When I was young, one of my favorite stories was O. Henry’s “The Gift of the Magi.” Originally published in 1905, the short story became standard fare in public school reading classes and I doubt that there are any of you out there who have not read it. But just in case — the story is about a young couple, poor and deeply in love. At Christmas, they have no …
In the midst health care cynicism, an affirmation of enduring love
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 54-year-old man is evaluated during a follow-up visit for five previous episodes of nephrolithiasis. Two of these stones were composed primarily of uric acid. After his third episode, potassium citrate was initiated. Medical history is notable for type 2 diabetes mellitus, hypertension, and hyperlipidemia. He does not have a known history of gout. …
MKSAP: 54-year-old man with nephrolithiasis
Recently, there has been a great deal in the press surrounding organ transplantation. Sarah Murnaghan, the courageous little girl with end stage cystic fibrosis, captured the nation’s attention as she waited for a life saving lung transplant. The organ transplantation and procurement system in the US today is not without flaws. Organs are at a premium and finding the best way to allocate them to matched patients who …
The effect of Facebook on organ donor registration
Imagine your 7-year-old son’s face, abdomen, and legs begin to mysteriously swell one morning. Your initial reaction as a parent would likely be to worry first. However, your second instinct is probably to rush to your computer and search the Internet for what might be going on. This is easy enough for the roughly 72% of people in America who have a computer with Internet access in their homes.
Now, imagine …
How to revolutionize health prevention efforts around the world
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 26-year-old man is evaluated for a 3-day history of fever, lower abdominal pain, tenesmus, hematochezia, and watery diarrhea. Seven months ago, he underwent a cadaveric kidney transplantation. At the time of transplantation, the transplant donor was seropositive for cytomegalovirus, and the patient was seronegative for this virus. Current medications are tacrolimus, mycophenolate …
MKSAP: 26-year-old man with fever and lower abdominal pain
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 51-year-old man is being followed in the hospital after receiving chemotherapy for acute myeloid leukemia 1 day ago. Kidney function was normal at the start of his treatment, which consisted of normal saline at a rate of 200 mL/h and rasburicase on the day of chemotherapy. He reports no symptoms except for some …
MKSAP: 51-year-old man with acute myeloid leukemia
As a doctor who also happens to be an end stage renal disease (ESRD) patient, I appreciate this opportunity to reflect on the great strides that have been made to improve the lives of ESRD patients and the steps that still need to be taken to make sure kidney patients have access to the best dialysis treatment possible and the best chance …
We need greater access to home hemodialysis
When I first lay eyes on Marilyn, I don’t think she will survive another week. Eighty-nine years old with short, curly gray hair, she sits in a wheelchair in the examination room. According to the nursing sheet, she weighs one-hundred and nine pounds. She wears a bulky white sweater over a gray dress that seems too big for her tiny body. Her …
If these are your final days, how do you want to spend them?
That was Virginia’s second visit to the hospital in the ten days of the new year. It also ended up being the last.
Virginia was a patient we all knew. She came to the hospital frequently. The aphorism of our intern year was, if you had not taken care of Virginia once, you were not going to graduate out of internship. And that was hardly an exaggeration- almost no one in …
A patient who’s the very reflection of our healthcare system
I pulled the stifling surgical mask off my face as I left my last patient’s room. I had just finished suturing a complicated facial laceration and was bone-tired from the evening. Glancing at the clock, I saw that mercifully, my shift was over.
Collapsing into my chair to finish up my charting, I was slightly annoyed when my nurse held a clip-board in front of my face, “Here is your next …
A rare case when needs of the dying should be secondary
More than 40 years ago as a third year medical student, I recall the Chief of Medicine praising a fellow student for his rare diagnosis of paroxysmal nocturnal hemoglobinuria in a patient who had presented with the common symptom of “painless hematuria.” The lesson was not lost on any of us: good medicine means an expansive differential diagnosis and an even longer list of tests (including expensive ones) to “rule them …
Reward doctors for evidence based problem solving, not test ordering
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 62-year-old man is evaluated for a 2-month history of progressive fatigue, dyspnea on exertion, anorexia, and nausea. He has no other medical problems and takes no medications.
On physical examination, temperature is normal, blood pressure is 157/88 mm Hg, pulse rate is 86/min, and respiration rate is 22/min. BMI is 31. The conjunctivae are …
MKSAP: 62-year-old man with a 2 month history of progressive fatigue
A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
As a critical care anesthesiologist, I care for patients when they are most vulnerable. Critical care patients require intravenous (I.V.) fluids and medications, frequently through central venous access. These are catheters inserted into larger veins with a special procedure. I believe managing I.V. lines requires procedural skills, …
The role of IVs and central lines in critical care
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Chico (all identifying information removed) was a patient we cared for in the hospital.
Admitting diagnosis: “acute kidney injury,” medical-speak for kidney failure. He would need dialysis.
From my point of view–an instructor teaching residents and medical students–there were two key questions about Chico:
1. What caused his kidneys to fail?
2. Given his kidney failure was “acute,” was there any chance that it’d be reversible? Could Chico’s kidneys heal to the point where …
When patients need to find a new equilibrium
At the end of long days I often stand gazing out my window at the beautiful, timeless Rocky Mountains in Colorado Springs and am taken by their sense of permanence. I recently returned from Nampa, Idaho, where I presented hospital Grand Rounds on Accountable Care Organizations.
The parallels between the timeless mountains and the physicians I met in Nampa struck me. Strange, you say? Maybe, but I am accustomed to the …
What does an ACO mean in small town America?
One of the most memorable discussions regarding the cost of care was at 4:45AM during surgical morning rounds.
As usual, the interns would present the overnight events of their patients to the chief resident and a plan for the day would be agreed upon. These morning rounds were particularly intense: in addition to the 30 patients that an intern had to manage solo over night, the brutal hours that the surgical …
Is the daily blood draw in the hospital truly necessary?
On a late afternoon in mid-July I was finishing up my first Sunday on call as a third year medical student. I glanced over the patient list for 4 East, the internal medicine floor I had been assigned to cover. Familiar with patients in their eighties and nineties, I was surprised to see a 22-year-old patient admitted with acute kidney injury.
He was a nice-looking young man in good spirits. Spanish …
Failure of communication led to an excessive hospital stay
The trouble with many significant advances in medicine is that that they take us out of our moral depth. They may raise quite different problems from the ones we are used to and, if we are not careful, we may inadvertently undermine the wonderful potential of new technologies by forcing them into existing legal, ethical and institutional frameworks.
Transplantation is a case in point. Transplants save and transform lives; but the …
How transplants are causing ethical dilemmas
Hospitals commonly espouse a commitment to patient-centered care (PCC). Most fail to achieve it. Causative factors are legion. PCC is often considered a strategy or a tactic, for example, when it really should be integral to an organization’s culture, and enabled by a supportive vision. Some organizations appreciate this, yet still struggle. This is understandable. Today’s health care providers were not trained to provide PCC. They lack the requisite skills, …
Is patient-centered care an outmoded concept?
I have been asked a lot lately, owing to the release of my novel Altamont Augie, what writing fiction and being a doctor could possibly have in common? Patients and colleagues seem shocked that the rational, left-brain doctor they have come to know and depend on to deliver technologically complex medical care to patients with kidney failure could produce such a right-brain thing as a novel. Where did this …
What does writing fiction and being a doctor have in common?
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