Status Diabetic Ketoiatrogenicus (DKIA)

Sometimes the ill effects of status iatrogenicus go largely unnoticed except by those that directly bear the burdens of care and ultimately pay the bills.

Imagine a 29 year old type I diabetic and who's still using 70/30 insulin in the post-Ultralente Lantus era because he can't afford the latter.  So, when WalMarts runs out of 70/30, he tries to get by with regular insulin, and lo and behold a week later he's in the ER in DKA (diabetic ketoacidosis).

If you're a perspicacious doctor familiar with the treatment of low income diabetics, this case is not a great mystery.  Insulin non-compliance eventuating in DKA.  Easily treated with fluids and reinstitution of insulin.  The case may be slightly more difficult if it were a female with pyelonephritis, slightly more with shock and MSOF, and maybe totally different if it were a 59 year old male with a stroke or an MI and MOSF and DKA in an inscrutible and tangled causal web.

"It'll break her ribs": Checking boxes on the Code Blue Sushi Menu

For more reasons than I wish to enumerate here, the discussions of death and dying that physicians are having with patients at the end of life are so simplistic, myopic, confused, and lacking in nuance that they resemble a theater of the absurd.

The implications for individual patient care and health care in general are weighty indeed, but I will defer their statement to other commentators or other posts.  Herein, I review some of the absurd elements of the approaches I often see used to broach the topic of decision making at the end of life, and offer some (admittedly vague) suggestions about how this sorry state of affairs can be improved upon.

Let us begin with what has been called the "Chinese Menu" for "Code Status".  I prefer to call it a Sushi Menu.  I should pause to explain terminology.  When a patient dies in the hospital (we have various euphemisms for death in the hospital - "passing", "coding", "full arrest" [curiously, there is no "partial arrest"], etc. - but the key point which we must confront directly - not tangentially - is that people do eventually die) a "Code Blue" is called overhead.  Code blue called overhead on the hospital PA system activates a team of various hospital employees of sundry disciplines, who respond and attempt to resuscitate him.  A patient's "Code Status" is medical jargon that signals to that team what the patient wants them to do in the event that they die in the hospital. In the simplest of its various forms Code Status is dichotomized to either "Full Code" meaning the patient has directed the team to "do everything" that is reasonable to resuscitate him; or to "DNR/DNI" which means Do Not Resuscitate/Do Not Intubate - that is, do not intervene and allow the patient to die naturally in the event that they stop breathing or their heart stops.  Why would a patient choose to die naturally rather than be resuscitated?  Because often being resuscitated forestalls death only for a short time during which the patient cannot communicate or get his affairs in order - time that has little value and may increase the net burden of suffering, all of it in the hospital in a state of questionable consciousness, connected to machines and being poked and prodded and "run through the ringer" until death inevitably intervenes.  As a sage friend once said "Death is not the enemy."  Indeed it is not.  Suffering is.

Miffed at the Myth of MIVF and nonplussed by nil per os (NPO)

I will have to consult with physicians from a former generation to determine from whence came the concept of "maintenance intravenous fluids" or MIVF.  Early in medical school, especially during the pediatrics and surgery rotations, medical students are taught how to calculate fluid deficits and ongoing losses with the goal of selecting the optimal electrolyte solution and rate with which to replace them.  (Internists generally just select some base-10 friendly number such as 100 or 150 cc/hour and call it a day.)  This is a worthy enough goal, because dehydration is indeed one of the easiest and most worthwhile things to correct in the acutely ill patient.  (If you've ever puked your guts out for a day and then gotten a liter of intravenous fluid, you know what I mean.)

But the whole practice begs the question:  If there is a fluid deficit, why not just correct it once and be done with it?  If the average deficit in diabetic ketoacidosis (DKA) is 5 liters, why not just give 5 liters and stop?  I used to chide the residents during their ICU rotation:  "Bolus is for resus, rates are to maintain" to reinforce the notion that deficits should be repleted quickly.  But now I have come to question the second clause in that aphorism - do we need rates to maintain?

Specious Ideas: CO2 is bad for you and acidosis is a killer too



Here's some bad acid and CO2

Certain biases in the way we think in medicine are so pervasive and so misleading that I'm going to make a special section on this blog for them:  The Specious Ideas Series.  We'll begin with my favorite, the approach to hypercarbia (high CO2) and acidosis (low pH) both in and out of the ICU.

Patients with serious illness often have derangements in PaCO2 (arterial partial pressure of CO2; hereinafter abberviated CO2) and pH.  But it does not necessarily follow that patients are experiencing physiological stress because of CO2 and pH, and it likewise does not follow that actions to normalize these values will make patients better.  Indeed, such actions are often not only a distraction and a waste of time, but they can also be harmful.

When the elderly need a protection order against warfarin-wielding physicians

This is a tree.  If you want to see the forest, back up.

(Added 1/11/12 - This post was prescient:  See this article in today's NYT: Interactive Tools to Assess the Likelihood of Death which reviews this JAMA article: Prognostic Indices for Older Adults; here is the Prognosis Website - In my opinion, it's too complicated to be useful, but it's a start.)

Ever since I was in medical school, I have been hearing the tired old refrain about how warfarin for stroke prevention in atrial fibrillation is underutilized in just about everybody, especially the elderly.  Well, if you want to see uber-high rates of warfarin underutilization, you need look no further than trials of stroke prevention such as the original SPAF trial (Ezekowitz, NEJM, 1992), where more than 93% of screened patients were excluded from the trial and not given warfarin!  There's an interesting contradiction.  Moreover, it is likely that warfarin is not as underutilized as has been stated because of inadequate data on appropriate exclusion criteria (see Srivastava, Thrombosis Journal, 2008).