anymore is that I want to ride in this car with him forever. As we drive into the morning light, he tells me something he knows, something that can redeem him. "It's hard to be the person you want to be."

This essay won second prize in the 2005 Arnold P. Gold Foundation Humanism in Medicine Essay Contest and originally appeared in Academic Medicine. Lara Devgan was a fourth-year student at Johns Hopkins University School of Medicine when she wrote this.