Sunday, May 5, 2013

Of kidneys and conferences and textbooks

So once again it has been a while...

I suppose that's what another busy rotation does to you!  I just finished the Nephrology consult services.  In other words, I am (was) your friendly neighborhood kidney doctor.  It was a relatively busy month, covering two to three connected hospitals with at least one and not uncommonly two new consults prior to 0900 attending rounds.  But Nephrology is an interesting field.  I enjoy working through acid-base problems.  I like using the primary data to inform my clinical decision making.  Yes, that means I looked at a lot of urine.  Well, okay, to be precise I centrifuged samples of urine and examined the sediment under a microscope.  It's actually fun.  I promise.

And should any of you be struggling with acid-base, I will pass on the NFR approach to acid-base.  Fun for the whole family.  If your family are physicians.  Otherwise they might switch topics.

1. What is the pH?  Acidemic, alkalemic, or noremic?  (REMEMBER: -emia is the status, -osis is a process).  This gives a clue as to the primary problem, because you can NEVER compensate past normal.

2. Look either at the bicarb or the pCO2 next, based on what your results are and what the pH is.  Does there seem to be an acidosis, or an alkalosis?

3. Check for appropriate compensation by applying the requisite formula.  No compensation?  You've got a double disorder!

4. Calculate your anion gap, remembering to correct for albumin.

5. Calculate your delta gap (observed gap minus expected gap) and if you have an anion-gap metabolic acidosis, calculate your  delta-delta gap (change in AG over the change in bicarb, or just add the delta gap to the bicarb and see what it comes out to be.)  If the delta-delta is greater than about two, or adding to the bicarb makes it over about 29, you've got a concommittant metabolic alkalosis.  If it is still low, you have a concommittant non-gap acidosis.

6.  You should have thought of most of these, though because you took a good...HISTORY!

Like I said, fun for the whole family.

We had some great attendings and I learned a lot; each had a different style.  I prefer to have one rounder for at least two weeks but ideally a full month, but I guess there is something to be said for experiencing different approaches.  The overarching message seemed to be to think critically, and never rush dialysis.  And of course avoid nephrotoxins and measure those ins and outs and electrolytes.

Now I'll be moving on to night float.  We work from 8:00pm to 10:30am maximum, three nights on and two nights off.  It's not a terrible schedule as night float goes.  But I don't think well in the middle of the night.  I'm tired and my brain shuts down.  So, I'm a bit worried about being the senior resident and being responsible for proper workup of my patients.  I'll just have to do my best.

In other news, we are quickly approaching oocyte retrieval and then of course transfer day.  I honestly just want this to be over.  Surrogate told me her endometrium is the thickest it's been in any of the cycles thus far, which I guess is a good thing; and there are several follicles developing in my Donor.  I don't want to get my hopes up, though.  I just want this cycle over with.

Meanwhile, of course it's almost M-day (and I'm NOT talking about my name!)  Last year this time I was fresh from losing Sweetpea before he/she even made it to six weeks.  It was a hard day.  This year it will be my fourth married un-mother day.  But I decided to buy myself something:

I didn't want something angry because I don't want to make a scene at Mother's Day, and I want to focus on my own wonderful Mother and Mama Phyll.  But I want people to know that it's a hard day for me, and that I wish I too was a mother.  (I found the shirt at Cafe Press, by the way.)  For the newer infertiles, I have no good advice on surviving the day.  Sorry :o(  At least there are usually sweets.

Hmmm...what else?  I came back from a major medical conference at which I had a wonderful time.  We were in a city I'd never visited before and it is lovely, very walkable and with two key features: a fabulous bookstore and a Cheesecake Factory :o)  I partook of both, of course!  I presented a poster about a patient of mine with Turner's Syndrome and Coronary Artery Disease.  It was a bit nerve-wracking but it turned out there was no on-site judging (had all been in the submission phase) so I didn't have to present formally, and if I do say so myself, I looked pretty good in my brand new suit and my sparkly eye makeup with my killer mascara.  I also attended a great update on chronic kidney disease and some wonderful workshops, one on narrative medicine and one on patient-centered interviewing.

Since then?  Well, it's become spring overnight here in my home town.  The trees are all blossoming: cherry trees, magnolias, dogwoods (I think?) and others I can't name.  The air is pure perfume and the sun is finally shining.  It does wonders for my mood.

Anyway, I think it's time to finish this VERY long post.  But wait -- I wanted to tell you, dear readers, of my "marathon" goal, in the style of K who is working from couch to 5K right now.  Training for a marathon isn't feasible now, although I try to powerwalk my way through lectures as much as possible. But my personal marathon is more career based.  The Internal Medicine "bible" is a text called Harrison's Principles of Internal Medicine.  (If you read Cecil, sorry.  It's not the same.)  I intend to complete all of it.  Yes, I mean ALL.  There's plenty of time.  My first goal is the section on cardinal manifestations and presentations of common illnesses.  I will do one topic a week at least.  I also want to finish Nephro since I'm close.  And otherwise, read according to my patients, at least twice a week.

Can I do it?  Let's find out?  And if you're a doctor, you're welcome to join me :o)  Otherwise, see you on my powerwalks outside.  Can we get four a week?

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