13 March 2011

Fluid balance

Nature is generally more impressive in poorer countries. Cause and effect.
Insult to injury to injury to injury. It's like tropical diseases that are almost impossible to eradicate in vectors. It's like cultural staple foods that decrease iodine uptake and are almost devoid of nutrients. It's like the balance of climate change falling where farming and subsistence depend entirely on climate and predictability.

In the city where I grew up, tornadoes only strike on the south side of town. The bad ones, anyway. (With the exception of one recent instance). Always. And that’s the poor side of town. Living to the north of that, after a number of years, I learned to not really worry during the watches that sometimes turned into warnings. Basically, we'd always be okay. It's a lulling, a complacency.

And so somehow it’s more marking, and there’s more news (or that’s my current perception) when this happens to a richer country. It’s more of a shock, so to speak - because when insult does get added to injury to injury - the magnitude, at a point, is no longer imaginable. Maybe.
Then again, tragedy is always tragedy.
And no matter where something happens, it's the poorer, less advantaged, less resourced, more dependent-on -the-natural-movements-of-the-earth that is the most devastated.
And the fact that the US was worried about the coast of California is…well, if something thousands of miles away could have a visible, tangible, destructive effect... it just shows how small so many of the things we’re capable of doing really are. Any of the things

So many large movements of the earth, natural and non, right now. And during the day, I can and do just concentrate on trending my patient’s pain level, hemoglobin, electrolytes, vital signs. On surgery, they always, always want to know the “ins and outs.” Report as totals then break it down: in: IV fluids (what kind), p.o. (oral), medication infusions, etc. Out…also…has several forms. All are meticulously recorded on 24 hour balance sheets.
It’s a vital sign – and it does give you the best indicator of fluid retention/dehydration/kidney function. Patients can be “fluid up” or “fluid down” – you just subtract. You know exactly where the extra or the deficit is, and there are ways to work on fixing both, and there are particular things you start to worry about.
Fluid balance.

If there’s a major, major earthquake on one side of the vastest ocean on the planet, the waves move all the way across to the other side, and quickly.
Fluid balance.


Conservation of energy

“Japanese nuclear safety officials and international experts said that because of crucial design differences, the release of radiation at Daiichi would most likely be much smaller than at Chernobyl even if the plant had a complete core meltdown, which they said it had not.” – The New York Times, March 12,2011

“Most likely be much smaller than at Chernobyl…”
And this just passes by uncommented in the article. Chernobyl was 25 years ago and it’s a ubiquitously known word/event. And Chernobyl was 25 years ago.
Here's something that won't, can't spare anyone.. though there is the small wonder of what employees were actually there and what the real estate is like in the direct vicinity.

But there’s no way to understand/wrap head around this type of thing. Not for me, anyway. If in 10, 20 years I have a patient who was around Daiichi and develops thyroid cancer/leukemia/lymphoma/melanoma/etc… it’ll take on a different meaning. On the public health level, they’re giving people iodine. (scanty, scanty, scanty evidence. From what I can find). And - it's Japan. They have iodized salt. And they eat a lot of fish. And this is on the coast. I'm not sure how much more replete with iodine they could possibly be.
Prevention is a hard sell; you don't see things if they don't happen, and you can't be relieved that they didn't. Current death tolls are countable. Japan, though...knows. This. What it does.


The doctor-head and the public health-head

My patients would never want to hear about the second one.

The public health head wonders about cost-efficiency and allocation of resources – not monetarily, necessarily, but medical resources, including personnel.

And yet it’s done all the time. That’s what tumor boards do – they decide, together, what the best course of treatment is. That’s what transplant committees and UNOS do – they decide who’s the best candidate and at what rank someone should be placed on the list.

Many months ago, I saw a patient in the ICU who had been labeled “futility of care.” He was…perhaps…39, in kidney failure. Or liver failure. It doesn’t matter. Whatever it was, he needed a transplant to survive much longer. Otherwise, he was healthy enough, and his health status would have qualified him. He might have had decent matches, I don’t know. But his wife – not he – was a polysubstance user. Because of that, because they deemed he wouldn’t have enough psychosocial support after the transplant, to help with recovery and anti-rejection regimens and all matter of things – he didn’t get to have a transplant. Futility of care. Two physicians have to agree. Nothing else to be done. At this point, harm exceeds benefit of treatment. Comfort care. Thirty-nine. Could otherwise have received a transplant.

Then there’s the patient who’s had multiple, multiple, multiple coronary artery bypass grafts (CABG. Open heart surgery). Multiple multiple stents, multiple replaced valves. He’s fifty-five. It’s atherosclerotic disease 2/2 (secondary to) smoking, maybe to drugs, too, that have caused heart infections. Does it matter? It could have been congenital. Maybe it was because of high cholesterol, and/or maybe the high cholesterol was a familial, genetic thing. Tobacco and other drugs are addictive. There are chemical propensities for addiction. And everything has psychosocial factors.
None of this should matter, theoretically.
But at this point – it’s the fifth operation – they’re still operating. And I can’t help but wonder about this allocation of resources. Someone else who needs surgery, one, any surgery, and can’t get it for lack of resources, ability to pay or access a hospital. All this time and energy into someone so chronic, because, at some point, we can’t do this anymore.
No one will say when that is.
Doctors are the worst optimists when it comes to predicting mortality. Two, three, four times the “actual” lifespan. I’m not saying he’s dying right now. He’s not. And this patient is a lovely person. I enjoy talking with him. Not that that should matter anyway. I wish him the absolute best and I am engaged in taking care of him and working to find and provide the best things we can.

But yes there are starving children…everywhere… and so many conditions that could be completely averted, and not enough vaccine access, and not enough medication access or access when things have presented far too late, or going into bankruptcy for life saving interventions…

The public health head wonders where the line is. One patient versus hundreds versus thousands and millions. Physicians in out-patient practice, these days, have 1000 to 2000 patients in their cohort. Not that they see all regularly; some may never have come back. But this actual “thousands” of patients, added to the hundreds/thousand in medical school and thousands in residency – is how we actually end up seeing extremely rare conditions.
Each patient is an individual and a single data point. In the encounter, I am focused on the one person. That’s why physicians who are perfectly well-skilled in epidemiology are still referring for mammograms at age 50 and pap smears every year for everyone. That’s why they’re still doing PSA tests for men over 50. Rationally, these things have been proven to not make sense and be inefficacious. Public health looks at things in “numbers needed to treat” – the NNT is part of how you decide whether to do an intervention for everyone (screening) or not. How much money (yes) but moreover how many needless complications for one person found with the disease, one person treated, one person saved? There are no absolute thresholds. But this is part of how guidelines are decided. The cost of screening isn't just what you see (mammograms, blood tests, Xrays, et al). It's what you don't see, from the outside perspective. It's the many, many individuals who had false positives and then the anxiety of thinking they had cancer (not insignificant), unnecessary biopsies, perhaps surgeries, each of which comes with risk and side effects and consequences. Radiation, risks and consequences. The NNT is a question of what level of unnecessary harm (and how bad is it) is worth it to maybe find and help one person. It's still an individual question, on that level, if you think about the prototypical wrong diagnosis (false positive) who might go all the way to surgery for no need. It is an individual decision (if the patient's insurance will cover it, or if the patient will. And some "insurance" does not even cover screening based on US Preventative Services Task Forces guidelines (USPSTF. They make the official recommendations). Is the risk acceptable?
But on a population level, somebody has to make the decision. As a society, what can we accept, and what is reasonable. 

The public health head cares most about the population. And the doctor head might do everything possible for the one person in the exam room. Even if it doesn’t actually make sense. You can’t notBut the public health head is always there.

In disasters and in chronic states of health/baseline rates of disease, it's about allocation of resources. With increased risks, you have to re-and-re-allocate. 
If patients knew that a lot of what (surgeons) worry about is their ins and outs, spreadsheet balance, it might seem horribly impersonal. Voiced concerns are taken into account - pain. Everything. But it's the tight spreadsheet columns that help the best, sometimes, to know how the body is coping, especially after surgery. It's basic accounting. It's checkbooks or second grade math.

When calculating maintenance fluids (to keep at baseline/not dehydrated and not fluid-up) for patients who can't drink and regulate their own fluids (or whose balance is thrown off for another reason), we talk about "insensible losses." 
"Insensible losses" means water you lose through evaporation (sweat) and by breathing (we breathe out water vapor). There's a way to calculate the basic amount and to take that into account.

Calculating ins and outs, we know about insensible losses. That's in the background. (and we call them 'insensibles.')

Fluid balance. Insensible loss.


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