It Happens All the Time

(by whizbang) Sep 26 2016

I get some test results. They are not yet optimal for whatever the patient has, so I want to make a medication change. We are using a well-established drug with minimal side effects. At the time it was first prescribed, we reviewed alternatives, and the family was in complete agreement with starting this treatment. The drug is also incredibly inexpensive, one of those most pharmacies will provide for $4 per month.

We call to increase the dose, and the family tells us they stopped the drug. Not because it caused side effects or other problems. They have decided to try some supplements for a more natural treatment.

We manage to renegotiate treatment with the original drug. We will now have to test again to assess its effects, at further cost. The insurance covers the cost of the drug, pretty much in full. The supplements the family substituted easily cost five times their out-of-pocket expense for the pharmaceutical agent. So they are more expensive as well as ineffective.

But somehow the family was willing to shoulder those expenses to be "natural," even though there is little "natural" about these supplements. These supplements "support" the systems involved in their child's health issues, so they were worth a try.

Isn't it time to get rid of this costly BS that the supplement industry is allowed to spew?

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Bitch and Proud of It

(by whizbang) Sep 16 2016

In 2009 I wrote the following for another blog, and I have reposted it several times as it remains relevant to this day. A kerfluffle erupted this week about the word bitch, thanks to the New York Times.  There are those who clutch their pearls when this word is uttered, but many of us now consider it a badge of honor. I have obviously been on that bandwagon for some time.

Now for my bit of history:

Once upon a time, there was a woman who felt that her gender should not be an issue in her career. She wanted to be treated as an equal, she acted like she was equal, and the men called her a bitch.

Bitch -noun

1. a female dog.
2. a female of canines generally.
3. Slang.

a. a malicious, unpleasant, selfish person, esp. a woman

 

b. a lewd woman.
4. Slang.

a. a complaint.

 

b. anything difficult or unpleasant: The test was a bitch.

 

c. anything memorable, esp. something exceptionally good: That last big party he threw was a real bitch
Why does this 5 letter word have such power over women? We are raised to be “nice.” Malicious, unpleasant, and selfish are the opposite of this goal; however, this means that demanding equality may appear bitchy! At so many gatherings I have heard women ask how they can get their needs met without being called a bitch (generally these women spell the word rather than say it). The short answer? You cannot! Anytime you assert your needs and put yourself ahead of someone else, others may call you a “female dog.”
When my daughter was starting middle school, I explained the world to her in my own warped way. I give my students the same advice. If you have a voice that gets heard in the world, someone will call you a bitch. If you perform acts of kindness and charity, someone will say that the bitch is showing off! If you show more spine than a jelly fish, someone eventually will brand you a bitch. Accept it. If someone calls you a bitch, you are probably doing something right.
About a year later a classmate turned to her and called her a bitch. She thanked him for noticing, and then related how she had not reached her mother’s level of “bitchdom” yet. He said nothing more, and did not try to insult her the rest of the year. She came home from school empowered rather than insulted.
Now, this advice does not mean you should be a bitch. Do not be mean or evil, and never treat those lower than you on the ladder of life with contempt. Always have a sounding board of friends who can help you determine the line between reasonable and bitchy. Sometimes you will cross the line, but, with their help, you will recognize this behavior and apologize for it. If you find yourself crossing the line too often, you may need to reexamine your attitudes and behavior. Do not be afraid to do this and make necessary adjustments. It is called “growth.”
Someday I hope we get beyond the name-calling, but until then take pride in some bitchiness. It may just mean you are acting like a human being instead of an invertebrate. It may just mean you are living your life.
Of course, I am not alone in claiming bitch as a term of honor. May I present Amy and Tina:

Bitch is the new black.

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Wanted: Pediatric Nephrologists

(by whizbang) Sep 15 2016

Are you a pediatric nephrologist? Or one in training?

childrens-logoAs the soon-to-be section chief at Oklahoma University Health Sciences Center, I am ready to start recruiting a junior faculty member!

We have a nice children's hospital  with an amazing group of 3 current nephrologists. We have a transplant program and a hospital-based pediatric dialysis unit. We are working to officially post the job, but it's coming soon.

Contact me via email or social media - hell, you can even write via snail-mail if you want. If you see me at Kidney Week, give me a yell.

A four-person group makes for a livable call schedule. Besides, you get to work with me; what's not to love about that?

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Service? Try Again

(by whizbang) Sep 14 2016

I feel your pain.

pillsA lot of my patients have to deal with "mail order" pharmacies for chronic medications. Often insurers require that these "services" be used. They often present challenges for healthcare providers. Now I have a perspective from the other side of things.

My husband has been on chemotherapy since April. His regimen involves an oral drug that he takes at home, with few side effects. It is expensive, and our health insurance makes us use a specific national pharmacy. He is to get a round of treatment next week, so I called yesterday to ship the next refill. The pharmacy said they did not have the prescription. OK, I contacted the doctor's office, and they called it in (even though they had faxed back the refill 2 weeks ago - yes, medicine is keeping the fax machine alive).

This morning, I called to arrange the shipment. The prescription , given verbally, is still being "scanned in." They cannot verify the claim and arrange shipment until that happens.

Never mind that we only use this service because our insurer demands it. Never mind that we have filled this prescription monthly for 5 months. None of that is adequate to allow them to schedule the shipment. I have to call back in 2 hours. They cannot make a note to ship when approved. No, I have to call again during my clinic. I can't imagine dealing with this "service" without my medical background.

How this level of red tape saves anyone money is beyond my understanding.

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From a Tiny Seed of Truth

(by whizbang) Sep 12 2016

A colleague helpfully pointed me to a website that could put me out of business. The headline promised to repair your kidneys naturally with one ingredient.

I had to know more! Here's the magical advice:

Repairing the kidneys after damage just may lie in a common household item, which you probably already have in your kitchen cabinet. Yes, we are talking about baking soda. In this articled we are going to show you how to cleanse and improve the function of your kidneys with just ½ tsp. of baking soda,every day.

The site goes on to try and explain the magic of sodium bicarbonate, implicating a variety of body systems.

So what's the tiny seed of truth? Acid may be bad for our kidneys.

Being alive generates acid. Metabolizing the food we eat produces acid. Our kidneys produce bicarbonate to neutralize this acid, as well as excreting it in the urine. There is some evidence that higher loads of acid may promote kidney problems, including chronic kidney disease and stones. Eating a lower acid load, by minimizing meat and maximizing fresh fruits and vegetables, may slow the progression of kidney problems.

So could ingesting baking soda help? Yes, but probably not at the level recommended.

1 teaspoon of baking soda can neutralize ~72 mEq of acid. Net acid production for children is 1-2 mEq/kg body weight/day. So a lean, 70 kg adult likely produces at least 70 mEq daily. This dose of baking soda would neutralize about half of that.

The real payoff here is the advice at the bottom of the article, recommending less meat and more fruits and vegetables. A healthy diet seems to be good for everything!

Besides, baking soda is pretty nasty.

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The Call to Action, Pain Management Edition

(by whizbang) Sep 05 2016

We have now completed two months of the new academic year, and times have been a-changing. We had to rearrange the way our patients get covered by residents in the hospital. We attendings have been taking more direct night call on our inpatients as a result. After taking insistent calls from nurses, I have become even more concerned about how we assess and treat pain.

For example, a kid with a kidney disease or transplant comes in with an infection in the urine or a virus. They are not taking fluids well, and they need some intravenous support and/or antibiotics. The kid looks like they feel sick from whatever the underlying problem may be. We start acetaminophen for fever and pain. Later on, when routine vitals get collected, they get asked if they have pain. They then rate the pain on the infamous 1-10 scale. Then, we start getting called about "unrelieved pain."

Patients with kidney problems, including transplants, must avoid non-steroidal anti-inflammatory drugs (NSAIDs; Advil etc). Filtration in the kidney is often dependent on prostaglandins, and these drugs work by inhibiting prostaglandins. In sick infected patients, generous dosing of NSAIDs can lead to  kidney failure that might even be permanent. That means pain unrelieved by acetaminophen quickly escalates to pain requiring opioids.

If the kid is sick enough to be admitted, I have no objection to the occasional dose of hydrocodone in the evening (even if I would have told my own kid to put on their big kid underwear and deal with it in a similar situation). It often becomes difficult to scale back the medication during an inpatient stay because we have become so focused on "unrelieved pain" assessment. The number of calls for this while covering a handful of relatively well patients was startling. I cannot imagine the pressure to just hand out "the candy" with more problematic patients and a busier service.

Treating pain is important, but we need to have strategies that do not involve medications. Children often respond well to distraction, relaxation, and other behavioral techniques. Unfortunately, these may be difficult to administer, especially in the middle of the night. And why are we waking them up and asking about pain when they should be sleeping anyway?

I am not a pain doctor. I just wish for a more rational strategy that does not create obvious rewards for overtreatment that may lead to addiction.

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Toilet Police

(by whizbang) Aug 23 2016

ToiletLoveFor many years I have ridiculed self-flushing toilets. What problem do they solve? They seem to go off at random, at least on some occasions becoming a bidet in the process. What a waste of water.

Then I overheard this conversation in a public restroom:

Mother: All done?

Child:  Yes

Mother:  No, do not flush. That handle is dirty.

They then left the waste floating while they left. They did wash their hands.

I just wanted to scream at them! How many people will now avoid that stall because it might be out of order? Do you think public establishments have someone who just runs around flushing the toilets periodically? You need to wash your hands anyway after wiping your naughty bits, so touching the flush handle is not going to harm you. If you're that skittish, wrap some toilet paper around your hand and then throw it in the trash before you wash your hands.

This behavior is why we need toilet police, not stalking!

2 responses so far

Major Milestone

(by whizbang) Jul 14 2016

On January 19, 2016, I got a call that my spouse was not doing well at work. Within 48 hours his head was cracked open, and we began a roller coaster of cancer and complications.

Today, almost 6 months later, he officially is back in his office for the first time. He is trying to do administrative work only on Tuesdays and Thursdays. He has to deal with some changes in the way his brain works (they did remove a major chunk of his left frontal cortex). Until he starts interacting at a higher level, he won't be able to figure out how to compensate for those missing neurons.

There were many days this year that I wondered if his return to work would be feasible, ever, at any level. Today is a great day indeed!

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A Fine Line

(by whizbang) Jul 07 2016

Yesterday I wore a statement necklace to work. This piece composed of faux turquoise and coral added just the right pop to my plain black dress. As the day went on, I wondered where the line fell between what I wore, which was clearly influenced by Native American culture, and cultural appropriation.

Every creative type has inspiration boards with images influencing their current trends. Sometimes these pictures come from nature, but other times they are human creations. The artwork of every culture seems to have had its moment in high fashion.  When I sort my scarves and jewelry, I can see bits and bobs that would fit right into National Geographic.

Of course, I usually limit myself to a single “ethnic” piece. Looking like an extra on a movie lot would generally be in bad taste. But the line falls well before full buckskin, war paint, and feathered headdresses. It’s just hard to know exactly where before you screw up.

If you think my wardrobe item has crossed the line, please let me know why. We need to discuss this stuff in real life, not just ridicule off-duty models and actresses who make their mistakes on a big stage. 

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K Lowering Drugs

(by whizbang) Jun 30 2016

As kidney function deteriorates, patients often suffer elevated levels of potassium (K) that can lead to cardiac rhythm disturbances and other bad things. For years we have prescribed sodium polystyrene sulfonate (Kayexalate), a resin that exchanges sodium (Na) for K in the gut. While it's good to then poop out the K, the patient can absorb more Na, a problem for those with kidney disease. Also, this drug is so old (how old is it?) that it was not subjected to the current level of FDA safety and efficacy studies.

Our pharmaceutical companies have provided an alternative. Patiromer (Veltassa) is a polymer that binds K without releasing Na. So far, so good. It does reduce K levels in patients. Unfortunately, it cannot be taken with other medications because it  can bind them and prevent their absorption into the body. Kidney disease patients generally require a whole bunch of drugs, so this is a bit of an issue.

I have a patient who requires some Kayexalate every day to keep blood levels normal, and it works well. However, the texture is gritty. I want to know if patiromer also has a gritty texture. I know it is more expensive, but if it annoys patients less it could be worth the money.

Have you taken patiromir or prescribed it? Let me know what you or your patients think in the comments please!

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