Thursday, February 15, 2007


Mr. Thomas is not doing well. He was admitted to the ICU because the surgeons taking care of him thought his atrial fibrillation was beginning to give them difficulty managing his blood pressure and heart rate on the ward. About two hours after being transferred to us though, Mr. Thomas proved the surgeons wrong by going into septic shock, taking several days to recover. Now he has two problems, which have taught me another rung on the ladder towards being a doctor.

The first problem is his kidneys are dying. The creatinine level in his blood, a measure of how well your kidney are filtering junk, is going up, from an almost normal value of 1.0 on admission to almost 4.0 now. An increase of that magnitude over a week is pretty ominous, so we called nephrology to get their input.

The second problem is related, and is in his lungs. Mr. Thomas' chest x-ray implies that he has too much fluid in his body, and the cure for that is a diuretic. There is a risk in using diuretics, because they are essentially poisons for your kidneys, but the one we're using, furosemide, is pretty well tolerated.

Son, your ego is writing checks your body can't cash.

Here's where the real problem lies. Nephrology took a look at the labs I had ordered, and decided that Mr. Thomas' problem was acute tubular necrosis, or ATN, meaning his kidneys had just taken the episode of septic shock poorly. Their recommendations were to increase the amount of fluid Mr. Thomas is getting, allowing his kidneys to get more blood flow, and to hold off on the furosemide. My attending though, thinks that the problem is acute interstitial nephritis, AIN, and believes that the chest x-ray is showing increased fluid, not pneumonia. The problem then, is that my attending thinks nephrology is wrong, and the patient needs less fluid, and to have a regular diuretic dose, and the nephrologists think my attending is wrong, and that the patient needs more fluid, and no diuretic dose. Neither has a rock-solid case for their opinion, but nothing in medicine is 100%. So what do we do?

When I became a man, I put away childish things.

The process of moving from medical student to MD involves a steadily increasing level of knowledge, experience, understanding, responsibility and decision-making ability. As third year starts we report facts and accept blindly the decisions of superiors. As that year progresses, ideally the medical student learns, and starts making suggestions, always expecting to be wrong, but still starting to think, to put the patient's picture together. By the end of fourth year, we should be making decisions with a high expectation of being right. After all, for someone like me, starting July 1 of this year, I'll be making treatment decisions for very sick people at all hours of day and night, so I should be getting pretty comfortable with making decisions and giving orders, bearing in mind of course that I am still learning, and that if I'm not sure, I most decidedly should be getting my superior's opinion.

And in the case of Mr. Thomas, I'm making that transition, though perhaps inappropriately. I'm with the nephrologists, in that I think the x-ray is showing pneumonia, I think Mr. Thomas needs more fluid, and that his kidneys are showing ATN. But I can't make that decision over the top of my attending, so I have to write notes that reflect his opinion. It is immensely frustrating to write something I don't believe, but maybe I need to get used to that too. I just don't want Mr. Thomas to pay the price.

We'll see what happens. The good thing is, having done some reading just for this little post, I have a few ideas that might help me sort out what's really going on. And who knows, I might even be wrong.


Matt said...

I had a similar case on peds. He had a bad liver, so he would accumulate so much fluid it would seep into his lungs, and he also had awful kidneys, and we would alternate days killing his kidneys with diuresis, then killing his lungs with cessation of diuresis. The only cure would have been a new liver, and we eventually sent him to the ICU for better management of that dance. Have you checked Mr. Smith's liver enzymes?

Nathan said...

Mr. Thomas is this guy's psuedonymn. Smith was a few posts back (Charles Dickens I am not) Anyway, yeah, with this guy we have checked his liver enzymes, they are normal, but his lipase is sky high. So his pancreas isn't in the best of shape either. It's a confusing case. I think I'm going to order a specifically eosinophil stain on this guy's blood sample, which would point us more towards AIN.

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