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.
For 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?
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!
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!
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.
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!
My sapphire blue tweexy
This weekend I tried out my new tweexy, a manicure aid. This silicon device holds your nail polish bottle on your hand while you paint its nails.
The device worked as advertised. My only issue involved lighting. I sat on a sofa with a nearby table lamp, and the nails on my left hand got shadowed by the tweexy. Having a more flexible light source would help the situation.
I used my tweexy to apply Afternoon Delight, a subtle lavender from Deborah Lippman Gel Lab Pro Polish. This base, polish, and top coat set provides a long-lasting manicure, even for someone who is hard on their nails. I typically get 5 days of wear with this system (vs 2-3 with regular stuff).
Afternoon Delight by Deborah Lippman
One of the milestones we use to judge pediatricians in training involves uncertainty in the clinical world. We often deal with probability when diagnosing conditions or prescribing treatments. Many times we are convinced that we know what the patent has, but confirming it definitively cannot be easily accomplished, especially in a timely fashion. We make a provisional diagnosis, treat the condition, and, if the patient gets better, congratulate ourselves on our clinical acumen.
At times, the response to treatment remains uncertain, even when the diagnosis is not. A biopsy-proven kidney disease may respond to a certain treatment 90% of the time. If your patient is in the unlucky 10%, then you must develop another plan to try.
We gauge our trainees' abilities to handle this uncertainty that is part of medicine. We discuss odds and statistics with our patients, but how can we help them deal with this uncertainty? This can be especially fraught with potentially fatal illnesses as I am learning on a daily basis. Do we make a long-term goods purchase? How far in advance do we plan things? What will the future hold?
Odds ratios and averages and other statistics give us information, but we cannot know where each patient fits into the disease spectrum until whatever is going to happen happens. It makes having a disease that much more stressful and frightening.
This morning I saw a blurb in one of my newsfeeds about "potential new treatment target for deadly brain cancer."
It was indeed a new study on the cellular biology of glioblastomas, the type of cancer in my husband's head. We just finished the first round of radiation and chemotherapy. The next 4 weeks will be blissfully treatment-free. Instead, we will devote his time to weekly fasting lab studies and a whole bunch of doctor appointments. Oh, and he gets to go to the dentist this week.
This discovery involves the basic cell biology of these cancer cells, and may help explain why they are so resistant to treatment. They interview the author of the study, Dr. Arezu Jahani-Asl, who explains why she chose to study glioblastoma:
"The fact that most patients with these brain tumours live only 16 months is just heartbreaking,"
That's a particularly heartbreaking reminder with which to begin my day.
Keep plugging away, scientists. It's only through your efforts that we have hope. We also have no idea who will find the key piece of information that leads to improved survival or even a cure; it may be someone studying insects in the rainforest rather than a neuroscientist looking at this tumor. That's why we need to fund as much science as we can.
So we all can have hope.
This post is an apology of sorts to new commenters. I have things set so that once you have an approved comment on my site, all future comments will ultimately appear immediately. Even with an effective, aggressive spam filter, two or three inappropriate things try to get through every week or so. To know that there are comments awaiting moderation, I have to sign into my site.
I no longer do this every day because, life.
Anyway, that's why some of you, even though your comment was inoffensive and even welcome, saw a lag before it made its public debut. I am sorry for that, but not sorry enough to change my moderation habits.
In other words, deal with it (although you're likely on the good list now)!
Today I took my husband to Grand Rounds, a Pediatric Educational Lecture (for my non-MD readers). I noticed on the announcement yesterday that a person he knew well from our St. Louis days was giving a named lectureship in honor of the retirement of a colleague here at Oklahoma. I asked if he wanted to go; he said he would.
He arrived bright and early, and quickly impressed people who knew of his illness and issues with his stamina and resilience. He paid enough attention to the lecture to get upset when I scrolled through non-emergent messages on my phone. He chatted with colleagues at the reception afterwards, until I retrieved my bag and took him home.
He slept most of the afternoon (while I went to the dentist for a tooth repair), ate a quick dinner, and then retired again for the night.
During the marriage vows, one typically swears in front of god-and-everybody to stay together through a number of circumstances, including for better or for worse. So far, 2016 has been a butt-load (to use the technical term) of for worse. Today, I finally saw some for better, even if it did wear him out.
I will take what I can get right now.