Monday, June 7, 2010

Heart failure....and summer!

I think I promised a while back to have some less depressing stories from my 3rd year of medical school. I've been saving this one. Now, don't judge. Although I find this absolutely hilarious on some level, it's still sad that there are people who really let things get this bad.

Last week of my medicine rotation we get a consult on a patient who is in kidney failure (yes, I know the title is heart failure). She has no history of previous kidney failure. She has pitting edema in both her legs. Pitting edema is just what it sounds like, you push your fingers into her legs and the imprint of your fingers stays there like a pit. Hers was particularly bad. I was sent in to get her history. You know it's bad when...

"Well, I last went to the doctor about 3 months ago and I was so surprised because I had lost about 20 pounds, and all I had been eating was cheesy puffs. So I figured, if I could lose 20 pounds eating cheesy puffs, it must be because of the cheesy puffs. So that's all I've eaten for the past 3 months."

Me: "When you say that's all you've eaten, do you mean that's mostly what you've eaten?"

"Nope. I am on the cheesy puffs diet. Sometimes I have water, because they make me thirsty."

Far as we can tell, she was on such a low protein, high salt diet that several things happened. The decrease in protein in her circulation allowed her blood vessels to get really leaky and her blood volume got squished out into her interstitium (area in tissues that is not in blood vessels). This made her functionally dehydrated, even though she was full of fluid weight that was making her all puffy (the pitting edema). Her heart was trying hard to keep up with the decreased fluid by pumping faster than it was used to. Over time, this put her into heart failure causing fluid to back up further and contribute even more to her edema. This also made less blood available to the kidneys, which are very sensitive to changes in blood flow. The kidneys were also seeing all this extra salt that made them think the body was very dehydrated, holding on to as much fluid as possible and making her more fluid overloaded, which also ended up in her interstitium. Also over time, this led to renal failure, which was then picked up on routine labs and ended her up in the hospital.

Lesson: though cheetos are delicious and a fun bright orange snack, they are in no way enough to maintain a human being for any sustained length of time. Sorry Cartman.

The good thing, for this woman it's a reversible condition treated readily by protein replacement and fluids. And likely lots and lots of nutrition counseling.

More good news: she'll likely lose even more weight after all the fluid is diuresed from her legs.

The best news: this was actually the day before I was done at this particular hospital, so I didn't have to be responsible for the care of this misguided patient.

Ah memories.

I'm happy to say that my subinternship ended well and that I had a wonderful time. I learned so much and I feel like there's no doubt in my mind that this is what I want to do and that I found "my calling." I find that folks in medicine are always on about where their passion lies and what they are called to do. Considering all the training that goes into medicine, it doesn't completely surprise me that people want to end up doing something that really speaks to them and will make all that work worth it. I'm glad that I've decided to bite the bullet and do that. When I started med school I was pretty focused on "lifestyle" specialties which could afford me a lot of free time and good pay. But, ultimately what I do for a living will have to make me happy while I do it, since so much of my time will be spent working, regardless of the field I enter.

And for now, I'm even happier to say that summer is here and I'm home to enjoy it! Today starts the first time off I've had in some time and I am looking forward to it. So are my feet. They get tired standing for 14 hours at a time. I am taking my Step 2 board exams this month, so it's not a complete vacation, but I think it will probably seem like it! And the way fresh air feels in the morning in the summer is something I'm excited to experience again! I love summer!!!! Shoot me an email or text or let me know when you all have some free time! I'm looking forward to catching up again!